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Spine Surgery Education

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1 Spine Surgery Education
Pre-admission Spine Surgery Education Thank you for choosing Doctors Hospital Human Motion Institute for your spine surgery. You will be glad to know that we are rated top 10% in the nation in orthopedic care for the second year in a row by Healthgrades, a leading independent rating healthcare company. This information is intended to educate and prepare you for your spine surgery and recovery. Please read through the following packet. If you have follow-up questions, you may call our Spine Line at to speak with a physical therapist or bring your questions with you to your pre-op interview at the hospital. Again, thank you for choosing Doctors Hospital!

2 What we will cover today…
Preparation Surgery Recovery Understanding your spinal procedure Preparation for surgery Day of surgery expectations Discharge Instructions Recovery Process

3 Spine Anatomy 7 Cervical 12 Thoracic 5 Lumbar Sacrum and Coccyx
Provides us strength Allows us to stand Supports our weight Passageway for spinal cord and nerves The normal anatomy of the spine is usually described by dividing up the spine into 3 major sections: the cervical, the thoracic, and the lumbar spine. (Below the lumbar spine is a bone called the sacrum, which is part of the pelvis). Each section is made up of individual bones called vertebrae. An individual vertebra is made up of several parts. The body of the vertebra is the primary area of weight bearing and provides a resting place for the fibrous discs which separate each of the vertebrae. The lamina covers the spinal canal, the large hole in the center of the vertebra through which the spinal nerves pass. The spinous process is the bone you can feel when running your hands down your back. The paired transverse processes are oriented 90 degrees to the spinous process and provide attachment for back muscles. There are four facet joints associated with each vertebra. A pair that face upward and another pair that face downward. These interlock with the adjacent vertebrae and provide stability to the spine. The vertebrae are separated by intervertebral discs which act as cushions between the bones. Functions of the vertebral or spinal column include: Protection: of the spinal cord and nerve roots and internal organs Base for attachment: of ligaments, tendons, muscles Structural support: for head, shoulders, chest; connects the upper body and lower body; important for balance and weight distribution Flexibility and mobility: Flexion (forward bending); Extension (backward bending); Side bending (left and right); Rotation (left and right); Combination of above Other: production of red blood cells from the bones; mineral storage

4 Understanding Your Surgery
Laminectomy Creation of a “window” in the vertebrae. This allows more room for nerves and releases pressure on the nerve  What is It? Lumbar laminectomy is an operation performed on the lower spine to relieve pressure on one or more nerve roots. The term is derived from lumbar (lower spine), lamina (part of the spinal canal's bony roof), and -ectomy (removal). Why is it Done? Pressure on a nerve root in the lower spine, often called nerve root compression, causes back and leg pain. In this operation the surgeon reaches the lumbar spine through a small incision in the lower back. After the muscles of the spine are spread, a portion of the lamina is removed to expose the compressed nerve root(s). Pressure is relieved by removal of the source of compression part of the herniated disc, a disc fragment, a tumor, or a rough protrusion of bone, called a bone spur. What Happens Afterwards? Successful recovery from lumbar laminectomy requires that you approach the operation and recovery period with confidence based on a thorough understanding of the process. Your surgeon has the training and expertise to correct physical defects by performing the operation; he and the rest of the health care team will support your recovery. Your body is able to heal the involved muscle, nerve, and bone tissues. Full recovery, however, will also depend on your having a strong, positive attitude, setting small goals for improvement, and working steadily to accomplish each goal.

5 Understanding Your Surgery
Discectomy Creation of a “window” in part of the outer ring of the disc. This allows removal of a portion of the disc nucleus releasing the pressure on the nerve Discectomy is the surgical removal of herniated disc material that presses on a nerve root or the spinal cord. Before the disc material is removed, a small piece of bone (the lamina) from the affected vertebra may be removed. This is called a laminotomy, similar to what we discussed on the previous slide. This allows the surgeon to better see and access the area of disc herniation. The disc space may also be explored, and any loose fragments of disc can be removed. Microdiscectomy uses a special microscope or magnifying instrument to view the disc and nerves. The magnified view makes it possible for the surgeon to remove herniated disc material through a smaller incision, thus causing less damage to surrounding tissue. What To Expect After Surgery After a discectomy, you will be encouraged to get out of bed and walk as soon as the anesthetic wears off. You can use prescription medicines to control pain during the recovery period and will be advised to resume exercise and other activities gradually. Other things to think about include the following: You can sit as long as you are comfortable, but most people avoid sitting for longer than 15 to 20 minutes. After surgery, sitting can be uncomfortable for a while. Many people are able to resume work and daily activities soon after surgery. In some cases, your doctor may recommend a rehabilitation program after surgery, which might include physical therapy and home exercises. Why It Is Done When surgery is used to treat a herniated disc, it is done to decrease pain and allow for more normal movement and function. Surgery may be considered if tests show that your symptoms are due to a herniated disc and your doctor thinks surgery may help relieve the symptoms. In deciding whether to have surgery, you and your doctor will consider factors such as:1 A history of persistent leg pain, weakness, and limitation of daily activities that has not gotten better with at least 4 weeks of nonsurgical treatment. Results of a physical examination that show you have weakness, loss of motion, or abnormal sensation (feeling) that is likely to get better after surgery. Diagnostic testing, such as magnetic resonance imaging (MRI), computed tomography (CT), or myelogram, that indicates your herniated disc would respond to surgery. Surgery is considered an emergency if you have cauda equina syndrome. Signs include: New loss of bowel or bladder control. New weakness in the legs (usually both legs). New numbness or tingling in the buttocks, genital area, or legs (usually both legs).

