NOI physicians have experience in many areas of orthopedic care. If you
are not sure whom you need to see we recommend calling our office and
speaking with one of our patient specialists who can help you to identify
the right physician.
Contact us today.
Dr. Michael Gordon specializes in Orthopedic Care and Spine. For more information,
view the links below:
Dr. Michael Gordon trained at Johns Hopkins University and USC Spinal Cord
Injury Center, and has been at the leading edge in spinal surgical technology
since he began practice in Newport Beach in 1987. He specializes in a
range of spinal surgeries from minimally invasive to complex deformities
of the cervical and lumbar spine. Dr. Gordon has extensive experience
in complex reconstructive spinal instrumentation surgery of the cervical
and lumbar spine as well as disk replacement, adult deformity and degenerative
FAQ - Lumbar Spine Surgery
I’ve just had my MRI of the Lumbar spine - what is a disk herniation
and what does it have to do with my sciatic nerve? (The sciatic nerve
itself is NOT pinched in disk herniations).
Below on the left is a normal lumbar MRI. There are no disk herniations,
pinched nerves, stenosis or arthritic changes at any levels. On the right,
there is a large disk herniation causing nerve compression at Lumbar 4-5.
The symptoms of compression of nerve roots in the spine is called sciatica
but more formally, lumbar radiculopathy. The sciatic nerve itself is not
pinched - it actually is a large nerve that exits the pelvis near the
hip. However, pain, numbness, tingling and weakness occurs in the leg
due to irritation or compression o f the sciatic nerve at its origin in
the spine - hence the word “sciatica”- which describes pain
radiation down the leg.
What exactly is a disk herniation, and are there different types of disk
herniations? How do they cause nerve pain?
The space between vertebra in the spine is occupied by a complex cartilage
and fibrous tissue Disk. Disks provide a cushioning action and allow motion
between vertebrae in the spine. The disk itself is made up of two types
of cartilage - one fibrous and relatively stiff in the outer ring or annulus-
and one of softer cellular material that is more viscous and shock absorbent
-the nucleus. The cartilage is not “liquid” but more like
very tough gristle.
- When disks “herniate” they push through the annular lining
of the disk and press on nerves within the spinal canal - hence the word
“herniated nucleus pulposus”. Herniations cause nerve pain
through a combination of direct nerve compression, and by nerve damage
through inflammation. Cells within the disk herniaiton secrete several
substances known to cause direct nerve damage. The larger the disk herniation
and the more nerve compression, the more likely there is to be leg pain,
numbness and weakness, the signs of nerve damage.
- Disk herniations come in several shapes sizes and locations. They range
from small protrusions to large extruded fragments.
- They may be central causing bilateral symptoms, or off to one side (lateral)
causing symptoms on only that same side. Mostly disk herniations occur
within the spinal canal. Sometimes disk herniations occur outside the
spinal canal and are called “extraforamenal” disk herniations.
- Disk herniation sizes can wax and wane with time. Symptoms can come and
go as well. Large extruded disk herniations can resorb over time if patients
are fortunate. Nerve damage usually improves, but not always, and the
longer patients have pain and weakness and numbness, the more likely they
are to have permanent nerve damage.
What is a lumbar microdiskectomy?
Microdiskectomy is a minimally-invasive, microscopic-assisted outpatient
surgery that is employed to remove herniated disks. Herniated disks cause
pressure on nerves in the spine leading to back pain, leg pain, numbness
and weakness which are indicative of nerve damage.
What exactly is done during a microdiskectomy surgery?
This is a surgery that is done as an outpatient, but done within the Hoag
Hospital Irvine operating room. Specialized equipment is required. It
is almost always done under general anesthesia.
A small incision is made in the skin, usually no more than an inch long.
It is larger, obviously, in larger and heavier people, and smaller in
skinnier people. The muscles of the lower back are carefully moved to
the side by especially non-traumatic retractors which prevent muscle injury
and limits bleeding. Muscles are not cut during the operation. A small
amount of bone - the lamina- is removed from the vertebra to allow access
to the spinal canal where the disk is situated. Nerves are then carefully
retracted (moved to the side and protected) while the fragments of disk
material that press on them are removed. Once nerve compression is relieved,
the retractors are removed, the incision is closed usually with one or
two sutures, and the skin is closed.
