Microdiscectomy
- Microdiscectomy is performed under general anasthesia
- The patient will be in a prone position during surgery
- The surgeon will use an operating microscope
- After deep dissection, the correct disc space is confirmed with x-ray. Once confirmed, the ligamentum flavum and lamina are dissected to expose the nerve root. The opening in one lamina is termed semihemilaminectomy.
- When the nerve root is identified, all ligaments obstructing the view of the disc and nerve roots are cleared away. The nerve root structures are able to be moved medially using a nerve root retractor
- Usually the disc is excised and disc fragments carefully removed
- The wound area is then irrigated and the wound is closed
- Only a small incision is made in microdiscectomy permitting minimal blood loss
- This type of surgery can lead to faster recovery time and improved patient outcomes
Please press the picture link below to access images demonstrating microdiscectomy
Open Discectomy
Minimally Invasive Discectomy
The picture below illistrates the use of the tubular retractor.
- Open discectomy is the same procedure as microdiscectomy, except the surgeon does not use an operative microscope. Thus, a larger incision is required (Strayer 2005).
Minimally Invasive Discectomy
- This technique involves the discectomy to be performed through a very small incision with minimal disruption to adjacent tissues
- It is usually performed as an outpatient or overnight stay
- The surgeon uses a tubular retractor system or operating microscope
- The tubular retractor is placed through a small incision and deep dissection and the surgery is performed through this tubular retractor
The picture below illistrates the use of the tubular retractor.
Postoperative nursing care of discectomy patient
Postoperative nursing management of the discectomy patient includes regular observation, pain management, early ambulation and patient education (Brown and Edwards 2005). Nursing staff must also follow the postoperative orders from the neurosurgical team.
BASIC OVERVIEW OF CARE
OBSERVATION
A baseline set of observations should be performed on the patients arrival to the ward and throughout their stay in hospital as per protocol. These observations include:
PAIN MANAGEMENT
Acute unrelieved pain may lead to stress, anxiety and fear, impacting on the patients recovery. Immobility related to pain may lead to poor venous return and deep vein thrombosis and the possibility of pulmonary embolism and hypoxaemia. Pain relief is very important for postoperative discectomy patient, as with other post operative patients. Implementing effective pain control methods includes regular pain assessment and pharmacological management as well as the use of non-pharmacological measures. Nursing staff need to make sure the patient has adequate pain relief charted by the doctor. Nursing staff also need to encourage patients to take pain relief regularly to prevent pain from becoming too severe. Inform the patient of side effects of medications (Brown & Edwards 2005).
Pain relief that might be prescribed includes:
Non-pharmacological methods of pain relief may include:
URINARY RETENTION AND CONSTIPATION
The postoperative discectomy patient is at risk for constipation due to swelling and pain around the surgical area; decreased physical activity; lack of privacy; and due to the use of narcotic analgesia. Nursing staff need to administer eperients and educate the patient regarding becoming constipated postoperatively (Doenges et al 2006). Nurses must also be aware that the patient may be at risk for urinary retention. This may be caused by a variety of reasons; anasthesia depresses the nervous system, including the micturition reflex arc and the higher centres that influence it. This causes the bladder to need to fill more completely before the urge to void is felt. Anasthesia also impedes voluntary mictruition. Voiding ability is however probably impaired to the greatest extent by immobility (Brown & Edwards 2005).
MOBILITY
Discectomy patients should mobilise on arrival to the ward, unless ordered differently due to complication eg. dura tear and subsequent CSF leak. The patient should be educated about mobilisation techniques eg; when moving out of the bed the patient should be instructed to roll on his/her side and slowly bring the legs over the side of the bed while simultaneously rising up from the torso. This technique minimizes twisting at the waist; minimising pain and stress on the lumbar. Additionally, when standing the patient must use their legs to rise and not push off with the back (Strayer 2006).
Postoperative exercise programs designed to strengthen the back and abdominal muscles have been shown to bring about significant improvements in spinal function; including improvements in pain and disability (Dolan et al 2000).