6 Understanding Your Surgery
Fusion A graft ( bone or bone protein material) placed between 2 or more vertebrae. Provides stability to the spine- many times screws are used to maintain stability while healing occurs. Spinal fusion is a surgical procedure used to correct problems with the bones (vertebrae) of the back (spine). The spine is stabilized by fusing together two or more vertebrae, using bone grafts and metal rods and screws. Spinal fusion is used to treat: Injuries to spinal vertebrae; Protrusion and degeneration of the cushioning disk between vertebrae (sometimes called slipped disk or herniated disk) ; Abnormal curvatures of the spine (such as scoliosis or kyphosis) ; Weak or unstable spine caused by infections or tumors Spinal fusion eliminates motion between vertebral segments, which can be a significant source of pain in some patients. The surgery also stops the progress of spinal deformity, such as scoliosis. Spinal fusion will take away some spinal flexibility. But most spinal fusions involve only small segments of the spine and thus do not limit motion very much. Recovery following fusion surgery is generally longer than for other types of spinal surgery. Patients generally stay in the hospital for 2-5 days, depending on the type of approach used. It also takes longer to return to a normal active lifestyle after spinal fusion than many other types of surgery. This is because you must wait until your surgeon sees evidence of bone healing. The fusion process varies in each patient as the body heals and incorporates the bone graft to solidly fuse the vertebrae together. The healing process after fusion surgery is very similar to that after a bone fracture. In general, the earliest evidence of bone healing is not apparent on X-ray until at least six weeks following surgery. During this time, the patient’s activity is generally restricted. Substantial bone healing does not usually take place until three or four months after surgery. At that time activities may be increased, although continued evidence of bone healing and remodeling may continue for up to a year after surgery.

7 Understanding Your Surgery
How fusion is done Bone Graft Immobilization Types of fusion Posterolateral Interbody ALIF PLIF TLIF XLIF Fusion is performed with bone grafting and/or immobilization. Bone Grafting Bone is the most commonly used material to help promote fusion of the vertebrae. Generally, small pieces of bone are placed into the space between the vertebrae to be fused. Sometimes larger solid pieces are used to provide immediate structural support. The bone is either supplied by the patient (autogenous bone) or harvested from other individuals (allograft bone). Bone-graft substitutes are being developed, but have yet to be proven as cost-effective substitutes for autogenous bone graft for general use. Immobilization After bone grafting, the vertebrae are held together to allow fusion to progress. The bones are held immobile with metal rods and screws. External bracing or casting may also be used. Both forms of immobilization may be necessary. It is best to check with your surgeon about bracing. If a brace is required, you will need to purchase the brace prior to your hospitalization. There are two main types of lumbar spinal fusion, which may be used in conjunction with each other: Posterolateral fusion places the bone graft between the transverse processes in the back of the spine. These vertebrae are then fixed in place with screws and/or wire through the pedicles of each vertebra attaching to a metal rod on each side of the vertebrae. Interbody fusion places the bone graft between the vertebra in the area usually occupied by the intervertebral disc. In preparation for the spinal fusion, the disc is removed entirely. A device may be placed between the vertebra to maintain spine alignment and disc height. The intervertebral device may be made from either plastic or titanium. The fusion then occurs between the endplates of the vertebrae. Types of interbody fusion are: Anterior lumbar interbody fusion (ALIF)- the disc is accessed from an anterior abdominal incision Posterior lumbar interbody fusion (PLIF) - the disc is accessed from a posterior incision Transforaminal lumbar interbody fusion (TLIF) - the disc is accessed from a posterior incision on one side of the spine Extreme lateral interbody fusion (XLIF) – The XLIF procedure is an innovative technique because not only is it minimally disruptive, but also it allows the surgeon to access the spine from the side of the body, which inherently means less soft tissue to have to traverse to get to the spine. It gives the surgeon access to the spine through the side of the body, thereby avoiding the major muscle groups in the back, and the major organs and blood vessels in the abdomen. In most cases, the fusion is augmented by a process called fixation, meaning the placement of metallic screws (pedicle screws often made from titanium), rods or plates, or cages to stabilize the vertebra to facilitate bone fusion. The fusion process typically takes 6–12 months after surgery. During this time external bracing (orthotics) may be required. External factors such as smoking, osteoporosis, certain medications, and heavy activity can prolong or even prevent the fusion process. If fusion does not occur, patients may require reoperation. In the neck, the anterior approach is more common; lumbar and thoracic fusion is usually performed posteriorly. The ultimate goal of fusion is to obtain a solid union between two or more vertebrae.

