These two procedures are alternatives to open lumbar decompression for lumbar canal stenosis and in some cases lumbar fusion.
The aim of these procedures is again primarily to relieve leg pain though may address some patient’s back pain.
The basic principle behind an interspinous distraction decompression – IDD – is to insert a spacer between the spinous processes to hold two vertebrae apart and relieve the nerves trapped between them.
The idea behind an interspinous stabilisation - IS – is to strap the spinous processes together and thereby reduce movement. You can, at the same time, insert a spacer and so do an IDD at the same time or indeed you can perform an open decompression with some of these devices.
The devices used for the IDD include the X-Stop and the In-Space. Devices employed for an IS are the DIAM, the Wallis or the Coflex
What are the potential advantages?
The advantage of the IDD does not lie in an improved success rate, indeed we suspect their long term success rates may be lower, but in the fact that they are relatively keyhole, avoid opening the spinal canal and thereby endanger the spinal nerves. More particularly, the nerves are not exposed so there is no scarring forms around them. Whilst scarring only seldom causes symptoms, spinal stenosis will eventually always recur. The recurrence is due to wear and tear. The device reduces movement and thereby one would assume the rate of wear and tear and so perhaps the recurrence of symptoms. When recurrence does occur, a larger spacer may be fitted. More particularly, if open surgery becomes necessary it is straight forward as there are no scars around the nerve to hide and endanger them. It is our view that there is no permanent cure for lumbar canal stenosis – if you live long enough it always comes back. You may need revision procedures latter on. They only get complicated when the nerves are scarred up from previous surgery. The IDD procedures allow for a period of relief before the canal has to be opened and so defers the day when a difficult operation is needed.
So for the young patients they keep things simple and for the older patient they are easier to tolerate than open surgery.
The advantage of the IS procedures is when they are judged in comparison with a major fusion procedure. The IS is relatively minimal access surgery with a much quicker recovery.
What are the potential disadvantages?
They are not suitable for all patients. They are difficult but not impossible at the lowest level – L5/S1. You cannot have them if you have osteoporosis/thin bones. They cannot be used when there is substantial instability/slippage of the spine/spondylolisthesis and even when the instability is minor, IS is unlikely to prove as effective long term as a major fusion.
How is the operation done?
The operation is performed via a keyhole incision on the back of the spine, requires general anaesthesia and utilises and X-ray system to guide the surgery.
Please here here for details regarding how the surgery is performed.
Once you are anaesthetised, you are taken through into the operating theatre and placed face down on the operating table. A slight curve is placed in the operating table so as to open the spine.
Before the incision is made, local anaesthetic is also used to numb the area of skin and the muscles below. This reduces the amount of painkiller the anaesthetist has to use with the general anaesthetic and makes it safer. Also, the local anaesthetic has adrenaline in it so as to constrict the local blood vessels. This decreases bleeding which makes the operation safer and lengthens the effect of the local so as to lessen the immediate post-operative pain. This is called a ‘local block’
An incision is made on the centre of the back – over the spinous processes. Its length is determined by the number of levels involved but for one level is approximately 2cm. We use an Image Intensifier (X-ray machine) to determine where precisely to make the incision. The muscles are parted to reveal bone over the back of the spine. This phase of the procedure is known as the ‘access’.
Normally, a decompression would be completed by removing thickened bones and ligaments from the back of the spine. This exposed all the nerves. The advantage of the IDD procedures is that they do not require opening of the spinal canal and this exposure of the nerves.
The muscles are cleared from the bone and a probe is placed between the spinous processes at the back of the spine so as to move the bones apart. The probes are slowly enlarged until the bones have been separated enough to open the central spinal canal as well as the intervertebral foramen. Effectively, the segment is now in the position it is when the spine is bent forwards so that the remainder of the spine can be held upright without the narrowed segment closing down as it did. Now the implant, (X-Stop), is inserted in the place of the probe.
In the case of the In-Space, a similar device is put in position using a percutaneous keyhole method from a small incision to the side of the spine.
In the case of an IS operation, the implants (Wallis, DIAM or Coflex), have straps at the top and bottom which are passed around the spinous process above and below and tightly secured so as to limit movement and provide a degree of stability. In some of these procedures, the spinal canal is opened and the nerves exposed so as to fully ensure there is a good decompression.
