How is the Operation Performed

Once you are anesthetised, you are taken through into the operating theatre.  You are placed face down on the operating table and a slight curve is placed in the operating table so as to open up the spine. 

The incision, (cut in the skin), is made on the centre of the back in the middle and runs up and down over the spinous processes.

Its length is determined by the number of levels involved. By using X-ray guidance and perhaps too an operating microscope, we can keep this as small as possible though seldom are these “keyhole” operations. The muscle is then parted to reveal the bone over the back of the spine. This phase of the procedure is known as the access. 

I usually inject local anaesthetic to numb the area of skin where the incision is to be made and the tissues below. This reduces the amount of painkiller the anaesthetist has to use with the general anaesthetic and makes it safer. The local anaesthetic has adrenaline added so as to constrict the local blood vessels. This decreases bleeding which makes the operation safer and lengthens the effect of the local which makes the immediate post operative pain. This is called “a local block”. 

Now comes the business end of the operation.

Decompression is completed by removing the thickened bones and ligaments from the back of the spine and this is advanced with the aid of the operating microscope. If the central canal is narrow, the bone and ligaments are cleared from it so as to perform a “central canal decompression”. The nerve sac is then mobilised away from any disc prolapse and the prolapses removed.  Any pulp lying within the disc is cleared. This is the “discectomy”. The bone of the adjacent vertebrae is cleaned meticulously of all disc fragments so that the bone surface will grow into the grafts – see below. The foramina (hole) which the individual nerve roots exits from the spine is now widened as necessary. Again, this is done by shaving bone and ligament from the walls as this will have thickened to cause the narrowing. This is called a “nerve root decompression” or undercutting facetectomy. After making certain that there is no further pressure, active bleeding or leakage of spinal fluid the wound is then closed. 

The fusion comes next. This has two elements to it; the instrumentation and the bone graft.

The instrumentation phase usually begins by inserting screws into the back of each of the vertebral bones to be fused. These are large and are placed into the left and right side of the vertebrae at each level. The anterior part of the spine is instrumented by excising the disc and fixing a cage into the intervening gap.

Bone graft is placed into the anterior part of the spine by filling the cage with bone graft – the anterior fusion. Further bone graft is placed around the side of the spine between the bony fins on the lateral aspect of the spine - the lateral fusion. Finally, bone graft is placed over and in the facet joints which are first prepared by abrading their bony surfaces – the posterior fusion. Combined this anterior, lateral and posterior bone grafts achieve a 360° fusion.

Once this has been completed there comes the “closure”. Again meticulous care is taken to stop any bleeding and the wound is then stitched in layers using internal absorbable stitches.  A drain is usually placed at the base of the wound. This is rather like a drip and is removed at 24 hours. The skin may be closed in a number of ways though most commonly a series of separated stitches or metal skin clips rather like little staples. A top up to the local block is given.  A dressing is applied.

You are then woken up and I write some notes on how things went and what we found. I call any relatives who may be waiting for news – please, when I come to do your consent form before the surgery give me the name and number of anyone you would like me to call.

Removal of the suture/clips occurs at approximately 10 days. This can be done either at the hospital or at your GP’s surgery or at home by district nurse. If we have used clips we will give you a clip remover before you go home.

Risks

Complications of any operation and indeed any long period spent in bed include chest infection and blood clots forming in the deep veins of the legs (deep venous thrombosis or DVT). Parts of the blood clots may break off and fly up to the lung where they block the blood flow (Pulmonary embolus or PE). Very rarely people die from these blockages. You may have heard of these complicating long plane journeys. We can reduce the incidence of these by giving you injections to thin the blood, supportive stockings (which I request you wear at all times whilst in hospital) and compression pumps on the legs worn while in bed. We use the stockings and pumps in theatre but do not start the injections until 24 hours after the surgery so as not to provoke bleeding into the fresh wound.