8 Preparation for Surgery
Obtain all required pre-admission testing recommended by surgeon and bring information to Pre-Op (may include blood work, EKG, chest x-ray, medical clearance from primary doctor, or self-donated blood) Clear all medications with your physician, including any herbal substances or nutritional supplements you may be taking Bring All insurance cards & picture identification to Pre-Op Do not eat or drink after midnight the night before your surgery

9 What to bring to the hospital…
Personal care items (such as toiletries) Rubber soled / non-skid shoes or closed back slippers Comfortable clothing for therapy Loose fitting pajamas and /or light weight robe Bedside snacks Important contact phone numbers List of medications, including the ones you may stopped prior to surgery, dosing information Eyeglasses instead of contacts Dentures / hearing aids if needed Brace if you have one and are asked to bring it Walker or cane if used at home Important: Leave all valuables at home!!!

10 General Health Guidelines
Weeks before the surgery, you should concentrate on the following: Nutrition Eat healthy Drink plenty of fluids Do not drink alcoholic beverages Stop smoking Take your daily medication as directed by your physician Discuss with your physician any nutritional and/or herbal supplements you are taking Smoking increases the risk of infection. Ask us how to quit!

11 Day Before Surgery… Pre-operative shower
Take the evening before or day of surgery Wash with Triseptin soap provided at pre-op Do not eat or drink after midnight As directed by your physician, take required medications with a sip of water only

12 Morning of Surgery Your specific surgical time will be determined at your pre-op visit Report to the Main Lobby at the time appointed in your pre-op visit Surgery will last 1-2 hours Time in the recovery room is generally 1-2 hours During surgery your family will wait in the surgical waiting room After recovery, you will be transferred to the nursing unit on 2 South where family members can see you

13 Evening of Surgery… Following your surgery, you may have:
Intravenous therapy (IV) to provide fluids, medication and/or antibiotics Drain at your incision site which prevents fluids from building up Urinary catheter to help drain your bladder Foot pumps to prevent blood clots Incentive spirometer to help with deep breathing exercises

14 Pain Management You will see anesthesia at your pre-op visit
General anesthesia or a spinal anesthetic will be administered during surgery Pain relief options after surgery include: Epidural anesthesia Patient controlled analgesia (PCA) pump Injections (as needed) Oral medications (as needed) Just remember that you will experience some pain, but we have ways to manage the pain as listed here on the slide.

15 Pain Scale 10 Worst possible pain 9 8 Very severe pain 7 6 Severe pain
5 4 Moderate pain 3 2 Mild pain 1 0 No pain Notify nursing when your pain starts to get uncomfortable. DO NOT WAIT for the boiling point. We want you to be able to participate in your care, daily functional activities, and therapy so you can get home safely. Feel free to ask nursing, your physician, or anesthesia if your pain management plan is not working or needs to be adjusted. THIS IS YOUR CARE!

16 Blood Clot (DVT) Management
Leg exercises and support stockings (TEDS) or foot pumps help keep the blood flow in your legs moving and to prevent blood clots (DVT) How it happens…. Ways to help prevent it… We help to prevent DVTs with mobility (getting out of bed) and walking. We also use foot pumps, a mechanical device worn while in bed, to keep blood flowing through your legs. Last, your doctor may prescribe anticoagulant therapy or a medication that helps prevent blood clots.

