Frequently Asked Questions

FAQ

What is a Lumbar Fusion?

The procedure

A lumbar fusion stabilizes the vertebrae of the spine, creating less chance for slippage of the discs. During this operation, bone is used as a graft. The bone graft comes from either the local bone of the operative site, or as allograft bone (“off the shelf” from donors). The graft is inserted between the vertebrae, and then rods and screws are placed.

Surgery will last approximately 3 to 5 hours. You will be in the hospital approximately 2 to 3 days and may go to a rehabilitation unit after a few days in the hospital.

Anterior and posterior surgery

Some people will undergo a staged surgery, meaning that it is a two-part surgery:

1. Anterior surgery: The first stage, the anterior surgery, is done through an incision in the abdomen. The anterior surgery is usually done first. The stay after the anterior surgery is approximately 2 to 3 days.

2. Posterior surgery: After the anterior surgery, a second surgery—known as the posterior surgery—is scheduled after completion of the first stage.

You will be in the hospital approximately 2 to 3 days and may go to a rehabilitation unit after the 2-3 days in the hospital.

Laminectomy and Discectomy

A laminectomy is a procedure which involves removing bone from the back side of the vertebrae to allow more space for the nerves. It relieves pressure off the nerves and decreases symptoms such as pain, numbness, tingling, and weakness. Depending on how many levels will be operated upon, the surgery will last approximately 2 to 3 hours. You will be in the hospital approximately 2 days.

What is a Lumbar Discectomy?

Pain radiating down the legs is often due to a lumbar disc herniation, which presses on the nerve which causes it to send a pain signal. A discectomy is simply the removal of all or more often, just part of the disc that is putting pressure on the nerves and causing the leg pain, numbness or weakness. Surgery will last approximately 2 hours. You will most likely be in the hospital 1 night or less. You will go home the day after surgery.

Preparing for Spinal Surgery

Talk to your surgeon

Don’t be afraid to ask questions. Make sure you understand the surgery, and what to expect in the weeks and months to follow. Have realistic expectations about the results, and keep a positive attitude. Discuss the goals of the surgery with your surgeon. If you suffer from both back and leg pain, the chances of the surgery resolving your leg pain are very high compared to relieving your back pain.

Take our survey

To provide high-quality care, we routinely collect patient information through a web-based survey. The survey assesses current pain level, functional ability, and beliefs about healthcare and wellness. The information is provided to your surgeon to help improve surgical care and management of your recovery. If you haven’t already completed the survey on your first visit, please go to our website.

Stop smoking

If you are a current smoker, we advise that you quit smoking tobacco products at least 1 month prior to surgery. Nicotine, in any form, is a hindrance to bone fusion and healing. Because Nicotine is the source of the problem when it comes to healing and bone fusion, smoking cessation products such as Nicorette® gum or nicotine patches must be discontinued as well. Please discuss smoking cessation plans with your medical doctor. There are new medications available to help with this.

Obtain medical clearance

You will be expected to see the Preoperative Admission Testing Center (PAT) for a physical examination, medical history and other testing. Please call your surgeon’s office to discuss this.
If you have heart disease, diabetes or any other diseases and are following by a specialist, you will be expected to receive clearance from them prior to surgery. This clearance must be in writing and sent to your surgeon’s office.
Your surgeon will discuss whether it is necessary for you to meet with one of our anesthesiologists prior to your surgery based on your health history and age.
If you are suffering from extreme stress or anxiety or have signs of depression, make sure you address this with your primary health provider and spine care team before surgery.
If you see a pain management specialist, make sure to share the news of your surgery.
Perform the required testing: WITHIN 30 DAYS OF YOUR SURGERY DATE A comprehensive history and physical will be required that will include:

CBC with differential, Full chemistry, PT/PTT/INR
Urinalysis with culture
EKG
Chest X-Ray
Type and screen can only be performed here at Memorial or Selby

If you have a history of cardiac disease then a stress test may be needed If you choose to have your testing done at Memorial, please call your surgeon’s office and they will make an appointment for you in our Preoperative Evaluation Center.

