Bringing You Back

Bringing You “Back” Guidebook for Spines

Two West 42nd Street l Scottsbluff l 308.630.1947 l PhysiciansClinic.net

2

Guidebook for Spines Welcome ......................................................................... 2 Frequently Asked Questions................................................. 3 Lumbar Laminectomy Lumbar Fusion Cervical Laminectomy Cervical Fusion SECTION 1 Risk Factors and Complications ............................................ 14 Controlling Risk Factors Possible Complications SECTION 2 Pre-operative Exercises....................................................... 19 Preparation for Surgery ....................................................... 22 Four to Six Weeks before Surgery One Week before Surgery Day before Surgery Night before Surgery SECTION 3 Hospital Care ................................................................... 25 Day of Surgery Understanding Pain Management Discharge Plans and Expectations SECTION 4 Post-operative Care ........................................................... 29 Caring for Yourself at Home SECTION 5 Post-operative Activity Guidelines .......................................... 33 Body Mechanics and Positioning SECTION 6 Discharge Plans and Expectations ......................................... 43 Cervical Laminectomy Cervical Fusion Lumbar Laminectomy Lumbar Fusion Reasons to Call Your Doctor SECTION 7 Home Setup after Spine Surgery ........................................... 50 Nutrition Glossary .......................................................................... 53

1

Guidebook for Spines Welcome Thank you for choosing Regional West Physicians Clinic-Neurosurgery & Spine Center.

We follow a patient-focused clinical pathway, which accounts for our high levels of patient satisfaction. The Spine Center is a specialized unit staffed by nurses, therapists, and other professionals trained in the care of patients undergoing spine surgery.

More than 200,000 people undergo spine surgery each year. Almost all of them have pain that they no longer wish to tolerate. Many suffer from nerve compression, which may produce numbness, tingling or weakness. Surgery aims to relieve pain, restore independence, and return patients to work or daily activities.

Most patients having spine surgery recover quickly. Some may be able to walk or even go home the day of the surgery. Generally, patients can return to driving in one to two weeks, to sedentary jobs and activities in three to four weeks, and to vigorous physical activities in six to twelve weeks. Patients undergoing more complicated operations such as a multilevel spinal fusion may require three to six months to return to full activities.

Regional West Physicians Clinic-Neurosurgery & Spine Center has developed a comprehensive planned course of treatment. We believe that patients play a key role in ensuring a successful recovery. Our goal is to involve patients in their treatment through each step of the program. This guidebook provides the information needed to maximize a safe and successful surgical experience.

Our team includes nurses, physical and occupational therapists, and neurosurgeons specializing in spine care. Every detail, from preoperative teaching to postoperative exercising, is considered and reviewed with each patient. The Spine Center will guide patients through the surgical experience and help develop individualized discharge plans.

Features of the center’s program include:  Nurses and therapists who specialize in the care of spine surgery patients  Emphasis on individual care  Family and friends participating as “coaches” in the recovery process  A comprehensive patient guidebook to follow pre-op and beyond

2

Frequently Asked Questions Lumbar Laminectomy Q. What is wrong with my back?

A. You have a “pinched nerve.� This can be caused by one or more herniated discs and/or areas of arthritis in your back. The discs are rubbery shock absorbers between the vertebrae and are close to nerves that originate in the spine and then travel down to the legs. If a disc is damaged, part of it may bulge (herniate) or even burst free into the spinal canal putting pressure on the nerve and causing leg pain, numbness, or weakness. Bone spurs associated with arthritis may do the same thing.

Q. What is required to fix the problem?

A. The discs or bone spurs pressing on your nerve must be removed. This is done by making an incision (usually two or three inches long) in the middle of your lower back, moving the mu pine to the side, and making a small window into your spinal canal for the operation. The nerve is exposed, moved aside and protected, and the protruding disc or bone spur is then removed. This decompresses the nerve and in most cases leads to rapid improvement in nerve pain, numbness, and/or weakness. Sometimes the abnormality may be more extensive; extending over several disc segments thus requiring a longer incision for decompression.

Q. Who is a candidate for lumbar laminectomy and when is it necessary?

A. The primary reason for this operation is pain that is intolerable to the patient.

Sometimes increasing nerve dysfunction (particularly weakness) or loss of bowel or bladder control may make the surgery necessary even if pain is not severe. In most cases, nerve dysfunction is not severe and pain can be controlled by nonsurgical means. If this does not happen and if the pain and subsequent disability becomes intolerable, surgery is a reliable way to solve the problem. Since the patient is the one feeling the pain, the patient is usually the one who decides when he or she is ready for surgery.

