For patients having back surgery

This information is intended to help you understand what will happen
when you have your back operation and to help you with your recovery.
We want you to know what to expect and what you can do to recover as
quickly as possible.

It has been written by different healthcare professionals including
Physiotherapists, Nurses and Spinal Surgeons.

The information is of a general nature and may be different according
to your individual situations. This information will answer some of the
questions that you may have, but if there is anything that you and
your family are not sure about then please contact your consultant or
appropriate healthcare professional.

Why are you having spinal surgery?

Your spine is made up of squares of bone (vertebrae) stacked on top of each other with shock absorbers (discs) in between them. The spinal cord sits behind this, lying in a hole through the centre with nerves coming off it to your arms and legs. Joints and more bone (where muscles and ligaments attach) lie behind the spinal cord protecting it from behind.

Surgical treatment is done for people whose symptoms prevent them carrying out daily activities. Operations for the lower back are usually done to release pressure on the nerves that go down your leg causing leg symptoms. These might include pain, pins and needles, numbness, heaviness or weakness, which may be different between people. All these can contribute to difficulty in walking.

The leg pain doesn’t always improve immediately after surgery but can improve over a period of time, often months, as the nerve recovers. Improvement of your back pain is more difficult to predict and is not the main aim of the surgery.

What surgery can be done?

As part of the normal ageing process soft tissues and bones in your back may harden and become thickened. Stenosis means narrowing of the exit holes for the nerves (canal or foramina) due to the thickened tissues and bones. In some people this can lead to pressure on the nerves causing leg symptoms. Most patients who have spinal stenosis have slow build up of symptoms.

Treatment for this can involve decompression surgery, which is the process of making more space around a nerve by removing a small amount of bone.

As you get older it is normal for the discs between the vertebrae to be less plump and to bulge a little. Despite the term ‘slipped disc’, the disc doesn’t slip in and out however some of the disc material can bulge backwards and impinge on a nerve. In the vast majority of cases the body will reabsorb this material and heal itself without needing treatment.

Sometimes the bulge doesn’t heal itself and can be near a nerve and large enough to push on it, causing leg symptoms. Treatment for this can involve discectomy surgery where the piece of disc pressing on the nerve is removed. Microdiscectomy involves less disturbance of the tissues as a portion of the disc is removed while using a microscope.

In some cases your surgeon may need to join the bones using a bone graft or sometimes metal screws and rods, as shown below. This is done to steady the spine and would be discussed with you prior to the operation. This is called Decompression with Fusion.

If you have a lumbar fusion, the exercises and advice you are given after surgery may vary slightly from if you have surgery which doesn’t include metal work and screws.

Discectomy and decompression can be performed in one operation if needed.
The surgeon does not remove a whole disc or bone and there are no gaps left in the spine. Up-to-date surgical practices mean that healing takes place very quickly and once it is healed the back is as strong as ever.

The above surgeries are done under general anaesthetic (you are asleep).

What are the possible risks or complications of this surgery?

Deep infection – approx. 1 in every 100 cases. You would usually be given antibiotics into a vein at the time of surgery to lessen this risk.
Superficial wound infections – 4 in every 100 patients get this and may need a short course of antibiotics.
Bleeding – less than 1 in every 100 patients have a major bleed, which may need treatment.
Durotomy – the dura is the delicate sac that contains the spinal nerves inside the spinal canal. Occasionally, 1 in 25, this can become snagged or torn by accident during the surgery. This can usually be identified and mended at the time and would not cause any long term problems, You might have a headache for a couple of days afterwards.
Blood Clots – in the deep veins of the legs or lungs. You will be given surgical stockings and pumps on your legs during surgery to reduce this risk, although we cannot eliminate it.
Sensory change or muscle weakness in legs – is uncommon, approx 1 in 300 cases. When it does occur it is usually temporary but on occasion can be longstanding. Problems with nerve function in up to 31% of patients, most of these were temporary.
Post-op bladder or bowel dysfunction – The risk of damage to the nerves that supply your bladder and bowel is very rare, 1 in 1000.
Repeat surgery – 1 in every 100 patients have more back surgery during the ten years that follow due to continued wear and tear elsewhere in the spine.
Back pain – Around 1-2 out of every 100 patients develop ongoing low back pain after spinal decompression. This can often be treated without surgery.
Age – For elderly patients some risks are slightly increased. Risk of blood clots, heart attacks, urine/chest infection, and heart failure are all increased with advancing age.
Recurrence of Pain – In less than 1-5 in 100 people the natural process of healing by scar tissue causes pain to return by covering nerves in too much scar tissue. This is treated by Physiotherapists and sometimes referral to the Pain Team after surgery.
Another operation was needed in up to 6% of patients.
Temporary damage to blood vessels, urinary tract infection, urinary retention and vertebral fracture, each in up to 1% of patients.
Problems affecting the digestive system in up to 7% of patients.
Problems with metal work – this may involve breaking of screws or rods or the bone failing to heal around the metal leading to movement of the screws. This may or may not need more surgery in the future. Problems with the cage supporting the vertebrae, or the bone graft, in up to 3% of patients.
Positioning during surgery – in rare cases this can cause pressure problems, skin and nerve injuries and eye problems (very rarely blindness). Special operating tables are used to lessen these risks. Shoulder problems and upper limb nerve problems are also a risk which we aim to reduce.
Persistent pain – 20-25% of patients may be better but still have ongoing leg pain.
5% of patients may have no benefit at all.
1% of patients may be worse in terms of pain.

Very rare but serious complications include:

Damage to the Cauda Equina (the collection of nerves at the end of the spinal cord) resulting in paralysis or loss of bowel and bladder function. This can occur due to bleeding into the spinal canal after the surgery (a haematoma). Every effort would be made to reverse this by returning to surgery to wash out the haematoma, however recovery of the nerve damage cannot be guaranteed.
Stroke, Heart Attack or other medical or anaesthetic problems. Please check RCOA, Royal College of Anaesthetists patient information. See link: 03-YourSpinal2020web.pdf (rcoa.ac.uk)
Extremely rare death, reported in 1 out of 250000 cases under general anaesthetic.

What you can do to prepare for the surgery?

Stay healthy, eat a well balanced diet and try and keep your weight down
Ask questions so you feel informed about the procedure and what you are signing on the consent form
Make plans for your recovery at home following surgery. This may include telling your employer, ensuring you have put in a care package if you feel you will need help and that there is someone to take you home when discharged. Please ensure that you have organised meals, childcare and carers if these are needed.
If you smoke, it is very important that you stop, or at least cut down – please speak to the pre-operative assessment department for help and advice via their ‘live well stay well’ campaign.

Pre-operative – before the surgery:

Prior to admission to the hospital you will be sent an appointment for the preoperative admission assessment unit.
Plan for half-a-day at the clinic. A family member or another person may come with you. There is a hospital cafeteria on site for refreshments and food.
A nurse will check whether you are fit for surgery. This involves a general check of your health, laboratory tests (blood and urine), x-rays and any other tests that may be needed.
You will also be asked about any medication you are taking including herbal medicines. Please bring your medicines to the Pre-Operative Assessment Clinic with you, or if this if not possible bring a list of your current medication.
Before the day of surgery if you feel that there have been any changes in your medication or health please inform the pre-operative assessment department.