From patient education packets provided to patients prior to surgery.

Anterior Lumbar Fusion

Purpose

This booklet is designed to be an information source for you concerning your lumbar fusion. It is not meant to replace any personal conversations that you might wish to have with Dr. Kitchel, his assistant, his office, or other members of the health care team. My hope in preparing this booklet for you is that it will answer some of your questions and serve as a stimulus for you to ask appropriate questions about the surgery.

General Overview

Low back or lumbar fusions have been performed safely around the world for over 50 years. They are indicated for the treatment of instability in the lumbar spine, in certain spine fractures, and to control other conditions causing back pain.

The concept of a lumbar fusion is to make the back rigid over the vertebrae that are being fused. This is done in an attempt to eliminate any instability which is present or could come about as a result of fractures or other pathologic conditions. The joints and discs at the level of the fusion are removed and bone grows solidly across one vertebra to another for prevention of any further motion.

Lumbar fusions have gotten a somewhat bad reputation over the last decade. This is because a great many of them were done for people with low back pain and no evidence of instability or underlying pathologic condition. Fusion surgery for low back pain without instability or other pathologic conditions is not highly successful. In most of the studies that have been done, it is proven to be only about 50% successful in relieving the back pain. However, when patients are selected carefully and the fusions done for specific pathologic conditions, the success rate approaches 90%. Dr. Kitchel will explain to you the underlying condition in your back and the reasons he believes the fusion will be helpful in your particular case.

Indications for Surgery

The indication for lumbar spine fusion is instability in the lumbar spine. This can either be acute instability as a result of a fracture, or instability of a more chronic nature which has come on as a result of previous surgery, degenerative diseases, or diseases which have taken away bone in the lumbar spine, thereby causing abnormal motion. In general, lumbar spine surgery is not indicated simply for the treatment of low back pain.

In most cases, some attempt is made at conservative treatment before fusion is recommended. This will generally include a course of exercises and possibly bracing to stabilize your back. The course of conservative treatment is helpful because it may eliminate the problem and make your body tolerate the surgery better, if it is done.

Often fusion is accompanied by other procedures being done in the lumbar spine. Frequently, it will be necessary to remove pressure from the nerve roots where they are coming out of the back. At the time of removing the bone and ligaments necessary to decompress the nerve roots, the back may be rendered unstable. If this is the case, then the fusion would be done at the same time as the decompressive procedure. Sometimes the instability in the back will not become evident until sometime after the decompressive laminectomy has been done. In that case, the fusion would be suggested at a later date.

Preparation for Surgery

There are a number of things that will allow you to have a better result from your surgery by preplanning them before the surgery is done. The most important of these is that you go into the surgery with a complete understanding of what is to be done and a positive attitude that you are taking the right step. This is best accomplished by being sure that all of your questions are answered. Please do not hesitate to contact Dr. Kitchel or his assistant with any questions which you think may be too foolish or too trivial to bother them with. We truly want you to understand the procedure at length and to have all of your questions answered.

You should be sure that Dr. Kitchel is aware of any health problems which you may have or medications that you are taking before surgery. He may want to stop some of the medications because of the possibility that they can increase your bleeding at the time of surgery. He may also ask you to see your family doctor or internist so that they can pronounce you fit and a good candidate to undergo the surgery. It is also possible that other medications may interact with the anesthesia and the anesthesiologist may ask you to modify how you are taking them.

If you are a smoker, it is advisable that you stop smoking before the surgery. Smokers have a higher rate of wound problems and also have lower fusion rates than nonsmokers. It is desirable that your body be in the best possible condition for surgery. Your heart, lungs, and spine need to be as strong as possible. It is possible that Dr. Kitchel may recommend a program of aerobic, strengthening, or stretching exercises before surgery. It is also possible that you may be asked to see a physical therapist before surgery to show you a conditioning exercise program.

Lumbar fusion may require blood replacement. If Dr. Kitchel feels there is a possibility that you may need a blood transfusion after your surgery, he will ask you to store some of your own blood ahead of time to avoid the transmission of blood borne diseases such as hepatitis or AIDS. If you are asked to store your own blood, you will be given nutritional supplements such as iron and calcium to maintain your blood balance. The blood will be stored in a blood bank and given to you in the hospital following surgery.

With anterior lumbar surgery, it is desirable to have your stools softened before surgery. I advise that you start on Metamucil, one teaspoon in a glass of juice or water, twice a day, five days before surgery. You should also take Milk of Magnesia the two nights before surgery as directed on the package.

You will be scheduled for a preoperative visit prior to surgery. At that time, you will be given a lumbar corset. Please bring the corset with you at the time of hospital admission.

Surgery

For lumbar fusion you are admitted to the hospital the morning of surgery. It is no longer necessary for you to come into the hospital the night before. This allows containment of costs at the time of surgery and also allows you to have a good nights' rest at home before you enter the hospital. It is important that you do not eat or drink anything after midnight the night before surgery. This will allow the anesthesia to be safely administered. Please bring the corset with you.