Once this has been completed, there comes the ‘closure’. Again, meticulous care is taken to stop any bleeding and the wound is then stitched in layers using internal absorbable stitches. A drain is seldom used. The skin may be closed in a number of ways though most commonly a few simple sutures are used. A top up to the local block is given and the dressing is applied.
Removal of the sutures occurs at approximately 10 days. This can be either done by at the hospital or at your GP’s surgery or at home by the district nurse.
What happens after the surgery?
Normally you mobilise from the bed a few hours after the surgery and go home at around day two or three. However, rather than having a fixed idea about when you are going home we suggest you are ready. This will vary from person to person. The time of your discharge is something we will discuss with you in the days that follow the surgery.
Please click here for details of the post operative period.
The post operative period
There will usually be an intravenous drip in one of the veins in your arm. This gives you fluids so you do not need to eat or drink if you feel sick. The anaesthetist may wish for you not to eat or drink for a while after the operation and will advise you of this. Most of you are soon having a cup of tea.
In addition, there will often be a separate small drip providing you with pain relief. Usually, there will be a button for you to press in order for the pain relief to be delivered i.e., you will control the amount of pain relief you get. This is a very safe and effective way of making sure you get analgesia when you need it. You cannot overdose yourself by pressing it too much – the device will simply fire blanks when the maximum safe dose has been reached. Often, you only really get pain when you move. It takes a little time for the pain relief to work. A good tip is to press the button a few minutes before you want to move. Some patients find that too much causes a headache or nausea. If this is a significant problem we will need to use a different system but for most people it is the most effective way to deliver pain relief.
Very occasionally there will be a drain coming from the wound. This is like a drip and will be connected to some sort of collection device (small plastic bottle) next to you. This is usually removed the next day.
Wound care is important. You will have some form of surgical dressing on the wound – usually a light waterproof but “breathing” dressing. The wound should not be allowed to get wet until the day after the suture is removed. In general, we like to disturb the dressing as little as possible. If it is becomes stained but is intact, it is often better to put one over the top rather than to take it off.
If you need to go to the toilet you may normally get up and use the facilities in your bathroom. If you are on bed rest or are in too much pain to do that then ask for a bottle or bed pan.
Nearly always you can get up immediately if you wish. Of course you should have a nurse or physiotherapist with you on the first occasions.
This is a leakage of fluid from the sack containing the nerves and has to heal before you get up. It is very rare with this kind of surgery and only affect those IS procedures where the spinal canal is opened. The fluid, cerebrospinal fluid, or CSF, is clear and watery. We can see the leak at the operation and will tell you of the event. Whilst this does not adversely affect the outcome of the operation it does mean you have to lie flat for five days.
You may not get up at all for any reason. This is a great bore though as mentioned does not alter the outcome of the operation. During this time, you can roll over or lie on your front if you wish but you must not end up with your head higher than your bottom. The column of fluid in the spine extends up to the head and thus if the head is high compared to the base of the spine, fluid will tend to escape into the wound.
What Are The Risks?
No procedure is without risk though this is a routine operation which rarely causes harm and usually works very well.
It is vital that you are aware of the risks before you consent to surgery. We expect you to have read the information we provide if you are having surgery with The Spine Surgery London.
Please click here for details of the risks associated with surgery and this operation in particular.
The risks of keyhole lumbar spinal surgery
Complications of any operation and indeed any long period spent in bed include chest infection and blood clots forming in the deep veins of the legs (deep venous thrombosis or DVT). Parts of the blood clots may break off and fly up to the lung where they block the blood flow (Pulmonary embolus or PE). Very rarely people die from these blockages. You may have heard of these complicating long plane journeys. We can reduce the incidence of these by giving you injections to thin the blood, supportive stockings (which I request you wear at all times whilst in hospital) and compression pumps on the legs worn while in bed. We use the stockings and pumps in theatre but do not start the injections until 24 hours after the surgery so as not to provoke bleeding into the fresh wound.
There is a risk to life and limb. Any anaesthetic and any operation may kill you. Any spinal surgery may paralyse you which in the instance of a lumbar operation will mean loss of all leg, bowel, bladder and sexual function. At its worst, this may be complete and permanent. Such disasters are extremely rare and are in the order of the risk of your being run over by a bus. People do get run over by buses but it is exceptionally rare. Of course, if you do not have the operation the disc may fully prolapse and paralyse you itself.
