Mr Neil Orpen

MBChB FRCS (Ed) TR & Orth

Consultant Spinal Surgeon

Spinal Stenosis/Deformity

This term refers to any condition which results in narrowing around the spinal cord or spinal nerves resulting in a group of symptoms termed claudication. Claudication is the symptom of leg pain which occurs with standing or walking and improves with rest, sitting down or leaning forward.

These symptoms can be caused by pressure on the spinal nerves ( spinal claudication ) as well as constriction of blood vessels in the legs ( vascular claudication ). Your surgeon will conduct a clinical examination and may request special investigations, such as an MRI scan to be certain of the cause of the claudication symptoms before suggesting treatment.

What are the symptoms indicating spinal stenosis may be present?

Patients typically complain of pain or heavy aching in the calves or thighs which occurs with walking. With time, the symptoms start to develop with shorter distances of walking and amy be slower to resolve with rest.

These symptoms may improve with leaning on a shopping trolley and some patients will notice that they do not occur with riding a bicycle. This is due to the fact that slight leaning forward tends to open up the spinal canal which releases pressure on the spinal nerves. Occasionally the symptoms are intermittent and last for a few weeks and then resolve followed by a further episode some time later.

Eventually the symptoms progress and occur on standing upright and may progress to not improving regardless of position. Some patients may complain of aching in the calves while sleeping which may wake them at night. These may be described as cramping or heaviness. When the condition occurs in the neck, pressure on the spinal cord may produce similar symptoms but in the arms rather than the legs and only later when severe are the legs affected.

This can be in the form of unsteadiness with walking, dropping things all the time and occasionally sudden shooting pains up and down the neck and back. Tightness around the spinal nerves can produce neck pain and headaches too.

The condition tends to progress rather than resolve spontaneously but this progression is slow and so patients don’t usually need to rush into having treatment unless the symptoms are particularly troublesome. However, with prolonged severe pressure on the spinal cord, permanent damage can occur which does not improve with surgery and therefore you may be advised to have surgery before this stage is reached.

What is occurring to the spine?

As degenerative changes develop in the spine, general structural changes occur in the disc which then breaks down and narrows and looses its ability to work as a cushion between the vertebrae. The disc bulges outward toward the spinal canal. Degenerative/ arthritic changes occur in the facet joints and the ligmentum flavum ( thick protective ligament behind the nerves) hardens and bulges inwards.

All these result in narrowing of the space available to the nerves. When the patient walks there is typically an increase in the blood flow to the nerves which increases their size which further narrows the space available to the nerves and the further the patient walks the more the nerves are affected. Patients then start experiencing pain or aching along the course of the particular nerves that are affected and may also feel pain in the back or neck.

Because it is a degenerative condition, this tends to occur later in life and spinal stenosis is the most commonly treated spinal condition in people over the age of 60. There are however other conditions that may result in a similar narrowing of the spine so that any age group may be affected by the symptoms of spinal claudication.

What conditions may be confused with spinal stenosis?

• Vascular stenosis due to narrowing of blood vessels

• Arthritis of the hips or knees

• Diabetic neuropathy

• Trochanteric bursitis due to inflammation of the tissues around the hips

There are a number of other conditions and your surgeon will ensure the diagnosis is correct prior to considering surgery. What is the best treatment Like all spinal conditions there are either conservative or surgical options and a conservative approach is usually followed in the first instance.

This may involve combinations of anti-inflammatory medication, physiotherapy, steroid injections and nerve blocks. None of these will change the underlying condition causing the symptoms but are rather aimed at improving symptoms of pain. Surgery involves relieving the pressure on the nerves and spinal cord and a number of techniques can be used depending on the underlying condition of the spine.

Typically a decompression of of the nerves is required and in some conditions of spinal instability leading to stenosis, the spine may also require stabilisation in the form of a fusion. There is evidence that surgery is likely to produce the best outcomes in the long term but delaying surgery in the first instance does not worsen the outcome when surgery is eventually chosen.

There are some special instances where surgery will be suggested urgently to avoid permanent spinal cord damage but this very unusual. Are there any minimally invasive/ key-hole techniques available? There are some techniques available that can be used in certain patients and these include interspinous distraction devices and micro-decompression surgery.

These are not suitable for all patients and you should be able to discuss this at your consultation.

