Discectomy 椎間盤切除術

Dr. Adrian Leung > Discectomy 椎間盤切除術

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Background 背景

When the intervertebral disc prolapsed, it will occupy the space for nerve (intraspinal canal) and might pinch on the transiting nerves. Neuropathic pain, weakness and numbness over the legs might be resulted.
The surgery aims at removing the prolapsed disc. It will decompress the pinched nerve and provide the best environment for it to recover. Least, the neurological deficit would not deteriorate.
In order to create enough space for nerve and gain access. Removing part of the overlying bone (laminotomy) and bone spur of the small joint (medial facetectomy) might be performed concurrently.

There are 3 different ways of performing it.

  • Endoscopic discectomy.

Full endoscopic procedure, with a small wound of 8mm, done under sedation. Least invasive, but most expensive.

  • Microdiscectomy

A minimal invasive surgical procedure done under microscope through a tubular retractor. The small incision of 22mm made discharge possible within 24 hours.

  • Standard discectomy

A time honoured surgery will most clear exposure. It is best indicated for deformed spine as well for cases with multiple levels involvement.

當椎間盤突出或脫出時，它將佔據神經通過的空間（椎管），並可能壓傷神經。可能導致腿部有神經性疼痛（坐骨神經痛），乏力和麻痺。
手術旨在移除脫出的椎間盤。它將鬆解被壓的神經，並為其提供最佳的康復環境。即使未必能夠逆轉已壓壞的神經，至少，神經功能缺損不會惡化。
為了給神經創造足夠的空間，可能同時把椎板骨作部份切除（椎板做孔術）和把小關節的骨刺移除（內側小關節切除術）。

有3種不同的手術施行方式。

  • 內窺鏡椎間盤切除術。

病人在鎮靜下進行全內窺鏡手術，傷口直徑只為8mm。入侵性最小，但費用最昂貴。

  • 顯微椎盤切除術

在顯微鏡下通過管狀牽開器進行的微創手術程序，只需22mm的小切口。病人可在24小時內排出。

  • 標準椎間盤切除術

傳統手術是3種方式中的黃金標準。因切口較長，所以最能夠清楚地暴露患處。對於脊柱變形以及多椎間同時發病的病例最好適合。

Microdiscectomy 椎間盤切除術
discectomy 椎間盤切除術
Endoscopic discectomy 內視鏡椎間盤切除術

Indication 適應症

  • Discogenic Back Pain 椎間盤源性腰痛
  • Sciatica due to prolapsed disc 因椎間盤引起的坐骨神經痛
  • Lumbar Radiculopathy 腰神經根病變
  • Spinal Stenosis 椎管狹窄

Preparation 預備

  • Pre-op workup 手術前身體檢查
  • Walking >10000 steps a day 堅持每天1萬步強化背及腿肌
  • Do more deep breath 多深呼吸
  • Continue usual medication on operative day 手術當天照常食藥
  • No food or drink for 6 hours 手術前6小時禁食及禁喝水
  • Admit to hospital 3 hours before surgery  手術前3小時到醫院
  • Inform your relative despite surgery takes less than 2 hours, you will return no earlier than 3 hours. 通知家人即使手術只需2小時，但回病房可能是3小時後

Risk 風險

While all medical and nursing professionals endeavor to provide best and safest practice, complications still would occur.

General operative risks including heart attack, stroke, wound infection, wound hemorrhage, urinary tract infection, deep vein thrombosis, etc, is possibly encountered.

Dural tear (with need of staying in bed for 2 days and additional procedure) is not uncommon but seldom has consequence.
Single nerve root injury is rarely occurred risk.

Other rare complications include major neurological deficit, abdominal viscera injury, major vascular puncture, wrong level surgery have been reported. Risk is higher for older patients, more significant compression on nerve, and more prolonged compression period. Anatomical variants also carry more risk.

Same level recurrence is around 10%, which should be counted as natural course rather than complication.

儘管醫生和護士都會盡最大努力提供最佳和最安全的治療，但併發症仍會發生。

一般手術可能會遇到的風險，包括心臟病發作，中風，傷口感染，傷口出血，尿道感染，深層靜脈血栓形成等，這手術也不例外。

硬膜穿破可致腦脊液滲漏，雖並不罕見，但少有後遺症。但需要臥床休息2天甚或需進行附加手術。

單根神經根損傷是很少遇上的風險。其他罕見的併發症包括嚴重的神經功能缺損，腹部內臟損傷，腹部血管穿刺，錯誤腰椎位。

老年患者的風險更高。神經受壓更嚴重或受壓時間較長的患者，或先天結構異常也會有更高的風險。

同位復發大概為10%，但這屬疾病的自然進程，不屬併發症。

Budget Estimation 預算費用

CPT code and RVU is as follows

  • 63030 Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; 1 interspace, lumbar, RVU 13.18
  • 62380 endoscopic diskectomy, RVU — (not covered)