Instructions for medications prior to surgery

You will be required to STOP any nonsteroidal anti-inflammatories such as Ibuprofen (Advil, Motrin), Naprosyn (Aleve), Celebrex, Mobic, Indocin, and Lodine 7-10 days prior to your surgery.
You will need to STOP taking aspirin and any anticoagulants including coumadin and Plavix®, Lovenox®, Eliquis or Xarelto. Please check with your doctor about when and how this should be done.
Please STOP taking any herbal supplements and certain vitamins 7-10 days prior to surgery including but not limited to St. John’s Wart, Garlic, Ginseng, Gingko Biloba, Vitamin E and Vitamin C, as these tend to thin your blood.
Diabetic patients should not take any oral hypoglycemic agents and insulin products the morning of surgery. Metformin (Glucophage) is the most vital to make
sure to avoid.
You should not take any diuretics the morning of surgery (i.e. Lasix, HCTZ) (Unless you have congestive heart failure)
You should not take any ACE/ARB the morning of surgery. These are classes of antihypertensive medications. Examples include Lisinopril, Lotrel, Captopril, Lotensin, Monopril, Prinzide, Atacand, Benicar, Diovan and Avalide.

Perform the following tasks before surgery

Make sure you review the postoperative exercises and restrictions which include no bending, twisting, and lifting greater than 8 pounds.
Arrange for a family member or friend to check on you in your home and help you through the first couple of weeks after your surgery. The type of surgery you have will determine the length of time you will need help.
If you are coming from out of town, you may want to stay in a hotel the night before surgery. The morning surgery begins at 7:30am and you are expected to arrive at the pre-operative area 2 hours prior to your surgery.
Arrange to have someone drop you off the morning of surgery and pick you up after discharge. You will not be able to drive yourself home on the day of discharge.
Your surgeon and staff will send you a list of medications to avoid prior to your surgery. Please pay special attention to this information as you will have to stop some of the medications 5-7 days prior to surgery.
You will be required to fast the night before surgery, and will be given guidelines before surgery. You should not have anything to drink or eat after midnight the night before surgery. This is for your safety with anesthesia.
Please follow the attached instructions regarding the surgical cleanse before surgery. Some surgeons will ask that you use Chlorhexidine, which is an antiseptic skin cleanser.
Pack lightly for your hospital stay. Please do not bring any valuables to the hospital. It is a good idea to bring sneakers and comfortable clothes with an elastic waistband.

Day of Surgery

What are your responsibilities on the Day of Surgery?

Please arrive 2 hours prior to your scheduled surgery time (i.e. if your surgery is 7:30am, please arrive at 5:30am) and report to pre-op area the morning of surgery.

It is essential that you bring your MRI, CT scans, and X-rays on the day of your surgery if you have not given them to your surgeon already.

If you have brought a copy of your advance directive or living will, please provide the pre-operative nurse with a copy.

What happens in the Pre-Op holding area?

You will meet with a provider from the spine team who will review the surgical consent forms with you again and confirm your preop symptoms. With a small marker, we will initial the surgery site on your skin. You will also meet with the anesthesiologist prior to your surgery.

He or she will begin an IV as well as place TED stockings on your legs.

You will wear TED stockings throughout your hospital stay. These can be removed at time of discharge from the hospital. These stockings help avoid leg swelling and reduce the risk of blood clots.

Once you are anesthetized (put to sleep), a Foley catheter will be inserted which will empty your bladder during surgery. The next morning following your surgery this catheter will be removed and you can urinate naturally.

Where will you go immediately after surgery completed?

Once your surgery is over, you will be transferred to the Recovery Room. No visitors are allowed in recovery. Once you are fully awake and stable, you will be transferred to the med surg unit, in a private or semi-private room at the main hospital.

First Days After Surgery

After surgery, you will be advised to avoid excessive twisting or bending.

Most people will need to wear a brace after surgery. However, your surgeon will inform you if a brace is required and one will be ordered either before or while in the hospital.