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Cervical Nerve Root Blocks

Pain originating from a spinal nerve root is referred to as radicular pain. This pain is typically felt in the distribution of the nerve that arises from the root as it radiates away from the spine. In the lumbar spine this is typically along the course of the sciatic nerve and therefore is referred to as sciatica.

It may also follow the course of the femoral nerve (femoralgia) with a subtle difference in the distribution of pain. In the upper limbs pain is felt in a typical distribution described as brachialgia and follows the specific distribution of specific nerves extending down the shoulder or arm and may extend into the hand. In many patients numbness, tingling, pins and needles may also be felt.

Commonly the pain does not follow a typical pattern and it is the surgeon’s job to try and identify the cause of this pain, which will typically be done with a combination of clinical examination, MRI scanning and possibly also diagnostic blocks. Nerve pain is caused by either pressure on the nerve at its origin in the spine or from the inflammatory process surrounding the pathology at the nerve root origin.

This may be a disc prolapse, inflamed facet joint or cysts and a number of other processes which cause inflammation. Very rarely infection and tumours may be the cause of pain but this is very uncommon. The inflammatory process can not be visualized on scans but is the part of the process that responds to steroids or anti-inflammatory medication such as ibuprofen/ Brufen or voltarol.

Nerve root blocks are performed for two main reasons. One of these is the ability to provide diagnostic information as to the cause of pain. In situations where clinical examination and scans or x-rays do not conclusively identify the source of symptoms, a block of that nerve can assist the process. The principle is that by placing local anaesthetic around the nerve, this should block any pain originating from that nerve.

This means that while the local anaesthetic is working, the pain should improve if that nerve is responsible for the symptoms. Patients are asked to record the pain response in the early post block period and specifically to remember what the early response was. As local anaesthetic typically lasts for 30 min- 1 hour for lignocaine which is used for cervical nerve root blocks, and for 8-12 hours ( marcaine) for lumbar and thoracic nerve root blocks, it is important to recall this early response which may be easy to forget 6 weeks later.

A caudal epidural also aims to place steroid around the nerve roots and spinal structures but it is placed into the spinal canal through a slightly different root. Although this is often easier to perform it is a little less specific in directing where the steroid goes and so is not as good as giving diagnostic information.

This procedure can be performed under a light general anaesthetic or sedation as it is usually a little more uncomfortable than performing a nerve root injection. It can also be performed in patients that are pregnant where we commonly want to avoid using x-rays as the procedure may be performed under US guidance. An additional benefit for the patient is the therapeutic benefit from the steroid, which is introduced at the same time as the local anaesthetic.

Steroids work simply as long working anti-inflammatories. Whereas a tablet of ibuprofen typically lasts for 8 hours and therefore needs regular doses three times a day, a steroid injection lasts for approximately 6 weeks after one dose. An additional advantage is that by applying this locally the systemic side effects are reduced and as it is only one dose, the long-term side effects are also reduced.

A disadvantage is that the onset of action of a steroid is quite slow so following an injection, the benefit may not be felt immediately. For these reasons a typical response to a nerve root injection or epidural injection is a short term benefit from the local anaesthetic followed by a recurrence of the pain, although commonly reduced, and then a slow drop in pain over the course of weeks from the steroid.

Procedure

Nerve root blocks as well as caudal epidurals can be performed under local anaesthetic although lumbar and thoracic blocks can be performed under sedation or general anaesthetic if a patient prefers. A very small needle is passed under x-ray control and placed next to the spinal nerve root outside the spinal canal. An x-ray contrast agent is used to confirm the position as being accurate and while this is being introduced an increase in limb pain is often described.

This is not severe or concerning and may be helpful as a diagnostic response. Immediately after the procedure the local anaesthetic can cause numbness and weakness of the affected limb or both limbs which causes a temporary limp to develop in the leg. This will make driving unsafe for this 12 hour period so plans should be arranged for getting home from hospital.

A follow up appointment should be made for 2 weeks following the procedure.

Risks

This is a safe procedure but specific risks are worth considering. Infection is very rare, but a bruise in the area or a small increase in pain for a few days can occur and is not itself a worrying sign. Due to the presence of the vertebral artery in the neck, a small incidence of strokes is described following cervical nerve root blocks.

This incidence is less than 1 out of every 4000 cases. You should not drive immediately after the injection as the numbness in the limb may impair the ability to drive safely, but this will only last for the day of the procedure. You can return to work the following day.

