Lumbar decompression surgery
Lumbar decompression surgery is a type of spinal surgery used to treat some conditions affecting the lower back (lumbar spine) that haven't responded to other treatments.
The main aim of this type of surgery is to improve problems affecting the legs, such as persistent pain and numbness, caused by pressure on the nerves in the spine. It is not a treatment specifically for back pain, although some people do have reduced pain in their lower back after surgery.
Lumbar decompression surgery is often used to treat:
spinal stenosis – where a section of the spinal column becomes narrowed and places pressure on the nerves inside
a slipped disc and sciatica – where one of the spinal discs becomes damaged and presses down on an underlying nerve
spinal injuries – such as a fracture or the swelling of tissue
metastatic spinal cord compression – where cancer in one part of the body, such as the lungs, spreads into the spine and presses on the spinal cord or nerves
What happens during lumbar decompression surgery
You will usually have at least one of the following procedures:
laminectomy – where a section of vertebrae (the lamina) is removed to relieve pressure on the affected nerve
discectomy – where a section of a damaged disc is removed to relieve pressure on a nerve
spinal fusion – where two or more vertebrae are joined together with a section of bone to stabilise and strengthen the spine
In many cases, a combination of these techniques may be used.
Lumbar decompression is normally carried out under general anaesthetic, which means you will be asleep during the procedure and won't feel any pain as it's carried out. The whole operation usually takes at least an hour, but may take much longer, depending on the complexity of the procedure.
Recovering from lumbar decompression surgery
You will usually be well enough to leave hospital about one to four days after surgery, depending on the complexity of the surgery and your level of mobility before the operation.
Most people are able to walk unassisted within a day of having the operation, although more strenuous activities will need to be avoided for around six weeks.
You may be able to return to work after about four to six weeks, although you may need more time off if your job involves driving for long periods or lifting heavy objects.
How effective is lumbar decompression surgery?
There is good evidence that decompression surgery can be an effective treatment for people with severe pain caused by compressed nerves.
Up to three in every four people who have the operation experience a significant improvement in pain. Also, people who found walking difficult before surgery because of leg pain or weakness are often able to walk further and more easily after the operation.
What are the risks?
Although lumbar decompression is often successful, like all types of surgery it carries a risk of complications.
Complications associated with lumbar decompression surgery include:
infection at the site of the operation and, in rare cases, infection elsewhere (such as a chest infection)
a blood clot developing in one of your leg veins – deep vein thrombosis (DVT), which in rare cases can dislodge and travel to the lungs, causing a serious problem called a pulmonary embolism
damage to the spinal nerves or cord – resulting in continuing symptoms, numbness or weakness in a part of one or both legs or, in rare cases, some degree of paralysis (inability to move one or more parts of the body, or control your bowel or bladder)
When lumbar surgery may be recommended
Lumbar decompression surgery is usually only considered for problems affecting the lower (lumbar) spine if non-surgical treatments have not helped.
These may include painkillers, antidepressants, physiotherapy, orcorticosteroid injections.
If these treatments have not been effective and your symptoms have a significant impact on your quality of life, lumbar decompression surgery may be recommended if you are thought to be healthy enough to withstand the effects of the anesthesia and surgery.
Some of the conditions that may require surgery are described below.
Spinal stenosis is a condition where the space around the spinal cord (the spinal column) narrows, compressing a section of nerve tissue.
The main symptoms of spinal stenosis include pain, numbness, weakness and a tingling sensation in one or both legs. This can make walking difficult and painful, although sitting down or leaning forward can offer relief in some cases.
Most cases of spinal stenosis are age related and usually occur in people over 60. As a person gets older, the bones and tissues that make up the spine can become worn down, which can lead to a narrowing of the spinal column.
Cauda equina syndrome
A rare and severe type of spinal stenosis is cauda equina syndrome.