Q. Who performs this surgery?

A. Both orthopedists and neurosurgeons are trained in spinal surgery and both specialists may perform this surgery. It is important that your surgeon specializes in this type of procedure.

Q. Is the entire disc removed?

A. No, only the ruptured part and any other obviously abnormal disc material are removed. This generally amounts to no more than 10 to 15 percent of the entire disc.

3

Q. Will I need a blood transfusion?

A. Transfusions are rarely needed after this kind of surgery. We do not recommend preoperative donation of your own blood.

Q. What can I do after surgery?

A. You may get up and move around as soon as you feel like it and may drive short distances when you feel able. You should avoid bending, lifting and twisting for six weeks to allow for healing of the surgical area.

Q. When can I go back to work?

A. That depends on the kind of work you do and how long you have to drive to get there. Surgical patients can return to sedentary (desk) jobs that they can reach with a drive of 15 minutes or less whenever they feel comfortable (usually two to three weeks). You should not drive long distances (30 minutes or more) for about one month after surgery.

Q. What is the likelihood that I will be relieved of my pain?

A. Approximately 90 to 95 percent of patients get relief of their leg pain. Some patients (about 15 percent) will continue to have noticeable back pain in some situations and may require additional treatment.

Q. Could I be paralyzed?

A. The chances of neurologic injury with spine surgery are very low and the possibility of catastrophic injury; such as paralysis, impotence, or loss of bowel or bladder control, are highly unlikely. Injury to a nerve root and isolated numbness and/or weakness in the leg is possible.

Q. What other risks are there?

There are general risks with any type of surgery. These include, but are not limited to, the possibility of wound infection, uncontrollable bleeding, collections of blood clots in the wound or in the veins of the leg, abdominal problems, pulmonary embolism (a blood clot to the lungs), or heart attack. The chance of any of these complications happening, particularly to a healthy patient, is low. Rarely, death may occur during or after any surgical procedure.

Q. Will my back be normal after surgery?

A. Though you may have excellent relief of pain, a disc is never completely normal after it has herniated. If your problem has been caused by arthritis, the arthritis cannot be cured even if the bone spurs are removed and the nerves decompressed.

You may have more back pain than a normal person would have and there is an increased risk of re-herniation of the damaged disc. However, most people can resume almost all of their normal activities after recovering from surgery.

4

Q. What should I do after surgery?

A. You should resume low-impact activities as soon as possible starting with walking.

Try to walk a little farther each day; building up to a brisk three-mile walk each day by six weeks after surgery. Once your sutures are removed you may swim, which is very back-friendly. By two or three weeks after surgery you may try more vigorous activities such as an exercise bike.

Q. Could this ever happen to me again?

A. Unfortunately, yes. As mentioned above, only part of the disc is removed and there is no way to return the disc to normal again, which means recurrent herniation occasionally occurs. Also, adjacent discs may be abnormal, too, and could rupture in the future.

Q. What shouldn’t I do after surgery?

A. In general, you should limit heavy lifting, bending, twisting and high impact physical activities including contact sports. Consult your surgeon for details.

Q. Should I avoid vigorous physical activity?

A. No. Exercise is good for you! You should get some sort of vigorous, low-impact aerobic exercise at least three times a week. Walking either outside or on a treadmill, using an exercise bike and swimming are all examples of exercise that is appropriate for spine patients.

5

Lumbar Fusion Q. What is wrong with my back?

A. You have one or more damaged discs and/or areas of arthritis in your back. This produces pain and may produce abnormal motion or misalignment of your spine.

Discs are rubbery shock absorbers between the vertebrae and are close to nerves that travel down to the legs. If a disc is damaged, part of it may bulge or even burst free into the spinal canal putting pressure on the nerve and causing leg pain, numbness, or weakness.

Q. What is required to fix the problem?

A. Your condition requires both a nerve decompression (freeing the nerves from pressure) and a spinal fusion. In this case, both nerve decompression and spinal fusion would be done.

