Lumbar Fusion Surgery
A lumbar fusion surgery is designed to stop the motion at a painful vertebral segment. This in turn should decrease pain generated from the joint. There are many approaches to lumbar spinal fusion surgery. All of them involve adding bone graft to an area of the spine. It will set up a biological response that causes the bone graft to grow between the two vertebral elements and create a fusion. Hence, it will stop the motion at that segment.
Conditions for Spinal Fusion Surgery
An abnormal and excessive motion at a vertebral segment results in severe pain and inability to function. A lumbar fusion surgery may only be considered if the patients is suffering from the following;
- Degenerative Disc Disease
- Isthmic, Degenerative or Post-Laminectomy Spondylolisthesis
Other conditions that may be treated by a spinal fusion surgery include a weak or unstable spine (caused by infections or tumors), fractures, stenosis or deformity.
At each level in the spine, there is a disc space in the front and paired facet joints in the back. Working together, these structures define a motion segment and permit multiple degrees of motion. Two vertebral segments need to be fused together to stop the motion at one segment. This will make an L4-L5 (lumbar segment 4 and lumbar segment 5) spinal fusion practically a one-level spinal fusion.
A spine fusion surgery involves using bone graft to cause two vertebral bodies to grow together into one long bone. During the spine fusion surgery, a bone graft can be;
- Taken from the patient’s hip (autograft bone)
- Harvested from cadaver bone (allograft bone)
- Manufactured (synthetic bone graft substitute)
Schedule a Consultation
In general, a lumbar spinal fusion surgery is most effective for the conditions involving only one vertebral segment. Most patients will not notice any limitation in motion after a one-level spine fusion. A level three or more fusion surgery can only be considered for the pain alone in rare cases. Although, it may be necessary in cases of scoliosis and lumbar deformity.
When necessary, fusing two segments of the spine may be a reasonable option for treatment of pain. However, spinal fusion of more than two segments is unlikely to provide pain relief. This is because it removes too much of the normal motion in the lower back. It also places too much stress across the remaining joints. It should only be performed in rare cases.
Types of Fusion Surgery
There are several types of spinal fusion surgery options, such as;
- Posterolateral Fusion (PLDF)
This procedure is done through the back. It can be done with or without instrumentation.
- Lumbar Interbody Fusion (PLIF/TLIF)
This procedure is done from the back. It includes removing the disc between two vertebrae and inserting bone into the space created between the two vertebral bodies.
- Anterior Lumbar Interbody Fusion (ALIF)
This procedure is done from the front and includes removing the disc between two vertebrae and inserting bone into the space created between the two vertebral bodies.
- Anterior/Posterior Spinal Fusion (APSF)
The procedure is done from the front and the back
It is important to note that with any type of spine fusion surgery, there is a risk of clinical failure. It means that the patient’s pain might not go away partially or completely despite achieving a successful fusion. Obtaining a successful result from a spine fusion requires and accurate preoperative diagnosis, a technologically adept surgeon, and a patient with a reasonably healthy lifestyle, (such as a non-smoker, non-obese). The patient must be motivated to pursue rehabilitation and restoration of their function.
Preparation before Surgery
- Optimizing your physical condition before surgery will improve your recovery, as well as
- Maintain a healthy, balanced diet before surgery.
- Stop Smoking. Smoking can significantly delay healing, increase risks, and adversely affect outcomes. Smoking cessation cannot occur with use of nicotine supplements such as nicotine patches and nicotine gum.
- Minimize the use opioid pain medications. The decrease in their preoperative utilization correlates with better long-term outcome. It also allows for more reliable postoperative pain management.
Risks of Surgery
- The most common risk of any of the modern spine fusion surgical techniques is the failure to relieve lower back pain symptoms following the surgery.
- There is also a risk that the vertebrae may not fuse together following the surgery. This condition is called This condition occurs in approximately 5% to 10% of spine fusion surgeries with modern techniques.
- It is well documented in the medical literature that people who smoke have a lower rate of successful spine fusion.
- If pedicle screws are used, there is a risk that the screws may break, cut out of the bone or become loose. In such a case, they may require further surgery to remove or revise the screws and rods.
- Anterior grafts and cages can migrate or subside. Such a condition may require repeat spine surgery. If the anterior devices were placed anteriorly (from the front), rather than through a PLIF or TLIF (approaches through the back), it is safest to do this revision spine fusion surgery with a posterior approach (from the back).
- There is also a risk of a spinal fluid leak occurring, also called durotomy. If such condition occurs, it must be repaired as soon as possible. It often requires patients to lay flat on their back with possibility of lumbar drains. Such patients are typically required to return to the operating rooms.
Complications of Surgery
All spine fusion surgeries have the potential for complications. Thankfully, most of the complications occur infrequently. The complications that can occur also include those that would be associated with any other type of surgery. These include infection, bleeding, and anaesthetic complications etc.
Another potential complication of spine fusion surgery in the low back includes any type of nerve damage. Major loss of the strength and sensation to the legs or loss of bowel or bladder control can occur. However, such occurrences are rare.
A complication can occur in a very small percentage of men who have had an anterior fusion surgery. They experience difficulties with ejaculation following the surgery. There is a small plexus of nerves in front of the L5-S1 disc space that helps control ejaculation. If these nerves are affected then the valve will not close that forces the ejaculated material forward. The chances of this happening are only about 1%. The most significant side effect of this complication is that it is very difficult to complete conception. Potency is not affected, and the sensation of sex is still largely the same. In about half of cases this complication resolves over the course of about 6 to 12 months.