There is a risk to life and limb. Any anaesthetic and any operation may kill you. Any spinal surgery may paralyse you which in the instance of a lumbar operation will mean loss of all leg, bowel, bladder and sexual function. At its worst, this may be complete and permanent. Such disasters are extremely rare and are in the order of the risk of your being run over by a bus. People do get run over by buses but it is exceptionally rare. Of course, if you do not have the operation the disc may fully prolapse or a spondylolisthesis progress and paralyse you themselves. Again, I see this though very rarely - these buses associated with the natural history of the condition are indeed extraordinarily rare and you can usually see them coming and so take evasive action.

The “cauda equina syndrome” is the term used to describe paralysis of this part of your nervous system. The patients usually have a phase of excruciating pain followed by numbness, paralysis and an inability to pass urine which classically is painless. i.e., you know you have an overfull bladder but it does not hurt – “painless retention”. An early warning may be numbness around the private parts/perineum. If you notice anything like this you need to see a doctor, any doctor – don’t wait for me - immediately.

This syndrome is a surgical emergency. You need to have the nerves decompressed immediately i.e., that day / night.

Nerve root injury affecting just the nerve that passes out from the spine at this level - it is not quite so rare but is far from common. Obviously, the nerve root is handled during the procedure and even though microsurgical techniques reduce this to a minimum the risk of an individual nerve being permanently lost remains. It is low – less than 1 %. This might mean that the ability to stand on tip toe is lost or to lift up the foot (a foot drop) results. Again, if you do not have the operation, pressure from the pathology itself may do this anyway.

The spinal nerves are contained in a sack and this is filled with fluid secreted by and in communication with the brain. As the disc fragment presses directly on this sack it may leak cerebrospinal fluid during the course of the operation. This should not adversely affect the outcome of the operation though does mean you will need to lie flat for five days as described above. Nearly always the leak can be seen during the surgery and therefore I will give instructions for you not to be mobilised for the five days. If you are told you may get up then I have not encountered a leak. This occurs about 1 in 20 times though is more frequent when patients have had surgery before.

Failure of an operation to achieve its intended goal is always possible. In this instance, it will mean the persistence of back and leg symptoms as they were before. In the case of spondylolisthesis, this is uncommon though some manageable levels of back pain may persist. In those of you having this surgery for “discogenic” back pain, there is by contrast a failure rate of up to 50%. That is to say half of these procedures fail. In addition, even in the successful cases persistence of some non-disabling levels of back pain is common. It is not uncommon for a degree of pre-existing weakness and numbness to persist particularly if it was severe beforehand. The longer they have been present the more likely this is. However, most patients experience an improvement in weakness and numbness if not complete resolution.

Recurrence of symptoms may occur. That is to say you may get better only for things to get worse again later. There are a number of reasons why and again this may be in the form of back or leg pain. Back pain may occur in acute bouts and can be minimised by your being diligent with the post-operative physiotherapy. Leg pain may arise from narrowing of the spinal canal developing at an adjacent level or indeed at the original level, scarring occurring around the nerve roots at the original level and damage caused by the original compression leaving the nerve root hypersensitive as it attempts to recover in the post-operative months. Finally, the instrumentation may irritate the nerves and muscles of the spine. Usually, it is an element of each of these pathologies which operate together to cause recurrent leg or back pain. A degree of pain is almost universal. Precisely how severe and how often is still a matter for some debate.

To find out a true recurrence rate, thousands of patients need to be followed for tens of years and for none to drop out during that time. There is no perfect study but it is my impression from those studies that have been done and from my experience, that perhaps 1 in 5 of the discogenic group eventually have substantial persistent or recurrent trouble. This is much lower for the spondylolisthesis group for whom I suspect 70% to 80% do well long term.

Deterioration is a possibility. Operations can make you worse, can do you harm or may leave you with new problems to cope with. This is rare and I suspect deterioration directly as a result of the surgery probably affects around 1% to 2% of patients – certainly less than 5% or 1 in 20. Quite a few patients may have a transient increase in numbness or weakness though persistent significant problems are rare indeed. 

