Preparing For Lumbar Fusion Surgery

Surgery of any kind is a big deal, let alone when it's on your spine. Here's a step-by-step look at what to expect before, during, and after lumbar fusion surgery.

There are many specific spinal fusion techniques employed by orthopedic surgeons to correct spinal problems. In general, spinal fusions involve placing bone or bonelike material within the space between two spinal vertebrae. They make sure the vertebrae hold together by using a combination of metal plates, screws, and rods. Eventually, the vertebrae heal into one solid unit.

Spinal fusions have benefits, risks, and potential complications. Your health care provider will consider many different factors when making the decision to recommend surgery. They’ll want to know whether you have other conditions, like rheumatoid arthritis or osteoporosis, and whether you have a history of smoking. Your health history helps them evaluate your risk of complications.

In turn, you should ask your health care provider as many questions as you need to. It’s important to make sure the most appropriate procedure is chosen to address your underlying spinal conditions, taking into account your lifestyle demands.

The goal of spinal fusion surgeries is to stabilize your spine and help you regain function and reduce pain. It’s necessary when two spinal vertebrae have slipped out of the correct anatomical position or have degenerated. Conditions that are associated with these situations include:

• Spondylolisthesis: When one or several vertebrae slip out of place in relation to the other vertebra. It’s often linked to osteoarthritis.

• Scoliosis: An abnormal curvature or twisting of the spine.

• Spinal stenosis: A narrowing of the spaces in your spine, which can compress your spinal cord and nerves.

• Herniated discs: When the discs between the vertebrae become compressed and bulge outward.

Before coming to the hospital for surgery, you can do some things to prepare your home to make your recovery easier, such as:

• Place the telephone or your phone charger in a convenient area, such as near the bed or a chair.

• Prepare food or purchase easy-to-prepare foods.

• Move food, pots, pans, and other cooking utensils to high shelves or counter tops so you can avoid bending to reach them.

• Identify a person who will be able to help you with shopping and other chores.

• Place shoes, clothing, and toiletries at a height where you can reach them without bending.

• Remove or secure any throw rugs so you won't trip over them.

• Think about what changes you'll make if you need to stay on one floor of your home.

Equipment Needs

Some people may be fitted for a brace before surgery. This brace is an important part of your recovery process.

Your therapist and doctor may also prescribe several types of medical equipment to help you in your recovery. Insurance coverage for equipment varies from one company to another and may change over time. You should check with your insurance company to find out if you have coverage for durable medical equipment (DME), such as a walker or commode, so you can prepare for any co-pay or equipment that may not be covered.

The home-care coordinator will help order the equipment and verify your insurance coverage. Your medical equipment will be ordered a few days before your discharge and delivered to your home. Equipment may include:

• Walker

• Elevated commode or toilet seat extender

• Tubseat, bench, or chair to use in the bathtub or shower

• Long-handled reacher

Hospital beds are necessary only for patients with specific medical needs and must be prescribed by your doctor.

Medication

Stop taking any prescribed or over-the-counter nonsteroidal anti-inflammatory medicines (NSAIDs), such as ibuprofen and aspirin, two weeks before your surgery. If you aren't sure which of your medications are NSAIDs, check with your doctor or pharmacist.

Once your NSAIDs are discontinued, you may take extra-strength Tylenol for pain relief. If this does not relieve your pain, call your doctor for other pain-relieving medicine.

If you take aspirin or Coumadin for a heart condition, or blood thinners, please contact your doctor for further instructions.

On the day of surgery, please bring a list of your routine medications with you to the hospital.

Stop Smoking

If you smoke, it is important that you stop smoking for at least two weeks before your surgery and for six weeks after your surgery. Studies have shown that smoking interferes with healing of your bone graft.

Preadmission Testing and Evaluation

Your orthopaedic doctor may ask you to visit a medical doctor to be sure you have no health problems that could interfere with your surgery. The medical doctor will confer with your family physician or internist about any specific medical problems you may have. He or she will also follow your medical status after your surgery.

Your doctor's office will schedule your appointment for a preadmission evaluation, which may include some or all of the following:

• Medical history and physical examination by a nurse practitioner

• Anesthesia interview

• Blood and urine tests

• Electrocardiogram

• Flexion and extension spine X-rays/chest X-ray

• Patient teaching

Blood Donation

Blood donation is available for patients interested in giving their blood and having it held for their own use during and after the operation. About two to four weeks before your surgery you can donate units of your blood, one week apart. You can donate your blood at your local American Red Cross. Your doctor will give you a prescription for this.