The risk of damaging the spinal cord is very low. It is very unusual to have any difficulty with micturition after a nerve root block or caudal epidural but should this occur after hours, you should go down to the local A&E department so that you may be seen by the on call spinal team. Approximately 60-70% of patients can avoid surgery for nerve root pain by trying a nerve root block and the risks associated with this procedure are considerably less than with surgery so should be considered as an alternative where possible.

Post operative course

Immediately after the procedure numbness is usually felt in the leg or arm and this may last up to 12 hours. This will cause a limp in the leg and weakness in the arm so will make driving or work difficult during this time. It is reasonable though to plan a regular day the day after the procedure allowing as much general rest as reasonable to allow the nerve root to settle down and benefit from the procedure.

It should not be necessary to take time off work, unless in a heavy manual job. The original pain may then return although often to a lesser extent than before the procedure. The steroid action may take up to 6 weeks to have a maximal effect. It can be useful to keep a pain diary during this time so as to accurately record the effect of the procedure, as it may be difficult to remember this later down the line.

A follow-up appointment is usually arranged for 2 weeks following the procedure.

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Caudal Epidural Injections

General Information:

Epidural Steroid Injections (ESIs) are a common method of treating inflammation associated with low back related leg pain, or neck related arm pain. In both of these conditions, the spinal nerves become inflamed due to narrowing of the passages where the nerves travel as they pass down or out of the spine.

Why Get an Epidural Steroid Injection?

Narrowing of the spinal passages can occur from a variety of causes, including disc herniations, bone spurs, thickening of the ligaments in the spine, joint cysts, or even abnormal alignment of the vertebrae (‘slipped vertebrae’, also known as spondylolisthesis). The epidural space is a fat filled ‘sleeve’ that surrounds the spinal sac and provides cushioning for the nerves and spinal cord. Steroids (‘cortisone’) placed into the epidural space have a very potent anti-inflammatory action that can decrease pain and allow patients to improve function. Although steroids do not change the underlying condition, they can break the cycle of pain and inflammation and allow the body to compensate for the condition. In this way, the injections can provide benefits that outlast the effects of the steroid itself.

How Are Epidural Steroid Injections Performed?

There are three common methods for delivering steroid into the epidural space: the interlaminar, caudal, and transforaminal approaches. All three approaches entail placing a thin needle into position using fluoroscopic (x-ray) guidance. Prior to the injection of steroid, contrast dye is used to confirm that the medication is traveling into the desired area. Often, local anesthetic is added along with the steroid to provide temporary pain relief.

An interlaminar ESI, often referred to simply as an ‘epidural injection’, involves placing the needle into the back of the epidural space and delivering the steroid over a wider area. Similarly, the caudal approach uses the sacral hiatus (a small boney opening just above the tailbone) to allow for needle placement into the very bottom of the epidural space. With both approaches, the steroid will often spread over several spinal segments and cover both sides of the spinal canal. With a transforaminal ESI, often referred to as a ‘nerve block’, the needle is placed alongside the nerve as it exits the spine and medication is placed into the ‘nerve sleeve’. The medication then travels up the sleeve and into the epidural space from the side. This allows for a more concentrated delivery of steroid into one affected area (usually one segment and one side).  Transforaminal ESIs can also be modified slightly to allow for more specific coverage of a single nerve and can provide diagnostic benefit, in addition to improved pain and function.

All three procedures are performed on an outpatient basis, and you can usually return to your pre-injection level of activities the following day. Some patients request mild sedation for the procedure, but many patients undergo the injection using only local anesthetic at the skin.

What Happens After the Injection?

The steroid will usually begin working within 1-3 days, but in some cases it can take up to a week to feel the benefits. Although uncommon, some patients will experience an increase in their usual pain for several days following the procedure. The steroids are generally very well tolerated, however, some patients may experience side effects, including a ‘steroid flush’ (flushing of the face and chest that can last several days and can be accompanied by a feeling of warmth or even a low grade increase in temperature), anxiety, trouble sleeping, changes in menstrual cycle, or temporary water retention. These side effects are usually mild and will often resolve within a few days. If you are diabetic, have an allergy to contrast dyes, or have other serious medical conditions, you should discuss these with your NASS doctor prior to the injection.

