Lumbar Discectomy Periprocedural Care

Updated: Sep 22, 2015
  • Author: Lawrence S Chin, MD, FACS; Chief Editor: Jorge E Alvernia, MD  more...
  • Print
Periprocedural Care

Equipment

Standard lumbar discectomy equipment includes self-retaining retractors, high-speed handheld drills, Kerrison and Leksell rongeurs, pituitary rongeurs, and various straight and angled curettes. Surgical loupes and an operating microscope help in visualization and improved illumination. Intraoperative use of the C arm is important for localization of the desired spinal level.

Next:

Patient Preparation

Anesthesia

In most cases, the discectomy is performed under general endotracheal anesthesia. Regional anesthetic techniques such as spinal epidural block can also be used for lumbar discectomy, but local anesthesia is not advised.

Positioning

The patient is anesthetized in the supine position and then turned into the prone position on the Jackson table or other suitable operating table with the Wilson frame, which helps open the interlaminar space and improves access to the disc. The endotracheal tube must be firmly secured and the eyes appropriately lubricated and eyelids closed and protected before turning the patient into the prone position.

The patient’s chin is inspected to ensure it is free from compression, and the breasts are medially displaced to prevent pressure on the nipples. The groin, anterior superior iliac spine and knees are appropriately padded with the abdomen resting as free as possible to prevent venous compression, which can lead to worsened intraoperative bleeding.

Lower-extremity pulses should be checked to ensure that the abdominal aorta and femoral arteries are not compressed. A padded roll is placed under the ankles so the knees are bent and feet suspended. The upper extremities should be positioned with the shoulder abducted to about 45° and elbow flexed to about 90°. The elbows should be supported with adequate foam padding to prevent nerve compression, mainly of the ulnar nerve, which lies subcutaneously at this level.

Previous
Next:

Monitoring & Follow-up

Patients can experience more pain in the immediate postoperative period than in their preoperative state, mainly owing to paraspinal muscle stripping. For this reason, patients are continued on their preoperative pain regimen. Some patients require supplemental pain medications to cover the postoperative period. Pain control usually involves a combination of narcotic analgesics, nonsteroidal anti-inflammatory drugs (NSAIDs), and muscle relaxants. Inadequate postoperative pain control can be counterproductive, since it may limit the patient’s physical activity and involvement in physical therapy programs.

Patients are typically discharged home the next morning or sometimes the same day and are allowed to do activities as tolerated with only a few limitations. They are encouraged to ambulate as soon as the postoperative pain can be tolerated but must avoid heavy lifting (no more than 10-15 pounds) and strenuous physical activity for a variable period, which is determined by the surgeon.

Patients with sedentary work can resume their work in 1-2 weeks, while patients with more physically demanding jobs may have to wait longer before resuming work. At one-month follow-up, physical restrictions are lifted, and patients are encouraged to gradually increase their physical activity, as tolerated, to normal. Light aerobic activities and walking are encouraged to prevent general complications such as deep venous thrombosis and pneumonia and to reduce local muscle spasm.

Further treatment such as physical therapy or rehabilitation may be recommended after lumbar discectomy. Some evidence has shown faster pain relief and disability when the exercise programs were started at 4-6 weeks postsurgery as compared to no treatment. Similarly, higher-intensity exercise programs were shown to be more helpful for earlier pain relief and improvement in disability than low-intensity programs. [17]

Previous