Anterior Cervical Discectomy & Fusion :: Posterior Cervical Laminectomy :: Lumbar Laminectomy :: Lumbar Microdiscectomy :: Lumbar Decompression & Fusion :: Fusion for Scoliosis :: Pedicle Subtraction Osteotomy
Back pain caused by ligament or muscle strains can often be relieved with rest, medication, or physical therapy. However, back pain associated with numbness, tingling, pain, or weakness in the legs may indicate compression of the spinal nerves. This condition is more serious than a strain and may not improve without surgery.
Before surgery is recommended, several tests are performed to determine the exact cause of your back and leg pain. Tests may include X-rays, MRI scan, CT scan, EMG test or myelogram. If these tests show that you have significant arthritic changes in your spine and compression of the spinal nerves, you may need surgery to relieve your symptoms if treatment with physical therapy & spine injections has not been successful.
An operation to join separate bones in the vertebral column with a solid bridge of bone is called a spinal fusion. The healed fusion stabilizes the spine by stopping the painful motion of the vertebrae that happens as parts of the spine begin to wear out. In addition to the fusion, using screws and rods to initially stabilize the spine offers unique advantages. They improve the success rate of the fusion and post-operative comfort may improve because the screws and rods halt painful motion immediately.
As the discs, ligaments, and joints in the spine begin to show significant wearing, normal positioning of the vertebrae may also change over time. A spinal deformity occurs when one or more vertebrae shift out of normal position. The deformity changes the delicate balance of how the pieces of the spine work together. A spinal fusion with placement of screws and rods can prevent a spinal deformity from becoming worse and allow for better correction of the deformity.
Details Of Surgery
The goals of this operation are to free up the nerves that are being pinched (called “decompression”) and to obtain a solid fusion at one or more levels to provide stability to your spine. The surgery is usually more helpful for nerve pain (leg pain) than back pain but many patients report improvement in back pain after the recovery period.
The first step of the surgery is to expose the bones in preparation for the work that will be done. The second step is to take pressure off nerves that are pinched (this is called a decompression). The third step is to insert pedicle screws and rods to stabilize the spine. In some cases, a cage may be inserted into the space between the vertebrae (after the disc is removed). Bone graft is then placed between the vertebrae being fused. This is the fusion part of the surgery. The wound is then closed and the surgery is completed.
As with any surgical procedure, there are potential risks to this operation. Risks of the operation include, but are not limited to: anesthetic complications, bleeding, risks of transfusion, injury to the nerves, weakness, loss of bowel and bladder control, dural tear, incomplete resolution of pain, failure of the fusion, failure of the implants, possible need to remove the implants, and dislodgement of the implants. These complications are uncommon, and many precautions are taken to prevent or minimize risks but because human biology is at times unpredictable, no surgery is risk free. The most common complication is a dural tear, especially if you have had previous surgery on your back. If a dural tear does occur, I will repair it during surgery, and after surgery you will remain flat in bed for a few days (usually 2-3 days, sometimes longer depending on the size of the tear). The reason we keep you flat in bed is to eliminate gravity and thus allow the repair to heal. There are no longterm sequelae from a dural tear if it is treated appropriately, but it will change your postoperative care for the first few days after surgery, the main change being the flat bedrest. Medical problems may include pneumonia, blood clots, heart attack, and stroke. You must see your primary care medical doctor prior to the surgery to help minimize these complications.
Please note that smoking prevents fusions and soft tissue from healing because it decreases blood supply to the fusion area. I strongly advise you to stop smoking prior to the surgery and during the healing process. Smoking will have a significant negative impact on your healing process and ultimately, the outcome of the operation. The healing process lasts up to one year.
Preparing For Surgery
- About 2-4 weeks prior to your surgery, you should see your primary care physician for a complete medical examination and for “medical clearance”. Your doctor may order tests prior to your surgery to evaluate your risk of being put under general anesthesia.
- If you take the following medications, stop taking them for 1 week prior to surgery:
- Aspirin, anti-inflammatory drugs (Ibuprofen, Advil, Motrin, Aleve, Naprosyn, Celebrex, Mobic, Arthrotec, Voltaren, etc.), Vitamin E and Glucosamine, all prescription diet medications or herbal supplements
- If you take Plavix, Persantine, Ticlid, stop these medications 1 week prior to surgery but be certain to notify your primary care physician or cardiologist before you stop taking these medications.
- If you take Coumadin for any reason, you should stop taking Coumadin 5 days prior to surgery, but be certain to notify your primary care physician or cardiologist before your stop taking this medication to ensure it is safe for your situation.
- YOU SHOULD CONTINUE all other medications that you normally take.
- Please let me and the anesthesiologist know about alcohol use. If you drink more than 2 alcoholic beverages a day, you may experience withdrawal symptoms after surgery. Symptoms may include mild shakiness, sweating, hallucinations and other more serious life-threatening side effects. Interventions can be taken before surgery to minimize withdrawal symptoms.
- Do not eat or drink anything (including water) after midnight the night before your surgery.
- You should make plans to have some assistance at home after your surgery. The level of assistance you need depends on the extent of the surgery, your age, and general health.
You should arrive at the hospital at least 2 hours before your scheduled surgery time. I will see you before you go back to the operating room to answer any additional questions you may have. You will then be taken back to the operating room where the anesthesiologist will give you a general anesthestic. The duration of the operation is variable depending on how many levels need to be fused and the severity of nerve compression.
After the surgery, you will be taken to the recovery room where your blood pressure, temperature, pulse and respiration will be checked frequently. The nurses will also give you enough pain medication to make sure your pain is under control. You will stay in the recovery room for one to three hours. Meanwhile, I will speak with your family or friends in the waiting room regarding your condition and the details of the surgery. You will then be transferred to a regular hospital room. Your family and friends are welcome in your room at this time.