Epidural steroid injections have been performed for many decades, and are generally considered as a very safe and effective treatment for back and leg pain or neck and arm pain. Serious complications are rare, but could include allergic reaction, bleeding, infection, nerve damage, or paralysis. When performed by an experienced physician using fluoroscopic guidance, the risk of experiencing a serious complication is minimized. Overall, ESIs are usually very well tolerated and most patients do well.

Although not everyone obtains pain relief with ESIs, often the injections can provide you with improvement in pain and function that last several months or longer. If you get significant benefit, the injections can be safely repeated periodically to maintain the improvements. Injections are also commonly coupled with other treatments (medications, physical therapy, etc) in an attempt to either maximize the benefit or prolong the effects.

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Facet Joint Injections

Back pain may have a number of clearly identifiable causes for which treatment protocols may differ widely. The assessment of patients presenting with back pain as a symptom involves predominantly clinical assessment and special investigations (x-rays, MRI scans, diagnostic blocks) aimed at identifying a treatable cause for the symptoms and then devising a short and long term treatment plan to control or resolve the pain.

Facet joint pain is typically that pain felt over the spine which may radiate to the paraspinal region. In the neck commonly pain is felt to radiate into the back of the head, shoulders or parascapular area. In the lumbar spine it may radiate into the buttocks, back of thighs or hips.

Typically pain worsens with extension or rotation and then is relieved by rest or forward flexion. Most commonly facet joints become painful due to degeneration ( eg. arthritis) but may also be the source of pain due to strain, whiplash injury and there may be very little change identified on x-ray.

A number of patients will not present with a classic picture and symptoms may be difficult to differentiate from pain from other pathological causes (spinal stenosis, disc prolapse, fractures.) Each of these other pathologies requires a different diagnostic approach and different treatment regime and often a diagnostic injection may then be used to identify the pain source.

Treatment of facet joint pain involves a predominantly conservative / non-operative approach based around physiotherapy to strengthen spinal musculature and core control as well as maintaining flexibility. Some patients are in too much discomfort to attempt physiotherapy and facet injections with steroid can allow them to control pain adequately to enter a rehab protocol.

In patients where pain is not controlled for long enough for them to benefit from physiotherapy, facet joint rhizolysis can provide greater a longer period of benefit in carefully selected patients as the sensory nerves that detect pain are cauterised. This can allow them to enter and benefit from a rehab regime.

In some patients with pure facet joint pain where the pain can be isolated to a small number of joints, fusion of these joints will relieve pain. This is only suitable for a small number of patients and will not typically be the first treatment option to consider.

Procedure

This will usually be performed under local anaesthetic in most patients but can also be performed under sedation or general anaesthetic if a patient feels they are unlikely to tolerate local anaesthetic alone. This is a day case procedure and will either be performed in the operating theatre or radiology suite.

After administering a local anaesthetic a small needle is placed into the facet joint and around the joint where the nerve supply originates from. Typically a long working local anaesthetic (Marcain) and a steroid (depomedrone) are used. The local anaesthetic will provide pain relief for approximately 8 hours and it is common for there to be an increase in pain the following day which may continue for a few days.

This is due to bruising and should not cause alarm as it will gradually settle. The anti-inflammatory effect of the steroid may only start having a significant effect in some people after a few weeks. As soon as a positive effect is felt, physiotherapy should commence as it is the physiotherapy that is likely to give a long term benefit and is the key to long term improvement.

Injections may be repeated if only a short a short lived benefit is felt and consideration can also be given to facet joint rhizolysis which can have a longer effect than facet joint injections in correctly selected patients.

Facet joint injections should be considered safe although there are some risks which may be considered. The risk of infection or damage to nerves or the spine is extremely rare and unlikely. It is normal to have an increase in pain for a few days after the procedure and not all patients will have a beneficial response to these injections of steroid.

Mr Orpen will ask you to recount the response to the injections in the first hour, 6 hours, 12 hours, 24 hours and 1 week and 2 weeks and will normally like to see you in clinic after 2 weeks.

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Facet Joint Rhizolysis

Back or neck pain may arise from a number of anatomical structures and one of these is commonly the facet joints. These joints are part of the mobile structure of the spine and therefore are prone to degenerative changes as part of the normal aging process of the spine. They may also be part of other inflammatory processes which affect joints such as in conditions such as arthritis and so may be a source of pain. These joints may be inflamed in conditions such as whiplash or after minor sporting injuries.