Wound infection can occur with any operation. In the spine, it is rare as there is so much muscle covering it. Muscle fights infection well. However, if an infection ever sets in the effects can be very serious. The risk is around 1%. Diabetic patients are at a higher risk of this. Superficial wound infection may be successfully treated with antibiotics alone. However, if the infection gets deep into the wound and affects the metal work then this often eventually has to come out. This may take months to treat.

Obviously, you must know what the aims and risks of any operation are. We will document in the notes that we have explained these to you, as it is routine to do so. Do not sign the consent form if you feel we have not.

We will write something like this in your notes:- make sure you feel it is true

“I have explained the aims and risks of the procedure including those to life and limb (ie. death paralysis and disaster), of failure (the procedure does not work), recurrence (you get better but it comes back) and deterioration, (you are made worse), of death, paralysis, wound problems, of nerve/ nerve root injury, as well as the likely natural history of the condition (what happens if nothing is done), the possible impact of alternative managements and treatments, along with the usual post procedure recovery and its variants (i.e., how much time off from work, what help you will need at home, what the wound care is).”

These are all things you will need to have had covered. Again, do not sign the consent if you are not sure.

What happens on the day of surgery

The day will begin with you in the ward. Some of you will have come in the night before though increasingly patients come in on the morning of surgery which may mean a very early start as you are often needed at the hospital by 7am. My office or our Spinal Nurse will be able to tell you when.

Make sure you have your scans – no scan, no operation.

The night before or that morning you will sign your consent form and meet the anaesthetist. This is a good time to give me the telephone number of any relative you would like me to ring when the operation is over – I am always happy to do this.

You will have had nothing to eat or drink for a substantial period before the anaesthetic. 

The precise length of this period, (usually 6 hours), is prescribed by the anaesthetist and you need to be clear about this the day before the surgery. My secretarial team or our Spinal Nurse will clarify this also.

One of the hospital porters will come and collect you from the ward and will take you to theatre, with one of the ward staff. They deliver you, on a trolley, to the anaesthetic ante-room adjacent to the operating theatre. There you will meet the anaesthetist again. They will usually put a small drip into a vein on the back of the hand.  After asking you to breathe some oxygen they will send you off to sleep with an injection into the drip. 

The next thing you are aware of is waking up in the recovery area or back on the ward. 

What happens if you don’t have it done?

Discogenic pain will often eventually settle. If you are having surgery before a year there needs to be a good reason – progressive motor or sensory loss, worsening rather than consistent or declining pain, or an associated narrowing of the spinal canal of such severity that it threatens paralysis. You should know what the reason is for such a rapid progression to fusion surgery.

However, if after this time there is no clear pattern of improvement in symptoms many of you are stuck at least for a long time. Many of you will have had a very gradual onset of symptoms perhaps years ago. Again, in these circumstances it is likely that you are stuck.

In spondylolisthesis, there is sometimes a risk of progressive neurological symptoms – weakness and numbness and this may be permanent. However, this is unusual and usually occurs slowly giving plenty of time for us to react.

From this, you can appreciate that there are virtually no circumstances where you should feel rushed into a fusion operation. They are elective operations which should be done after very careful consideration.

What alternative procedures are there?

The principle alternative to fusion for discogenic pain is artificial disc replacement (ADR). This preserves and restores motion. In general, ADR is our preferred option. The reason we may have suggested fusion instead is if you have had complex abdominal surgery barring our access to the front of the spine, if there is significant instability requiring stabilisation, or if the level is L5/S1 and the patient a male as anterior surgery here can lead to infertility. If the facet joints are causing the pain then fusion is the only option. In addition, if there is severe canal stenosis then this can only be really radically cleared with posterior access and ADR is not possible from behind. There is no surgical alternative for spondylolisthesis or other instability or deformity cases.

The operation is always the last resort. Instead you could try injections or further conservative treatment (physiotherapy, osteopathy, chiropractic, acupuncture, tablets and time.) Obviously, we will usually have formed the view that these are unlikely to bring you to comfort any time soon. Occasionally, I will have warned you that bad paralysis of nerves may occur if things are left and in these circumstances there is little choice but to proceed.

