Health Society of South Africa

SPINAL FUSION
Understanding your surgery

Planning for Spinal Fusion Surgery

Living with a problem back or neck can be frustrating. Pain may keep you from doing what you like or need to do. You may have tried other treatments, including surgery, which didn't relieve your pain. Now, you and your doctor have decided that spinal fusion may be the best way to control your pain. Spinal fusion permanently connects two or more bones in your spine. This information lets you know what to expect before, during and after your surgery.

Your Painful Spine
Back or neck problems can have many causes. They include:

Damage from overuse
Damage from an injury
Medical problems such as arthritis

No matter what the cause, the weakness, numbness or pain that you feel is disrupting your life. You may find it hard to do your job, exercise or keep up with your daily errands. And your family and social life may be strained as a result. But relief may be within reach.

Spinal Fusion May Help
During spinal fusion, your surgeon locks together, or fuses, some of the bones in your spine. This limits the movement of these bones, which may help relieve your pain. Your back or neck won't be quite as flexible. Even so, you may feel more flexible after a fusion because you can move with less pain.

Types of Spinal Fusion Surgery
Which section of the spine is fused depends on where your pain is. Sections of the spine that may be fused include:

The neck (called cervical fusion)
The lower back (called lumbar fusion)

Fusion can be done from the front (anterior) side of the body or the back (posterior) side of the body. Your surgeon will decide which is best for you.

Anatomy of a Normal Spine

Learning about your spine can help you better understand how spinal fusion surgery works. The spine is made up of hard bones (vertebrae) with soft cushioning (discs) between them. This makes the spine strong and flexible.

The Parts of the Spine
The vertebrae are the 24 bones that connect like puzzle pieces to make up the spine.
The transverse process is the wing of bone on either side of each vertebra.
The spinous process is the part of each vertebra you can feel through your skin.
A disc lies between each of the vertebrae.

Fusing the Vertebrae
Normally, the vertebrae fit together but can move separately. Sometimes vertebrae move too much, squeezing nerves and causing pain. Spinal fusion locks two or more vertebrae together. The fused vertebrae can no longer move separately. As a result, pain is lessened.

Understanding Bone Graft

To fuse the spine, very small pieces of extra bone are needed. Called bone graft, this bone acts as the "cement" that fuses the vertebrae together. Bone graft comes from a bone bank or from your own body. Your surgeon will choose the type of graft that's best for you.

From a Bone Bank
Bone banks collect, evaluate and store bone. The bone comes from human donors who are recently deceased.
Donors are checked for their cause of death and medical history. Tests are done to check for viruses such as HIV and hepatitis. The bone is also treated before it is used as a graft. The risk of getting a disease from bone graft is very slight.

From Your Own Body
If bone from your own body is used, a small amount of bone is taken from the surface of the front or back of your pelvic bone.
The bone is removed during the fusion surgery - a separate surgery is not needed. Bone may be taken through the incision made for your fusion, or through a separate incision. The area the bone is taken from can hurt quite a bit until it heals.
Bone from your own body may work better than bone from a bone bank. Your surgeon will decide whether it is a better choice for your fusion.

Preparing for Fusion Surgery

Here are guidelines for getting ready for your spinal fusion surgery. Follow these and any other instructions you're given. If you have questions, ask your nurse or doctor.

Your Medical Checkup
You may be told to see your primary care doctor to make sure you're in good shape for surgery. Tell your doctor what medications you take. This includes over-the-counter drugs like cold medicine and aspirin. Ask your doctor and surgeon if you should stop taking any medications before surgery.

Storing Your Blood
You may be asked to donate blood before surgery. If needed, this blood can be given back to you during or after surgery.

Preparing Your Home
To make life after surgery easier, get your home ready. Ask your doctor, nurse, or physiotherapist for suggestions. Also try the following:

Put things where you can get them without reaching or bending.
Pick up clutter. Remove throw rugs. Tape down electrical cords.
Arrange for someone to help you with chores after the surgery.

Stop Smoking and Stop Taking Aspirin
If you smoke, your bones may not fuse. At least 3 to 4 weeks before surgery, stop smoking or cut down as much as you can.
Aspirin, ibuprofen, and other non-steroidal anti-inflammatory medications (NSAIDs) can make you bleed more during surgery. They may also keep your bones from fusing. Ask your doctor if and when you should stop taking them.