You will be given IV fluids until you are able to drink on your own. You will also be given IV pain medication initially, and then oral pain medication depending on your level of pain. Most patients will have a PCA (patient controlled anesthesia) pump after surgery. This machine is set up so you can get a prescribed amount of pain medication at intervals by pushing a button. You will also receive oral pain medications. This medication is on an as needed basis. Keep in mind that after back surgery, pain is expected but it should be under control and tolerable. If you feel your pain is excessive, please ask your nurse to call me so I can adjust your pain medications.
Most patients are helped out of bed by the nursing staff on the day of surgery or by the next morning. After surgery, it is very important to get out of bed and start moving as soon as possible, ideally the day after surgery. You will have pain in your low back from the surgery which we will control with pain medications. Lying in bed for a long period of time can lead to blood clots forming in your legs and may predispose to complications such as pneumonia. To prevent these complications, you should make every effort to get out of bed the day after your surgery. Physical therapists will provide instructions on the proper ways to move around after surgery. The therapists will also assess your needs for medical equipment to be used at home.
Your wound drainage will be monitored closely. The drainage tube and original dressing are typically removed by the second day after surgery. A new dressing will be placed over your incision. When you return from surgery, you may have a drainage tube (Foley catheter) in your bladder that is connected to a collection bag. This is typically removed on the first day after surgery. Once you are able to drink, eat, and take your pain medication by mouth, your IV line will be removed. Most patients can go home 2 to 4 days after surgery. You will be discharged from the hospital when the following goals have been met:
- Your pain is reasonably controlled with oral pain medication
- You are able to eat a meal without nausea or vomiting
- You are able to walk safely on your own
- You are able to urinate on your own.
- Your vital signs (temperature, blood pressure, heart rate, respiration) are normal.
Depending on how soon the above 5 goals are met, some patients are able to go home two days after surgery, while others require up to 4 days.
A social worker will assist you with planning for discharge after surgery. If you go home, you may be a candidate for in-home therapy and a skilled nurse visit. The social worker will assist in selecting a home care agency that is covered by your insurance. Certain criteria must be med to be eligible for homecare services.
Some patients need to go to a rehabilitation facility (skilled nursing facility or “SNF”) after they leave the hospital. The physical and occupational therapists will assess your ability to ambulate and perform your activities of daily living while you are in the hospital. If you are not safe to go home, or if you do not have adequate help at home during your recovery period, you will be taken to a rehabilitation facility for a short period of time until you are able to care for yourself at home. Your stay in rehab can be from a few days to several weeks, depending on your specific situation. If you wish to, you may want to tour 2 or 3 facilities before your surgery so you can select a facility that meets your needs when you are discharged from the hospital. Again the social worker will provide a list of skilled facilities that are covered by your insurance and will assist you in making arrangements for a short stay.
Although the nerve has been freed, it is still injured. The pain, numbness, or tingling in your leg usually begins to improve shortly after the surgery. In some cases, it may take several days before an improvement is noticed. Occasionally, it may even take a few weeks before the symptoms show a notable improvement. Nerves heal very slowly. It is common to still have some numbness, tingling, or discomfort for several weeks after your surgery. Every patient experiences this healing process differently.
At Home After Surgery
The post-operative instructions outlined below will give you the best possible chance of having a positive outcome from this surgery:
- Take short walks as your comfort allows. You can start walking the morning after your surgery. Gradually increase the amount of walking you do each day. Walk 15-30 minutes three times a day. Your goal is to walk 1 mile by end of the first month after surgery
- Avoid bending over at the waist, twisting or bending motions for the first 6-8 weeks. Do not bend over to tie your shoe laces. Also avoid lifting anything heavier than 20 lbs for the first 6 weeks
- Avoid all strenuous activities for 3 months. Do not lift heavy bags or luggage
- Wound care:
- On the second day after your surgery, you can take a shower but keep your incision covered with gauze and Tegaderm dressing to keep the incision dry. After showering, pat the incision dry and cover it with a new dressing.
- Keep your incision covered with Tegaderm dressing for 1 week when you take a shower. After that, you can shower without anything covering your dressing as long as there is no drainage from the incision. Do not take baths or soak your incision (swimming, etc.) until your wound is fully healed, usually at around 3 weeks.
- Do not apply any lotions or creams to the incision.
- Reasons to contact us immediately:
- If there is any redness around the incision
- If there is any drainage from the incision after the second day.
- If you have a fever higher than 101 deg F.
- If your leg pain or numbness is significantly worse than before surgery. You should expect some pain and stiffness in your low back from the surgery. This improves with time as the wound heals.
- If you have any problems with bowel or bladder function, you should go to the emergency department right away.
- Returning to work depends on your occupation and your employer’s acceptance of your activity restrictions.
- No driving for 4-6 weeks after surgery depending on your level of pain and weakness. You may drive when you no longer require pain medications.
- You may resume sexual activity as your comfort allows. Please keep in mind the activity restrictions listed above.
- I will see you in the office 2-3 weeks after your surgery. If you do not have an appointment, please contact the office.
- Three months after surgery, you will begin physical therapy. The therapist will help you strengthen your back muscles with back exercises. These exercises should be part of your lifelong fitness program. The therapist will also teach you about doing everyday tasks with proper body mechanics. This exercise program is a critical part of your recovery.
- Fusions heal slowly. It can take up to one year for a spinal fusion to fully heal. You will need to see me periodically in the office during this healing period. I will check your progress with X-rays at each of your follow-up appointments.