Wichita Mountain
Neurosurgery & Spine

Lumbar Spinal Fusion

David M. Pagnanelli, M.D.

A patient is a candidate for a fusion when they have severe mechanical back pain that has been refractory to non-operative treatment. This may be present when there is severe degeneration of a disc, slippage of the vertebrae, or general instability. To fuse a spinal level, the vertebra above and below the level are linked together so as to allow a boney bridge to develop.

Mechanical, discogenic low back pain that has failed conservative care has traditionally been treated by lumbar fusion. Fusion procedures have evolved over time. Fusions were initially performed through a posterior approach. This posterior procedure required the dissection of the paraspinal musculature off the bone elements. The dissection caused significant muscle injury and is informally known as “fusion disease.” The muscle damage is caused by direct compression of the muscle tissue by the retractors and is analogous to a tourniquet applied to the muscle of an extremity. This compression and damage causes decreased arterial inflow and decreased venous outflow to the muscle capillary beds with resultant microvascular and metabolic changes in muscle tissues. Also, the blood supply to the muscles is traumatized, and the nerves supplying the muscles damaged.

Spinal instability and disc-related back pain may interfere with a patient’s quality of life, making procedures such as posterior lumbar interbody fusion (PLIF) or transforanimal interbody fusion (TLIF) necessary. These procedures are often performed in conjunction with pedicle screw fixation, which has been recommended as safe and efficacious for many spinal conditions. Standard spinal stabilization surgery requires a 4-in to 6-in incision and stripping of the paraspinous muscles away from their attachments to the spinous processes, laminae, facets and transverse processes. In contrast, use of the minimally invasive (MIS) techniques allows the surgeon to perform these surgeries in a muscle-sparing, minimally invasive fashion through two paramedian, 1-in incisions.

Not everyone is a candidate for a MIS fusion. There are several techniques available, and I will determine the one suited to you.

How It’s Done

The incisions vary, but basically are two paramedian incisions, about 1-1.5 inches long. Each pedicle screw is placed through the incisions, using a series of dilators. The screw is placed through the last dilator.

This procedure is performed for placement of all necessary screws.

Next an interbody graft(spacer) is placed. This is insertion of a structure into the disc place, between the levels that have screws. This will promote growth of bone between the vertebrae, and provide the actual “fusion.”

The interbody spacers can be made of bone, titanium, or a plastic called PEEK. I generally fill the grafts with a bone growth stimulant and some bone fragments removed at the time of surgery.

After the interbody spacer is placed, the screws are put into proper position. This is accomplished through the small incisions and with real time x-ray imaging. A screw is generally placed on each side of each level involved in the fusion.

	A rod is passed through the heads of the screws using a sophisticated arc that is applied to the screw heads. This avoids the necessity to make a large incision.
Screws have been placed into each vertebra in question, and connected with small rods.

Possible Complications:
• Significant complications can accompany a lumbar fusion whether it is performed from the front or the back.
• Untoward effects of anesthesia
• Bleeding or hemorrhage with the possible need for blood transfusions
• Nerve root injury that could result in paralysis, loss of feeling, or loss of bowel and bladder control
• Infection
• Spinal fluid leak
• Blood clots in the veins of the legs or pelvis
• Pulmonary embolus
• Tear in the covering of the nerves with leaking of cerebrospinal fluid
• Injury to blood vessels
• Injury to bowel or ureters
• Pseudoarthrosis- failure of the fusion to take place. Successful fusion may not be able to be determined for over one year
• Impotence due to retrograde ejaculation in which sperm goes into the bladder (ALIF)
• Prolonged ileus, a condition in which the bowel stops functioning
• Pain from the bone graft donor site
• Dislodgment or backing out of the implant
• The possibility of unforeseen complications