Is this a minimally invasive procedure?
Yes this is a minimally invasive procedure with little or no blood loss,
minimal risk, short operating times, and short hospitalizations and short
The average incision length is less than one inch. It is often done with
the assistance of an operating microscope.
How long does the microdiscectomy operation take?
Most lumbar microdiskectomy procedures last no more than 45 minutes.
Factors that make surgeries take longer include such variables as patient
health and “comorbidities” (other diseases such as obesity,
heart disease, chronic lung problems or diabetes), patient size, the location
of the disk herniation, a history of a prior surgical procedure in the
spine, and certain anatomical variants that make the surgery more technically
demanding. The RARE microdiskectomy takes more than an hour and a half.
How long will I be in the hospital? Will I go home the same day as an out
patient or do I have to spend the night in the hospital?
The entire hospitalization process is usually no more than 5 hours but
it is variable. More than 95% of patients go home the same day, feeling
improved neurologic function almost immediately. Issues that might make
patients spend more time in the hospital include the need for more pain
medication, postoperative problems such as nausea or vomiting which occasionally
occurs after anesthesia, heart or lung problems that might come up requiring
a little more time being monitored in the recovery room or on the hospital
floor. Fewer than 5% of patients require an overnight stay.
How long is the recovery period and exactly how is this figured after I
have a microdiscetomy?
The word “recovery” means different things to different patients
and of course is dependent on many patient-specific issues and pain tolerance.
Remember that surgery, however small, is a big stress and as I always
remind patients, it is always best to let yourself recover fully with
attention to your own well- being.
Let’s consider benchmarks of normal patient recovery after microdiskectomy surgery:
- Out of the hospital and home resting in bed or on a couch - same day.
- Standing and walking - same day.
- Activity restricted to close to home, i.e. 15 minute trips in the car -
one to three days postop.
- Return to work - obviously depends on what “work “is...
- Desk jobs requiring mostly sedentary work with little demands for bending
stooping and lifting usually are acceptable within 7 days. If the commute
is lengthy, such as a 45 minute to 1 hour drive, up to two weeks are usually
required before patients are totally comfortable being in the car that long.
- Heavier work involving frequent bending stooping and lifting, or lifting
25 pounds on a regular basis throughout the day requires 3-4 weeks off
and a reconditioning exercise program.
- Very heavy work, such as construction, heavy equipment operation, big rig
driving, concrete work or pipe fitting (a job where 100 lbs to 150 lbs
is regularly carried) usually requires 3 months of postoperative recovery.
- We recommend prompt return to sedentary activities on post op day 1. Most
daily activities such as preparing a light meal, dressing, bathing, walking
around the home, are safe and with the passage of a few days, more activity
is tolerated well. A twice daily walk of 15 minutes is an excellent first
step in recovery. . A more aggressive exercise program is recommended
a week postop. The gym as allowed 3-4 weeks postop and the “straight
ahead sports” such as treadmill, elliptical, stair stepper, and
pool swimming is encouraged. Light weight training is OK also but we stress
no squats, no lunges, and no dead lifts in the first 4-8 weeks.
- Exercise and activities are usually no longer restricted at 10 weeks. We
allow golf, tennis and other racquet sports at this time. We caution against
lengthy periods of repetitive twisting such as the driving range or tennis-serving
drills for 4-6 months. Ocean sports such as surfing, kayaking, paddle
boarding are restricted for 10-12 weeks. Very heavy sports activity such
as return to football, mountain climbing, marathon running or triathlons,
body building as so forth is considered on a case -to -case basis.
What activities can I do, and not do,after a microdiskectomy?
Be sensible. Listen to your body. Don’t be a hero. If an activity
hurts - stop doing it. Patients often ask this open-ended question and
it is very difficult to answer for everyone, so generalizations abound.