The Night Before Your Surgery
Unless told otherwise, don't eat or drink anything after midnight. This includes water, coffee, chewing gum and mints. If you take daily medication and have been told to continue it, take it with small sips of water. You can brush your teeth on the morning of surgery.

Arriving and Getting Ready
You'll most likely arrive at the hospital a few hours before your surgery. If you have not pre-registered, you will be given forms to fill out. After you change into a gown, certain tests may be done. Then, one or more IV (intravenous) lines may be started. These lines provide the fluids and medications you need during surgery.

Anaesthesia
At the start of your surgery, you'll be given general anaesthetic. This medication will make you "sleep" through the surgery. An anesthetist is in charge of the anaesthesia. He or she may meet with you before the surgery begins to talk to you and answer your questions.

Risks and Complications
The risks and possible complications of spinal fusion surgery include:

Infection (less common in cervical fusion)
Nerve damage
Bone graft shifting out of place
Bones not fusing
Blood clots in legs

Cervical Fusion

Fusing vertebrae in the cervical curve may help ease neck and arm pain. Two or more vertebrae in your neck are fused. Cervical fusion is usually done through an incision in the front of the neck. It may sometimes be done through the back of the neck, or through the front and back. The surgery generally takes from 1 to 4 hours.

The Fusion Procedure
These steps apply to fusion from the front of the neck:

The disc is removed from between the vertebrae
Bone graft is packed into the now-empty space between the vertebrae. In time, the graft and the bone around it will grow into a solid unit.
To help keep your spine steady and promote fusion, extra support may be used.
The incision is closed with sutures or staples.

If Extra Support is Needed
Metal supports called instrumentation may be used to help steady your spine while it fuses. These supports are not removed. Your surgeon may use one or more types of support. The most common type of support used with cervical fusion is a plate.

Anterior Lumbar Fusion

Fusing vertebrae in the lumbar curve may help ease lower back and leg pain. Anterior lumbar fusion is done through an incision in your stomach area. Depending on how many vertebrae are fused, the surgery may take from 3 to 8 hours.

The Fusion Procedure
The disc is removed from between the vertebrae to be fused.
Bone graft is packed into the now-empty space between the vertebrae. In time, the graft and the bone around it grow into one solid unit.
To help keep your spine steady and promote fusion, extra support may be used.
The incision is closed with sutures or staples.

If Extra Support is Needed
Metal supports called instrumentation may be used to help steady your spine while it fuses. These supports are not removed. Your surgeon may use one or more types of support. The most common type of support used with anterior lumbar fusion is a cage.

Posterior Lumbar Fusion

Fusing vertebrae in the lumbar curve may help ease lower back and leg pain. Posterior lumbar fusion is done through an incision in your back. The graft is put between the vertebrae in one of two places: in the disc space or between the transverse processes. Depending on how many vertebrae are fused, the surgery may take from 3 to 8 hours.

Fusing the Transverse Processes
Bone graft is packed between the transverse processes ("wings") on the sides of the vertebrae. Occasionally, other nearby parts of the vertebrae are fused as well.
To help keep your spine steady and promote fusion, extra support may be used.
The incision is closed with sutures or staples.

Fusing the Disc Space
The disc between the vertebrae is removed.
Bone graft is packed in the now-empty space between the vertebrae. In time, the graft and the bone around it grow into a solid unit.
To help keep your spine steady and promote fusion, extra support may be used.
The incision is then closed with sutures or staples.

If Extra Support is Needed
Metal supports called instrumentation may be used to help steady your spine while it fuses. Your surgeon may use one or more types of support. Below are two common types of support used with posterior lumbar fusion:

A cage may be used when fusing the disc space.
Screws and rods may be used when fusing the transverse processes. In rare cases, these supports may be removed after fusion is complete.

Recovering in the Hospital

After the surgery, you'll go to the PACU (post-anaesthesia care unit) or recovery room. You'll stay there until you are fully awake, usually a few hours. Then you'll go to your ward. With cervical fusion, you may go home the next day. With lumbar fusion, you may stay in the hospital for 2 to 7 days.

In the PACU (recovery room)
When you first wake up from surgery, you may feel groggy, thirsty or cold. Your throat may feel sore. You may have tubes in your body to drain blood and fluid from your incision. IV lines continue to provide fluids and medications. You may also have a tube called a catheter to drain your bladder for a few days.