IN THE HOSPITAL
Pain Control - Most patients are placed on a PCA pump (patient controlled analgesia). When pain is present, push your pump button to get immediate delivery of medication. The pump prevents overdosing, even if you push the button more than you should. If pain is still present, additional pain medication is available. At the appropriate time, pain pills will replace the PCA pump. There will always be more pain medicine available if you have pain.
Eating - For most surgeries involving the back part of the spine, patients begin drinking clear liquids the night of surgery. Over the next few days, a regular diet is resumed when we are sure you are tolerating liquids first. For patients requiring surgery from the front of the spine (through the side or through the abdomen), it often takes 1 - 3 days to regain bowel function and be ready to eat. Eating too soon can cause nausea and vomiting since the stomach and the intestines have not fully awakened from surgery. If you are able to eat regular food, friends and family may bring in food from outside the hospital
Walking - Unless specifically instructed, you should plan on getting up and walking the day after surgery. Physical therapists and the nursing staff will help you. You may require a walker at first to keep your balance safely. As soon as you don't need the walker, you can walk on your own. Plan on walking three times a day, increasing the distance as you are able.
Bowel Movements - Since the bowels are slowed by surgery and some of the pain medicine, it takes time to get them going again. You will be placed on a daily stool softener pill, and you may be given a suppository to help get things going. In some cases, an enema may be required. Things which you can do to help your bowels awaken quicker include sitting up in a chair several times during the day, and going for at least two walks a day. The more you are up, the faster you will get back to a normal bowel schedule. Be aware however that it may take up to 2 weeks to get back to a normal bowel routine.
Length Of Hospital Stay - Most patients are ready to go home from 2 - 4 days after surgery, depending on what was done in surgery and your general health. The more motivated patients are, the faster the recovery tends to be.
Going Home or to a Rehabilitation Center? - When you are ready for discharge from the hospital, a decision will be made as to your immediate needs. If the hospital's physical therapist considers you independent, or if you have help at home, you will be released to go home. A visiting nurse or therapist may be requested by your physician to visit you at home on a daily basis for a few weeks, if it is covered by your insurance plan. For patients who still require additional therapy before they are independent, or for those without any help at home, discharge to a rehabilitation center or skilled nursing unit may be appropriate. At the care center, the focus will be on physical therapy and becoming independent.
THE FIRST TWO WEEKS AFTER SURGERY
Help at Home - For patients going home, it is very reassuring to have someone there who can physically help and provide positive emotional encouragement for the first few to several days. Help is most often needed with making meals, getting in and out of bed or a chair, and with bathroom and bathing activities. Some patients do not need the help, while others require assistance with bathroom and bathing activities for a few weeks. Plan accordingly.
Pain control - Strong narcotic pain medication is used immediately after surgery for the first two weeks. After that, you will slowly be weaned to a lesser strength pain medication. Often, additional medication will be prescribed along with the pain pills to "boost" the effect and pain relief. Patients who follow our pain medication recommendations will not become addicted. We will make certain.
Eating - It is common to have a decreased or absent appetite after major surgery. However, it is very important to begin eating a normal diet as soon as possible after surgery. A large number of calories are needed to heal a large surgery such as spinal fusion, and to prevent infection. This is not the time to go on a diet! Try several small meals and snacks until a healthy appetite returns.
Bowel Regularity - For the first few weeks after surgery, it is very common to have some constipation. This is usually caused by the narcotic pain medicine used to control your pain, and from the general anesthetic used to put you asleep for surgery. If you continue to sit up several times a day and walk at least three times a day, thing will get back to normal. You may have to continue an over-the-counter stool softener such as Colace for a few weeks, and you may require an occasional enema. Ask your family doctor or call our office if you have any questions or concerns.
If you have been asked to wear a brace, you need to learn to use the bathroom with the brace on. Wiping your bottom is a challenge but can often be managed by slightly loosening the brace. You may require help with keeping your bottom clean, if you have to wear a brace.
The Incision - This is easier than you may think. Your incision was closed with self- dissolving suture. There are no staples or stitches to remove. You will notice that under the dressing are "steri-strip" tapes on the incision edges. Do not remove the "steri-strip" tapes that hold the skin edges together. They will begin to peel off all by themselves after a week or two. If they are still there after 3 weeks, you can peel them off if you like.
Please do not put any salves, vaseline, neosporin ointment, vitamin E, aloe vera, or anything else on it during the first 3 weeks. You may keep it covered with a clean light bandage for the first week, but actually no dressing is needed.
It is not uncommon to have a small amount of clear yellow fluid drainage from the incision. This should decrease in amount daily and should be completely dry by one week. If you notice any drainage beyond a week, any increase in drainage, or drainage which becomes cloudy (pus), or if the edges of the incision become red, please call us immediately. If you have any concerns about your incision, it is better to call.
Showering - If you want to shower during the first week, tape plastic over the incision to keep it dry. After the first week, you do not need to put anything on the incision. An alternative to showering is to sponge bath for the first week.
Avoid bending in the shower. Make sure the soap, shampoo, etc is within reach while standing. Have someone else wash your legs, dry your legs, and shave your legs (if you are so inclined). Some people are more comfortable with an elevated bar stool to sit on in the shower.
No baths yet. It is too much stress on the fusion to get in and out of the tub. You can take a bath after 3 - 5 months, depending on your surgery.
Walking - Plan to take at least 3 slow walks each day. The distance you walk should slowly increase. No matter how good you feel, do not walk more than 1/2 mile at a time. This is the time to let your spine heal, not to exercise.
Activity Level - Avoid bending, stooping, kneeling, crawling, and lifting more than 5 - 8 pounds. Try not to spend the entire day laying down. The more you are up, the better your appetite, digestion, circulation, lung function, and mental attitude will be. Sitting is permitted and encouraged. Lay down to rest when you need to.
It is too soon to exercise. The fusion must have a chance to heal without stress. For this reason, walking is the only form of physical activity permitted. It is too soon for swimming.
You can go for short trips in the car as a passenger. It is too soon to be driving though.
WEEK 2 - 6 AFTER SURGERY
Help at Home - The need for assistance with the activities of daily living becomes much less between weeks 2 and 6. Patients become more independent with personal care, food preparation, getting the brace on and off, and moving around the house. Assistance in the bathroom is sometimes still needed, however. Most patients do not need constant assistance at home after 6 weeks. Family, neighbors, or friends who stop by or call once or twice a day is usually sufficient.
Pain control - Pain medication is safely used as needed during this time. Post-operative pain from the surgical procedure is much less by 4 - 6 weeks and the need for narcotic pain medications decreases. Often by 6 weeks, people are taking only a rare pain pill, and managing their pain primarily with extra-strength tylenol or something similar. In some cases, pain pills are needed up to 3 months. After 3 months, we want our patients off narcotic pain pills and taking over-the-counter medications such as tylenol for pain.
The incision - The incision should be completely dry. Dressings are no longer required. If the steri-strips are still present, peel them off. You do not need to cover the incision when you shower. After 4 - 6 weeks, if you really want to put lotion, salve, or vitamin E on the incision, it is safe to do so. We do not know of any value from such topical treatments, however. The size and thickness of your scar is related to your body's scar forming tendencies, not which lotion you apply.
The incision will be a pink to light red line. The color of the scar will fade to normal skin tone after several months.
Walking - Start increasing your slow and casual walking. You can now walk up to a mile at a time, so long as you do it slowly. This is NOT power-walking. It is meant to maintain baseline muscle tone and circulation, and help your mental attitude. It is not meant to be exercise.
Activity level - Continue to avoid bending, lifting > 10 lbs, stooping, crawling, and kneeling. Short rides in the car are permitted. If you are still using a walker and feel stable, consider switching to a cane.
Back to School - For children and teen-agers of school age, plan to be back in school in 3 weeks. No carrying more than one book at a time, and no back packs.
Sex - After 3 weeks, sexual activity can be resumed. It is advised that you assume the role of being a passive partner on the bottom. This will decrease the stress across the healing spine fusion, and will avoid back pain. If sex is painful, tell your hopefully understanding partner that you need to stop. After 3 months, your fusion should be solid enough to allow you to become more active. After 3 months, there are no restrictions.

