TUGAS PRESENTASI KASUS FRAKTUR LUMBAL

IRENE FAUSTA WIJONO / 406152029 / FK UNTAR 9 Januari 18 Maret 2017

Decompression is a surgical procedure that is performed to alleviate pain caused

by pinched nerves (neural impingement). During a lumbar decompression back surgery, a
small portion of the bone over the nerve root and/or disc material from under the nerve
root is removed to give the nerve root more space and provide a better healing
environment. There are two common types of spine surgery decompression procedures:

1. A microdiscectomy (a microdecompression) is typically performed for pain from a

lumbar herniated disc. The surgery is considered reliable for leg pain caused by the
herniated disc, most commonly called sciatica by patients, and most commonly referred to
by medical practitioners as a radiculopathy.

2. A lumbar laminectomy (open decompression) is typically performed for pain from

lumbar spinal stenosis. The goal of the surgery is to allow more room for the nerve root,
thus reducing pain (and potentially any leg weakness or neurological symptoms) and
restoring the patients ability to participate in everyday activities.

Microdiscectomy (Microdecompression) Spine Surgery

Typically performed for a herniated disc, a microdiscectomy relieves the pressure

on a spinal nerve root by removing the material causing the pain. During the procedure, a
small part of the bone over the nerve root and/or disc material under the nerve root is taken
out.
 A microdiscectomy (also called a microdecompression) is usually more effective for
relieving leg pain (also known as radiculopathy, or sciatica) than lower back pain:1-3

For leg pain, patients will normally feel pain relief almost immediately after a
microdiscectomy. They will usually go home from the surgery with significant
pain relief.

For numbness, weakness, or other neurological symptoms in the leg and foot, it
may take weeks or months for the nerve root to fully heal and any numbness or
weakness to subside.

As general rule, microdiscectomy is considered a relatively reliable surgery for

immediate, or nearly immediate, relief of sciatica from a lumbar herniated disc.

Minimally Invasive Microdiscectomy

There are two common options in an outpatient lumbar discectomy

microdiscectomy and endoscopic (or percutaneous) discectomy. A microdiscectomy is
generally considered the gold standard for removing the herniated portion of a disc that is
pressing on a nerve, as the procedure has a long history and many spine surgeons have
extensive expertise in this approach. While technically an open surgery, a
microdiscectomy uses minimally invasive techniques and can be done with a relatively
small incision and minimal tissue damage or disruption. Some surgeons have now gained
sufficient experience with endoscopic or minimally invasive techniques, which involve
doing the surgery through tubes inserted into the operative area, rather than through an
open incision.A microdiscectomy is typically performed by an orthopedic surgeon or
neurosurgeon.

Indications for Microdiscectomy

If a patient's leg pain due to a disc herniation is going to get better, it will generally
do so within about six to twelve weeks of the onset of pain. As long as the pain is tolerable
and the patient can function adequately, it is usually advisable to postpone surgery for a
short period of time to see if the pain will resolve with non-surgical treatment alone.

If the leg pain is severe, however, it is also reasonable to consider surgery sooner.
For example, if despite nonsurgical treatment the patient is experiencing pain so severe
that it is difficult to sleep, go to work, or perform everyday activities, surgery may be
considered before six weeks.

These are typical reasons for recommending a microdiscectomy:

Leg pain has been experienced for at least six weeks

An MRI scan or other test shows a herniated disc
Leg pain (sciatica) is the patients main symptom, rather than simply lower back
pain
Nonsurgical treatments such as oral steroids, NSAIDs, and physical therapy have
not brought sufficient pain relief

The results of surgery are somewhat less favorable after three to six months have
passed since the onset of symptoms, so doctors usually advise people not to postpone
surgery for an extended period (beyond three to six months).4

Traditional Microdiscectomy Surgery Step-By-Step

A microdiscectomy is performed through the back, so the patient lies face down
on the operating table for the surgery. General anesthesia is used, and the procedure
usually takes about one to two hours.