Pain from the facet joints will often settle without any intervention as the body’s natural healing action takes care of the inflammation and this may be aided by the use of anti-inflammatory medication and physical therapy offered by your physiotherapist or osteopath.

Facet joint injections of steroid may be useful when facet joint pain has not improved with these conservative measures. Please see www.spine-care.co.uk for additional information on this procedure.

What is Rhizolysis

The facet joints are innervated by a small branch of nerves which carry pain impulses from the joints to the brain. These impulses may be blocked by the use of a local anaesthetic for a short period or for a longer period by coagulating the nerve with a radiofrequency wave. By placing a needle probe on the nerve a very specific and isolated area can be coagulated without having an effect on other structures in the area.

Rhizolysis is the process of cauterisation and is provided by the specialised machine that generates the radiofrequency pulse. The procedure itself is performed in a very similar way to facet joint injections and is performed using specialised needles placed percutaneously.

Am I suitable for Rhizolysis?

Mr Orpen will specifically assess whether you may be suitable to consider this procedure and usually will suggest trying facet joint injections and physiotherapy in the first instance before considering facet joint rhizolysis.

Should facet joint inejections only provide temporary improvement on two separate occasions, then rhizolysis may be considered as an alternative to repeated facet injections and will provide improvement in back or neck pain in 60-70% of patients for over a year while rehabilitation continues. The procedure can not be guaranteed to work but after a correct diagnostic work-up, is a relatively small procedure to be performed as an alternative to surgical intervention

Are there any risks?

The risks associated with the procedure are low and the machine itself performs a test to ensure no other nerves are cauterised other than specifically the pain sensing nerves from the facet joints. It is normal to have an increase in back pain for a couple of weeks after the procedure as the bruising settles and it may take up to six weeks to realise the full benefit.

The risk of infection or inadvertent nerve injury is low. The procedure can be repeated as in some patients even after a positive response the nerves regenerate and so pain may return. This may take some years. All procedures such as this, will have a reduced risk if performed by surgeons with experience and appropriate training in the technique.

Follow-up arrangements

An appointment should be made to see Mr Orpen in clinic two weeks after the procedure. Rhizolysis is performed as a day case under local anaesthetic. Arrangements should be made as it is not recommended to drive yourself home after any spinal procedures. You will not be required to take time off work and you may return to driving as soon as you are comfortable which is usually the following day.

It is recommended that you start physiotherapy as soon as you are comfortable. It is reasonable to remain on your regular pain medication for a few weeks after a rhizolysis procedure and Mr Orpen can advise on how to effectively reduce the dose of your medication at the two week visit following the procedure.

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Cervical Spine Disc Replacement

Disc prolapses occur in the cervical in a similar way to the lumbar spine and cause neck and arm pain ( brachialgia). Successful decompression of the disc prolapse is an effective way of managing pain and this is performed through an incision in the front of the neck.

Once the disc is removed the surgeon has a choice as to what is put in its place and typically this would be either bone (fusion) or an artificial disc replacement. There are specific indications for when each is used and your surgeon should be able to inform you which is best suited for your specific condition.

Disc replacements have been used throughout the spine but the most successful outcomes are reported when used in the cervical spine. A number of implants are available but Mr Orpen uses the Prestige Disc Replacement (Medtronic) as this implant currently has the best outcomes with the best long-term data. prestigedisc.com

The principle behind this implant is that by imitating the normal motion of the spine, the loads and stresses that would otherwise be transferred to adjacent levels are spread in a more natural pattern. This leads to less stress on the other discs and prevents them degenerating earlier than they otherwise would.

So by preserving the natural motion of the spine, degeneration in other segments is prevented and thus the need for further surgery in the future is reduced. A disc replacement is not beneficial in all instances and Mr Orpen will be able to advise you on whether you would be suitable and would benefit from this specialised form of surgery.

The procedure

This procedure should only be performed by a surgeon specifically trained and experienced in the indications and technique of the surgery. An operating microscope is routinely used to enhance the safety of surgery around the spinal cord. A right sided approach is most commonly used, using an already present skin crease at the front of the neck if possible

The incision will be 3-4cm long and due to the position of the scar, with time it becomes quite well hidden in the natural creases of the neck and so is not very obvious to see. The tissues to the front of the spine are moved out the way and as very little is actually cut during this approach, post operative pain is seldom a big problem and post operative recovery is fairly quick.