In cauda equina syndrome, all the nerves in the lower back suddenly become severely compressed, causing a range of problems including numbness in the skin around the back passage, inability to urinate or not being able to control your bladder (urinary incontinence) and loss of bowel control (bowel incontinence).
Cauda equine syndrome requires emergency hospital admission and emergency surgery, as the longer the condition goes untreated, the greater the chance that a person will be left permanently paralysed and incontinent.
Slipped disc and sciatica
A slipped or herniated disc is when the tough coating of a disc in your spine tears, causing the jelly-like filling in the centre to squeeze out. The torn disc can press on a surrounding nerve or nerves and cause pain in parts of your legs.
This pain may be accompanied by tingling, pins and needles, numbness or even weakness in certain areas of your legs. The pain is often referred to as sciatica. The pain is sometimes worse on straining, coughing or sneezing.
The most common symptom of sciatica is pain radiating out from the lower back, down the buttocks and into one or both legs, right down to the calf. The pain can range from mild to severe.
A slipped disc can happen at any age, but is more common in people between 20 and 40 years of age. Initially minor degeneration may occur and then in some cases an awkward twist, turn or minor trauma, or even a cough or sneeze, can cause the filling in the centre of the affected disc to squeeze out.
In many people with a slipped disc, however, the exact cause is unknown.
Metastatic spinal cord compression
Cancer in one part of the body, such as the lungs, sometimes spreads into the spine and presses on the spinal cord. This is known as metastatic spinal cord compression.
Initial symptoms can include:
back pain, which may be mild at first but then usually gets worse over time; the pain is constant and is often worse at night
numbness in your toes and fingers
problems passing urine
If it's not treated, metastatic spinal cord compression is potentially very serious and can result in permanent paralysis (inability to move parts of your body, which in this case would be your legs).
For people in good enough health to withstand surgery and with a good enough outlook, metastatic spinal cord compression is best treated with surgery. However, in cases where the problems become apparent late on, many people are too ill to withstand or benefit from surgery.
Injury to your spine, such as dislocation and fractures, or the swelling of tissue can put pressure on your spinal cord or nerves.
Abnormal growths and tumours can form along your spine. These are usually not cancerous (benign), but growing tumours may compress your spinal cord and nerve roots, causing pain.
What happens during lumbar decompression surgery
If you and your consultant decide that you could benefit from lumbar decompression surgery, you will be put on a waiting list.
Your doctor or surgeon should be able to tell you how long you are likely to have to wait in your area.
Before the operation
To help you recover from your operation and reduce your risk of complications, it helps if you are as fit as possible before surgery.
As soon as you know you are going to have lumbar decompression surgery, it is advisable to stop smoking if you smoke, eat a healthy dietand take regular exercise.
You will be asked to attend a pre-operative assessment appointment a few days or weeks before your operation.
During this appointment, you may have some blood tests and a general health check to make sure that you are fit for surgery, as well as an X-ray or magnetic resonance imaging (MRI) scan of your spine.
The pre-operative assessment is a good opportunity to discuss any concerns you may have or ask any questions about your operation.
You should be told at your pre-operative assessment who will be doing your operation and you may be introduced to them. Lumbar decompression surgery is performed either by a neurosurgeon or an orthopaedic surgeon with experience in spinal surgery.
You will be admitted to hospital on the day of your operation or the day before. Your surgeon and anaesthetist will explain what will happen during your operation. This will give you the opportunity to ask any questions you may have.
Before having the operation, you will be asked to sign a consent form to confirm that you know what the operation involves and what the potential risks are.
You will not usually be allowed to eat or drink for about six hours before your operation.
During lumbar decompression surgery, you will usually lie face down on a special curved mattress to allow the surgeon better access to the affected part of your spine and reduce the pressure on your chest, abdomen and pelvis.
The operation is normally carried out under general anaesthetic, which means you will be asleep during the procedure and won't feel any pain. The whole operation usually takes at least an hour, but may take much longer, depending on the complexity of the procedure.
