Lumbar decompression surgery

Lumbar decompression surgery is a type of surgery used to treat compressed nerves in the lower (lumbar) spine.

It's only recommended when non-surgical treatments haven't helped. 

The surgery aims to improve symptoms such as persistent pain and numbness in the legs caused by pressure on the nerves in the spine.

Lumbar decompression surgery is often used to treat:

• spinal stenosis – narrowing of a section of the spinal column, which puts pressure on the nerves inside
• a slipped disc and sciatica – where a damaged spinal disc presses down on an underlying nerve
• spinal injuries – such as a fracture or the swelling of tissue
• metastatic spinal cord compression – where cancer in one part of the body, such as the lungs, spreads into the spine and presses on the spinal cord or nerves

What happens during lumbar decompression surgery

If lumbar decompression surgery is recommended, you'll usually have at least one of the following procedures:

• laminectomy – where a section of bone is removed from one of your vertebrae (spinal bones) to relieve pressure on the affected nerve
• discectomy – where a section of a damaged disc is removed to relieve pressure on a nerve
• spinal fusion – where two or more vertebrae are joined together with a section of bone to stabilise and strengthen the spine

In many cases, a combination of these techniques may be used.

Lumbar decompression is usually carried out under general anaesthetic, which means you'll be unconscious during the procedure and won't feel any pain as it's carried out. The whole operation usually takes at least an hour, but may take much longer, depending on the complexity of the procedure.

Recovering from lumbar decompression surgery

You'll usually be well enough to leave hospital about 1 to 4 days after having surgery, depending on the complexity of the surgery and your level of mobility before the operation.

Most people are able to walk unassisted within a day of having the operation, although more strenuous activities will need to be avoided for about 6 weeks.

You may be able to return to work after about 4 to 6 weeks, although you may need more time off if your job involves driving for long periods or lifting heavy objects. 

Effectiveness of lumbar decompression surgery

There's good evidence that decompression surgery can be an effective treatment for people with severe pain caused by compressed nerves. 

Up to 3 in every 4 people who have the operation experience a significant improvement in pain. People who found walking difficult before surgery because of leg pain or weakness are often able to walk further and more easily after the operation.

Risks of lumbar decompression surgery

Although lumbar decompression is often successful, like all types of surgery it carries a risk of complications.

Complications associated with lumbar decompression surgery include:

• infection at the site of the operation, or in rare cases an infection elsewhere
• a blood clot developing in one of your leg veins, known as deep vein thrombosis (DVT); in rare cases, the clot can dislodge and travel to the lungs, causing a serious problem called a pulmonary embolism
• damage to the spinal nerves or cord – resulting in continuing symptoms, numbness or weakness in one or both legs, or in rare cases some degree of paralysis 

Lumbar decompression surgery is usually only considered if non-surgical treatments for your lower spine haven't worked and symptoms are affecting your quality of life.

Non-surgical treatments include painkillers, physiotherapy and spinal injection therapy. Spinal injection therapy is a course of spinal injections that can be used in combination with other therapies, such as physiotherapy. Local anaesthetic and steroids are injected to help reduce swelling and inflammation.

Lumbar decompression surgery may also be considered if you experience serious side effects when taking medications that affect your ability to work.

Surgery will only be recommended if you're healthy enough to withstand the effects of the anaesthetic and the surgery.

Some of the conditions that may be helped by lumbar surgery are described below.

Spinal stenosis

Spinal stenosis is a condition where the space around the spinal cord (the spinal column) narrows, compressing a section of nerve tissue.

The main symptoms of spinal stenosis are pain, numbness, weakness and a tingling sensation in one or both legs. This can make walking difficult and painful.

Most cases of spinal stenosis occur in people aged over 60. As you get older, the bones and tissues that make up the spine can become worn down, which can lead to a narrowing of the spinal column.

Cauda equina syndrome

Cauda equina syndrome is a rare and severe type of spinal stenosis where all of the nerves in the lower back suddenly become severely compressed.

This causes a range of problems, including numbness in the skin around the anus (back passage), not being able to pee or control your bladder (urinary incontinence), and a loss of bowel control (bowel incontinence).

Cauda equina syndrome requires emergency hospital admission and emergency surgery, because the longer it goes untreated, the greater the chance it will lead to permanent paralysis and incontinence.

Slipped disc and sciatica

A slipped or herniated disc is where the tough coating of a disc in your spine tears, causing the jelly-like filling in the centre to spill out. The torn disc can press on a surrounding nerve or nerves, causing pain in parts of your legs.

This pain may be accompanied by tingling, pins and needles, numbness or weakness in certain areas of your legs. The pain is often referred to as sciatica and is sometimes worse when straining, coughing or sneezing. 