During the days following your surgery, physical therapy (PT) and occupational therapists will work with you while in the hospital. They will provide you with exercises to regain your strength. They may recommend equipment such as a reacher or a cane or walker to help you resume your normal activities and increase safety. They will also teach you how to best get out of bed, sit in a chair and walk. This usually occurs the day after your surgery. Once you are tolerating walking in the halls with the physical therapist, you will be reintroduced to stairs.

Who are the other people you will meet in the hospital?

A social worker will discuss your home needs while you are in the hospital and order durable medical equipment such as braces, and walkers, which can be delivered to your home. If you feel the need to speak with pastoral counseling, there are chaplains, rabbis, priests or ministers of your faith. Memorial Hospital does hold mass every Sunday and patients and their family members are welcome to attend.

What about pain management and diet advancement after surgery?

Immediately following surgery, you will be given pain medications through an IV. The IV medication as well as pain pills by mouth will be given as needed. Once you are tolerating clear liquids, your diet will be advanced to a regular meals again.

Going Home After Surgery

Most people will be discharged home. But for some, rehabilitation may be necessary as a bridge to going home. Marietta has a rehabilitation floor and your insurance may cover the stay. Depending on availability, you may also go to our sister rehabilitation unit at Selby or other Hospitals depending on your needs.

Pain medications

You will be discharged with pain medications. Be sure to drink plenty of fluids, take stool softeners prescribed and increase your fiber intake while taking narcotic medications as they tend to cause constipation. Do not allow constipation to progress more than 2 days without intervention i.e. laxatives. You should begin to wean yourself off of the pain medications with a goal of stopping within 2-3 months from surgery. If you are still requiring narcotic medications after 3 months, we will be happy to help you find a pain management specialist either here at Memorial or in your local area.

Medication restrictions after a Lumbar (Low Back) Fusion Surgery

Please ask your surgeon how long you should refrain from non-steroidal anti-inflammatory medications. Usually patients are asked to avoid these medications for 3 months after surgery but this decision can be made by your surgeon.

These medications include, but are not limited to:

Ibuprofen (Advil, Motrin), Naprosyn (Aleve), Celebrex, Mobic (Meloxicam), Indocin, Voltaren, Aspirin, and Lodine.

Surgical incision care

Please Remember: *If you notice any increased or change in drainage, redness, swelling, or have a fever of 101.5F or greater, please call you surgeon’s office immediately or go to the emergency room. Your surgical incision may be closed with dissolvable sutures and steri-strips, staples or sutures. If you have staples or visible sutures, these will need to be removed 10 to 14 days after your surgery. Arrangements for a home care nurse can be made in the hospital by our home care coordinators. If you do not qualify for in-home care by your insurance company, you will need to make an appointment for staple/suture removal with your surgeon’s office.

Surgical incision care

While you are in the hospital, you will wear a dry gauze dressing. Once your incision is no longer draining; you may take off the dressing and leave the incision open to air. Do not apply any ointments or lotions to the incision while it is healing. YOU MAY NOT BATHE IN A TUB, SWIM OR USE A HOT TUB UNTIL YOUR INCISION IS HEALED AND UNTIL YOU HAVE SEEN YOUR SURGEON.

Sexual activity

You can resume sexual activity when you are feeling up to it. Caution and common sense are recommended. A safe rule of thumb for positions is if it hurts, then don’t do it.

Driving

You can drive when you feel up to driving and are not taking narcotic pain medications or after clearance by your surgeon. This is usually 2 weeks after a laminectomy and discectomy and 3 weeks after a lumbar fusion. Narcotic pain medications will delay your reflex time. Begin with short trips first and get out of the car every 30 to 45 minutes to walk around and reposition.

Return to work

Naturally, you will feel tired and weak after surgery. You will begin to feel yourself after 2 to 3 weeks and improve over the following weeks. You should tell your employer you will be out of work for approximately 6 to 10 weeks but may be able to return earlier than that.

Walking is the best activity you can do for the first 6 weeks after surgery. You should start out slowly and work up to walking 30 minutes at least twice a day.