The aim of lumbar decompression surgery is to relieve pressure on your spinal cord or nerves while maintaining as much of the strength and flexibility of your spine as possible.
Depending on the specific reason you are having surgery, a number of different procedures may need to be carried out during your operation to achieve this.
Three of the main procedures used are:
laminectomy – where an arch of bone, known as the lamina, is removed from one of your vertebrae
discectomy – where a section of a damaged disc is removed
spinal fusion – where two or more vertebrae are joined together with a bone graft
Your surgeon will be able to provide more information on what procedures are going to be performed during your surgery.
The main procedures are described in more detail below.
A laminectomy is done to remove areas of bone or ligament that are putting pressure on your spinal cord. Ligaments are tough bands of tissue that connect one bone to another. They can put pressure on the spinal cord if they deteriorate over time.
During a laminectomy, the surgeon makes a straight incision over the affected section of the spine and down to the lamina (the bony arch of your vertebra). The ligament joining the lamina is removed so the surgeon has access to the affected compressed nerve roots. The nerve roots originate from the spinal cord and travel to the legs to supply your legs with sensation and ability to move.
The surgeon will then pull the nerve root back towards the centre of your spinal column and remove part of the bone or ligament putting pressure on your spinal nerves.
The surgeon will finish the operation by closing the incision with stitches or surgical staples.
A discectomy is performed to release the pressure on your spinal nerves caused by a bulging or slipped disc.
As with a laminectomy, the surgeon makes an incision over the affected area of your spine down to the lamina and the ligament connecting the lamina and small area of adjoining lamina are removed so the surgeon has access to the affected nerve root.
The surgeon will then gently retract the nerve away to expose the prolapsed or bulging disc, which he or she will remove just enough of to stop pressure on the nerves. Most of the disc will be left behind to keep working as a shock absorber.
The surgeon will finish the operation by closing the incision with stitches or surgical staples.
Spinal fusion is used to join two or more vertebrae together by placing an additional section of bone in the space between the vertebrae.
This helps prevent excessive movements between two adjacent vertebrae, lowering the risk of further irritation or compression of the nearby nerves and reducing pain and related symptoms.
The additional section of bone can be taken from somewhere else in your body (usually the hip) or from a donated bone and more recently, synthetic bone substitutes.
To improve the chance of fusion being successful, some surgeons may choose to use screws put into an area of the vertebrae called pedicles, which are joined together using connecting rods.
Afterwards, the surgeon will close the incision with stitches or surgical staples.
Spinal compression surgery is usually performed through a large incision in the back. This is known as 'open' surgery.
In some cases, it may be possible for it to be performed using a microscope (such as a microdiscectomy) or a 'keyhole' technique known as microendoscopic surgery.
In this case, the operation is done using a tiny camera and surgical instruments inserted through a small incision in your back. The surgeon is guided by viewing the operation on a video monitor.
Microendoscopic surgery is complicated and is not suitable for everyone. Whether it is suitable depends on the exact problem in your lower back. There is also a slightly higher risk of accidental injury during this operation than with an open operation.
Some of the techniques used during microendoscopic surgery, such as using a laser or a heated probe to burn away a section of damaged disc, are relatively new. Therefore, it is still uncertain how effective or safe they maybe in the long term.
An advantage of microendoscopic surgery is that it usually has a much shorter recovery time. In many cases, people can leave hospital the day after surgery has been completed.
Lumbar spine illustration
1. Healthy disc
2. Nerve root
3. Extruded disc protrusion
4. Disc bulge
5. Spinal nerves (cauda equina)
Interspinous distraction is a new type of lumbar surgery for spinal stenosis. This technique involves making a small incision above your spine and placing a metal device, known as a spacer, between two vertebrae so that they cannot move onto the underlying nerve.
Interspinous distraction appears to be safe in the short term, but as it is a new technique, it is uncertain how it will fare in the long-term. One possible risk is that the spacer could move out of position, requiring further surgery to correct.
