Spinal fusion surgery is done in order to create a permanent junction between the vertebral bodies in the spine so that there isn’t any movement between the two vertebrae.
This procedure is found in cases of:
- Having other surgical procedures, such as spinal stenosis, foraminectomy or a laminectomy
- Having had a discectomy, particularly in the neck
- Having an injury or fractures in the spine
- Weak spine or unstable spine because of tumors or infections
- Having spondylolisthesis in which one vertebra is pulled forward upon another
- Having abnormal spinal curvature, such as kyphosis or scoliosis
Types of Spinal Fusion
There are two types of spinal fusion done in the lumbar area. These include:
- Posterolateral fusion. In such cases, the bone graft is placed between the transverse processes, which exist in the back and sides of the back. The transverse processes are fixed in place using screws or wires through the pedicles of the vertebrae with a rod attached on each side of the vertebrae.
- Interbody fusion. The bone graft in this procedure is placed in the spot that is usually where the intervertebral disc is located. During the procedure, the original disc is removed completely. A device is sometimes placed into the intervertebral space to keep the height the same between the vertebrae. An artificial disc can be placed in some circumstances. The fusion takes place between the vertebral endplates.
If both types of fusion are done at the same time, doctors call this a 360-degree fusion. Most procedures are of the interbody fusion type.
There are four types of interbody fusion:
- Posterior lumbar interbody fusion, in which the disc is accessed through a posterior incision
- Anterior lumbar interbody fusion. This is when the disc is located through an anterior abdominal incision.
- Transforaminal lumbar interbody fusion. This involves making an incision from a posterior angle on one side of the spinal canal.
- Transpsoas interbody fusion. The disc is located through an incision though the psoas muscle on one aspect of the spine.
In many cases, the spinal fusion is accompanied by “fixation”. This involves the placement of metal screws such as pedicle screws formed out of titanium, plates, rods or cages used to stabilize the vertebrae and to aid in bone fusion. This procedure usually takes place 6-12 months following the fusion procedure. Between the first and second surgery, some patients need external bracing to keep the spine stable.
Unfortunately, the fusion process can be interfered with by things like smoking, certain medications, osteoporosis and heavy activity. There can be a prolonged fusion or even a lack of fusion. If there is no fusion, the patient may need another operation.
There are newer technologies that avoid fusion and can save spinal motion. These include the artificial disc replacement procedure, which is gaining acceptance in the US. In other cases, minimally invasive procedures have been introduced into the market that are designed to reduce the recovery time and reduce complications when compared to spinal fusion.
While one thinks of the lumbar area for spinal fusion, cervical spinal fusions are possible in the area of the neck. This procedure fuses vertebrae in the cervical spinal area. Bone, screws, or metal plates can be used and in extreme situations, an entire vertebral body can be removed before doing the fusion procedure. In the majority of cases, just the intervertebral disc is removed prior to the fusion procedure; bone or metal grafting is then used.
Cervical spinal fusion is done for several reasons. It is used following trauma to the neck to stabilize the cervical spine and prevent fractures of the spine from doing injury to the spinal cord. Cervical spine fusion can, in addition, be used to remove pressure on the nerve roots which are because of bony fragments or perhaps a ruptured disc.
Before the Disc Fusion Procedure
Talk to the doctor about any medications, over-the-counter medicines, supplements, and herbs you are taking and not just the prescription medications.
If you are a smoker, you must stop as soon as you realize you are having surgery. If you continue to smoke following your spinal fusion surgery, you might not heal as well. If you need help quitting smoking, talk to your doctor about getting help.
Two weeks prior to surgery, you may need to stop taking certain drugs that can thin your blood. These include Motrin or Advil (ibuprofen), Aleve or Naprosyn (naproxen), or aspirin.
If you have heart problems, lung problems or diabetes, you will be asked to be cleared for surgery by your regular doctor. He or she will perform a physical examination and will be asked to have blood drawn before surgery.
At your preoperative visit, you need to talk to your doctor if you normally drink a lot of alcohol and you need to find out which drugs you should continue to take on the day of the surgery. Let your doctor know if you develop any kind of flu, cold, herpes breakout or other major illness prior to having the surgery.
Immediately prior to your surgery, you will be asked to stop drinking or eating anything for 6-12 hours before the time of your surgery. If you have medications to take before surgery, take them with a tiny sip of water.
Description of a Disc Fusion
The disc fusion surgery is major surgery that can be performed in several ways. It is always done under general anesthesia with three major possible incisions:
- On your neck or back with you lying face down. The incision is made vertically over the spine directly with the muscles and other tissues exposed over the spine.
- The incision is made while you’re on your back and is located on the side of your belly. The tissues and blood vessels in the way of the spine are retracted away from the spinal area where the surgery will be done.
- For cervical surgery, the incision is made on the front and side of the neck with tissues and blood vessels moved out of the way to make room for the actual surgery.
Before the fusion is done, the doctor must do a laminectomy, a diskectomy, or a foraminotomy to have better access to the area to be fused or to facilitate the fusion.
Bone or metallic material is used to fuse the bones together on a permanent basis. Strips of bony material are placed along the back of the spine in the neck or lumbar area. Bony graft pieces can be placed inside the intervertebral disc area—between vertebrae.
Cages can be set between vertebrae that are packed with bony graft material to hold the graft material in place. It allows for the graft to coalesce over the next few months and form a tight bridge between the vertebrae.