The majority of you in this urgent situation will have very severe narrowing of the spinal canal and progressive weakness and numbness. However, this is an unusual situation.

For the majority, it is pain that drives the surgery. In these circumstances, you have to feel that the degree of pain warrants the risk and effort involved in having the operation.

There will usually be an intravenous drip in one of the veins in your arm. This gives you fluids so you do not need to eat or drink if you feel sick. The anaesthetist may wish for you not to eat or drink for a while after the operation and will advise you of this. Most of you are soon having a cup of tea.

In addition, there will often be a separate small drip providing you with pain relief.  Usually, there will be a button for you to press in order for the pain relief to be delivered i.e., you will control the amount of pain relief you get.  This is a very safe and effective way of making sure you get analgesia when you need it. You cannot overdose yourself by pressing it too much – the device will simply fire blanks when the maximum safe dose has been reached. You will get more pain when you move and it takes a little time for the pain relief to work. So a good tip is to press the button a few minutes before you want to move. Some patients find that too much causes a headache or nausea. If this is a significant problem we will need to use a different system but for most people it is the most effective way to deliver pain relief.

There will often be a drain coming from the wound.  This is like a drip and will be connected to some sort of collection device (small plastic bottle) next to you.  This is usually removed the next day.

Wound care is important. You will have some form of surgical dressing on the wound – usually a light non-waterproof dressing. The wound should not be allowed to get wet until the day after the sutures/skin clips are removed (see below).

In general, we like to disturb the dressing as little as possible. If it is becomes stained but is intact it is often better to put one over the top rather than to take it off.

If you need to go to the toilet you may normally get up and use the facilities in your bathroom. If you are on bed rest (see paragraph below) or are in too much pain to do that then ask for a bottle or bed pan.

Nearly always you can get up immediately if you wish. Of course, you should have a nurse or physiotherapist with you on the first occasions. Many of you will need a brace when upright.  We will have discussed this beforehand though if one is required you must get used to putting it on and off and wear it whenever you get up. It will be custom made usually the day before the surgery and be ready the day afterwards. You need to wait for it before you get up.

CSF Leaks

With this kind of surgery, about one in twenty times there will be a leakage of fluid from the sack containing the nerves and this needs to heal before you get up. The fluid, cerebrospinal fluid, or CSF, is clear and watery. I can see the leak at the operation and will tell you of the event. Whilst this does not adversely affect the outcome of the operation, it does mean you have to lie flat for five days. You may not get up at all for any reason. This is a great bore though as mentioned does not alter the outcome of the operation. During this time, you can roll over or lie on your front if you wish but you must not end up with your head higher than your bottom. The column of fluid in the spine extends up to the head and thus if the head is high compared to the base of the spine fluid will tend to escape into the wound.

Discharge

However, there is no rush and you should stay until you can manage the journey home, life at home and have not needed the pain relief drip for 24 hours. 

If you live a long way off, live on your own or have a dependant family you will need to stay for longer. Occasionally, the less able who live alone might sensibly use a convalescent facility. Equally, some go home on day four or five though if you are an early leaver you should rest at home much as if you were still in hospital.

Don’t forget to take your X-rays and scans with you.

Remember there is no rush –go home when you are ready. You should be able to tick certain boxes:

• be able to mobilise and more or less dress yourself
• to have passed urine and opened your bowels
• to have tried some stairs with the physiotherapist
• to be able to manage on just oral medication and pain relief
• to be able to cope with your journey home
• to be able to survive comfortably with your personal home circumstance

Often day two and three are worse than day one in terms of pain. We tend to plan the precise discharge time on the ward rounds on day three or four.

How to get home

The front passenger seat in a standard car is fine. If the journey is long get out of the car every hour and do some simple stretches. Then get back in the car and carry on. It is often sensible to take some tablets before you leave the ward. Go to bed when you get home regardless of how well you feel.

Done once, even a long journey is OK. This is not a licence to drive every day.