Recovering from lumbar decompression surgery
When you wake up after lumbar decompression surgery, your back may feel sore and you will probably be attached to one or more tubes.
These may include:
a drip supplying fluids into a vein (intravenous drip), to make sure you do not get dehydrated
a drain to take away any fluid from your wound
a thin, flexible tube inserted into your bladder (urinary catheter), in case you have difficulty urinating
a pump to deliver painkillers directly into your veins every few hours
The tubes are usually only attached for a short time after your operation.
Immediately after surgery, you will have some pain in and around the area where the operation was carried out. You will be given pain relief to make sure you are comfortable and to help you move. The original leg pain you had before surgery usually improves immediately, but you should tell the nurses and your doctor if it doesn't.
A very small number of people have difficulty passing urine after the operation. This is usually temporary, but in rare cases complications, such as nerve damage, may cause the legs or bladder to stop working properly. It is important to tell your doctor and nurses immediately if you have problems.
It can take up to six weeks for the general pain and tiredness after your operation to completely go away.
You will have stitches or staples to close any cuts or incisions made during your operation. Deep stitches beneath the skin will dissolve and do not need removing. If dissolvable stiches are used they do not need to be removed.
Non-dissolvable stitches or staples will be removed five to 10 days after your operation. Before you leave hospital, you will be given an appointment to have your stitches removed.
Your stitches may be covered by a simple adhesive dressing, like a large plaster. When you wash, be careful not to get your dressing wet. After having your stitches out, you will not need a dressing and will be able to bath and shower as normal.
Your medical team will want you to get up and move about as soon as possible, usually from the day after the operation. This is because inactivity can increase your risk of deep vein thrombosis (DVT) and movement can help speed up the recovery process.
After your operation, a physiotherapist will monitor your specific needs and help you safely regain strength and movement. They will also teach you some simple exercises you can do at home to help you stay active during your recovery.
You will usually be able to go home about one to four days after your operation. How long you have to spend in hospital depends on the specific type of surgery you had and your general health.
When you get home, it's important to take things easy at first, gradually increasing your level of activity every day. Some help at home is usually needed for at least the first week after surgery.
Being active will help speed up your recovery. You should make sure you do the exercises your physiotherapist recommended and try not to sit or stand in the same position for more than 15-20 minutes at a time because this can make you feel stiff and sore.
Walking is a good way to keep active, but you should avoid heavy lifting, awkward twisting and leaning when you do everyday tasks until you are feeling better.
You may be asked to return to hospital for one or more follow-up appointments in the weeks after your operation to check how you are doing.
When you can go back to work depends on how you heal after surgery and the type of job you do.
Most people return after four to six weeks if their job is not too strenuous. If your job involves a lot of driving, lifting heavy items or other strenuous activities, you may need to be off work for up to 12 weeks.
Before starting to drive again, you should be free from the effects of any painkillers that may make you drowsy.
You should be comfortable in the driving position and able to fully control your car, including being able to do an emergency stop without experiencing any pain (you can practise this without starting your car).
Most people feel ready to drive after two to six weeks, depending on the size of the operation.
Some insurance companies do not insure drivers for a number of weeks after surgery, so check what your policy says before you start to drive.
When to seek medical advice
Call the hospital where you had your operation or your GP for advice if:
there is leaking fluid or redness at the site of your wound
your stitches come out
your dressing becomes soaked with blood
you have a high temperature (fever) of 38°C (100.4°F) or above
you have increasing pain, numbness or weakness in your legs, back or buttocks
you cannot move your legs
you cannot urinate or control your bladder
you have a severe headache
you experience a sudden shortness of breath (this could be a sign of pulmonary embolism, pneumonia or other heart and lung problems)
Risks of lumbar decompression surgery
Like all surgical procedures, lumbar decompression surgery carries some risk of complications.
Some of the main complications associated with lumbar decompression surgery are described below.