The level of surgery is checked with an xray and the whole disc is removed together with spinal ligament to reveal the front of the spinal cord. The appropriate nerve is then decompressed to relieve the pain. At this point Mr Orpen can either use a small cage to fuse the spine or a disc replacement is used. This decision is made prior to performing the surgery. Checks are made to make sure there is no bleeding and the skin is closed.

A small wound drain is often used and if so will be removed the morning after surgery. No collars are used after a disc replacement operation and most patients will go home the morning after surgery as long as they feel safe to do so.

Complications

Complications are rare from this surgery, but when they do occur, some can be very serious and so are responded to very quickly. From the approach it can be seen that many important structures are retracted and so there is a theoretical chance of damage to any of these during surgery. This includes the oesophagus, trachea, carotid artery, the spinal nerves and spinal cord. These are rare and although most patients will have the feeling of a lump in the throat for a week or two following surgery, few will experience this in the long term.

For any operation there is a risk of bleeding, infection, wound problems, anaesthetic complications and neck surgery is no different. Bleeding may present as an emergency with difficulty breathing which is why a drain is often used. Nurses are trained to pick this up and know how to respond rapidly. Infection risk is very low and wounds are commonly barely visible after a few months in most patients.

Nearly all patients have some discomfort swallowing due to the swelling but this usually settles in 2-3 weeks. Some also have a hoarse voice due to swelling of the nerves supplying the voice box but this usually will not persist. If the latter is permanent then referral to an ENT surgeon may be necessary to check the vocal cords. Implant related problems are fortunately rare but if displacement occurs then further surgery may be needed. In the case of most patients, wounds are commonly barely visible after a few months

Post-operative care

This is different for all patients but as a guideline:

Wound - normally no sutures, just paper strips or tissue glue.

Physiotherapy- the ward therapist will instruct on how to mobilise the neck but few restrictions are placed and most movements that are controlled and comfortable are allowed.

Driving - when safe and able to do an emergency stop, look in mirrors, reverse. Typically at 2-4 weeks

Work - depends on your job but commonly people return to a desk based job in two weeks and a more physical job in four weeks. No heavy tasks 2-3 months.

Information can also be found on the company website and Mr Orpen will also be able to discuss his experience with other disc replacement designs and discuss the biomechanics of the spine.

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Lumbar Microdisectomy

This commonly performed procedure is indicated in the treatment of a lumbar disc prolapse or slipped disc. Micro- refers to the use of an operating microscope which has now become a routine way of performing this procedure as it is considered safer and allows the surgeon to minimise the size of the surgical wound. Microscopes are considered routine in spinal surgery and you should discuss with your surgeon whether an operating microscope is going to be used.

Indications

Disc prolapses occur commonly but in the vast majority of cases will resolve spontaneously within 8 weeks. When this does not occur or when the disc prolapse is associated with bladder or bowel symptoms, then your surgeon will offer a micro-discectomy. An MRI will always be performed prior to surgery (please see website article on disc prolapse)

Aims of Surgery

The main aim of surgery is alleviate pain in the leg ( sciatica) and this occurs in excess of 90% of patients. Most experience immediate relief, although because the nerve is swollen, complete relief may take longer to occur and in approximately 5% of cases it may take up to 6 months to get the full benefit of surgery. If weakness or numbness is present, then this may take some time to recover and in many cases does not recover at all. Pins and needles/ paraesthesia typically does respond to surgery but may take some time to resolve.

Procedure

Prior to surgery, you will be seen in the pre-operative clinic and consent will be obtained and routine investigations including screening for MRSA. This will usually precede admission by a few days. You will be admitted to the ward on the day of surgery and will have an opportunity to discuss any concerns before you go to theatre.

The surgery involves making an incision at the level of the disc prolapse and the size of this will depend on the size of the patient. X-rays are used to confirm the level and you must inform Mr Orpen if there is any chance that you may be pregnant as x-rays in early pregnancy may affect the developing fetus. Careful blunt dissection to the spine is performed, retracting the muscle gently.

A piece of ligament and often bone is then removed to reveal the spinal nerve as it leaves the spinal canal. The nerve is gently retracted to one side and the disc prolapse identified. All loose disc material in the canal is searched for and removed. As much disc as possible remaining in the disc space is left behind (where it has a job to do), but loose fragments are always removed. Closure is with internal sutures. Local anaesthetic is placed in the skin and muscle. A small dressing is used.