Post-operative back care

Physiotherapy

You may well have been given specific instructions by the hospital’s physiotherapist.  Indeed, you are likely to be given a sheet with diagrams of various exercises. The precise details of these exercises and how often they should be done will vary from one individual to another. However, these details are of less importance than your response to them.  That is to say, if you develop pain on doing these exercises, you should stop them.  In the first few weeks all that can occur is the simple healing process. Physiotherapy maintains your mobility during this time but should not be allowed to interfere with the healing process. Therefore, if it hurts, you should stop and you should not be anxious if, as a result, you are quite stiff by the end of this early period.  Physiotherapy begins in earnest around the fourth to sixth week when the wound and back will be stable enough to allow real progress to be made.

Exercise

The aim here is to do small amounts but often.  For most of the first week, you will either be in hospital or should be pottering about inside your home.  For the second week, the amount of activity undertaken should essentially be unchanged.  You should simply be moving about as if you were in fact still in hospital.  It would be perfectly reasonable to fix your own meals and to look after yourself though you should not be doing housework or looking after others. You may go out for short walks. From the second week onwards, light exercise may be taken.  You may go on very short car journeys (10-15 minutes) and go out for longer walks.  Prolonged outings, lengthy or frequent trips to the office will be bad for you.  Problems most often arise when patients do a little too much a little too often, i.e., one trip to the office may be alright but three cause troubles.

Sitting

You are better to be standing or lying following back surgery.  If you wish to sit, a high, upright dining room style chair is the most appropriate.  It is certainly reasonable to start sitting for your meals when you have gone home but it is sensible to stand up and stretch between courses.  This should be back to normal around about the four to six week mark.  However, it will always be advisable to avoid prolonged periods sitting and very soft or low armchairs

Baths and showers

You should in the early days avoid baths as lying curved in them is likely to cause back pain. In addition any waterproof dressing is unlikely to keep out all water if submerged. Showers or and assisted standing baths are better. Please don’t fall over.

Sex

If it hurts, don’t.  If you think it will hurt, don’t - until of course you think it won’t and it doesn’t.

Wound care

You should not get the wound wet until the day after the sutures have been removed.  It is perfectly reasonable to have a shower, providing the wound is covered with a waterproof dressing.  The ward will provide you with this before you leave.  In general, we like to change the dressings on wounds as infrequently as possible. The wound should be kept dry and a non-waterproof dressing used so that the wound may breathe.

That is to say, whilst you should cover the wound in a waterproof dressing for showers this should usually be replaced by a dressing which breaths. Cunningly, there are now dressings which let moisture out but not in. These are ideal. Ask the nursing staff/my spinal nurse which it is you have on.  

Removal of Stitches

The stitches, of which ever type, should be removed at or shortly after the tenth day. Most often a nurse linked to your G.P. or the district nursing service do this. If you are near one of my hospitals you may be able to have these removed there. You need to have agreed an arrangement for this to be done before you, leave hospital - our ward nurses who will liaise with your GP, district nurse or one of the local hospitals as is appropriate. I often use a single stitch which runs under the skin and which can be pulled from one end. (Get an adult to help you.) I also usually put steristrips (small sticky tapes) across the wound and two in parallel with the wound to hold the stitch ends. The ones holding the stitch ends need to be pulled off and then the suture can be removed. For some I use skin clips. These are like small staples and are removed with a special clip remover. You will be given a clip remover by the ward for you to give to the nurse who will be doing the removal.

Bending, lifting, carrying

In the first few weeks you should not be doing this.  The physiotherapy, which will begin about the fourth to sixth week, will teach you how to bend correctly and how best to lift.  It should certainly be something that you keep to a minimum in the first months.

Driving

In the first few weeks, you should be driven i.e., you should not drive the car yourself.  In the weeks that follow, you should limit journeys to short periods.  As physiotherapy commences and progress is made, you may gradually start to extend this.  In general it is best to have the car seat set as high and as upright as possible.  If you are becoming uncomfortable you should stop, get out and do some light stretches before continuing.