In Your Hospital Ward
You'll be encouraged to get up and walk. At first you'll need help, and you may not get far. But walking helps keep your blood moving and your lungs clear of fluid.
Your IV gives you fluids and nutrition until you can eat on your own, usually within a few days.
You may wear special stockings or boots to prevent blood clots in your legs.
You may be given a neck collar or back brace. Wear this as your doctor instructs.
You may see a physiotherapist, who will teach you how to protect your spine when you move.

Managing Your Pain
Your nurse may give you your pain medication. Or you may have a PCA (patient-controlled analgesia) pump. This allows you to control your own pain medication. When you push a button, medication is pumped through an IV line. At first, you may feel some pain even with medication. This is normal. But if you are very uncomfortable, tell your nurse.

Recovering at Home

If you've had neck surgery, recovery takes about 3 months. For lower back surgery, recovery takes about 6 months to a year. To help protect your healing spine during this time, follow these guidelines and any other directions you have been given.

Use Pain Medication as Directed
You'll be prescribed medication for pain. Don't wait for the pain to get bad before you take your pain medication. Take it as directed and on time. Depending on your surgery, you may need this medication for 1 to 3 weeks or longer.

See Your Surgeon
Visits after surgery let your surgeon keep track of your healing. If your stitches or staples weren't taken out before you left the hospital, they may be removed at one of these visits.

Get Moving
The right kind of movement can help your recovery.

Take a few short walks each day. Increase your walking time as you heal.
If you feel more pain than usual after an activity, you may have overdone it. Take it a little easier for a few hours.
Ask your surgeon what activities to avoid. Also ask when you can return to work, driving and sex.
You may see a physiotherapist who will teach you how to move after surgery. He or she may also teach you exercises to help you heal.

When to Call the Surgeon
Call if you have any of these symptoms during your recovery:

Increased pain, redness, or drainage from the incision
Fever over 37.8(C

Moving Safely

Learning how to move safely can help protect your spine while it heals. After you heal, keep moving safely to help your neck and back stay healthy. Keep your ears, shoulders and hips in line. Try the following tips. Also, be sure to follow any other guidelines from your doctor, surgeon or physiotherapist.

Standing and Turning
Stand with one foot slightly in front of the other, as if you just took a step. Or, stand with your feet shoulder width apart.
Keep your knees relaxed and your stomach muscles tight.
Turn with your feet, not your body.

Getting In and Out of a Chair
To sit down:
Back up to the chair. Tighten your stomach muscles.
Lean forward from your hips (not from your waist).
Use your leg muscles to lower yourself onto the front of the chair. Then scoot back.

To get up from a chair:
Scoot to the front of the chair. Tighten your stomach muscles. Place one foot slightly in front of the other.
Hold the side of the chair or the armrests for support.
Bend at the hips (not the waist). Use your leg muscles to push your body up.

Lying in Bed
Lie on your back with a pillow under your knees.
Or lie on your side, with your knees bent toward your chest and a pillow between your knees.

Turning in Bed
Tighten your stomach muscles. Bend your knees slightly toward your chest.
Roll to one side, keeping your ears, shoulders and hips in line. Be careful not to bend or twist at the waist.

Getting Out of Bed
Tighten your stomach muscles. Turn onto your side.
Slowly scoot to the edge of the bed.
Push your body up with one elbow and the other hand. At the same time, gently swing both legs to the floor. Keep your stomach muscles tight.
To stand up, follow the instructions for getting out of a chair.

Other Tips to Protect Your Spine
Bend your knees if you need to pick something up off the floor. Keep your back straight.
You may find it easier to dress and undress while lying on your back. Bend your knees and raise one leg at a time. A tool called a dressing reacher may help.
Avoid pushing, pulling or twisting. Also avoid lifting anything heavy. Ask your surgeon for specific guidelines.
Walk to stay in shape and keep your spine healthy.

Your Surgical Checklist

Use this list to help remind you what to do before and after your surgery. Ask your health care provider to confirm what applies to you. After your surgery, be sure to keep walking. Try to walk a little more each week. That way, you can ease back into activity safely.

Before Your Surgery
See your doctor. Have any tests that your doctor orders.
Stop smoking or cut down.
Stop taking aspirin and ibuprofen as instructed.
Stop eating and drinking as instructed before surgery.
Check which medications you can take on the day of surgery.

After Your Surgery
Schedule your first follow-up visit after surgery.
Take care of your incision and bathe as directed.
Complete your physiotherapy programme if one has been prescribed.
Ask your surgeon to list which activities you can do, and when.