The most common characteristic of sciatica is pain that radiates out from the lower back, down the buttocks and into one or both legs, right down to the calf. The pain can range from mild to severe.

A slipped disc can occur at any age, but is more common in people from the ages of 20 to 40. If a disc becomes damaged, it sometimes only takes an awkward twist or turn, a minor injury or even a sneeze to cause the filling in the centre of the disc to spill out.

However, the exact cause of a slipped disc is often unknown.

Metastatic spinal cord compression

Cancer in one part of the body, such as the lungs, sometimes spreads into the spine and presses on the spinal cord. This is known as metastatic spinal cord compression.

Initial symptoms can include:

• back pain, which may be mild at first, but usually gets worse over time; the pain is constant and often worse at night
• numbness in your fingers and toes
• problems urinating

Without treatment, metastatic spinal cord compression is potentially very serious and can result in permanent paralysis in the legs.

For people in good enough health to withstand surgery, metastatic spinal cord compression is best treated with surgery. However, if the problems only become apparent late on, many people are too ill to withstand or benefit from surgery.

Spinal injury

Injury to your spine (such as dislocation or fracture) or the swelling of tissue can put pressure on your spinal cord or nerves.

Spinal tumours

Abnormal growths and tumours can form along the spine. They're usually benign (not cancerous), but growing tumours may compress your spinal cord and nerve roots, causing pain.

If you and your consultant decide you could benefit from lumbar decompression surgery, you'll be put on a waiting list.

Your doctor or surgeon should be able to tell you how long you're likely to have to wait. Read more about NHS waiting times.

Before the operation

To help you recover from your operation and reduce your risk of complications, it helps if you're as fit as possible before surgery.

As soon as you know you're going to have lumbar decompression surgery, it's advisable to stop smoking (if you smoke), eat a healthy, balanced diet and take regular exercise.

Pre-operative assessment

You'll be asked to attend a pre-operative assessment appointment a few days or weeks before your operation. 

During this appointment, you may have some blood tests and a general health check to make sure you're fit for surgery, as well as an X-ray or magnetic resonance imaging (MRI) scan of your spine.

This assessment is a good opportunity to discuss any concerns you may have or ask questions about your operation.

You should be told who will be doing your operation and you may be introduced to them. Lumbar decompression surgery is carried out either by a neurosurgeon or an orthopaedic surgeon with experience in spinal surgery.

The operation

You'll be admitted to hospital either on the day of your operation or the day before. Your surgeon and anaesthetist will explain what will happen during the operation. This will give you the opportunity to ask any questions.

Before the operation, you'll be asked to sign a consent form to confirm that you know what's involved and the potential risks.

You'll usually be asked not to eat or drink for about 6 hours before the operation.

During lumbar decompression surgery, you'll usually lie face down on a special curved mattress to allow the surgeon better access to the affected part of your spine and reduce the pressure on your chest, abdomen and pelvis.

The operation is carried out under general anaesthetic, which means you'll be asleep during the procedure and won't feel any pain. The whole operation takes at least an hour, but it may take much longer, depending on its complexity.

The exact level of decompression required will be determined using an X-ray. An incision will be made in the middle of your back, running vertically along your spine. The length of the incision will depend on:

• how many vertebrae and/or discs need to be treated
• the complexity of the surgery
• whether fusion has been considered

The muscles in your back will be lifted from the back bone, to expose the back of the spine. The affected tissues or nerves will be removed little by little, taking the pressure off the spinal cord or nerves. Once adequate decompression has been achieved, the muscles will be stitched back together and the incision will be closed and stitched up.

Surgical procedures

The aim of lumbar decompression surgery is to relieve the pressure on your spinal cord or nerves, while maintaining as much of the strength and flexibility of your spine as possible.

Depending on the specific reason you're having surgery, a number of different procedures may need to be carried out during your operation to achieve this.

3 of the main procedures used are:

• laminectomy – where a section of bone is removed from one of your vertebrae (spinal bones) to relieve pressure on the affected nerve
• discectomy – where a section of a damaged disc is removed
• spinal fusion – where two or more vertebrae are joined together with a bone graft

Your surgeon can give you more information about which procedures are going to be performed during your surgery.

The 3 main procedures are described in more detail below.

Laminectomy

A laminectomy removes areas of bone or tissue that are putting pressure on your spinal cord.

The surgeon makes an incision (cut) over the affected section of spine down to the lamina (bony arch of your vertebra), to access the compressed nerve. The nerve will be pulled back towards the centre of the spinal column and part of the bone or ligament pressing on the nerve will be removed.

To complete the operation, the surgeon will close the incision using stitches or surgical staples. 

Discectomy

A discectomy is carried out to release the pressure on your spinal nerves caused by a bulging or slipped disc.

As with a laminectomy, the surgeon will make an incision over the affected area of your spine down to the lamina.