You will need to take one iron tablet twice daily, starting one week before your first blood donation. Continue taking the iron until you come to the hospital. You can purchase the iron tablets over the counter at your local pharmacy without a prescription. We also recommend that you take one multivitamin daily during the two weeks before surgery.

Evening Before Your Surgery

Between 4 and 9 p.m. the evening before your admission, a member of the hospital scheduling staff will call you to confirm your procedure and tell you what time to come to the hospital. Inform staff of any change in your health such as a fever or cold.

It is important that you do not eat or drink anything after midnight the night before your surgery. If you are to be admitted the morning of your surgery, do not eat any solid foods after 9 p.m. or drink any liquids, even water, after midnight. Your doctor may advise you to take an enema the evening before surgery.

You should also remove your rings, including wedding bands, the night before surgery, as your fingers may be swollen in the morning.

What to Bring to the Hospital

For your comfort, you will want to bring your own toiletries to the hospital. Also pack underwear and comfortable, loose pajamas or nightgowns. You will also need a robe (not floor length), and slippers or soft, low-heeled shoes with closed backs, such as sneakers, walking shoes, or loafers. If you will be wearing a brace after surgery, bring cotton T-shirts with you to wear under your brace.

Do not bring any valuables to the hospital. If you have equipment such as a walker, commode, or long-handled reachers, you may want to have someone bring them in for you after surgery. If you do bring your own equipment to the hospital, label the items with your name.

Morning of Your Surgery

Most patients are admitted on the morning of surgery and should report to the admission unit to be prepped. Check in advance with the hospital on how many visitors may come with you on the morning of your surgery.

To prepare for surgery, the nurse will ask you to remove your clothing and to put on a hospital gown. In addition, you should remove any contact lenses, dentures, wigs, hairpins, jewelry, or artificial limbs. Please give these and other personal belongings to your visitors to hold while you are in surgery and until you are in your assigned room. You will be asked to go to the bathroom to empty your bladder before you leave your room.

An escort will transport you to the operating room on a stretcher about an hour before your surgery is scheduled. At that time, the nurse will direct your visitors to the surgical family waiting area. When the surgery is over, your doctor will phone your visitors there.

Before entering the operating room, an anesthesiologist will ask you a few questions and begin an intravenous line in your arm. Antibiotics will be started intravenously and continued after the operation to help decrease the risk of infection.

Once you are in the operating room you will be given the anesthesia that you and the anesthesiologist have discussed. Your surgery will take several hours. This time frame includes the skin preparation, positioning, and anesthesia time. Some patients require spinal monitoring called somatosensory evoked potentials (SSEP) during the procedure to help protect their spinal cord and nerves during the operation. If you are having SSEP, a technician will place adhesive electrodes on your body.

How Spinal Fusions are Performed

There are several different types of lumbar spinal fusion techniques. Each of these techniques aims to fuse one or more vertebrae and stabilize the spinal segment, but the approaches taken vary. These include:

• Posterior lumbar interbody fusion (PLIF): The surgeon makes an incision in the patient’s back and removes the affected spinous process, facet joints, or degenerated disc. Then, they add metal and a bone graft to fuse the vertebrae to make them stable and reduce pressure on compressed nerves.

• Transforaminal lumbar interbody fusion (TLIF): The surgeon makes an incision in the patient’s back or side, thus allowing less invasive and more exact access to the disc space.

• Oblique lumbar interbody fusion (OLIF): The surgeon makes an incision in the patient’s side. Compared with PLIFs and TLIFs, this is considered a minimally invasive procedure, since it doesn’t require removal of spinal muscles.

• Lateral lumbar interbody fusion (LLIF): This approach is similar to OLIF. The surgeon makes an incision on the patient’s side rather than the back. With this approach, the surgeon can reach the vertebrae and intervertebral discs without moving the nerves or opening the muscles in the back.

• Anterior lumbar interbody fusion (ALIF): The surgeon accesses your spine through your abdomen (stomach). While this doesn’t require the surgeon to move spinal nerves, it does require organs and blood vessels to be moved to the side. This typically requires the assistance of a vascular surgeon.