Minimization of Risks and Complications
The Spine Physicians Institute prides itself in having an extremely low complication rate. Our rate of complications is far below the published norms. We attribute this to our physicians having greater than ten years of experience. We constantly stay up to date with the spine surgical literature. The superior training our physicians receive ensures a severe lack of occurrence of complications.
Risks are further minimized by the utilization of Intraoperative Neuromonitoring (IONM). IONM offers insight into the nervous system during spinal surgeries. Use of IONM facilitates the surgical process and can reduce surgical risk. It can provide critical information and alerts to surgeons of potential harm or compromise to spinal cord or neural structures. IONM provides better insight into a patient’s condition during surgery to support better decision-making that enables the practice of better medicine.
On the day of your surgery you will meet a member of IONM team. He or she will provide your neuromonitoring for you during your surgery.
Some spine surgeons restrict a patient from bending, lifting, or twisting for the first six weeks following surgery. However, we recommend that the patient return to normal level of functioning immediately. Since the patient’s back is mechanically the same there must be little difficulty.
There have been some reports in the medical literature that indicate this. They show that immediate return to normal activity does not lead to an increase in recurrent lumbar herniated disc.
Time Away from Work
How much time you need off work primarily depends on the type of work you do. After the surgery, you can expect to have a lumbar brace in place. We recommend that all patients need some time at home recovering after surgery. This time must last at least a week. During the postoperative period, you must observe restrictions to your normal activities. You must reduce them to a level you feel are warranted. Remember, a spinal fusion takes about three months to heal.
During the first six weeks as you must wear the lumbar brace. Some patients wear the brace for the entire 6 weeks. While others rapidly discontinue using it. You should not drive a car for the first 6 weeks.
You should not drive a car for the first 6 weeks.
If your job is sedentary, then you may feel comfortable returning to work within a few days. However, if your work is very strenuous, we recommend allowing the back to fully heal. It might take an entire 6 weeks off of work.
Generally, we advise patients to inform their employers that they are going to require 6 weeks to recover. If post-operatively, you feel you can return sooner, our office will always be happy to provide the proper documentation to you to allow for such. Remember, no one knows your work environment better then you, thus our work release is always based on patient’s consensus.
When you arrive for your surgery, you will meet the anaesthesiologist, neuromonitoring technician, and surgical nurses. They will discuss with you their procedures and make you feel more at ease. Usually, general anaesthesia will be given for the surgery. You will be given antibiotics to prevent infection, and support stockings. The sequential compression devices will be placed on your legs. The surgeon will then go to operating room and perform the procedure.
Most PLDFs require between two to four hours, and postoperatively you spend about an hour in the recovery team. During the surgery, the surgeon will call out to the waiting room and give your family routine updates. Afterwards, patients are transferred back to the day surgery unit where they started. Then they are discharged home.
When you awaken after surgery, you will receive pain medication and your nurses will closely monitor you. You will have a bulky postoperative dressing with one to two surgical drains in place. You will have an indwelling urinary catheter in place along with a Patient Controlled Analgesia Pump. You can self-administer additional pain medication as needed through this instrument.
You will slowly resume a normal diet and start physical therapy immediately after surgery. You will remain in the hospital for up to three nights. Usually, by no later then the third post-operative day you will either be discharged to home or an inpatient rehabilitation unit, depending on your progress. For patients going home on a discharge, you will be given a detail set of discharge instructions. You will also be given prescription pain medications. Often times, if deemed appropriate, patients going home will be set up with home health. It might assist them during the initial post-operative recovery.
For patients with risk factors, such as smokers, or who are undergoing a multi-level fusion, will be given special instructions. Often, they will be prescribed with a spinal bone stimulator to promote bone healing. In these cases, the patient will be contacted at home post-operatively by the representative for the spinal bone stimulator company. This representative will make arrangements to get you this unit for your use. These units are utilized for the first 6 months after surgery.
The support stockings you are given in the hospital should be utilized for the first six weeks after surgery. These reduce the risk of blood clots after surgery.
Patients with external stitches will return two weeks post-operatively just for a wound check and to have their stitches removed. Otherwise, patients will return for their first postop visit usually six weeks after their date of surgery. We will check radiographs of the patient’s back. Depending upon how much healing is present at that time, we will decide whether we can begin discontinuing the use of lumbar brace.
Successful Lumbar Fusion Surgery consists of not only a correct procedure, but also aftercare and rehabilitation. The initial rehab program is simply composed of performing routine day to day activities while observing your post-operative restrictions. We encourage patients to participate in a daily walking program, progressing at their level of comfort. We do not start formal outpatient physical therapy until the three-month postoperative visit, if warranted.
During this process, please do not hesitate to ask questions. Our team is always available to help you at any of our spine health centres. Our goal is to give you best possible care in the most safe and pleasant way possible. Although surgery is not always easy for a patient. It requires a lot of work. Regardless, you must remember that you are having the surgery because we expect a good result. We wish you a speedy recovery.
For more questions, contact our offices located in Dallas, Irving, Red Oak, Plano, Southlake, Grapevine, Colleyville and Duncanville marketplaces.