PATIENT GUIDE TO LUMBAR FUSION

An operation has been recommended to you that is called a LUMBAR FUSION. This is a surgical procedure that secures two spinal bones (vertebrae) to one another to, in effect, make one bone. This extensive procedure requires at least three hours of surgery, and several months of recuperation before the final result has been achieved.

PREPARATION
There is no special preparation for this procedure. You should have nothing to eat after midnight of the evening before your surgery. If you take medications in the morning, you should do so with a sip of water before leaving for the hospital. There is no special cleansing of the back that should be performed prior to this operation.

On the day of your surgery, you will be escorted to a part of the operating room called the "holding area." An intravenous line will be started, and you will meet with the anesthesia staff and me. I will ask you if there are any questions, and we will sign a consent form together. You will then be wheeled into the Operating Room at which time you will drift off to sleep.

The incision required for the procedure is several inches long, though we will minimize it as much as possible. The average is about the length of your index finger. The first part of the procedure involves finding if any nerves are pinched. This is done in as minimally invasive manner as possible, and sometimes under an operating microscope. During this part of the operation, we will make a small opening into the back of the spine (about the size of a postage stamp) that accomplishes two purposes. First, it gives us access to the nerves so that they can be freed up to eliminate any sciatica you may have. Second, it provides your own bone for use later in the fusion.

The second part of the procedure is called the instrumentation. Four screws are placed, two in the bone (vertebra) above and two in the bone below. These are secured with metal rods approximately the diameter of a pencil. As soon as these are placed, the two bones that are either slipping on one another, or are connected by a worn out disk, are secured to each another. The position of these screws is carefully checked with X-rays at the time they are placed.

The third part of the procedure is called fusion. Although the rods and screws are extremely strong, they have the potential to loosen over time. To ensure that the bones are secured to one another throughout your lifetime, bone is placed that will grow from one vertebra to the other creating a strong bridge that will last forever. The bone that is placed is a combination of what we had taken earlier in the procedure, and a special material to stimulate the bridging of bone from one vertebral segment to the other. In essence, the two bones will grow together to make one bone.

At the time of surgery, we will make the determination as to whether the worn out disk should be removed and replaced with a piece of bone to make the fusion even stronger. This is called a posterior lumbar interbody fusion. It adds about 10 minutes to the procedure. If we can safely carry this out, we will do so.

The final part of the procedure is closing the incision that we have made. We usually place what is called a drain. This is a small tube that travels from the area of the operation to a small container that will be outside your body. This is to prevent internal bleeding that could cause problems. This will generally be removed the day after the surgery.

POSTOPERATIVE CARE
This is an extensive procedure that should be viewed in a manner similar to a hip or knee replacement. It is a several hour surgery, and a several month recovery. The amount of back pain that is experienced after surgery is highly variable. Some patients feel little more than a moderate muscle pull that is noticeable when they twist, such as when getting into and out of a car. Other patients have more extensive pain requiring strong medication. You can expect at least two weeks of pain sufficient to limit your activity at home. This may require narcotics such as Percocet or Vicodin. We will do our best to keep you comfortable during this time.

The average length of stay in the hospital is two nights/three days. We will encourage you to stand up and walk on the day after the surgery, and progressively become more active after that.

RECOVERY AT HOME
Recovery from a lumbar fusion requires several months. You should be able to walk and function normally at home by the time of your arrival from the hospital. Three days after the surgery, you may take a shower and the incision may get wet. We encourage you to keep it covered with a bandage when you are not in a shower until we see you in the office in a week or so after your surgery.

You begin driving six days after the surgery. We encourage relatively short, reasonable distances. In regard to returning to work, the standard for a "white collar" form of employment is a return in four to six weeks. Return to a more physically demanding job such as driving a truck or heavy lifting generally requires two to three months.

We do not recommend braces. They have never been shown to assist in either the fusion or the long-term outcome of the procedure. Sitting in straight chairs with arms is recommended. Avoid low, soft chairs. Walking is the best exercise. Begin slowly and work up to several miles a day. You may use a cane if you wish Do not lift anything heavier than 5 pounds for the first week. No heavy shoulder-bags, handbags or knapsacks.

You may assume any position that is comfortable in bed. You may begin sexual activity when comfortable. Pregnancy should be avoided during the first year after this surgery.

LONG-TERM FOLLOWUP
I will try to call you at home a day or two after your discharge to answer any questions that may have arisen. We will then see you in the office approximately one week after the surgery to make sure that the operation is healing well. X-rays are approximately three months, six months, and 12 months after the surgery. Please bear in mind that the fusion takes a minimum of three to six months to solidify and for the two vertebral levels to begin to turn into one.

COMPLICATIONS
All operations have benefits and risks. The benefit is to improve your back and leg pain. The success rate is approximately 80%. This determination of success or failure is generally made six months from the time of the surgical procedure. We are hopeful that you will have minimal or no pain, and will be able to discontinue all prescription painkillers. You may need to remain on anti-inflammatory medications such as Bextra or Celebrex indefinitely. Approximately 20% of the time, even when all has healed well, there is no pain relief. In this event, we would evaluate whether the fusion has solidified or if any other issues are present.

In general, this is a safe surgical procedure. The most common risk is infection. This is a long, involved procedure, and the infection rate is approximately 2%. This can generally be treated with antibiotics or simply good hygiene to the affected areas. The more serious complications, such as paralysis or needing a wheelchair, are well under 1%. I have performed complex spinal procedures for over 25 years, and have never caused such a problem. The risk of a serious medical complication such as heart attack or death from the anesthesia or other cause is less than 1 in 100,000.

The screws and rods that we place are made of a metal called titanium. This is extremely strong, and fortunately will allow you to undergo MR imaging of both the back and elsewhere in the body in the future. In my career, I have had only one screw breakage, though others have reported this. It is also possible that the screws can back out of the bone; however, this has not happened in my experience. The titanium rods can also become loose or fracture, though I have not seen this in my over 10 years of performing instrumented spinal procedures.

The first priority in placing the screws is to securely seat them in the bone. The second priority is to avoid hitting the nerves that are only a fraction of an inch away. We have many ways of doing this. The most important is that the screws are carefully monitored with an X-ray machine called a fluoroscope. We also use a technique called "stimulation" to make certain that the nerves are safe. Nonetheless, at times the screws could loosen or move, or the fluoroscope could be misleading. This could result in a damaged nerve that could cause permanent pain or weakness. A second operation to re-position the screw might be needed. In my many years of doing this procedure, to my knowledge I have not damaged a nerve in this manner on even a single occasion.

A membrane called the dura covers the nerve and lower spinal cord. During placement of screws, or unpinching of the nerves, we will sometimes uncover small holes in the dura from which spinal fluid can leak. This problem, called a "CSF leak" will usually over on its own, but on rare occasion will require another operation for its repair.

During the course of your procedure, we will unpinch the lower spinal cord and nerves. Although, this portion of the procedure is often done under a microscope with the greatest of care, this could result in partial weakness or paralysis associated with numbness down the legs and feet. Fortunately, in my over 20-year career, I have not seen this problem.

If there are any questions, please do not hesitate to contact our staff. This is an extensive operation with a prolonged recovery. You should make your decision carefully. If you wish to discuss it further, please call my office to either talk with me or set up another appointment.

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Stephen Saris M.D.

Neurosurgery Associates, Inc.
3 Davol Square, Suite B200
Providence, Rhode Island 02903

(401) 453-3545
FAX (401) 453-3533

email: questions@neurosurgery-associates.com

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