Indications for surgery:
Symptomatic stenosis causing either spinal claudication or radicular pain.
Neurological deficit: weakness or numbness occasionally bladder and bowel problems Occasionally severe stenosis may present with predominantly back pain
Epidural steroid injections may improve symptoms such as pain
Physiotherapy may improve pain and functional limitation though less likely to be of benefit in severe compression
Evidence for surgery:
Many studies looking at this subject. Bigger randomized controlled trials have limited value as high cross over in randomisation. However, these studies show no significant benefit to surgery over best physical therapy and medical treatment. Many other less well designed cohort studies showing improvement in patient symptoms following surgery. Despite the lack of strong scientific evidence the benefits of surgery for well selected patients, are accepted throughout the worlds medical and surgical communities.
Benefits of surgery:
Improvement in leg and sometimes back pain
Improvement in walking and standing time before onset of claudication. This results in a functional improvement in activities
Possible improvement in weakness or numbness though typically more slowly and not consistently.
Risks of surgery:
Serious risks – death, neurological worsening – serious weakness, numbness, bladder and bowel dysfunction – all rare risks <1%
More common risks – The quoted risks across several series looking at this operation and its outcome. I will discuss your individual risks at the time of consent.
incidentaldurotomy and CSF leak ~5% in literature
significantongoing pain approx 10-20% patients in literature
worsened pain approx 5% in literature
spinal instability requiring future spinal stabilisation approx 2-5%
infectionapprox 1-5% patients in literature
medical or anaesthetic complications
After this operation you return to the hospital ward and I will encourage the ward team to begin to mobilize you on the same day as the surgery. This will overall reduce your stiffness. Typically patients are discharged one or two days following the surgery, though some patients may require more time before discharge. You will be assessed by our physiotherapy team, to determine if you are safe to return to your home environment. Occasionally some patients may benefit from a short period of rehabilitation.
Pain is typically well controlled with Paracetamol and NSAIDS.
Mobility restrictions are designed to limit discomfort and reduce risks of disc recurrence. I would advise sitting for a maximum of 30 minutes at a time and then walking around. Patients should avoid lifting anything heavier than a full kettle of water. Bending should be at the knees only. Exercise should be walking on the flat, building distances up over the six week post-operative period.
Driving should be avoided for the first 2 weeks post op and then should be commenced only if there is no foot weakness and good range of movement without discomfort to allow the driver to easily be in full control in an emergency situation. If this is not the case the patient is legally bound to avoid driving.
Return to work is variable between different types of jobs. A minimum of 2 weeks off is necessary and usually I would recommend returning to work in a graduated fashion starting after your 6 week post operative consultation.