The usual post-operative plan is to commence mobilisation as soon as possible with the nurses and physiotherapists on the ward and patients are usually discharged home after a day or two. Post-operative pain is usually well controlled and if you are in discomfort, the nurses will be able to use medication to keep this to a tolerable level.

Post-operative care

The ward physio-therapist will instruct on how to safely mobilise and give careful instructions on rehabilitation while on the ward. This physio-therapy may then be continued in the post-operative period if necessary.

Sutures will dissolve and do not need removing. Usually you will instructed to keep the wound as dry as possible for the first 10 days and completely dry for the first 5 days.If there are concerns about a discharge from the wound, then you should let Mr Orpen know through his secretary so that an early follow-up review can be arranged. Should there be a sudden increase in pain or worsening of symptoms then you should also let him know.

Driving: be prepared to be off driving for 4-6 weeks although many patients return to driving sooner. Essentially you should feel safe to perform an emergency stop and it is wise to practise this action in the car before recommencing driving. If you are unsure the DVLA is the best to advise and your surgeon and physio will not be in a position to sign you back onto driving.

Work: let you employer know that you may be off work up to eight weeks but you will not be stopped from returning to work sooner than this if you are feeling comfortable and would like to return. The exact time of return to full function will depend on your functional demands so it is worth discussing this prior to surgery. Heavy work is usually commenced at 3 months and desk jobs at 4 weeks. No heavy lifting or contact sports are recommended for 3 months following surgery (i.e. no straining). Normally, from 2 weeks you may swim or cycle on an exercise bike. When running, to start on a treadmill, then soft surfaces before road running.

Complications

All operations have risk attached which is why in most circumstances, non-operative measures are pursued first. At the time of consenting for surgery this will be discussed in detail. Fortunately most complications can be treated and although they are inconvenient and cause setbacks there are often no long term consequences. Total paralysis cannot occur form this type of surgery but a nerve has to be retracted and can theoretically be damaged, as can the nerves going to the bladder and bowel. Fortunately this is very rare (<0.1% cases).

Other complications include:

Bleeding, Infection, CSF leak, Recurrence

Bleeding - if significant may need further surgical exploration but this is very uncommon

Infection - often antibiotics suffice but may need a surgical washout, MRSA infections are very unlikely

Spinal fluid may leak (1%) and you may need to lie flat post-operatively, this can give a headache in the post-operative period but seldom gives longer term problems

Recurrence: 10% of people will have a recurrence over the next 10 years. This is irrespective of activity and may need further surgery sometimes needs further surgery. Due to the genetic nature of disc prolapses, further prolapses may also occur at other levels.

Scarring - some is inevitable, but sometimes the nerve becomes stuck down which is why early mobilisation is important

Back pain - sometimes post-discectomy back pain develops – especially in the big prolapses. Often physiotherapy suffices, but sometimes further surgery may be indicated.

These are the main surgical complications, but of course, any operation is a major undertaking for you and a stress on your body and so can cause cardiorespiratory, vascular, renal or gastrointestinal problems. If you have other medical conditions then this can affect the outcome of your surgery and these should all be notified to Mr Orpen, the nurses in clinic and the anaesthetist prior to your operation. Smoking is a clear cause of a poorer outcome after surgery and all efforts should be made to stop smoking prior to and when recovering from the surgery.

The aim of this is to inform and reassure. The list describes the main problems that may occur and if you have any concerns, worries or questions regarding these or others not listed then please discuss these with Mr Orpen in clinic.

Follow up

Please ensure an outpatient appointment is arranged for 4 weeks after surgery but if you feel something has occurred in the recovery period which you are concerned about, please let Mr Orpen know through his secretary. Your GP or physio-therapist may also be able to offer advice

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Spinal Nerve Root Blocks

Pain originating from a spinal nerve root is referred to as radicular pain. This pain is typically felt in the distribution of the nerve that arises from the root as it radiates away from the spine. In the lumbar spine this is typically along the course of the sciatic nerve and therefore is referred to as sciatica. It may also follow the course of the femoral nerve (femoralgia) with a subtle difference in the distribution of pain.

n the upper limbs pain is felt in a typical distribution described as brachialgia and follows the specific distribution of specific nerves extending down the shoulder or arm and may extend into the hand. In many patients numbness, tingling, pins and needles may also be felt.