These steps are typical:

A microdiscectomy is performed through a 1 to 1-inch incision in the midline of

the low back.
 First, the back muscles (erector spinae) are lifted off the bony arch (lamina) of the
spine and moved to the side. Since these back muscles run vertically, they are held
to the side with a retractor during the surgery; they do not need to be cut.
The surgeon is then able to enter the spine by removing a membrane over the
nerve roots (ligamentum flavum).
Operating glasses (loupes) or an operating microscope allow the surgeon to clearly
visualize the nerve root.
In some cases, a small portion of the inside facet joint is removed both to facilitate
access to the nerve root and to relieve any pressure or pinching on the nerve.
The surgeon may make a small opening in the bony lamina (called a laminotomy)
if needed to access the operative site.
The nerve root is gently moved to the side.
The surgeon uses small instruments to go under the nerve root and remove the
fragments of disc material that have extruded out of the disc.
The muscles are moved back into place.
The surgical incision is closed and steri-strips are placed over the incision to help
hold the skin in place to heal.

In a microdiscectomy, only the small portion of the disc that has herniatedor leaked
out of the discis removed; the majority of the disc is left as is.Importantly, since almost
all the joints, ligaments and muscles are left intact, a microdiscectomy does not change the
mechanical structure of the patient's lower spine (lumbar spine).

After the Surgery

Patients typically stay in the surgery center or hospital for a few hours after
surgery before being released to return home. Depending on the patients condition, one
overnight stay in the hospital may be recommended. Following the operation, patients
may return to a relatively normal level of activities quickly. Patients are typically
encouraged to walk within a few hours of the surgery.
 The surgeon will provide home care instructions, typically including medications,
activity restrictions, a follow-up care appointment, and other information. A widely
performed surgery, microdiscectomy is considered to have relatively high rates of success,
especially in relieving patients leg pain (sciatica). Patients are usually able to return to a
normal level of activity fairly quickly.

References:

1. Zahrawi F. Microlumbar discectomy. Is it safe as an outpatient procedure? Spine (Phila Pa

1976). 1994;19(9):1070-4.
2. Pugely AJ, Martin CT, Gao Y, Mendoza-Lattes SA. Outpatient surgery reduces short-
term complications in lumbar discectomy: an analysis of 4310 patients from the ACS-
NSQIP database. Spine (Phila Pa 1976). 2013;38(3):264-71.
3. Lang SS, Chen HI, Koch MJ, Kurash L, McGill-Armento KR, Palella JM, Stein SC,
Malhotra NR. Development of an outpatient protocol for lumbar discectomy: our
institutional experience. World Neurosurg. 2014;82(5):897-901.
4. 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.

Lumbar Laminectomy Surgery for Spinal Stenosis (Open Decompression)

A lumbar laminectomy is also known as an open decompression and typically

performed to alleviate pain caused by neural impingement that can result from lumbar
spinal stenosis. A condition that primarily afflicts elderly patients, spinal stenosis is caused
by degenerative changes that result in enlargement of the facet joints. The enlarged joints
then place pressure on the nerves, and this pressure may be effectively relieved with the
laminectomy.
 The lumbar laminectomy is designed to remove a small portion of the bone over
the nerve root and/or disc material from under the nerve root to give the nerve root more
space and a better healing environment.

Laminectomy Surgery

The lumbar laminectomy (open decompression) differs from a microdiscectomy in

that the incision is longer and there is more muscle stripping.

First, the back is approached through a two-inch to five-inch long incision in the
midline of the back, and the left and right back muscles (erector spinae) are
dissected off the lamina on both sides and at multiple levels
After the spine is approached, the lamina is removed (laminectomy), allowing
visualization of the nerve roots.
The facet joints, which are directly over the nerve roots, may then be undercut
(trimmed) to give the nerve roots more room.

Post laminectomy, patients are in the hospital for one to three days, and the individual
patient's mobilization (return to normal activity) is largely dependent on his/her pre-
operative condition and age.

Patients are encouraged to walk directly following a laminectomy for lumbar stenosis.
However, it is recommended that patients avoid excessive bending, lifting, or twisting for
six weeks after this stenosis surgery in order to avoid pulling on the suture line before it
heals.