Again, we see this though it is very rarely. In other words, there are buses on which ever road you choose, they occur in approximately equal numbers on the two routes and rationally they should not influence your decision – though they clearly often do. These buses are indeed extraordinarily rare and you can usually see them coming and so take evasive action.
The “cauda equina syndrome” is the term used to describe paralysis of this part of your nervous system – the spinal nerve in the lumbar canal. The patient usually has a phase of excruciating pain followed by numbness, paralysis and an inability to pass urine which classically is painless. i.e., you know you have an overfull bladder but it does not hurt – “painless retention”. An early warning may be numbness around the perineum/private parts/the area where your pants go. If you notice anything like this you need to see a doctor, any doctor – don’t wait for us - immediately. This syndrome is a surgical emergency. You need to have the disc removed immediately i.e., that day / night. It is extremely rare with this kind of surgery
Nerve root injury is also very rare with this kind of surgery. The spinal nerves are contained in a sack and this is filled with fluid secreted by and in communication with the brain. As this sack is pressed on directly by the walls of the canal when an open procedure is combined with an IS the sack it may leak cerebrospinal fluid during the course of the operation. This should not adversely affect the outcome of the operation though does mean you will need to lie flat for five days as described above. Nearly always the leak can be seen during the surgery and therefore I will give instructions for you not to be mobilised for the five days. If you are told you may get up then I have not encountered a leak. This occurs about 1 in 20 times the canal is opened and only relates to IS procedures and not the IDD.
Failure of an operation to achieve its intended goal is always possible. In this instance, it will mean the persistence of leg pain as it was before. This is uncommon though remember the purpose of these particular operations is to relieve leg and not back pain. The latter may remain though is often reduced to some degree. Further, rehabilitation for the back pain is more likely to prove effective when the nerves are no longer compressed and the legs are free. That is to say we get rid of the leg pain with surgery and the low back pain thereafter with rehabilitation physiotherapy. The persistence of some non-disabling levels of back pain is common. It is not uncommon for a degree of pre-existing weakness and numbness to persist particularly if it was severe beforehand. The longer they have been present the more likely this is. However, most patients experience an improvement in weakness and numbness if not complete resolution.
Recurrence of symptoms may occur. That is to say you may get better only for things to get worse again later. There are a number of reasons why and again this may be in the form of back or leg pain. Back pain may occur in acute bouts and can be minimised by your being diligent with the post-operative physiotherapy. Leg pain may arise from the canal narrowing at the same level again or in the adjacent levels. By its nature, canal stenosis is a progressive process and so may occur again and with it leg pain. Indeed, it is likely that given long enough all patients would get a recurrence. To find out a true recurrence rate thousands of patients need to be followed for tens of years and for none drop out during that time. There has been no perfect study but it is our impression that a significant number of patients need second procedures at some point whatever is done. This of course largely reflects the natural history of disc disease rather than anything relating to the surgery itself though it is important that you appreciate the operations simply tackle current troubles and offer no protection against future problems at other levels and recurrence at the operated one. Obviously, we would not offer the surgery if we did not think that without it you are likely to fair worse than you are with it.
Deterioration is a possibility. Operations can make you worse, can do you harm or may leave you with new problems to cope with. This is rare and deterioration directly as a result of the surgery probably affects a fraction of 1% of patients.
Wound infection can occur with any operation. In the spine, it is rare as there is so much muscle covering it. Muscle fights infection well. However, if an infection ever sets in the effects can be very serious and the device will need to be removed. The risks are less than 1%. Diabetic patients are at slightly higher risk of this.
Before you have a procedure of any kind, however trivial you may feel it to be, you must be fully aware of the possible and likely consequences. You have to sign a consent form in which you state that you are fully aware. We will go over this with you in your consultation. Do not sign the consent form for a procedure with us unless you feel fully informed of its aims and risks, as well as the alternatives. Please make sure you are fully content with everything set out in our Informed Consent for Treatments: Operations and Injections.
Click here for details of an extract
Obviously, you must know what the aims and risks of any operation are. We will document in the notes that we have explained these to you, as it is routine to do so. Do not sign the consent form if you feel we have not.