CPT碼和RVU如下

  • 63030 椎板切除術，伴神經根減壓，包括部分小關節切除術，椎間孔切開術和/或椎間盤切除術； 1個腰椎間，RVU 13.18
  • 62380內窺鏡下椎間盤切除術，RVU-（未涵蓋）

Estimation based on general ward as in Aug-2020,

  • Surgeon fee $52,720
  • Anaesthetist fee $17,573
  • Ward round $1,200/day
  • Hospital charge $60,000

Total $130,293 around

根據普通房於2020年8月進行的估算，

  • 外科醫生費$52,720
  • 麻醉師費$17,573
  • 巡房費$1,200
  • 醫院費$60,000
  • 總計$ 130,293　左右
Operating microscope 顯微手術切除突出椎間盤
Operating microscope 顯微手術切除突出椎間盤

Reference figures from private hospitals　醫院提供的參考數據

St Paul’s Hospital 聖保祿醫院

Median Charge 收費中位數

  • Doctors’ fee 醫生費 $82,800
  • Hospital charge 醫院收費 $59,942
  • Total 總費 $142,742

Reference website

Cannosa Hospital 嘉諾撒醫院

Median Charge 收費中位數

  • Doctors’ fee 醫生費 $65,000
  • Hospital charge 醫院收費 $39,138
  • Total 總費 $104,138

Reference website

Baptist Hospital 浸會醫院

Median Charge 收費中位數

  • Doctors’ fee 醫生費 $107,600
  • Hospital charge 醫院收費 $58,671
  • Total 總費 $166,271

Reference website

Adventist Hospital 港安醫院

Median Charge 收費中位數

  • Doctors’ fee 醫生費 $86,000
  • Hospital charge 醫院收費 $82,768
  • Total 總費 $168,768

Reference website

Post-op care 術後照顧

  • Control inflammation with regular usage of anti-inflammatory drug.
  • The wound is covered by a waterproof dressing. You can shower, but do not take bath or rub on it. Keep the dressing intact, there is no need to change it regularly.
  • You can sleep on your back, your stomach or your side. But when you roll in bed, try not to twist your body but do it as “log roll”.
  • Walking and standing are encouraged. Restrict sitting within 10 minutes. Avoid bending forward.
  • Pay attention to ergonomics.
  • If need, wear a cable-fastening lumbar corset for short term.
  • A small prominent over the wound is expected. It would be flattened when muscle tone returns.
MRI finding　磁力共震影像
Intra-op X-ray 術間實時X光顯影
  • 定時服藥，控制發炎
  • 傷口已用防水敷料覆蓋。所以您可以淋浴，但不要浸澡或捽這敷料。你只需保持敷料完整，無需定期更換它。
  • 您可以仰臥，腹臥或側睡。但當您在床上轉身時，請盡量不要扭腰，而應像“木頭人滾動”一樣轉身。
  • 多步行和站立。盡量少坐。並避免向前彎腰。
  • 日常注意活動姿勢。
  • 如有需要，可短暫穿戴索帶拉緊式束腰衣。
  • 傷口上會比較突出。當背肌張力恢復時，它將自然變平。

Early Post-op Complication　手術後早期併發症

Notify surgeon in case you have

  • Persistent fever of more than 37.5 Celcius
  • Chills and rigor
  • Wound pain despite rest
  • Wound redness and swelling
  • Purulent discharge from wound
  • Calf pain
  • Ankle swelling, progressive
  • Sudden onset of shortness of breath
  • Chest pain

如發現以下情況，要立即通知醫生

  • 持續高燒（口探高於攝氏37.5度）
  • 發冷打顫
  • 無論運動或休息時，傷口痛楚都持續增加
  • 傷口持續發紅腫脹
  • 傷口有膿液
  • 小腿愈見痛楚
  • 小腿、腳踝和腿部腫脹持續增加
  • 突發性的氣促
  • 胸口突然疼痛
removed prolapsed intervertebral disc 移除的突出椎間盤
removed prolapsed intervertebral disc 移除的突出椎間盤
Microdiscectomy versus standard discectomy wound 微創及傳統椎間盤切除手術傷口比較
Microdiscectomy versus standard discectomy wound 微創及傳統椎間盤切除手術傷口比較

Rehabilitation after Day 14 手術後2週復健

Exercise of abdominal and back muscles:

  1. Lower Abds contraction:
    Lie on your back, tighten your lower abdominal muscles, just like a still sit-up, count 5 seconds, and then relax. Rest for 10 seconds and repeat 10 times.
  2. Glute bridge:
    Lie on your back, bent your knees, tighten your lower abdomen and buttocks, and maintain plank. Use your hind thigh to lift your buttocks 2 inches off the ground for 5 seconds, then relax for 10 seconds and repeat 10 times.
  3. Bird-Dog plank:
    Support with hands and knees, tighten the lower abdomen, maintain plank, leave the left hand and right knee off the ground, supported by the right hand and left knee, count for 5 seconds, then regain 4-limb support and relax for 10 seconds, repeat for the opposite side, repeat the whole set for 10 times.