I advise close adherence to the guidelines I’ve listed above but
also some simple common sense. Don’t choose the two weeks of relative
downtime from the surgery to rearrange the living room, dig up the back
yard, get the siding up on the tool shed, pull the transmission from the
car, or help your brother-in-law clean out the attic. Also, don’t
be a fearful couch potato and sit in front of the TV avoiding any activity
at all. Gradually increase the intensity and strenuous nature of your
activity and please be aware of any new symptoms of back pain or leg pain
How do I prevent disk herniations from happening?
- Most disk herniations occur randomly throughout populations.
- There is a measureable genetic influence on patients with disk herniations
- disk herniation risks cluster in families.
- Many patients blame a specific injury or activity that they feel, if avoided,
would have prevented the disk herniation. In the spine surgery literature,
there is little evidence for this link between activity and onset of disk
- Smoking has been associated with an increase in disk degeneration that
can lead to increases in disk herniations.
My spine surgeon says I need surgery immediately. What happens if I wait,
will there be permanent nerve damage? How will I know if my nerves are
- If you have severe pain, significant weakness and numbness, and a large
disk herniation, DO NOT WAIT.
- There have been many studies on nerve function recovery after surgery,
with special attention paid to the time interval between the onset of
symptoms and the timing of microdiskectomy surgery. Studies have been
done examining groups of patients with disk herniations and leg weakness
or numbness who have had surgery soon after the onset of symptoms, or
who have waited up to 6 months before having surgery.
- Several nationwide studies show that even with a noticeable degree of pain
and weakness, and a large disk herniation, that surgery can be delayed
from 3 weeks to even 3 months with no noticeable effect on recovery. This
is not to say that, in the presence of a severe foot drop or progressive
numbness, that a patient should take a wait-and-see approach.
- The more severe the nerve pain, numbness and weakness, the more likely
nerve damage is occurring and the more likely a prompt surgery will allow
for full recovery.
- There are no tests that can be done preoperatively that can determine whether
a lumbar nerve is permanently damaged. They simply do not currently exist.
The only way to determine that permanent damage has occurred to a nerve
is to wait for recovery of strength and sensation, and find that patients
are not 100% within 1 - 2 years after surgery.
- Therefore, in patients with noticeable weakness, numbness and pain I will
suggest prompt surgery to improve the chances of a complete recovery.
In patients with minimal findings of numbness and weakness, I will advise
a lengthier non-operative approach and can expect recovery without surgery.
Can the disk leak out again in the few months after the surgery? How about later?
- That actually doesn’t happen. Disk material is very tough, like cartilage
or gristle on a steak. It doesn’t leak like fluid. It slowly creeps.
When the disk actually does come out again, it is called either a “recurrent” or “persistent” disk herniation. This is a complicated issue because sometimes,
MRI scans done in the immediate postop period see “persistent disk
herniations” that are actually only fluid accumulations and cause
no problems. MRI scans can be thusly inaccurate in up to 25% of all patients
who have NO SYMPTOMS.
- Sometimes, patients have a period of pain and symptom relief for a few
months or so and then have symptoms again - I usually wait 4-6 months
before getting another MRI because of the “false positive”
rates of postop MRI scans that can confuse the issue.
- Reoperation rates within 3 months of surgery are done in rare occasions
where the MRI shows a very large “persistent” or “recurrent”
disk herniation and patients experience severe symptoms.
What is the reoperation rate after a microdiskectomy?
Reoperation after lumbar microdiskectomy involves several different clinical
scenarios with a range of statistical chances of requiring another surgery.
The numbers vary according to published studies. Return to the operating room for:
- Washing out the wound due to a superficial infection - 0.5-5%
- Repair of leaking dural puncture not responding to conservative treatment - 0.5%
- Repeat surgery to treat a recurrent disk herniation at the same level -
7-18% at 5 years
- Repeat surgery to treat a recurrent disk herniation at a different level
- 5% at 5 years
- Repeat surgery to treat severe disabling back pain requiring fusion - 2%
at 5 years
What kinds of complications can occur and how common are they?
- Microdiskectomy surgery is extremely safe, routine, and predictable in
the correct hands.
- You will not be maimed, paralyzed, killed nor suffer any major bodily harm.
Our main concerns are not the catastrophic outcomes most patients fear,
but more mundane problems that occur infrequently. Many patients then
ask what exactly are the chances of a problem, and what kind of problem
could it be?