Do not be surprised if you require frequent naps during the day. Between the narcotic pain medications you will be discharged with and the stress your body has undergone in surgery, you will be tired.

Don’t forget about your restrictions for the first 6 weeks after surgery. You need to avoid twisting and bending. You also need to avoid lifting, pushing or pulling objects greater than 8 lbs.

Lifting and activity restrictions will be gradually removed as the healing process takes place. Remember to keep your spine in the neutral position and maintain good posture throughout the day.

Below are some ways for you to avoid twisting and bending during daily activities. You will also need proper technique to lift light objects. Proper technique is essential for reducing pain and discomfort.

The best way to lift an object is as follows:
Stand close to the object, with feet firmly planted, and in a wide stance.
Bend your knees and keep your back straight.
Make sure you have a secure grip on the object and keep the object as close to you as possible.
Lift the load by slowly straightening your knees and avoid jerking your body.
When standing upright, shift your feet to turn instead of twisting.

Below are some ways for you to lift properly, but remember lifting objects greater than 8 lbs for the first 6 weeks after surgery is not recommended.

A proper technique can be difficult when lifting objects from the trunk of your car, but the following suggestions can help:

When lifting items in and out of your trunk, place your foot on the bumper of your car for support if it is not too high;
Items should be stored in the trunk close to the bumper;
Items can be lifted onto the car frame first and then lifted from car frame to carry;
Brace yourself with one arm if you need to reach something deep inside the truck.

Pushing and pulling objects greater than 5 lbs for the first 6 weeks after surgery is not recommended. If possible, always push rather than pull and remember to pace yourself and take frequent breaks. Proper body mechanics when pushing or pulling objects is important. The following examples display proper technique for daily activities. However, all of these activities should be avoided for the first 6 weeks.

Sacroiliitis Overview

Basic Overview of Sacroiliitis

Common. 22% of all patients with LBP
43% of all patients who had a prior lumbar fusion

II. Anatomy of Sacroiliac joint:

III. Symptoms & Clinical Presentation:

May mimic discogenic or radicular lumbar symptoms
Pain while sitting or lying
intensified by climbing hills or stairs
Unilateral dull ache below L5
Radiating pain in groin, thigh, or buttocks

IV. Provocative and Non-provocative Exam Techniques:

Easiest and Non-provocative is the Fortin Finger Test where the patient points to maximum site of pain two separate times and comes within 2 centimeters
Pelvis Compression
Distraction
FABER Test

V. Injections & Responses to Injections:

Diagnostic Test of Lidocaine into SI joint and patient gets immediate 75% relieve, then pain returns
Need to do those 2 times
Some say a positive Radiofrequency ablation (RFA) counts too

VI. Other Things on the Checklist:

Need negative Xr-ays of the hips

VII. Technical Aspects and Options to do the surgery:

Screw vs triangular metal pegs
X-Ray Fluor guided vs Robot

VIII. Typical Postop Care:

See at one month with X rays

IX. Prognosis:

Pretty good

X. Vendor Options:

SI-Bone – IFuse
Globus – SI-LOK
Medtronic – Rialto

Kyphoplasty Overview

Overview of Kyphoplasty for Patients

II. Clinical Presentation:

Low back pain
Either spontaneously or with even minor trauma
Usually, elderly post-menopausal women
Often in patient who use chronic steroids

III. Treatment based on Severity of fracture:
IV. Mild fracture

V. Moderate Fracture:

VI. Severe Fracture:

Need a spinal instrumented fusion
Not common

VII. Kyphoplasty treatment:

Also known as “balloons for bones”
Balloons for bones
Available for over 20 years
Dr. Shehadi did his Kypho training at Cleveland Clinic in 2003
It’s an outpatient procedure done under general anesthesia
Balloon creates cavity, then you fill it with bone cement

VIII. Any questions:

Please call our office and ask our knowledgeable staff

Sleeping After Surgery

The best sleeping position to reduce your pain after surgery is either on your back with a pillow under your knees or on your side with your knees bent and a pillow between your legs.