The surgeon will gently pull the nerve away to expose the prolapsed or bulging disc, which they'll remove just enough of to prevent pressure on the nerves. Most of the disc will be left behind to keep working as a shock absorber.

To complete the operation, the surgeon will close the incision with stitches or surgical staples. 

Spinal fusion

Spinal fusion is used to join 2 or more vertebrae together by placing an additional section of bone in the space between them.

This helps to prevent excessive movements between two adjacent vertebrae, lowering the risk of further irritation or compression of the nearby nerves and reducing pain and related symptoms.

The additional section of bone can be taken from somewhere else in your body (usually the hip) or from a donated bone. More recently, synthetic (man-made) bone substitutes have been used.

To improve the chance of fusion being successful, some surgeons may use screws and connecting rods to secure the bones.

Afterwards, the surgeon will close the incision with stitches or surgical staples.

Keyhole surgery

Spinal decompression surgery is usually performed through a large incision in the back. This is known as "open" surgery.

In some cases, it may be possible for spinal fusion to be carried out using a "keyhole" technique known as microendoscopic surgery. This is performed using a tiny camera and surgical instruments inserted through a small incision in your back. The surgeon is guided by viewing the operation on a video monitor.

Microendoscopic surgery is complicated and isn't suitable for everyone. Whether it's suitable for you depends on the exact problem in your lower back. There's also a slightly higher risk of accidental injury during this operation than with an open operation.

Some of the techniques used during microendoscopic surgery, such as using a laser or a heated probe to burn away a section of damaged disc, are relatively new. Therefore, it's still uncertain how effective or safe they may be in the long term.

An advantage of microendoscopic surgery is that it usually has a much shorter recovery time. In many cases, people can leave hospital the day after surgery has been completed. 

Recovery after lumbar decompression surgery will depend on your fitness and level of activity prior to surgery. This is why a course of physiotherapy before the operation may be recommended.

You’ll be encouraged to walk and move around the day after surgery and it’s likely you’ll be discharged 1 to 3 days afterwards.

It will take about 4 to 6 weeks for you to reach your expected level of mobility and function (this will depend on the severity of your condition and symptoms before the operation).

When you wake up after lumbar decompression surgery, your back may feel sore and you'll probably be attached to one or more tubes.

These may include:

• a drip supplying fluids into a vein (intravenous drip), to make sure you don't get dehydrated
• a drain to take away any fluid from your wound
• a thin, flexible tube inserted into your bladder (urinary catheter), in case you have difficulty urinating
• a pump to deliver painkillers directly into your veins every few hours

The tubes are usually only attached for a short time after your operation.

Pain

Immediately after surgery, you'll have some pain in and around the area where the operation was carried out. You'll be given pain relief to ensure you're comfortable and to help you move. The original leg pain you had before surgery usually improves immediately, but you should tell the nurses and your doctor if it doesn't.

A very small number of people have difficulty urinating after the operation. This is usually temporary, but in rare cases complications, such as nerve damage, may cause the legs or bladder to stop working properly. It's important to tell your doctor and nurses immediately if you have problems.

It can take up to 6 weeks for the general pain and tiredness after your operation to disappear completely.

Stitches

You'll have stitches or staples to close any cuts or incisions made during your operation. Deep stitches beneath the skin will dissolve and don't need to be removed. If dissolvable stiches are used, they don't need to be removed.

Non-dissolvable stitches or staples will be removed 5 to 10 days after your operation. Before you leave hospital, you'll be given an appointment to have them removed.

Your stitches may be covered by a simple adhesive dressing, like a large plaster. Be careful not to get your dressing wet when you wash. After having your stitches removed, you won't need a dressing and will be able to bath and shower as normal.

Rehabilitation

Your medical team will want you to get up and moving about as soon as possible, usually from the day after the operation. This is because inactivity can increase your risk of developing a blood clot in the leg (DVT), and movement can speed up the recovery process.

After your operation, a physiotherapist will help you safely regain strength and movement. They'll teach you some simple exercises you can do at home to help your recovery.

Getting home

You'll usually be able to go home about 1 to 4 days after your operation. How long you need to stay in hospital will depend on the specific type of surgery you had and your general health.

When you get home, it's important to take things easy at first, gradually increasing your level of activity every day. Some help at home is usually needed for at least the first week after surgery.

Being active will speed up your recovery. Make sure you do the exercises recommended by your physiotherapist, and try not to sit or stand in the same position for more than 15-20 minutes at a time, because this can make you feel stiff and sore.

Walking is a good way to keep active, but you should avoid heavy lifting, awkward twisting and leaning when you do everyday tasks until you're feeling better.

You may be asked to return to hospital for one or more follow-up appointments in the weeks after your operation to check how you're doing.

Work

When you can go back to work will depend on how quickly you heal after surgery and the type of job you do.