Q. What is a spinal fusion?

A. A fusion is a bony bridge between at least two other bones; in this case, two vertebrae in your spine. The vertebrae are the blocks of bone that make up the bony part of the spine; like a child’s building blocks stacked on top of each other to make a tower. Normally each vertebra moves within certain limits in relationship its neighbors. In spinal disease, the movement may become excessive and painful or the vertebrae may become unstable and move out of alignment putting pressure on the spinal nerves. In cases like this, surgeons try to build bony bridges between the vertebrae (usually from the pelvis) or from a bone bank. There are advantages and disadvantages to either source. The bone graft is either laid next to the vertebrae or actually placed between the vertebral bodies (the rubbery disc that normally lies between the vertebrae must be removed). In either case, the bone graft has to heal and fuse to the adjacent bones before the fusion becomes solid. Spine surgeons often use screws and rods to protect the bone graft and stabilized the spine while the fusion heals.

Q. Who is a candidate for lumbar fusion and when is it necessary?

A. When the back and nerve problems cannot be corrected with a more simple procedure and the pain persists at an unacceptable level, it is necessary to do a fusion. Some of the conditions which require spinal fusion are discussed in the answer to “What is Spinal Fusion?�

Q. Are there other risks involved?

A. There are general risks with any type of surgery. These include, but are not limited to the possibility of wound infection, uncontrollable bleeding, collections of blood clots in the wound or in the veins of the leg, abdominal problems, pulmonary embolism (a blood clot to the lungs), or heart attack. The chance of any of these complications happening, particularly to a healthy patient, is low. Rarely, death may occur during or after any surgical procedure.

6

Q. How is the operation performed?

A. A four to five-inch incision is made in the middle of the lower back. Muscles supporting the spine are pushed aside temporarily. The spinal nerve is exposed, moved aside and protected, and the ruptured disc or bone spur is removed to loosen the nerve. The fusion is performed as described above. The wound is then closed and dressings are applied. The operation typically takes a minimum of three hours and may be longer depending on the complexity of the problem. Sometimes the spinal fusion is performed with an anterior approach. In this case, the surgeon would make a four to five-inch incision in the lower abdomen, gently move the internal organs aside and proceed with the surgery as described above.

Q. Could I be paralyzed?

A. The chances of neurologic injury with spine surgery are very low and the possibility of catastrophic injury, such as paralysis, impotence, or loss of bowel or bladder control is highly unlikely. Injury to a nerve root with isolated numbness and/or weakness in the leg is possible.

Q. What are my chances of being relieved of my pain?

A. More than 90 percent of patients get relief of their nerve symptoms or leg pain.

Relief of back pain is less predictable occurring about 75 percent of the time.

Q. Will my back be normal after surgery?

A. No. Even if you have excellent relief of pain, the spine is not completely normal after a fusion. Stiffening one segment of the spine with the fusion may put additional strain on other areas. Other discs may have started to wear out. Even if they are not causing you pain now, they may do so in the future. For these reasons, you may have more back pain than a normal person would have. However, most people can resume almost all of their normal activities after their fusion has healed.

Q. How long will I be in the hospital?

A. The hospital stay is generally one to three days.

Q. What shouldn’t I do after surgery?

A. Generally, you should avoid bending, lifting and twisting for six to nine months.

Even if screws and rods are used, six to twelve months are required for the fusion to heal completely. You must protect your spine during this time. If you are a smoker, you definitely should not smoke until your fusion is completely solid, since smoking interferes with bone healing.

Q. What can I do after surgery?

A. You should get up and move around frequently as soon as you feel like it. If you feel well enough, you may begin driving in two to three weeks with your back brace on.

7

Q. When can I return to work?

A. Generally, patients may return to sedentary jobs whenever they are comfortable, which is usually within three to six weeks. If you drive more than 30 minutes to get to work, your surgeon may want you to wait longer. It takes much longer to get back to work at a job that requires strenuous physical activity due to the increased stress these activities have on the healing bone.

Q. Could this happen to me again?

A. Unfortunately, yes. A fusion may add stress to the levels above and below the fusion. If the fusion does not heal solidly, even with plates and screws, your symptoms may recur and additional surgery may be needed.

Q. Should I avoid vigorous physical activity?

A. No. Exercise is good for you! You should get some sort of vigorous, low-impact aerobic exercise at least three times a week. Walking either outside or on a treadmill, using an exercise bike and swimming are all examples of exercise that is appropriate for spine patients. You may start these activities as soon as you are comfortable.