17 First Day After Surgery
During your first day of recovery, you may have or begin: Lab tests Intravenous (IV) fluids, catheter and/or your drainage tube removed Your dressings or bandages changed To turn, ambulate, deep breath and use your spirometer Dressing and bathing activities Physical and Occupational Therapy

18 First Day After Surgery
Working with physical/occupational therapy to participate in walking, exercise and daily living activities programs Working with a Case Manager or Nursing staff to prepare you for the next level of care, your discharge location and any equipment needs Take pain medication as needed in order to participate with therapy

19 Getting In and Out of Bed
Roll your entire body instead of twisting at the waist Once on your side, ease your legs off the edge of the bed to sit up This is called a log roll. This is taught to protect your back and prevent rupture of your surgical incision.

20 Second Day After Surgery
Depending on your surgery, your recovery progression and your surgeon will determine if additional days are required in the hospital. During your second day in the hospital you will Continue to work with physical and/or occupational therapy Continue to deep breath and use your spirometer Continue to discuss discharge planning Take your pain medication as needed

21 Discharge Criteria You will be discharged from the hospital when you are able to: Eat and drink to prevent dehydration Empty your bladder without any problems Effectively manage any pain Increase your mobility (walking and exercising) Have bowel movement without complications Have a Plan A and a Plan B for discharge, especially if you live along or will not have help at discharge. Call your insurance company ahead of time regarding what equipment and discharge plans they will or will not cover. Plan ahead!!

22 Discharge Instructions
Your physician, nurse, or physical therapist will discuss the following: Spine precautions and special instructions Pain control and prescriptions Signs of infection or problems Bandage changes and care of incision site Approval for driving, sexual activity, and any other physical activities Signs and symptoms of infection could include redness around the incision site, increased drainage, increased pain, fever.

23 Back Precautions No bending or twisting back Keep back straight
Proper lifting techniques No bending or twisting back Keep back straight Limit sitting in upright chairs to min Log rolling to get in and out of bed Do not lay on your stomach Further instructions will provided at your post-operative physician appointment.

24 Recovery

25 How to prepare your home for discharge
Make modifications to your home prior to surgery that will decrease your risk for falls or injury These may include side rails on stairways into the house. Making these transitions before your surgery will make the transition back to home easier for you and your family.

26 Preparing Your Home Ensure hallways and stairwells are free of clutter. Install grab bars if necessary to get in and out of the bath safely. You may require additional equipment to shower. Talk to your occupational therapist about this. Ensure you can safely get in and out of your bed without breaking your back precautions. Make sure there is enough room to allow the log-roll technique.

27 Home Safety Tips… Remove or tack down throw rugs
Remove clutter from hallways and walkways Keep electrical and telephone cords safely out of sight (Use cordless phone, if possible) Rooms and hallways are well lit for visibility Safety and grab bars are installed as needed Keep items in the kitchen/bathroom at waist level for accessibility Arrange pet care, if needed

28 Recovering at home… Things to keep in mind:
Keep your incision clean and dry Shower with mild soap and do not put any creams on your incision Take your medication as prescribed Progressively increase activities as directed Use proper lifting techniques. Do not lift anything heavier than a light bag or book Sit in a supportive chair with arms Keep your walking areas free of clutter Keep moving!!

29 Frequently used equipment/aids
If prescribed by your physician, a case manager / nurse / therapist will educate you on the use of these assistive devices: Canes Rolling Walkers Elevated commode seats Bedside commode or 3 in 1 commode Back/neck braces Pillows to be used when sleeping Ankle pumps Reacher Sock aid

30 When to call the doctor Chest pain or difficulty breathing – Call 911
Sudden inability to move your leg(s) – Call 911 Fever above 101° Pain in your back, NOT relieved by medication Unusual redness, heat or drainage from your incision site New numbness/tingling in your leg(s) Changes in bowel or bladder

31 Steps WE take for Safer Surgery
To avoid infection: Antibiotics To Avoid Blood clots: Anticoagulants Foot Pumps To Avoid Heart Attacks: Talk with your doctor about your medications Courtesy of the Surgical Care Improvement Project Partnership (SCIP)

32 Safer Surgery Continued..
To avoid pneumonia Pneumonia vaccine is available, if ordered by your physician Early mobilization (or getting out of bed) Incentive Spirometry To avoid flu Flu vaccine is available, during flu season, if ordered by your physician

33 Surgical Site Infections
Precautions are taken prior to and during surgery to reduce risk Smoking increases risk. Ask us how to quit! Make sure your doctor and healthcare providers wash their hands or use sanitizer before exams, ask “Did you wash your hands?” Clean your incision based on your discharge instructions daily until follow-up with your doctor Call your Doctor if you have any signs or symptoms of infection (redness, increased pain, increased drainage, fever)

34 Questions? Thank you for reading through this presentation. If you have any questions, you may call our Human Motion Institute Spine Line at

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