Once you have been admitted to the hospital, you will be taken to a room and prepared for surgery. This will include instruction about the surgery, cleansing of your back and abdomen, as well as instruction about the postoperative period. In most instances, you will have met with the anesthesiologist before your admission to the hospital and have decided on the type of anesthesia. Dr. Kitchel has no preference as to the type of anesthesia and this should be worked out between you and the anesthesiologist so that you are both comfortable that it is being administered in the safest possible fashion.

About one-half hour before the surgery is actually to begin, you will be taken up to the operating room and put into a holding area. The anesthesiologist will come and visit you and start your IV at that time. You will then be taken to the operating room and anesthesia will be induced. Once the anesthetic has been successfully administered, you will be positioned for the surgery and surgery will be carried out.

After surgery you will wake up in the recovery room where your vital signs will be monitored and your immediate postoperative condition will be carefully watched. Most people stay in the recovery room between one and three hours after surgery. Once the anesthesiologist feels that you are doing well, you will be returned to your room in the hospital.

The evening of surgery, it is normal for your back to be very sore. The nursing staff will be checking to make sure that your vital signs are stable and that there is no problem with either the wound or nerve function in your legs. Dr. Kitchel will be by to see you the evening of surgery to discuss how the surgery went and make sure that things are going as expected.

You will be maintained at bed rest until the day after surgery. During this time, the nurses will frequently encourage you to turn from side-to-side to avoid the complication of blood clots forming in your legs or possible breathing problems associated with remaining flat in bed. On the day after surgery, you will begin to get out of bed with the corset which was fitted for you before surgery. The corset is a means of external support to allow better immobilization of your back and increases the likelihood of you achieving a solid fusion. The physical therapist will come in and help you with your movements and make sure that it is an easy transition from lying to getting your corset on and getting out of bed. Dr. Kitchel has prescribed a specific program of walking and exercises for the first few days after surgery.

Your intravenous catheter will remain in place for two days after surgery. This is to give you adequate fluids as well as 48 hours of antibiotics in an attempt to lessen any chance of infection. You will also be taking pain medication through your IV for the first day or two. After that, the pain medication will be given by mouth.

You will also have a catheter placed into your bladder. This is simply for your comfort and to allow you to not have to get on and off the bed pan. This will likely also be removed about 48 hours after surgery.

The dressing will be changed on the second postoperative day and a small drain tube which is left in the incision will be removed at that time. Once the drain tube has been removed, you are free to shower and the nurses will change the dressing each day.

Most patients go home from the hospital on the third or fourth day after surgery. Dr. Kitchel will see you in the hospital that morning and discuss with you the medications to take home as well as a prescribed program of activities. In general, you are not to be out of bed without your corset. You should do no bending, lifting, or stooping at home until you are seen back in the office by Dr. Kitchel. You should take your medications as he prescribes. Be sure that Dr. Kitchel answers all of your questions before you go home from the hospital that morning.

Generally, Dr. Kitchel will see you back in the office about ten days to two weeks after surgery to remove the skin staples. If, during that first week of surgery, you have any questions or problems, you should call him at the office immediately.

The Operation

Lumbar spine fusion attempts to eliminate instability in the back. This is done by fusing the vertebrae together to reduce their motion. The actual technique of accomplishing this is through an abdominal incision over the spine with dissection of the soft tissues to expose the bone and disc. At the levels that have been selected for fusion, all soft tissues will be removed and discs will be excised. Bone will be obtained from your pelvis to lay into place where the discs were, in an attempt to achieve a solid fusion.

In some cases, the instability is severe enough that further augmentation of the fusion is required. Dr. Kitchel and his assistant will discuss this with you if he thinks that you should have an implant put into your back to give some immediate stability. He might also recommend the use of an external electrical stimulator which is meant to stimulate bone growth and thereby achieve a solid fusion. Dr. Kitchel will discuss both of these options with you if he considers them to be appropriate.

In lumber spine fusion surgery there are two incisions made. The first of these is on the abdomen directly over the spine to gain access to the levels that are to be fused. The second of these is over the posterior aspect of the pelvis to obtain the bone graft which will become the fusion.

Risks and Complications

Your decision to undergo surgery should not be made lightly. You need to understand that there are certain risks and complications which accompany any surgical procedure. Thankfully, complications in lumbar spine surgery are rare. The most common complication is an infection. This occurs in approximately 1-2% of all spine surgery. Dr. Kitchel will do everything he can to avoid this complication. A sterile scrub will be performed on your back and the operation will be performed in a sterile room Gloves, gowns, and masks will be worn by all personnel in the room. You will be given antibiotics during the 48 hours following surgery. Despite all of these precautions, infection does occasionally occur. Infection is generally not a devastating complication, but may require that the patient come back into the hospital for further antibiotics and possibly to reopen the wound. If you have any personal history of susceptibility to infections, this should be communicated to Dr. Kitchel before surgery.

