The aim of this operation is to relieve the acute leg pain that is caused when a prolapsed disc traps a nerve. It is done under general anaesthetic through a 2 to 3cm (about 1 inch) incision and takes about 1 hour. Potential complications include a leak of the fluid (CSF) that surrounds the brain and spinal cord – around 5% - and damage to the nerve you are trying to “untrap” – less than 1%. Most patients have a significant improvement in, and often complete resolution of, their leg pain, and the vast majority go home the day after surgery.
I have carried out approximately 100 primary procedures and 7 revisions. Of my own primary operations there have been 3 recurrent disc prolapses requiring surgery, a rate that compares very favourably with large published series from centres of excellence. So far I have had only 1 CSF leak and no other complications. Almost all patients went home the day after surgery but recently this operation has been done successfully as a day case.
Lumbar spinal decompression
The purpose of this operation is to enlarge the space for the nerves in the lumbar spine, with the main aim being to prevent walking induced leg pain, numbness and weakness, and so improve walking ability. It is done under general anaesthetic, and the length of incision (and of the operation) depends on the number of levels that have to be decompressed. Complications are similar to microdiscectomy, although CSF leak is more common. Patients are usually up and about the day following surgery, and generally go home after 2 or 3 days. Success rate is about 90% in terms of significant relief of symptoms.
I have carried out over 100 lumbar decompressions on the Isle of Man, including a number of revisions. Aside from one patient who developed a chest infection post operatively the only complications have been minor CSF leaks in about 10% of patients, with no long term problems.
This operation involves removing one or more of the discs in the neck, through an incision on the front of the neck, with the aim of decompressing a trapped nerve that is causing arm pain, or decompressing the whole spinal cord to relieve symptoms caused by generalised cord compression. After the disc has been removed and the nerve freed, either a spacer device or bone graft is placed in the disc space, and sometimes a plate is used to stabilise the spine. The operation is done under general anaesthetic and takes about 2 hours. The most important risk of this surgery is paralysis caused by spinal cord damage. This risk is probably less than 1 in 1000 in most cases, but is higher in older patients and in cases of spinal cord compression. Most patients go home the day after surgery, and wear a firm collar for a few weeks.
So far on the island I've operated on about 20 patients, one at two levels, with most being discharged home the day after surgery. There have been no neurological complications. I no longer carry out this surgery, instead referring to Walton hospital, as the low numbers of cases made it difficult to maintain my skill in the procedure.
Lumbar Spinal Fusion
Fusion is carried out for a variety of reasons. It can be used in trauma, as a surgical treatment for back pain or as an adjunct to spinal decompression in certain cases. Personally I carry out very few fusions as I do not believe it to be a good operation for back pain. I occasionally use it along with a spinal decompression in cases of spondylolisthesis.
I've done about 10 spinal fusions for various reasons at Noble's Hospital. There were no immediate complications, and long term outcomes generally good in cases of spondylolisthesis.
Nerve root block
Some disc prolapses can be treated with a steroid injection placed alongside the trapped nerve. These injections are done in the operating theatre or the radiology department using local anaesthetic and X-ray control to guide the needle into the correct position. The injection can give temporary relief from the symptoms of a trapped nerve, and the hope is that the relief lasts long enough for the disc prolapse to resolve naturally. It is generally done as a daycase procedure.
In my first 2 years of consultant practice 59 patients have had a nerve root block, with no complications. Of these 68% required only a single injection to give a satisfactory result, 14% required a second injection, 1 patient had a third, and 17% went on to have surgery. The current total is well over 100 injections, with very few complications - 1 patient required readmission with a headache, possibly due to a reaction to the injection. These are now carried out in the XR department by Dr Dashfield
Facet Joint Injections
Some patients with back pain are referred to the radiology department or the pain clinic for pain relieving injections into the small joints at the back of the spine. Two or more injections are carried out using fine needles under X-ray control. This does not require general anaesthetic or sedation and patients go home straight away afterwards. Our audited results show that about 50% of people we refer for facet injections have significant pain relief for longer than 3 months after injection.
There is now a pain clinic on the Isle of Man - see the links page. Pain clinic can be helpful for many patients, particularly those with chronic symptoms, or with conditions for which surgery is not an option. I will often refer patients to the pain clinic for a consultation or for injection based treatments.