Most people return to work after 4 to 6 weeks, if their job isn't too strenuous. If your job involves a lot of driving, lifting heavy items or other strenuous activities, you may need to be off work for up to 12 weeks.

Driving

Before starting to drive again, you should be free from the effects of any painkillers that may make you drowsy.

You should be comfortable in the driving position and be able to do an emergency stop without experiencing any pain (you can practise this without starting your car).

Most people feel ready to drive after 2 to 6 weeks, depending on the size of the operation.

Some insurance companies don't insure drivers for a number of weeks after surgery, so check what your policy says before you start to drive.

Like all surgical procedures, lumbar decompression surgery carries some risk of complications.

Recurrent or continuing symptoms

Lumbar decompression surgery is generally effective in relieving symptoms such as leg pain and numbness. However, up to 1 in 3 people continue to have symptoms after surgery, or develop symptoms again within a few years of surgery.

Recurrent symptoms can be caused by a weakened spine, another slipped disc, or the formation of new bone or thickened ligament that puts pressure on your spinal cord. Scarring around the nerves can also sometimes develop after surgery, which can cause similar symptoms to nerve compression.

Non-surgical treatments, such as physiotherapy, will usually be tried first if your symptoms recur, but further surgery may sometimes be needed. Repeat operations have a higher risk of complications than first-time operations.

Unfortunately, there's no effective treatment for scarring around the nerves. However, you can reduce your risk of scarring by doing regular exercises as advised by your physiotherapist after surgery.

Infection

One of the most common complications is an infection where the incision was made. This is estimated to affect up to one in every 25 people who have lumbar decompression surgery. It can usually be treated successfully with antibiotics.

Blood clots

There's a risk of developing a blood clot after lumbar decompression surgery, particularly in your leg. This is known as deep vein thrombosis (DVT).  

DVT can cause pain and swelling in your leg and, in rare cases, may lead to a serious problem called a pulmonary embolism. This is where a piece of the blood clot breaks off and blocks one of the blood vessels in the lungs.

The risk of developing a blood clot can be significantly reduced by staying active during your recovery or wearing compression stockings to help improve your blood flow. Read more about preventing DVT.

Dural tear

There’s a risk of a dural tear occurring during all types of spinal surgery, including lumbar decompression surgery. The dura is a watertight sac of tissue that covers the spinal cord and spinal nerves.

There’s some uncertainty about the actual likelihood of a dural tear occurring, with estimates varying from around 2% to 17% of people who have spinal surgery.

If the tear isn’t identified and repaired at the time of surgery, it can lead to cerebrospinal fluid (CSF) leaking after the procedure (see below).

Your surgeon will be aware of the risk of a dural tear, and if it does occur  will close the tear with stitches. In most cases, the repair is successful and no further problems or issues arise. However, further corrective surgery may be required in a small number of cases.

Leakage of cerebrospinal fluid

During lumbar decompression surgery, there's a risk of accidental damage to the lining of the nerve, which can lead to the leakage of cerebrospinal fluid (CSF). 

If this is discovered during the operation, it will be patched and repaired. However, small leaks can sometimes only become apparent after the operation, causing problems such as a headache and the wound to leak. Further surgery to repair this may be needed.

Facial sores and loss of vision

As you're positioned face down during lumbar decompression surgery, you'll be resting on your forehead and chin while the operation is carried out.

The anaesthetist will check regularly to make sure this isn’t causing any problems, but many people will wake up with a slightly puffed up face. In some cases, a red sore can develop over the forehead or chin, which could last several days.

In very rare circumstances (about 1 in every 30,000 cases), a person can slip during the operation and rest on their eyes rather than forehead and chin. This could lead to loss of vision.

Nerve injury and paralysis

Around one in every 20-100 people who has lumbar decompression surgery will develop new numbness or weakness in one or both legs as a result of the operation.

Paralysis is an uncommon, but serious, complication that can occur as a result of lumbar decompression surgery. It's estimated to occur in less than 1 in every 300 operations.

Nerve injuries and paralysis can be caused by a number of different problems, including:

• bleeding inside the spinal column (extradural spinal haematoma)
• leaking of spinal fluid (incidental durotomy)
• accidental damage to the blood vessels that supply the spinal cord with blood
• accidental damage to the nerves when they're moved during surgery

Death

As with all types of surgery, there's a risk of dying during or after lumbar decompression surgery, although this is rare. A blood clot, a bad reaction to the anaesthetic and blood loss can all be life-threatening.

The British Association of Spine Surgeons (BASS) estimate that there's around one death for every 350 operations carried out to treat spinal stenosis, and one death for every 700 operations carried out to treat a slipped disc.

The risk of death is higher for spinal stenosis, because most people with the condition tend to be older and in poorer health than people with a slipped disc.