The complication of blood loss is rarely significant in lumbar spine surgery. The general blood loss will vary with how extensive a procedure must be done. If Dr. Kitchel feels that there is a possibility of enough blood loss to require replacement, you will be asked to predonate some of your own blood ahead of time so that it may be stored and used at the time of surgery. Your blood volume will be monitored carefully while you are in the hospital and if blood replacement is required, this blood will be returned to you.

Nonunion or pseudarthrosis is the complication of the fusion not becoming solid. This occurs between 5-20% of the time, depending on the underlying problem and the surgery. Dr. Kitchel will discuss with you what can be done in your individual case to make this less likely. Should this occur, another operation might be needed to add more bone graft.

New nerve damage is the rarest of all complications. This occurs in approximately 1/10,000 cases. If there is new damage to your nerve, it could result in numbness, tingling, or pain. In all likelihood it would not result in paralysis.

The risks of anesthesia should be covered in your conversation with the anesthesiologist. It is up to you to be sure that you are comfortable with the form of anesthesia which you have chosen.

Expectations After Lumbar Fusion

The desired result of your lumbar fusion is to eliminate the instability in your back and thereby reduce your back and leg pain. Before we are able to assess the final result it is necessary that the bone heal and become solid. This will take a period of a minimum of three months. You will likely continue to notice improvement in your condition for at least a year. The final result should not be judged for one year.

You will be wearing the light weight corset for at least two months after your surgery. You will be started on an exercise program to rehabilitate and strengthen your back at approximately the same time.

When you first go home from the hospital, the best form of therapy is simply daily activities and walking. You should always put on your corset before you get out of bed. You should not be out of bed without the corset except when showering. You may wear the corset to the shower, remove it, step in and shower, and then replace the corset after drying yourself. You should not bend over at the waist to dry your lower extremities without the corset. Other than showering, you should be in the corset at all times that you are out of bed. Dr. Kitchel will discuss a walking program with you for while you are wearing the corset. Walking is important and physical activity is important as this will increase the rate of healing of the fusion and also decrease your pain.

When You Go Home

Dr. Kitchel will generally tell you the evening before he plans to dismiss you the next morning. The hospital prefers that you go home in the morning before 11:00 a.m. That morning, Dr. Kitchel will come in and visit you to answer any questions as well as discuss your take-home medications and an appointment to see him back in the office.

When you get home, it is important to maintain moderate physical activities. You should not overdo it, but by the same token you should not spend all your time in bed or sitting. Sitting is a particularly difficult position on a lumber fusion as it increases the stresses across your back. It is okay to sit, but you should plan on frequent changes in position and no sitting for more than one-half hour without getting up and moving around.

You will have medications to take home as they are ordered by Dr. Kitchel. It is important that you take all of these on the schedule which he has provided you. His assistant will call you within a day or two of your discharge to make sure everything is going okay.

Unless Dr. Kitchel has specifically told you otherwise, it is all right to shower and cleanse the wound with simple soap and water. Simply dry the wound well after showering. It is not necessary to cover the wound unless there is any drainage. You should avoid movements of your lumbar spine when you are out of the corset showering.

Reasons to Call Dr. Kitchel After Surgery

1. New pain, weakness, or numbness that begins when you get home.

2. Fever, headache, or extreme fatigue.

3. Drainage from the wound that was not present at the time of being discharged from the hospital.

4. Difficulty with bowel or bladder control.

5. Any questions about your surgery which were not covered in your conversations with Dr. Kitchel, his assistant, or by this booklet.

The office telephone number is 393-0100. There is someone available at the office from 8:00 a.m. to 5:00 p.m. on weekdays. There is also a physician available on-call 24 hours a day, including weekends. Please do not hesitate to call if you have any questions.

Again, this booklet is not designed to replace your personal communication with Dr. Kitchel or his assistant. It is simply meant to serve as a reference about anterior lumber fusion surgery and to answer any questions you 'night have. I hope that it will help to ready you for your surgery and allow you to enter into it with a good understanding.

 

A WORD ABOUT PAIN MEDICATION

The use of oral pain medication continues to be a difficult and controversial problem in postoperative patients. It is certainly my primary concern that we give you enough medication to make you comfortable in the perioperative period. However, when you go home from the hospital, consideration must also be given to limiting that pain medication because of its side-effects and addictive nature.

I want to take this opportunity to make you aware of the policies of Orthopedic Spine Associates.   First, no pain medication prescriptions will be refilled after business hours or on weekends. This requires that you look ahead and plan the use of your medication such that should you need additional medications you can call during regular office hours between Monday and Friday. Second, it is also our policy that oral pain medications not be continued beyond one month following surgery.  There are certainly extenuating circumstances which will be considered on an individual basis. However, in general, the use of oral pain medication following surgery will be limited to one month. There is good scientific evidence to support this limitation based both upon the potential for addiction as well as the ineffectiveness of chronic oral pain medications.

I would be happy to sit down and discuss either of these policies with you on an individual basis. I do not mean this sheet to take the place of any personal conversation. However, I do believe it is my obligation to make you aware of these policies so that we can have the best possible doctor-patient relationship.