We will write something like this in your notes:- make sure you feel it is true
“I have explained the aims and risks of the procedure including those to life and limb (i.e. death paralysis and disaster), of failure (the procedure does not work), recurrence (you get better but it comes back) and deterioration, (you are made worse), of death, paralysis, wound problems, of nerve/ nerve root injury, as well as the likely natural history of the condition (what happens if nothing is done), the possible impact of alternative managements and treatments, along with the usual post procedure recovery and its variants (i.e., how much time off from work, what help you will need at home, what the wound care is).”
These are all things you will need to have had covered. Again, do not sign the consent if you are not sure
What happens if you don’t have it done?
The “natural history” is what happens when nothing is done and this must be compared with the scale of risks associated with the procedure. Lumbar canal stenosis develops slowly and so too do the symptoms - usually. In general, there is a progressive deterioration though for some patients it deteriorates rapidly and for others it fluctuates. Occasionally, it will resolve for a long time though eventually it returns. Whilst all this tends to drive one to surgery seldom are patients forced into surgery. Occasionally weakness, numbness or unmanageable pain arise to force things but for most it is a decision made in terms of the quality of life. If the symptoms are limiting your life, then that is the time to get something done.
What are the alternatives?
Much of this is covered elsewhere and will form part of our discussions. Open keyhole surgery and perhaps endoscopic spinal surgery are the principle operative alternatives. If this is relevant to you, we will discuss it. However, any operation is always the last resort. Instead, you could try injections or further conservative treatment (physiotherapy, osteopathy, chiropractic, acupuncture, tablets and time.) Obviously, we will usually have formed the view that these are unlikely to bring you to comfort any time soon before recommending surgery. Occasionally, we will have warned you that bad paralysis of nerves may occur if things are left and in these circumstances there is little choice but to proceed though this is rare. For the majority, it is pain that drives the surgery. In these circumstances, you have to feel that the degree of pain warrants the risk and effort involved in having the operation.
Most people go home on or around the third post-operative day. However, there is no rush and you should stay until you are ready.
Please click here for details of how to time your discharge.
Planning your discharge
Do not have a fixed plan. Make arrangements that are flexible. Surgery is not like fixing a new car.
You need to be recovered enough so that you can manage the journey home, life at home and have not needed the pain relief drip for 24 hours. If you live a long way off, are on your own or have a dependant young family you will need to stay for longer. Occasionally, the less able who live alone might sensibly use a convalescent facility. Equally, some go home on day one or two though if you are an early leaver you should rest at home as if you were still in hospital.
Remember there is no rush –go home when you are ready. You should be able to tick certain boxes:
- be able to mobilise and more or less dress yourself
- to have passed urine and opened your bowels
- to have tried some stairs with the physiotherapist
- to be able to manage on just oral medication and pain relief
- to be able to cope with your journey home
- to be able to survive comfortably with your personal home circumstance
Often, day two and three are worse than day one in terms of pain. We tend to plan the precise discharge time on the ward round on day two or three.
How to get home
The front passenger seat in a standard car is fine. If the journey is long, get out of the car every hour and do some simple stretches. Then get back in and carry on. It is often sensible to take some tablets before you leave the ward. Go to bed when you get home, regardless of how you feel.
Done once, even a long journey is OK. This is not a licence to drive every day.
Post-operative back care
This is obviously crucial to any procedure’s success. Even before you come in and again before you go home after surgery, we will have discussed some details of how to care for your back in the weeks that follow. Indeed, several members of the team will be involved in this. Below we give a general summary.
If you feel you are developing unexpected, troublesome or worrying symptoms, do not hesitate to call our office or the ward staff. If troubles arise out of hours, call the hospital and ask for the sister in charge.
Please click here for details of post operative back care.
Post-operative Back Care
You may well have been given specific instructions by the hospital’s physiotherapist. Indeed, you are likely to be given a sheet with diagrams of various exercises. The precise details of these exercises and how often they should be done are of less importance than your response to them. That is to say, if you develop pain on doing these exercises, you should stop them. In the first few weeks, all that can occur is the simple healing process. Physiotherapy maintains your mobility during this time but should not be allowed to interfere with the healing process. Therefore, if it hurts, you should stop and you should not be anxious if, as a result, you are quite stiff by the end of this early period. Physiotherapy begins in earnest around the fourth week when the back will be stable enough to allow real progress to be made.