- I remind patients that risks from surgery are directly related to the health
of the patient, and not surprisingly, the more medical problems one is
dealing with such as diabetes, high blood pressure, heart disease, kidney
disease, Parkinson’s disease and the like, the higher the risks are.
- I often ask patients to establish other types of risk/benefit scenarios
for common human activities so that they can accurately weigh the risk
of any surgical procedure.For many of these potential complications, the
rates are so small that is has been very difficult to quantify the risk
accurately, particularly in the very rare categories and few published
To start, let’s consider some other kinds of risk that are associated
with everyday life:
Chance of dying as a result of pregnancy in the USA or Western Europe:
5-10 deaths per 100,000 live births (0.005-0.01%) (Chang 2003,
Risk of death driving on the freeway daily in California per person per
year: 1-3 in 20,000 cars (Cal dept. transportation).
- Risk of drowning in a backyard pool in USA per year : 1 in 100,000
- Risk of being struck by lightning and killed in the USA per year : 1.8
ANESTHESIA in HEALTHY PATIENTS:
Chance of dying as a result of general anesthesia alone: somewhat less
than 11-16 deaths per 100,000 persons, depending upon general health of
the persons (0.01-0.016%) (Lienhart 2006,
Chance of dying due to complications resulting from the operation of removing
the womb (hysterectomy): 120 to 160 deaths per 100,000 operations (0.12-0.16%) (Bachmann 1990,
Chance of dying due to complications resulting from the operation of removing
the gallbladder: 150 to 1400 deaths per 100,000 operations, depending
upon health and technique of operation (0.15-1.4%) (Feldman 1994,
Chance of dying due to complications resulting from the operation of removing
the large bowel for cancer: 800 to 5000 deaths per 100,000 operations,
depending upon health and technique of operation (0.8-5.0%) (Nelson-2006).
“Common complications” related to Microdiskectomy surgery:
- Wound infections, all types : 1-6 in 200 (in my practice it is 1 in 200)
- Dural perforations causing CSF leakage requiring repair : 1-10 in 100
- Bleeding requiring return to the operating room : 1-3 in 1,500
- Worsening nerve function after surgery : 2-3 in 200
- Worsening lower back pain after surgery : 5-10 in 200
- Postoperative nausea, vomiting requiring additional hospital day : 1-6 in 200
- Temporary urinary retention requiring catheter insertion 1 in 500
- Temporary worsening of overall pain scores requiring increased meds : 1 in 80
- Permanent worsening of overall pain scores requiring increased meds : 3-15 in 250
- Permanent worsening of lower back pain requiring lumbar fusion in the next
2 years after surgery : 3-15 in 300
- Recurrent disk herniation in the first 3 months after surgery requiring
unplanned return to the operating room : 1 in 200
“Rare and Catastrophic” complications from microdiskectomy surgery:
- Death from anesthesia : less than 2 in 100,000
- Paralysis : less than 1 in 250,000
- Loss of bowel or bladder function after surgery : less than 1 in 100,000
What can I expect in the hospital before and after microdiskectomy?
- You will be given medications prior to the surgery to relax you and minimize
the likelihood of nausea and vomiting after the surgery.
- You will awaken in the recovery room and be attended one-on-one by a recovery
room nurse who will supervise your immediate postop status until you are
ready to be discharged.
- From the recovery room, you will either be discharged directly home, or
if there is a need, you will be transferred to a room on the orthopedic
spine floor for further monitoring.
- Prior to discharge you will be met by several facilitators (nurse case
managers and physical therapists) who will insure that you have the appropriate
home health needs, appropriate postoperative pain medications, and the
appropriate instructions in wound care necessary. You will be given instructions
in postoperative exercises and appropriate body mechanics.
When can I go back to work after microdiskectomy?
- This of course depends on the type of work you do. Office based occupations
with minimal demands for bending stooping and lifting can usually be resumed
within one week. This also depends on how much time is required for commuting
and what the office ergonomic environment is.
- Heavy jobs such a maintenance, mechanic or construction work, machinery
operators exposed to high vibration and heavy lifting environments require
extensive rehabilitation and strengthening prior to return to work.