Sports

You should not do this until we have reviewed your progress.  It should be deferred until you have completed the fitness programme that only begins with the physiotherapy at the fourth to sixth week and is likely to take a further four to six weeks at least.

Corset

This needs to be on at all times when upright if you had a fusion but is not needed in disc replacement surgery. If you have had both I will advise. Corsets are worn for the first 4 to 12 weeks – 6 on average.

General philosophy

The aim is for you to avoid things which aggravate your pain.  Once recurrence of back and leg pain has occurred, it is much more difficult to get it to go away.  It is much simpler to avoid it in the first place.  If in doubt, err on the side of caution. You can do most things after the first week or so. However, you will not be able to do much of them. “Can I drive?”, “pick up the baby?”, “go into the Office?” or “fly?” are all frequently asked questions. The answer is usually yes BUT not very often. It is not so much what you do but how often you do it. For example it is O.K. to be driven home a few days after the surgery but that does not mean it is alright to drive each day into the office.

Your Brace

The purpose of the screws is to hold the spine still while the bone graft fuses. Thereafter, the screws are redundant. If the graft does not fuse the screws and rods will either break or come lose. The graft takes two years to reach full strength but is pretty tough at three months. The brace protects the screws from the worst of the traumas. Many of you would be alright without a brace though it makes the process more certain and we therefore recommend it for six weeks at least- sometimes, if the bones are weak, more.

The braces are custom made to fit you by a professional orthotist – Garth Jones. He is a real professional who looks after the Royal National Orthopaedic Hospital. He will come just before or after the surgery, (always after if we are going to change your shape by correcting a deformity), and make a plaster of Paris mould. A day later, he returns with a plastic brace made to measure – he even offers a choice of patterns!

You get up after it has come and you should wear it whenever you are upright. If you are just up to the loo at night you may leave it off but that is the sole exception.

At first it is uncomfortable and difficult to get on and off. However, at the end of the six weeks many folk are reluctant to leave it off. You may need a few adjustments making as time goes on.

A safe return to work

This may reasonably be anytime between four and twelve weeks post surgery. This might seem like a ridiculously wide window and certainly I will advise you more precisely. In fact, some patients are back at work inside two weeks and others still off at four months. A brick layer commuting 50 miles by car each way will take longer than a librarian working next door to home. (Actually the former might sensibly try becoming the latter.)

Whatever the work a gradual return is best. A suitable regime for an average office worker with a reasonable commute might be: – perhaps two half days the first week (Tuesday and Thursday), three the second (Monday Wednesday and Friday) and four the fourth (Monday, Tuesday and Thursday, Friday). Work five half days the next and then start to increase the length of the days. It is important to keep up the physiotherapy during this phase.

Done in a graduated way, the return to work is a very positive part of your rehabilitation. It needs to be in your control and with the encouragement of your employer. If they will put up with you being part-time and unreliable they will see you sooner.

If by contrast your job is one whereby you have to be there fulltime and reliably or not at all, it will take longer. Then the job is not a part of the rehabilitation but the hurdle rehabilitation has to prepare you for. You will get back later as you need to fully recover before starting. If you have a long commute, your return will be further delayed.

The average commute time for many patients is in the region of one hour each way. From the spinal perspective, that is a two hour physical job in addition to your real work. Days spent working from home help.

Discuss this advice with your employer and make a plan. Obviously, the best laid plans may change due to circumstances and we will be able to advise on how likely your plan is to come off at the first out-patient session post surgery i.e., at about the four week mark.

Where can I get help?

First, you may ring my office number. If, it is during working hours, this is certainly what you should do. My secretarial staff will be able to contact myself, my clinical assistants or our spinal nurse and obtain advice for you.  If, it is out of hours, you may also ring this number and the machine will tell you what to do in the event of an urgent enquiry or you may leave a message.

Second, you may ring the hospital and ask to speak to my Spinal Nurse. In her absence, you should ask to speak to the hospital’s Duty Manager or to the ward staff.  

You may of course contact your general practitioner or any emergency service should you so wish or if the other avenues fail.