The aim here is to do small amounts but often. For most of the first week, you will either be in hospital or should be pottering about inside your home. For the second week, the amount of activity undertaken should essentially be unchanged. You should simply be moving about as if you were in fact still in hospital. It would be perfectly reasonable to fix your own meals and to look after yourself though you should not be doing housework or looking after others. You may go out for short walks. From the second week onwards, light exercise may be taken. You may go on very short car journeys (10-15 minutes) and go out for longer walks. Prolonged outings, lengthy or frequent trips to the office will be bad for you. Problems most often arise when patients do a little too much a little too often, i.e., one trip to the office may be alright but three cause troubles.
You are better to be standing or lying following back surgery. If you wish to sit, a high, upright dining room style chair is the most appropriate. It is certainly reasonable to start sitting for your meals when you have gone home but it is sensible to stand up and stretch between courses. This should be back to normal around about the four to six week mark. However, it will always be advisable to avoid prolonged periods sitting and very soft or low armchairs.
If it hurts, don’t. If you think it will hurt, don’t - until of course you think it won’t and it doesn’t.
You should not get the wound wet until the day after the sutures have been removed. It is perfectly reasonable to have a shower, providing the wound is covered with a waterproof dressing. The ward may provide you with this before you leave. In general, we like to change the dressings on wounds as infrequently as possible. The wound should be kept dry and a dressing used that allows the wound to breathe.
Removal of Stitches
The stitches should be removed at or shortly after the tenth day. We mostly use a single stitch which runs under the skin and can be pulled from one end. (Get an adult to help you.) I also usually put steristrips (small sticky tapes) across the wound and two in parallel with the wound to hold the stitch ends. The ones holding the stitch ends need to be pulled off and then the suture can be removed. Most often a nurse linked to your G.P. or the district nursing service do this. If you are near one of my hospitals you may be able to have these removed there. You need have agreed an arrangement for this to be done before you, leave hospital - our ward nurses who will liaise with your GP, district nurse or one of the local hospitals as is appropriate.
Bending, lifting, carrying
In the first few weeks, you should not be doing this. The physiotherapy, which will begin about the fourth to sixth week, will teach you how to bend correctly and how best to lift. It should certainly be something that you keep to a minimum in the first months.
In the first few weeks you should be driven i.e., you should not drive the car yourself. In the weeks that follow, you should limit journeys to short periods. As physiotherapy commences and progress is made, you may gradually start to extend this. In general it is best to have the car seat set as high and as upright as possible. If you are becoming uncomfortable you should stop, get out and do some light stretches before continuing.
You should not do this until we have reviewed your progress. It should be deferred until you have completed the fitness programme that only begins with the physiotherapy at the fourth to sixth week and is likely to take a further four to six weeks at least.
The aim is for you to avoid things which aggravate your pain. Once recurrence of back and leg pain has occurred, it is much more difficult to get it to go away. It is much simpler to avoid it in the first place. If in doubt, err on the side of caution. You can do most things after the first week or so. However, you will not be able to do much of them. “Can I drive?”, “pick up the baby?”, “go into the Office?” or “fly?” are all frequently asked questions. The answer is usually yes BUT not very often. It is not so much what you do but how often you do it.
The usual routine is to see patients three or four weeks after discharge and it is at that point that we can start the physiotherapy. This will need to be near to home though later may need to move nearer to work. We usually then see you after another six weeks and then a further three months.
Return to work
Please click here for further details.
Planning your return to work
This may reasonably be anytime between four and twelve weeks post surgery. This might seem like a ridiculously wide window and certainly we will advise you more precisely. In fact, some patients are back at work inside two weeks and others still off at four months. A brick layer commuting 50 miles by car each way will take longer than a librarian working next door to home.
Whatever the work a gradual return is best – perhaps two half days the first week (Tuesday and Thursday), three the second (Monday Wednesday and Friday) and four the fourth (Monday, Tuesday and Thursday, Friday). Work five half days the next and then start to increase the length of the days. It is important to keep up the physiotherapy during this phase. The program outlined above is very gradual and more rapid progress may be possible but if pain recurs you should ease off.
Done in a graduated way, the return to work is a very positive part of your rehabilitation. It needs to be in your control and with the encouragement of your employer. If they will put up with you being part-time and unreliable they will see you sooner.