Is lumbar microdiskectomy a dangerous surgery?
- This is a simple, straightforward, easy, reliable, safe and effective operation.
- I have personally performed over 2,000 diskectomy surgeries and I can say
without reservation, this is one of the safest spinal surgeries I perform
with minimal risk and predictable outcomes.
- Safety arises because of my strict adherence to appropriate perioperative
monitoring, highest professionalism in my anesthesia team and intraoperative
nursing, and careful attention to detail in the operating room. I am meticulous
regarding appropriate diagnostics and patient selection to insure good outcomes
I hear all my relatives and friends say never have any back surgery, and
that paralysis is a risk.
- With no disrespect to your friends and family, if they have a lengthy experience
with spine surgery you should listen to them. Otherwise be cautious about
- Spine surgery, particularly microdiskectomy, is extremely safe particularly
if your surgeon does ONLY spine surgery. Nationally, there is less than
1 in 250,000 chance of a severe neurologic catastrophe and it usually
has very little to do with the actual surgery, but more often to issues
with underlying defects of circulation within the nerves themselves.
- Spine surgery can be life and limb saving if done appropriately and at
the correct time. Patients should not allow themselves, because of their
fear of surgery, to deteriorate to the point where we cannot help them.
We understand that spine surgery is more complex than many other types
of surgeries, but can assure patients that we can explain all the risks
and benefits associated with spinal procedures.
- Over the last 20 years, there has been a remarkable advancement in the
accuracy of diagnostics and the lessening of the stresses of surgery that
has enabled much better outcomes and much safer surgeries. Spine surgery
has suffered from a very bad reputation among patients and family members.
This stems from admittedly poor diagnostic information and rudimentary
understanding of the nature of spinal problems and procedures that came
from the “early days” of spine surgery in the 1950’s
I’ve been told there is a “laser alternative” and have
seen many advertisements on TV and on the internet. This sounds like a
lot of hype, but I’ve heard it so often I’m not sure.
- It is safe to say that lasers have no place in my practice of spine surgery,
and very few surgeons in the USA find any value in the laser used during
spinal surgery. Incidentally, lasers cannot cut bone easily, but they
DO cut nerves easily.
- The following hospitals DO NOT have a laser for spine surgery (you can
imagine if it was a useful tool it would be widely used):
- Hoag Hospital, Mission Hospital, Saddleback Hospital, Long Beach Memorial
- UCLA, USC, UC Santa Barbara, UC San Diego, UC San Francisco
- Scripps, Mayo Clinic, Johns Hopkins Hospital
- There is no “truth-in-advertising” with regard to medicine.
Any practitioner can state anything in print and make even the most outrageous
claims about “remarkable new advances” and “miraculous
recoveries” without having to provide any proof. Unfortunately the
“LASER Institute” and other similar companies fall into this
hype categorization. Statements such as, “no one else in the country
has this technology,” or, ”we are the only ones who have perfected
this procedure and no one else can do it” should be recognized for
what they are: unsubstantiated.
- As a general rule in medicine, the larger and splashier the advertisement,
and the more remarkable the claims, the less likely the information is
true. IF IT SOUNDS TOO GOOD TO BE TRUE!!!!, AND MOST INSURANCES ARE ACCEPTED!!!,
AND YOU CAN COME IN FOR A FREE EVALUATION!!!!, AND WE ARE THE ONLY ONES
WITH A SPECIAL PATENTED APPROACH, AND WE HAVE LOTS OF PATIENT TESTIMONIALS!!!!,
AND IT’S COMPLETELY BLOODLESS SURGERY!!! THEN YOU SHOULD BE VERY
SUSPICIOUS AND VERY AFRAID.
I’ve been told there is an arthroscopic alternative.
I’ve been told specialized traction from my chiropractor will help
reduce the size of my disk herniation.
- There is no evidence traction of any kind; even “the spinal decompression
variety” has any effect on the size of a disk herniation, more than
the passage of time.