Sciatic nerve Differential gliding exercise:

  1. Unilateral tuck
    Lie on your back and bend your knee and bring it to the opposite chest for 5 seconds, then relax. Rest for 10 seconds. Repeat on the opposite side, repeat the whole set of exercises 10 times.
  2. Cross leg tuck
    Lie on your back, bend your left knee and cross your leg, hold the right knee to the right chest with both hands, count 5 seconds, and then relax. Rest for 10 seconds. Repeat in the contralateral side. Repeat the whole set of exercises 10 times.
  3. Straight leg stretch
    Lie on your back and straighten your left knee, bend your hips to 90 degrees, count 5 seconds, and then relax. Put it down and rest for 10 seconds. Repeat in the contralateral side, repeat the whole set of exercises 10 times.

Caution on low back care:

  • Do not stretch, twist, or bend your back suddenly to avoid spraining your back.
  • When brushing your teeth or washing your face, bend your knees slightly, do not bend over, and support your upper body with your hands on the washing basin.
  • When wearing shoes, you should sit or wear them while crossing the leg, or ask others to help. Or get a sneaker.
  • You can sit in the office for a long hours in 4 to 6 weeks after the operation, and do manual lifting no earlier than 3 to 4 months.
  • Increase the amount of activity gradually and avoid strenuous exercise, especially running and jumping.
  • Sex life can start at 6 weeks after surgery.
  • Avoid excessive back fatigue within one year.

腹肌、背肌的運動:

  1. 腹部收縮運動
    仰躺，緊縮下腹肌肉，就像靜止的仰卧起坐，數5秒，然後放鬆。休息10秒，重複10次。
  2. 拱橋運動：
    仰躺，曲膝，緊縮下腹及臀部，維持平板，後腿發力抬高臀部離地2吋，數5秒，然後放鬆10秒，重複10次。
  3. 狗式平板：
    手腳四肢支持狗式站，緊縮下腹，維持平板，左手右腿離地，由右手左腿支撐，數5秒，然後四肢支持及放鬆10秒，重複對側，整套運動重複10次。

坐骨神經伸展運動：

  1. 單側抱膝
    仰躺屈膝，兩手合抱膝部帶動到對側胸口，數5秒，然後放鬆。休息10秒。重複對側，整套運動重複10次。
  2. 蹺腿抱膝
    仰躺屈膝蹺腿，兩手合抱對側膝部帶動到對側胸口，數5秒，然後放鬆。休息10秒。重複對側，整套運動重複10次。
  3. 直腿伸展
    仰躺直膝，曲髖關節到90 度，數5秒，然後放鬆。休息10秒。重複對側，整套運動重複10次。

留意腰背保健：

  • 不可突然伸張、扭轉、彎曲背部，以免扭傷腰部。
  • 刷牙洗臉時，膝微彎，勿彎腰，上身以手支撐。
  • 穿鞋時宜坐著或蹺腳穿，或請別人幫忙穿。
  • 手術後4到6周可長坐辦公室工作，3到4個月後才可做體力勞動工作。
  • 漸進式增加活動量，避免劇烈運動，尤其是跑步跳躍。
  • 性生活手術後6周可恢復。
  • 一年內避免背部過度疲累。

Reference 參考文獻

  1. Jacobs WC, Van tulder M, Arts M, et al. Surgery versus conservative management of sciatica due to a lumbar herniated disc: a systematic review. Eur Spine J. 2011;20(4):513-22
  2. Dohrmann GJ, Mansour N. Long-Term Results of Various Operations for Lumbar Disc Herniation: Analysis of over 39,000 Patients. Med Princ Pract. 2015;24(3):285-90.
  3. Abraham P, Rennert RC, Martin JR, et al. The role of surgery for treatment of low back pain: insights from the randomized controlled Spine Patient Outcomes Research Trials. Surg Neurol Int. 2016;7:38
  4. Desai A, Bekelis K, Ball PA, Lurie J, Mirza SK, Tosteson TD, et al. Spine patient outcomes research trial: Do outcomes vary across centers for surgery for lumbar disc herniation? Neurosurgery. 2012;71:833–42.
  5. Weinstein MA, McCabe JP, Camissa FP Jr: Postoperative spinal wound infection: a review of 2,391 consecutive index procedures. J Spinal Disord 13:422 426, 2000
  6. Serdal Albayrakd et al. Dural Tear: A Feared Complication of Lumbar Discectomy. http://www.turkishneurosurgery.org.tr/pdf/JTNEPUB_14065_online.pdf