Potential Complications of Spinal Fusion Surgery

No matter which surgical technique is used to repair lumbar spine issues, there’s always the possibility of complications during and after the procedure. Some of these include:

• Anesthesia complications: Some people have bad reactions to anesthesia or may experience breathing difficulties associated with anesthesia. High blood pressure and other heart-related conditions may increase the risk of complications.

• Thrombophlebitis: Some people develop blood clots in the deep veins of the legs, causing swelling and pain. If a blood clot becomes loose, it may travel to the lung and lead to a pulmonary embolism.

• Infection: The incision site can get infected, as can the spinal cord and vertebrae.

• Hardware fracture: Fusion operations typically involve using metal screws and plates, which occasionally fracture. If they do, it can require more surgery to fix the issue.

• Implant migration: Sometimes an implanted device, such as a plate, rod, or screw, fails to stay in place and moves to another part of the body.

• Pseudoarthrosis: If there is not enough bone formation to create a solid fusion, it can lead to complications.

• Spinal cord or nerve injury: There is a risk of damaging the nerves exiting the spine or the spinal cord itself.

• Persistent pain: While many fusion procedures significantly reduce pain, some procedures are not successful, so a patient may still experience residual pain.

• Transitional syndrome: After a fusion, when other segments of the spine take on more of the stresses and loads from doing everyday tasks, it can lead to more wear and tear on the adjacent vertebrae.

In some severe cases, multiple vertebrae may need to be fused to restore stability.

After surgery you will awaken in the Post-Anesthesia Care Unit (PACU) or recovery room. Recovery from anesthesia usually takes an hour and a half to two hours. There, the nurse will frequently monitor your vital signs (heart rate, blood pressure, temperature, and respiratory rate). The nurse will also be checking your dressing and the circulation as well as movement in your toes and legs. A surgical team member will notify your family when the surgery is over.

Hospital Care

Each patient's procedure and recovery is different, although the usual hospital stay for lumbar spinal fusion surgery ranges from two to five days. Most patients will be discharged home but some may go to a rehabilitation facility before returning home. Each patient will be evaluated during the hospital stay to determine if he or she needs rehabilitation.

If you will be returning home, your doctor may ask the home care coordinator to arrange for a visiting nurse and/or therapist. If you will be going to a rehabilitation center, the social worker will coordinate your transfer.

The goal of your care after surgery is to help you become independent so you can return home. By discharge, you should be able to:

• Get in and out of bed by yourself

• Walk the hallway with or without a walker

• Climb stairs, if needed at home

• Bathe and care for your personal hygiene

• Understand all instructions for your recovery

To help you reach these goals, the staff will help you as needed, but they will also encourage you to actively participate and do as much for yourself as possible. Patients usually remain in bed the day of surgery but are encouraged to walk with assistance the first day after surgery. You will be helped getting out of bed and will begin your activity program in your room the day after surgery. The activity program includes leg exercises, walking, stair climbing, and activities of daily living such as bathing, dressing, and home management.

Transportation Home

You may travel home from the hospital by car, either reclining in the front passenger seat or lying down in the back seat. You must arrange your own transportation.

Recovery could take three to four months, and sometimes longer. To get the greatest benefits from a spinal fusion surgery, this period is crucial. Here are some important things to keep in mind:

• Keep your incision area as clean as possible.

• Call your provider if any of the following happens around the incision site:

  • It becomes redder

  • Becomes more swollen

  • Is draining fluid excessively

  • Feels warm to the touch

  • Begins to open up

• Keep your incision dry for the first week. You may want to enlist help with showering from someone you trust.

• Avoid smoking or consuming tobacco products.

• Avoid sitting for more than 20 to 30 minutes at a time.

• Sleep in any position that does not cause back pain.

• Discuss with your surgeon safe sex practices.

• If you’ve been prescribed a brace, use it as directed by your surgeon.

• When picking up items, use your knees to avoid bending at the waist.

• Don’t lift or carry anything heavier than 10 pounds (4.5 kilograms, or about 1 gallon of liquid).

• Avoid lifting anything above your head until your fusion heals.

Typically, you can begin to take short walks after six weeks. You’ll want to start out small and work up to 30 minutes at least twice each day. Continue to avoid any strenuous lifting, pulling, or twisting. If your doctor prescribed physical or occupational therapy, it’s important to attend these sessions. Make sure to follow any home exercises prescribed by your therapist.

It’s best to be proactive. Don’t hesitate to call your health care provider if you have concerns about medication, pain, swelling, breathing, or urination. Remember that you and your health care provider are partners on the healing journey.