If, by contrast, your job is one whereby you have to be there fulltime and reliably or not at all, it will take longer. Then the job is not a part of the rehabilitation but the hurdle rehabilitation has to prepare you for. You will get back later as you need to fully recovered before starting. If you have a long commute, your return will be further delayed. The average commute time for my patients is in the region of one hour each way. From the spinal perspective, that is a two hour physical job in addition to your real work. Days spent working from home help.
Discuss this advice with your employer and make a plan. Obviously, the best laid plans may change due to circumstances and I will advise on how likely your plan is to come off at the first out-patient session post surgery i.e., at about the four week mark.
Return to sport
Please click here for details of how to return safely to sport.
A safe return to sport
Clearly, the situation is different for the occasional exerciser than it is for the keen amateur sports person.
In general terms, for members of the general public it takes three months to get over the surgery and return to normal life. It takes a further three months to train you back up to competitive sport.
Some sports are tougher than others. We would not recommend significant long distance running, rowing machines or squash, (tennis and badminton are usually fine). However, most other sports are fine- after an appropriate training schedule to get you fit and to strengthen the spine.
Two sports need a special mention. You should miss a ski season, i.e., this needs to be a good six months off. Likewise, it should probably be six months before you do serious riding – much depends on the horse of course!
Essentially, done properly, skiing and horse riding are like advanced Pilates or core muscle exercises, i.e., they can be good for you. However, you would not leap into an advanced Pilates class any more than you would yoga and neither would you expect to do them if you were injured.
You may get back to your sport safely when the disc has firmly healed, (and you can do nothing to speed that up), and when you are cardiovascularly fit have achieved good flexibility and basic core muscle strength. Your physiotherapist will guide you.
It is all about being reasonable and phasing in the return. Start with a few holes of golf and don’t go for the big drive on your first few visits. Make sure there is time to recover before and after you play. Gently build it up.
Whatever your sport now is a good time to see a coach. Most professionals have injuries and there are ways to T off, to serve, to set up your bike and even to run, that are more back friendly than others. A professional coach will be able to help you if you explain your problem – “I have a bad back and want to run like Usain Bolt, please”. Good luck.
Data on the performance of the IPIDD operations is less numerous than for most standard lumbar operations. However, the result on the short-term outcomes seems to show it to be good, if not better, than the standard procedure. It is the longer term performance which remains the principle unanswered question.
What do you do in the event of problems?
If, once you have got home, problems arise, help is available from a number of sources.
Please click here for details of who and how to call.
Where can I get help?
First, you may ring my office number. If, it is during working hours, this is certainly what you should do. My secretarial staff will be able to contact myself, my clinical assistants or our spinal nurse and obtain advice for you. If, it is out of hours, you may also ring this number and the machine will tell you what to do in the event of an urgent enquiry or you may leave a message.
Second, you may ring the hospital and ask to speak to my Spinal Nurse. In her absence, you should ask to speak to the hospital’s Duty Manager or to the ward staff. Telephone numbers are given at the end of this information sheet.
You may of course contact your general practitioner or any emergency service should you so wish or if the other avenues fail.
We do not provide a 24 hour emergency service but can respond on most occasions.
Costs, Codes and Authorisation
A separate information sheet is available which covers all aspects of this. Please obtain this and read it before you confirm your surgery. The costs of private surgery are considerable and if you are hoping to use insurance you will need to obtain authorisation from your insurer and register this with us prior to admission. Some insurers/policies may not pay all surgical, anaesthetic or hospital fees. All costs remain your responsibility even if your insurer has agreed to help/pay direct. There are usually three bills you need to know about; the hospital, the anaesthetist and the surgeon. You are responsible for ensuring all are paid.
Other sources of information
Please click here for details of other sources of information
Other sources of information
We produce a number of other information sheets. You may obtain a title list from my office.
The Princess Grace Hospital produces information on a number of surgeries including spinal procedures. We were also involved in their production so they are not entirely independent. However, the physiotherapy and nursing issues are given an airing. You can obtain these from our Spinal Nurse – see contact details below.
Your General Practitioner will have seen other patients going through this kind of procedure and they can offer valuable insights into the practicalities behind the surgery. Of course, they may also be familiar with any other health concerns you have and be able to offer advice on how these might impact on recovery.