DISCHARGE PLANNING
The nurse will need to reinforce to the patient a few strategies for caring for their back and themselves post discharge, these may include:
BASIC OVERVIEW OF CARE
- Observations: neurovascular, vitals, pain and PCA (if the patient has PCA), wound observations.
- Pain management: Administer regular analgesic medication. Encourage the use of PCA and nurse administered analgesia.
- Monitor urine output: potential for retention post op.
- Monitor bowels: administer eperients as needed
- Mobility: Assist the patient when ambulating if necessary, encourage to mobilise as per post operative instructions.
- Discharge: Make sure patient is aware of strategies to care for their back.
OBSERVATION
A baseline set of observations should be performed on the patients arrival to the ward and throughout their stay in hospital as per protocol. These observations include:
- Neurovascular assessment:
- Vital observations:
- Pain observation:
- Surgical wound observation:
PAIN MANAGEMENT
Acute unrelieved pain may lead to stress, anxiety and fear, impacting on the patients recovery. Immobility related to pain may lead to poor venous return and deep vein thrombosis and the possibility of pulmonary embolism and hypoxaemia. Pain relief is very important for postoperative discectomy patient, as with other post operative patients. Implementing effective pain control methods includes regular pain assessment and pharmacological management as well as the use of non-pharmacological measures. Nursing staff need to make sure the patient has adequate pain relief charted by the doctor. Nursing staff also need to encourage patients to take pain relief regularly to prevent pain from becoming too severe. Inform the patient of side effects of medications (Brown & Edwards 2005).
Pain relief that might be prescribed includes:
- Codeine phosphate
- Oxycodone
- Neuropathic pain medications including gabapentin
- Regular paracetemol
Non-pharmacological methods of pain relief may include:
- Heat packs for spasm or muscular tension
- Ice packs (for no more than 20minutes per hour)
- Position changes regularly
- Gentle massage away from the incision site
URINARY RETENTION AND CONSTIPATION
The postoperative discectomy patient is at risk for constipation due to swelling and pain around the surgical area; decreased physical activity; lack of privacy; and due to the use of narcotic analgesia. Nursing staff need to administer eperients and educate the patient regarding becoming constipated postoperatively (Doenges et al 2006). Nurses must also be aware that the patient may be at risk for urinary retention. This may be caused by a variety of reasons; anasthesia depresses the nervous system, including the micturition reflex arc and the higher centres that influence it. This causes the bladder to need to fill more completely before the urge to void is felt. Anasthesia also impedes voluntary mictruition. Voiding ability is however probably impaired to the greatest extent by immobility (Brown & Edwards 2005).
MOBILITY
Discectomy patients should mobilise on arrival to the ward, unless ordered differently due to complication eg. dura tear and subsequent CSF leak. The patient should be educated about mobilisation techniques eg; when moving out of the bed the patient should be instructed to roll on his/her side and slowly bring the legs over the side of the bed while simultaneously rising up from the torso. This technique minimizes twisting at the waist; minimising pain and stress on the lumbar. Additionally, when standing the patient must use their legs to rise and not push off with the back (Strayer 2006).
Postoperative exercise programs designed to strengthen the back and abdominal muscles have been shown to bring about significant improvements in spinal function; including improvements in pain and disability (Dolan et al 2000).
DISCHARGE PLANNING
The nurse will need to reinforce to the patient a few strategies for caring for their back and themselves post discharge, these may include:
- Reinforce no lifting, bending twisting
- No sitting for extended periods
- Patient must change positions frequently
- Remind the patient not to drive while taking analgesic medications as they may cause drowsiness
- Sexual activity may be resumed 2 weeks postoperatively
- The surgical team should inform the patient of appropriate return to work recommendations
- Nursing staff will need to work with allied health teams to ensure the patient will be able to cope on return home. The patient should be able to make alternate arrangements in regards to everyday living activities including vacumming and laundry. Services including child care should be made available to patients who may not have support systems available to assist postoperatively.
- Assess the patients need for rehabilitation or outpatient physiotherapy
- The patient should be discharged with adequate analgesia eg, oxycodone