Bone grafts or other material for the fusion can be made from:
- Bone taken from your pelvic bone or other part of your body. This is known as an autograft. The surgeon opens up a small area near the hip and bone is taken from the posterior rim of the pelvic bones.
- Bone can be taken from a bone bank, known as an allograft.
- Synthetic bone substitute is possible.
In addition to bone or bone substitute, the doctor uses rods, plates, screws or cages that keep the vertebrae in one place until the grafts completely heal. In general, the procedure lasts about 3-4 hours.
Following the Procedure
You will likely remain in the hospital for 3-4 days following the surgery, if everything goes well. Your doctor will keep the IV in for a while in order to provide you with IV pain medications. Some patients are given a pain pump containing morphine that delivers just the right amount of pain relief.
The staff will teach you many things about how to move, stand, sit and walk after the surgery. For example, the nursing staff will teach you how to “log roll” when getting up from a reclining position. You’ll need to learn how to move your entire body at the same time without turning, flexing, extending, or twisting your spine. This maximizes the chances of a successful fusion.
The doctor may have you refrain from eating for the first 2-3 days after the fusion surgery. Instead of oral nutrition, you will be given IV nutrition. When it is time to leave the hospital, you may be asked to wear a cast or a back brace.
Risks for having a Spinal Surgery
There are risks for any surgery and spinal fusion is no exception. Some of the risks for spinal fusion surgery include:
- Pulmonary Embolism—a blood clot that begins in the legs and travels to the lungs, sometimes resulting in sudden death.
- Breathing problems from the anesthesia or from atelectasis, which is collapse of the alveoli in the lungs during and after surgery.
- Infection is always possible after surgery. Infection can occur in the lungs as pneumonia, the bladder or the kidney.
- Blood loss can occur at the time of the surgery or after surgery with post-operative bleeding complications.
- Heart attack during surgery, which places a stress on the heart.
- Stroke during surgery from a blood clot that goes to the brain.
- Reactions to medications, such as pain medications, blood pressure medications and anesthetics
- Wound infection at the site of surgery
- Infection within the bone graft, which can result in removal of the graft.
- Damage to a spinal nerve, which can result in pain, loss of sensation, paralysis, bowel or bladder problems after the surgery.
- The vertebrae above and below the level of surgery have a tendency to wear away more quickly than normal so you’ll have more back or neck problems later.
Prognosis after Surgery
If you had longstanding pain before surgery, you will probably still retain some of that pain afterward. Just having a spinal fusion generally won’t remove all of your pain and you will have residual symptoms. The surgeon won’t likely be able to tell you how much pain you’ll have after surgery and CT scans or MRI scans will not be able to predict your level of pain.
If you lose weight and gradually return to some kind of active exercise, your chances of doing better after surgery improve.
All spinal surgery patients have a chance of having future problems with their back. The fusion means that a segment of your back will be immobile so that the segments of your back above and below the surgical area take on more stress and can be damaged at a later date.
What to Expect at Home
A spinal fusion surgery is a big surgery and you will likely have a change in your lifestyle in the days and weeks following your surgery. Recovery after spinal fusion tends to take longer than with other types of back surgery. It usually takes 3-4 months following your fusion surgery to allow the bones to heal and some people won’t fully heal from their surgery for up to one year.
You will be off work after surgery for at least 4-6 weeks if you are otherwise young and healthy. If you are older, it could take 4-6 months before you can return to work. The length of recovery depends on what kind of shape you’re in before the surgery.
You should not sit in one place for longer than 20-30 minutes and you may have to sleep in a position you’re not used to because other sleep positions make your back pain worse. Sexual activity may have to be delayed until several weeks out from surgery.
You might be fitted for a corset or back brace to help support your recovering back. The back brace should be worn whenever you are walking or sitting. You don’t have to wear the brace while sleeping or even when getting up in the night to void.
Don’t bend at the waist. You should instead bend at your knees and squat when lifting or picking up something. You should not lift anything over ten pounds until your doctor clears you to do so. Avoid lifting any object above your head until the fusion is healed.
For the first two weeks after surgery, take only short walks. Slowly increase your walking length. When going up and down stairs, you can do this just once a day for 1-2 weeks.
You may need some physical or occupational therapy after surgery. They can teach you how to move safely and how to get up and out of a bed or chair. They can show you how to get dressed properly and how to get undressed. They can show you how to lift things safely and learn certain exercises to strengthen the muscles around the spine. They can contribute to your going back to surgery as early and safely as possible.
You should not drive for two weeks following the surgery and you should take only short trips until your doctor approves long trips. As a passenger, you should take only short trips. If your trip home from the hospital is long, stop every half hour on your way home to stretch out your back.
The Steri-strip bandages will fall off in about 7-10 days. You can remove any remaining strips that haven’t fallen off by that time. There will be numbness and perhaps pain around your incision. You should check the incision every day to look for redness, swelling, fluid drainage, warmth or opening up of the wound. Keep the incision completely dry for 5-7 days after the surgery. The first time you take a shower, have another person help you. Ask your doctor when it is a good time to begin taking showers.
Don’t smoke after this type of surgery as it can prevent the healing of the graft. Take pain medication as directed by your doctor. If you are increasing your activity, take a pain pill about a half hour before doing the activity.
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