WEEK 6 - 12 AFTER SURGERY
Activity Levels - Now is the time to start doing a bit more than you have been doing. Walking can be increased to up to 2 miles a day. You can begin to walk at a faster pace to where you become slightly "winded".
Bending, stooping, crawling, kneeling, and lifting are still avoided, though may be done on rare occasions if needed. Limit your lifting to 10 - 15 pounds. If you are wearing a brace, you still must wear it when ever you are up.
You may travel for long distances if you want. This includes air travel.
Driving - You may begin driving for short trips.
Work - Some patients want to get back to work as soon as possible. It is safe for you to return to work on a part-time or full-time basis if you feel up to it. This must be sedentary or light duty work. You must still adhere to the activity guidelines (no lifting, etc.) and wear your brace as directed.
Office Hours

Our office hours are Monday through Friday from 8:30 AM to 4:30 PM. We ask that you call between these hours with your questions, concerns, prescription refill requests, etc. As a surgeon, I am frequently in the operating room and therefore unable to be available during all office hours.

Prescriptions

All prescription refills and changes must be requested during office hours. We advise patients to monitor their need for refills so that refill requests can be made during your office visit.

Emergencies

We understand that emergencies arise. If you feel that it is absolutely necessary to speak with your doctor during non¬-office hours, our answering service is available, by simply dialing our office telephone number listed below. We ask that this service be reserved only for emergencies.

Office Phone 580-531-4600