- There are no published articles in any reliable journals of spine surgery
(Spine, Journal of Neurosurgery, Clinical Orthopedics, NASS Spine Journal,
European Spine Journal, Spinal Disorders, Journal of Bone and Joint Surgery)
that demonstrate effectiveness of traction beyond that of any other physical
Chiropractic manipulations, particularly vigorous, of the lumbar spine
in the presence of a large disk herniation, and with associated neurologic
findings such as numbness tingling or weakness,
should be avoided.
What activities do I have to avoid in order to prevent a recurrence?
- Avoidance of heavy or repetitive bending stooping and lifting tasks can
help to minimize the reoccurrence of a lumbar disk herniation.
- Interestingly, after many decades of study, the only clear predictors of
disk recurrence are the initial size of the disk herniation at surgery,
and the amount of disk material removed at surgery.
- In other words, very large disk herniations recur more often than small
ones. Removing more disk material at surgery decreases the recurrence
rate at the expense of slightly increasing the amount of postoperative
low back pain.
When can I have sex again?
- Let the wound heal first. Keep the wound off the bed. Use some common sense
(sometimes hard in matters of the heart, but really...)
What kind of anesthesia is used?
- General anesthesia is the preferred method of anesthesia at Hoag Orthopedic
Institute for outpatient spinal surgery. It is safe and well-tolerated
with a minimum of side effects.
What sorts of things should I do in preparation for surgery?
- Quit smoking if you do smoke.
- Minimize the use of narcotic medications.
- Minimize alcohol use.
- Make sure your diabetes or blood pressure or heart medications are up to date.
- If required, get your preop medical evaluation as soon as possible.
- Get informed about the procedure.
- Plan your postoperative regimen of appropriate diet, exercise and ergonomic
modifications at home and work.
How many of these microdiskectomies have you done?
- I’ve been in practice doing nothing but spine surgery since 1987.
I average 250 spine procedures per year or more. It is common for me to
do between 100 and 150 lumbar diskectomies a year. I estimate I’ve
done more than 2,000 microdiskectomies.
I want a second opinion.
- Our favorite patients are those who are comfortable with their physicians,
understand the nature of the surgery being recommended, and who feel their
questions have been adequately answered. We understand that when faced
with a spine surgery many patients want other opinions and we encourage
this practice. We can provide the names of other spine professionals in
the area who we believe offer the same level of expertise that we can offer.
Do I need a fusion with a discectomy? This is a recurrent disk herniation
I now have after the first surgery. What is different about the approach
towards surgery in this case?
- More than 90% of spine surgeons (including me) polled recently by the North
American Spine Society report that they “never” perform a
fusion at the time of a microdiskectomy for disk herniation.
If there is a recurrent disk herniation requiring surgery, the vast majority
of spine surgeons will perform a repeat microdiskectomy at the time of a
first recurrence of a disk herniation. Most will fuse a vertebral segment if
the disk herniation recurs a
second time. In other words, the first two disk herniations are treated with
microdiskectomy, the third with a fusion. On occasion these rules will
be bent depending on the type of findings and symptoms - back vs leg pain,
degree of degeneration and/or instability seen on MRI.
What’s the difference between a neurosurgeon and an orthopedic surgeon
in the field of spine surgery?
- The short answer is NOT MUCH if the surgeons are trained in SPINE. Orthopedics
and Neurosurgery share responsibilities in spine surgery, although most
spine surgery in the United States is done by Orthopedic Surgeons with
subspecialty Fellowship Training in Spine Surgery. We recommend that spine
surgery be performed by surgeons whose practice is exclusively devoted
to spine surgery. This is a trend that has been reinforced in the last
fifteen years in the USA because, given the complexity of spinal surgery
even as compared to brain surgery, better outcomes are seen with surgeons
whose only focus is spine surgery. We recommend that ALL spine surgery
be performed by surgeons who have passed the American Board of Orthopedic
Surgery specialty examination in Spine Surgery (or the equivalent in Neurosurgery).
Whether your surgeon began his or her training as an Orthopedic Surgeon
or a Neurosurgeon, the important issue is the additional training requirements
to be subspecialty-trained in spine surgery. Generally speaking, the notion
that “a Neurosurgeon is somehow better acquainted with nerves”
is an antiquated idea, and with no disrespect to my neurosurgical colleagues.