Lumbar Fusion Surgery
A lumbar fusion surgery is designed to stop the motion at a painful vertebral segment, which in turn should decrease pain generated from the joint. There are many approaches to lumbar spinal fusion surgery, and all involve adding bone graft to an area of the spine to set up a biological response that causes the bone graft to grow between the two vertebral elements and create a fusion, thereby stopping the motion at that segment.
For patients throughout Dallas, Irving, Red Oak, Plano, Southlake, Grapevine, Colleyville, Duncanville and throughout the DFW metroplex with the following conditions, if abnormal and excessive motion at a vertebral segment results in severe pain and inability to function, a fusion may be considered:
- Degenerative Disc Disease
- Isthmic, degenerative or postlaminectomy 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.
How Spinal Fusion Surgery Works
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, so that an L4-L5 (lumbar segment 4 and lumbar segment 5) spinal fusion is actually 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. Bone graft can be taken from the patient’s hip (autograft bone) during the spine fusion surgery, harvested from cadaver bone (allograft bone) or manufactured (synthetic bone graft substitute).
In general, a lumbar spinal fusion surgery is most effective for those conditions involving only one vertebral segment. Most patients will not notice any limitation in motion after a one-level spine fusion. Only in rare cases should a three (or more) level fusion surgery for pain alone be considered, 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 because it removes too much of the normal motion in the lower back and places too much stress across the remaining joints. It should be only performed in rare cases.
There are several types of spinal fusion surgery options, including:
- Posterolateral Fusion (PLDF): the procedure is done through the back. It can be done with or without instrumentation.
- Lumbar Interbody Fusion (PLIF/TLIF): the procedure is done from the back and includes removing the disc between two vertebrae and inserting bone into the space created between the two vertebral bodies
- Anterior Lumbar Interbody Fusion (ALIF): the 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
You are having the one that is checked.
It is important to note that with any type of spine fusion surgery, there is a risk of clinical failure (meaning that the patient’s pain does not go away) 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 (non-smoker, non-obese) who is motivated to pursue rehabilitation and restoration of their function.
Preparation before Surgery
Optimizing your physical condition before surgery will certainly improve your recovery and outcome. 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. Prior to surgery, try to minimize the use opiod pain medications, as decreased preoperative utilization correlates with both better long term outcomes and allows for more reliable postoperative pain management.
Risks of Surgery
The most common risk of any of the modern spine fusion surgery 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, called pseudoarthrosis. With modern techniques happens in approximately 5% to 10% of spine fusion surgeries.
- 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 and may require further surgery to remove or revise the screws and rods.
- Anterior grafts and cages can migrate or subside, which 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 encountering a spinal fluid leak (durotomy). If this is encountered it must be repaired and often requires patients to lay flat on their back with possibility of lumbar drains. Often these patients may require additional returns to the operating room.
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 type of surgery, such as infection, bleeding, and anesthetic complications.
Another potential complication of spine fusion surgery in the low back includes any type of nerve damage. Although major loss of the strength and sensation to the legs or loss of bowel or bladder control can occur, it is rare. In a small percentage of men who have an anterior fusion ALIF procedure), an infrequent complication results in difficulties with ejaculation following spine fusion 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 (which can happen 1% of the time) then a valve will not close that forces the ejaculate outward. The ejaculate then follows the path of least resistance, which is up into the bladder. 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.
The Spine Physicians Institute prides ourselves in having an extremely low complication rate, far below the published norms. We attribute this to having greater than ten years of experience, constantly staying up to date with the spine surgical literature, and the fellowship training Dr. Sethuraman received at the Mayo Clinic in Rochester, Minnesota.
Risks are 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 by providing critical information and alerts to surgeons of potential harm or compromise to the 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 that will provide your neuromonitoring for you during your surgery.
Time Away from Work
How much time you need off work primarily depends on the type of work you have. After the surgery, you can expect to have a lumbar brace in place. I think all patients need some time at home recovering after surgery, usually at least a month. During the postoperative period, you will observe restrictions to your activity level until your fusion has healed. A spinal fusion usually takes about three months to heal. During the first six weeks as you are diligently wearing the lumbar brace you should not drive a car. If your job is sedentary, then you may feel comfortable returning to work within a few weeks. However, if your work is very strenuous, I recommend allowing the fusion to fully heal which requires an entire three months off of work. Generally, I advise patients to inform their employers that they are going to require three months 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 are always predicated on your consensus.
When you arrive for your surgery, you will meet the anesthesiologist, neuromonitoring technician, and surgical nurses. They will discuss with you their procedures and probably make you feel more at ease. Usually, general anesthesia will be given for your surgery. You will be given antibiotics to prevent infection, and support stockings along with sequential compression devices will be placed on your legs. We will then go to operating room and I will perform your procedure. Most PLDFs require between two to four hours, and postoperatively you spend about an hour in the recovery team. During the surgery, I will call out to the waiting room and give your family routine updates
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 usually. You will have an indwelling urinary catheter in place along with a Patient Controlled Analgesia Pump through which you can self-administer additional pain medication as needed. 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 versus an inpatient rehabilitation unit depending on your progress. For patients going home, on discharge, you will be given a detail set of discharge instructions and prescription pain medications. Often times if deemed appropriate, patients going home will be set up with home health to assist them during the initial post-operative recovery.
For patients with risk factors, such as a history of smoking, or who are undergoing a multi-level fusion, often at times, I will prescribe a spinal bone stimulator to promote bone healing. In these cases, you will be contacted at home post-operatively by the representative for the spinal bone stimulator company, who once your home, 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. I will check radiographs of your back. Depending upon how much healing is present at that time, we will decide whether we can begin discontinuing the use of your lumbar brace.
Successful Lumbar Fusion Surgery not only is the result of the procedure, but also very importantly is the result of aftercare and rehabilitation. The initial rehab program is simply composed of performing routine day to day activities while observing your post-operative restrictions. I encourage patients to participate in a daily walking program, progressing at their level of comfort. I 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 centers conveniently located to the Dallas, Irving, Red Oak, Plano, Southlake, Grapevine, Colleyville and Duncanville areas. Our goal is to give you best possible care in the most safe and pleasant way possible. Although surgery is not always easy for you and requires some work, remember that you are having the surgery because we expect a good result. I wish you a speedy recovery.
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