One of the most common complications is an infection where the incision was made, which is estimated to occur in up to one in every 25 people who have lumbar decompression surgery.
In most cases, post-operative infections can be treated successfully with antibiotics.
There is a risk you could develop a blood clot after lumbar decompression surgery, particularly in your leg. This is known as deep vein thrombosis (DVT).
DVT can cause pain and swelling in your leg and may lead to a serious problem called a pulmonary embolism in rare cases. This is when a piece of the blood clot breaks off and blocks one of the blood vessels in the lungs.
However, the risk of developing a blood clot can be reduced significantly by staying active during your recovery or wearing compression stockings to help improve your blood flow.
Recurrent or continuing symptoms
Although lumbar decompression surgery is generally effective in relieving symptoms such as leg pain and numbness, up to one in every three people continue to have symptoms after surgery or develop symptoms again within a few years of surgery.
Recurrent symptoms can be caused by a weakened spine, another slipped disc, or formation of new bone or thickened ligament putting pressure on your spinal cord. Scarring around the nerves can also sometimes develop after surgery, which can cause similar symptoms to nerve compression.
Other treatments, such as physiotherapy, will usually be tried in the first instance if your symptoms recur, but further surgery may be needed in some cases. Repeat operations, however, have a higher risk of complications than first-time operations.
Unfortunately, there is no effective treatment for scarring around the nerves. However, you can reduce your risk of scarring by doing regular exercises as advised by your physiotherapist after surgery.
Dural tear and leakage of cerebrospinal fluid
During lumbar decompression surgery, there is a risk of accidental damage to spinal nerve lining (dura), which can lead to the leakage of cerebrospinal fluid (CSF).
If this is discovered during the operation it will be patched and repaired at the time with no serious problems. However, small leaks can sometimes only become apparent after the operation, causing problems such as a headache and leaking from the wound. In some of these cases, further surgery to repair this may be required.
Facial sores and blindness
As you are positioned face down for lumbar decompression surgery, you will be resting on your forehead and chin while the operation is performed.
The anesthetist will regularly check to make sure this isn’t causing any problems, but many people will wake up with slightly puffed up face which varies in severity. In some cases, a red sore can develop over the forehead or chin which could last several days.
In extremely rare circumstances (about one in every 30,000 cases), patients can slip during the operation and rest on their eye balls rather than forehead and chin, which could affect circulation to the eyes leading to partial or even complete, permanent blindness.
Nerve injury and paralysis
Around one in every 20-100 people who has lumbar decompression surgery will develop new numbness or weakness in part of one or both legs as a result of the operation.
Paralysis is an uncommon but serious complication that can occur as a result of lumbar decompression surgery. It's estimated to occur in less than one in every 300 operations.
Nerve injuries and paralysis can be caused by a number of different problems, including:
bleeding inside the spinal column (extradural spinal haematoma)
leaking of spinal fluid (incidental durotomy)
accidental damage to the blood vessels that supply the spinal cord with blood
accidental damage to the nerves when they are retracted during surgery
Paralysis caused by lumbar decompression surgery usually means you are no longer able to use your legs, you lose sensation in the lower half of your body and you lose bladder and bowel control (urinary incontinence and bowel incontinence).
If paralysis is the result of bleeding inside the spinal column or leaking of spinal fluid, it may be possible to reverse the problem with further surgery.
However, in cases where the blood vessels supplying the spinal cord are damaged, the paralysis is likely to be permanent.
As with all types of surgery, there is a risk of dying during or following lumbar decompression surgery, although this is rare. A blood clot, bad reaction to anaesthetic and blood loss can all be life threatening.
The British Association of Spinal Surgeons estimates there is around one death for every 350 operations carried out to treat spinal stenosis and one death for every 700 operations carried out to treat a slipped disc.
The risk of death is higher for spinal stenosis as most people with the condition tend to be older and in poorer health than people with a slipped disc.
Lumbar decompression surgery