A pillow placed behind the body and tucked under the back and hips can help you from rolling out of this position. Sleeping on your stomach is not recommended.

Changing positions in bed can be very difficult for people after surgery. To reduce discomfort, always use the log roll when turning. Use your legs and not your back to come to a standing position.

Sitting After Surgery

Sitting puts a lot of stress on your back and can be painful after surgery. It is important to maintain your normal spinal curves when sitting to help minimize this stress, because slouching or sliding down in your chair places strain on your back.

To avoid slouching, keep your ears, shoulders, and hips aligned. Make sure you have a proper chair that fits you. Choose a chair that allows your feet to be flat on the floor with your knees the same level as your hips. After surgery, avoid sitting in soft chairs and on couches where your hips drop below your knees. If a chair is too high for you, place your feet on a small stool or box to help maintain correct sitting posture. Take frequent breaks by standing up and stretching every 30 to 45 minutes.

Getting In and Out of a Chair or Car

Getting in and out of a chair or in and out of a car can be difficult after surgery. To get out of a chair, slide to the edge of the chair and straighten your hips and knees to lift yourself from the chair. Sometimes placing one foot in front of the other can help. If a chair has arm rests use your hands to assist you and remember to keep your back straight. To return to a sitting position, move backwards until the backs of your legs are touching the chair.

6 Week Follow-up Appointment

**Please call your surgeon’s office to make a 6 week follow-up appointment.**

Complete the on-line patient survey. This survey can be found — . Please contact your surgeon’s office for help. If you do not complete the survey before your visit you will be asked to arrive 30 minutes early to your follow-up appointment. A staff member will provide you with a paper copy to be completed prior to your visit.

X-rays

If you cannot have X-rays at Memorial, please call the office for a prescription ahead of time. It is important to obtain x-rays at your 6 week follow up appointment to evaluate healing.

Physical Therapy

At your 6-week follow-up appointment in the clinic, you may be given a handout of lower back exercises to begin at home. You may also be given a prescription for outpatient physical therapy, depending on how well you have recovered so far. You may go to the physical therapist of your choice. Until that time, focus on walking.

Please take the time to review the exercises you will begin to do at 6 to 12 weeks after surgery.

The Benefits of Quitting Smoking

Virtually the minute you quit smoking, your health begins to improve. The negative effects of smoking are clear: One in every three people who starts smoking will die prematurely of a smoking-related illness, according to the American Lung Association. And one in every five deaths stems directly from tobacco exposure. But the good news is that it’s never too late to quit smoking. The benefits of smoking cessation begin within a few minutes of your last cigarette and continue for life, even for people with lung disease. The Risks of Smoking Although the link between smoking and lung cancer is well known, smoking is even more likely to cause a range of other illnesses. According to a 2003 survey published in Morbidity and Mortality Weekly Report, some 8.6 million Americans were living with a major smoking-related illness in 2000. The most common smoking-related illness was chronic bronchitis (35% of cases), emphysema (24%), heart attacks (19%), non-lung cancer (12%), strokes (8%), and lung cancer (1%). The true number of people affected by smoking is probably much higher than the researchers stated because this study depended on people to report whether a doctor had ever told them they had a certain condition. People tend to underreport their own illnesses. In addition, the researchers did not look at non debilitating conditions, such as impotence and sinusitis, that are often caused by cigarette smoking. Regardless of how long you’ve been smoking, your health begins to improve shortly after your last cigarette. And the longer you are cigarette free, the greater the benefits become. Look at the timeline below:

Time Since Last Cigarette – 20 minutes: Elevated blood pressure levels begin to drop, and the temperature in your extremities begins to return to normal.
Time Since Last Cigarette – 8 hours: You achieve normal blood levels of carbon monoxide.
Time Since Last Cigarette – 1 day: Your risk of a heart attack begins to decline.
Time Since Last Cigarette – 2 weeks–3 months: Circulation improves, and lung function increases, decreasing the risk of lung infections.
Time Since Last Cigarette – 1–9 months: Shortness of breath, sinus congestion, coughing, and fatigue improve. A few months of smoking cessation improves lung function about 5% in patients with chronic obstructive pulmonary disease (COPD), and the risk of death from COPD declines.
Time Since Last Cigarette – 1 year: Your risk of having a heart attack is cut in half.
Time Since Last Cigarette – 5 years: The risk of cancer in the oral cavity and esophagus is already half that of continuing smokers, and the risk continues to decline with continued cessation.
Time Since Last Cigarette – 5–15 years: The risk of a stroke becomes similar to that of a lifelong nonsmoker.
Time Since Last Cigarette – 10 years: Your risk of developing lung cancer is 30–50% lower than it would be had you continued to smoke, and the risk continues to decline with continued abstinence. Also, you’ve significantly decreased your risk of developing cancer of the bladder, cervix, esophagus, kidney, mouth, pancreas, and throat.
Time Since Last Cigarette – 10–15 years: Your odds of dying of any cause are the same as those of someone who never smoked.
Time Since Last Cigarette – 15 years: Your risk of having a heart attack is the same as a lifelong nonsmoker.

Resources

American Academy of Orthopaedic Surgeons: www.aaos.org

Mayo Clinic: www.mayoclinic.com

North American Spine Society: www.spine.org

eSpine: www.espine.com

Spine Health: www.spine-health.com

Spine Universe: www.spineuniverse.com

Spinal Cord Stimulators Overview

Patient’s Guide to Spinal Cord Stimulators (SCS)

I. Indications (who needs One):

a. Patient who suffer chronic pain for greater than 2 years b. And who DO NOT have obvious ongoing nerve compression from structures pressing on nerves that need surgery to free up.

c. Usually patient who have had 2 or more previous spinal surgeries with scar tissue, etc.

d. Sometimes patients with Diabetic Peripheral Neuropathy (DPN)

e. Sometimes it’s a diagnosis of Complex regional Pain syndrome (CRPS)

II. Preparing for SCS surgery:

a. All the routine blood tests and Xrays that go before any surgery for patient general safety. This is called Pre

admission Testing (PAT)

b. Also, it is mandatory and routine that ALL patient undergo and pass a neuropsych evaluation prior to surgery.

Mandated by the insurance company.

c. Surgery done as an outpatient in hospital or Ambulator surgical Center

III. The device and Technology in layman’s Terms:

a. Its low levels of electric current that “scramble” the pain signal going towards the brain.

b. It’s electricity instead of Narcotics, which is a good idea IV. Battery:

a. Battery usually lasts 7-9 years based on the usage

b. Also more accurately called, Internal Pulse Generator (IPG) c. Then, this battery must be replaced by a short surgery where we swap out the old batter and put in a new one. This is a very short OUTPATIENT surgery.

V. The leads:

a. There are basically 2 different types of lead configurations b. A paddle lead or percutaneous “spaghetti” leads

c. I favor the paddle leads because they have more coverage and less likely to move

VI. Device Companies to choose from:

a. Medtronics is the biggest company

b. I favor Medtronics since they have an MRI compatible technology that the other companies do not yet have c. The competing companies only have MRI conditional, which is not as good, and has restrictions

VII. The Recovery:

a. We expect you will have a little soreness at first

b. That will improve

c. Keep incisions clean and dry for first 5 day

d. Then, you can shower, but no submersion baths

e. You will be given a remote control device

f. And you will communicate often with the Clinical coordinator from the spinal cord stimulator device company

VIII. Follow up:

a. Will be in the office in a few weeks,

b. Sometimes with follow up Xrays as needed

IX. Average expected Results:

a. About 70%-85% of patients will experience a Meaningful improvement in pain

b. Complications are very low, about 5% get an infection or lead breakage or lead migration

X. Any questions:

a. Call our office any time

Obesity

Click here to learn more about obsesity (Part 1)
Click here to learn more about obsesity (Part 2)

FAQ

Interesting links

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