Commonly the pain does not follow a typical pattern and it is the surgeon’s job to try and identify the cause of this pain, which will typically be done with a combination of clinical examination, MRI scanning and possibly also diagnostic blocks.

Nerve pain is caused by either pressure on the nerve at its origin in the spine or from the inflammatory process surrounding the pathology at the nerve root origin. This may be a disc prolapse, inflamed facet joint or cysts and a number of other processes which cause inflammation. Very rarely infection and tumours may be the cause of pain but this is very uncommon. The inflammatory process can not be visualized on scans but is the part of the process that responds to steroids or anti-inflammatory medication such as ibuprofen/ Brufen or voltarol.

Nerve root blocks are performed for two main reasons. One of these is the ability to provide diagnostic information as to the cause of pain. In situations where clinical examination and scans or x-rays do not conclusively identify the source of symptoms, a block of that nerve can assist the process. The principle is that by placing local anaesthetic around the nerve, this should block any pain originating from that nerve.

This means that while the local anaesthetic is working, the pain should improve if that nerve is responsible for the symptoms. Patients are asked to record the pain response in the early post block period and specifically to remember what the early response was.

As local anaesthetic typically lasts for 30 min- 1 hour for lignocaine which is used for cervical nerve root blocks, and for 8-12 hours (marcaine) for lumbar and thoracic nerve root blocks, it is important to recall this early response which may be easy to forget 6 weeks later.

An additional benefit for the patient is the therapeutic benefit from the steroid, which is introduced at the same time as the local anaesthetic. Steroids work simply as long working anti-inflammatories.

Whereas a tablet of ibuprofen typically lasts for 8 hours and therefore needs regular doses three times a day, a steroid injection lasts for approximately 6 weeks after one dose. An additional advantage is that by applying this locally the systemic side effects are reduced and as it is only one dose, the long-term side effects are also reduced. A disadvantage is that the onset of action of a steroid is quite slow so following an injection, the benefit may not be felt immediately.

For these reasons a typical response to a nerve root injection is a short term benefit from the local anaesthetic followed by a recurrence of the pain, although commonly reduced, and then a slow drop in pain over the course of weeks from the steroid.

Procedure:

Nerve root blocks can be performed under local anaesthetic although lumbar and thoracic blocks can be performed under sedation or general anaesthetic if a patient prefers. A very small needle is passed under x-ray control and placed next to the spinal nerve root outside the spinal canal. An x-ray contrast agent is used to confirm the position as being accurate and while this is being introduced an increase in limb pain is often described. This is not severe or concerning and may be helpful as a diagnostic response.

Immediately after the procedure the local anaesthetic can cause numbness and weakness of the affected limb, which causes a temporary limp to develop in the leg. This will make driving unsafe for this 12 hour period so plans should be arranged for getting home from hospital. A follow up appointment should be made for 2 weeks following the procedure.

Risks

This is a safe procedure but specific risks are worth considering. Infection is very rare, but a bruise in the area or a small increase in pain for a few days can occur and is not itself a worrying sign. Due to the presence of the vertebral artery in the neck, a small incidence of strokes is described following cervical nerve root blocks.

This incidence is less than 1 out of every 4000 cases. You should not drive immediately after the injection as the numbness in the limb may impair the ability to drive safely, but this will only last for the day of the procedure. You can return to work the following day.

It is very unusual to have any difficulty with micturition after a nerve root block but should this occur after hours, you should go down to the local A&E department so that you may be seen by the on call spinal team.

Approximately 60-70% of patients can avoid surgery for nerve root pain by trying a nerve root block and the risks associated with this procedure are considerably less than with surgery so should be considered as an alternative where possible.

Post operative course

Immediately after the procedure numbness is usually felt in the leg or arm and this may last up to 12 hours. This will cause a limp in the leg and weakness in the arm so will make driving or work difficult during this time. It is reasonable though to plan a regular day the day after the procedure allowing as much general rest as reasonable to allow the nerve root to settle down and benefit from the procedure. It should not be necessary to take time off work, unless in a heavy manual job.

The original pain may then return although often to a lesser extent than before the procedure. The steroid action may take up to 6 weeks to have a maximal effect. It can be useful to keep a pain diary during this time so as to accurately record the effect of the procedure, as it may be difficult to remember this later down the line.

A follow-up appointment is usually arranged for 2 weeks following the procedure.

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