The success rate of a lumbar laminectomy to alleviate pain from spinal stenosis is
generally favorable. Following a laminectomy, approximately 70% to 80% of patients will
have significant improvement in their function (ability to perform normal daily activities)
and a markedly reduced level of pain and discomfort associated with spinal stenosis .
Lumbar Laminectomy for Leg Pain and Back Pain Relief

The surgical results of a lumbar laminectomy are particularly effective for leg pain
(sciatica) caused by spinal stenosis, which can be severe. Unfortunately laminectomy
surgery is not nearly as reliable for relief of lower back pain.

This is because lumbar stenosis is often created by thefacet joints becoming

arthritic, and much of the low back pain is from the arthritis. Although removing the
lamina and part of the facet joint can create more room for the nerve roots, it does not
eliminate the arthritis. Unfortunately, the symptoms may recur after several years as the
degenerative process that originally produced the spinal stenosis continues.

Success Rate of Lumbar Laminectomy with Joint Fusion

In certain instances the success rate of a decompression for spinal stenosis can be
enhanced by also fusing a joint. Fusing the joint prevents the spinal stenosis from
recurring and can help eliminate pain from an unstable segment. Spinal fusion surgery is
especially useful if there is adegenerative spondylolisthesis associated with the stenosis.

Generally speaking, if there is multi-level stenosis from a congenitally shallow

canal, a fusion is not necessary; however, if the stenosis is at one level from an unstable
joint (e.g. degenerative spondylolisthesis), then a decompression surgery with a fusion is a
more reliable procedure.

A lumbar laminectomy is able to alleviate spinal stenosis pain by removing

painful pressure on the nerve root and/or disc space. However, the procedure is not
foolproof. Complications from this surgery for lumbar stenosis can result from a variety of
factors.

Lumbar Laminectomy Risks and Considerations

The potential risks and complications with a lumbar laminectomy include:

 Nerve root damage (1 in 1,000) or bowel/bladder incontinence (1 in 10,000).
Paralysis would be extremely unusual since the spinal cord stops at about the T12
or L1 level, and surgery is usually done well below this level.
Cerebrospinal fluid leak (1% to 3% of the time). If the dural sac is breached, a
cerebrospinal fluid link may be encountered but does not change the outcome of
the surgery. Generally a patient just needs to lie down for about 24 hours to allow
the leak to seal.
Infections (about 1% of any elective cases). Although an infection is a major
nuisance and often requires further surgery to clean it up along with IV antibiotics,
it generally can be managed and cured effectively.
Bleeding. While possible, this complication is uncommon as there are no major
blood vessels in the area.
Postoperative instability of the operated level (5 to 10% of cases).

This complication can be minimized by avoiding the pars interarticularis during

surgery, as this is an important structure for stability at a level. Weakening or cutting this
bony structure can lead to an isthmic spondylolisthesis after surgery. Also, the natural
history of a degenerative facet joint may lead it to continue to degenerate on its own and
result in a degenerative spondylolisthesis. Either of these conditions can be treated by
a spinal fusion surgery for the affected joint at a later date.

General anesthetic complications such as myocardial infarction (heart attack), blood

clots, stroke, pneumonia, or pulmonary embolism can happen with a lumbar laminectomy
as with any surgery. Although in the general population these complications are rare,
laminectomy surgery for spinal stenosis is generally done for elderly patients and therefore
the risk of general anesthetic complications is somewhat higher.

Definitive Management
 Spinal-Dose Steroids The National Acute Spinal Cord Injury studies (NASCIS I
and II) provide the basis for the common practice of administering high-dose steroids
to patients with acute SCI. A 30-mg/kg IV bolus of methylprednisolone is given over
15 minutes, followed by a 5.4-mg/kg per hour infusion begun 45 minutes later. The
infusion is continued for 23 hours if the bolus is given within 3 hours of injury, or for
47 hours if the bolus is given within 8 hours of injury. The papers indicate greater
motor and sensory recovery at 6 weeks, 6 months, and 1 year after acute SCI in
patients who received methylpredniso- lone