8

Cervical Laminectomy Q. What is wrong with my neck?

A. You have a “pinched nerve.” This can be produced by a ruptured disc or bone spurs. Discs are rubbery shock absorbers between the vertebrae and are close to nerves which travel down to the arms. If a disc is damaged, part of it may bulge or even burst free into the spinal canal putting pressure on the nerve and causing arm pain, numbness, or weakness. Bone spurs, usually the result of arthritis, can also put pressure on nerves. Occasionally, pressure from bone spurs or a ruptured disc may affect the spinal cord and cause abnormalities in the legs or lower parts of the body.

Q. What is required to fix the problem?

A. In most cases, a small (two to three-inch) incision is made in the anterior part of the neck. Muscles supporting the spine are pushed aside temporarily and a small “window” is made into the spinal canal for the operation. The spinal nerve is protected and the ruptured part of the disc or the bone spur is removed. If bone spurs and arthritis are the cause of your problem, you may require a bigger incision and more bone may have to be removed.

Q. When is this operation necessary?

A. In almost all cases, the major reason for spine surgery is pain which is intolerable to the patient. Often nonsurgical measures can control the pain satisfactorily.

However, if the pain persists at an unacceptable level, if you cannot function because of pain, or if weakness or other neurologic problems develops, then surgery may be necessary to relieve the problem.

Q. How long will I be in the hospital?

A. Most patients stay 24 hours. Complications may require longer stays.

Q. Will I need a blood transfusion?

A. There is usually very little blood loss with this operation and transfusions are almost never necessary.

Q. What can I do after surgery?

A. You should try to get up and move around as much as your symptoms allow. You may walk as much as you like.

Q. What shouldn’t I do after surgery?

A. For at least six weeks, you should avoid overhead lifting, frequent or repetitive neck movements and vigorous sports until instructed otherwise by your physician.

9

Q. When can I go back to work?

A. That depends on the kind of work you do and how far you have to drive. It can be as little as one week, but may be longer if your job involves manual labor or if you have to drive more than 30 minutes to get to work.

Q. What are my chances of being relieved of my pain?

A. Approximately 90 to 95 percent of patients get relief from their nerve pain. Neck and shoulder pain are less predictably relieved by disc surgery. Up to 15 percent of patients may have some neck and shoulder aching after surgery. This percentage may be higher in patients who have a substantial amount of neck and shoulder pain before surgery. Other conditions such as fibromyalgia may also produce continued pain even after successful disc surgery.

Q. Will my neck be normal after surgery?

A. No. Even if you have excellent relief of pain, the disc has still been damaged.

However, most people can resume almost all of their normal activities after disc surgery. People who do heavy work generally take longer to recover and may not be able to do everything they could do before their injury.

Q. Could I be paralyzed?

A. The chances of neurologic injury with disc surgery are very low and the possibility of catastrophic injury, such as paralysis, is highly unlikely. Injury to a nerve root and isolated numbness and/or weakness in the arm is possible.

Q. What other risks are there?

There are general risks with any type of surgery. These include, but are not limited to the possibility of wound infection, uncontrollable bleeding, collection of blood clots in the wound or in the veins of the leg, pulmonary embolism (movement of a blood clot to the lungs), heart attack, stroke and death. The chances of any of these events happening, particularly to a generally healthy patient, are low.

Q. Could this ever happen to me again?

A. Unfortunately, yes. As mentioned above, only part of the disc is removed and there is no way of making the remaining disc normal again, which means recurrent herniation occasionally occurs. Also, adjacent discs may be abnormal, too, and could rupture in the future.

Q. Should I avoid vigorous physical activity?

A. No. Exercise is good for you! You should get some sort of vigorous, low-impact aerobic exercise at least three times a week. Walking either outside or on a treadmill and using an exercise bike are all examples of exercise which is appropriate for spine patients.

10

Cervical Fusion Q. What is wrong with my neck?

A. You have one or more damaged discs in your neck. Discs are rubbery shock absorbers between the vertebrae and are close to nerves that travel out to the arms. If the disc is damaged, part of it may bulge or even burst free into the spinal canal putting pressure on the nerves and causing arm pain, weakness and/or pain in the neck or shoulder area. Occasionally this pressure may affect the spinal cord and cause abnormalities in the legs or lower parts of the body. Bone spurs, usually the result of arthritis, can also put pressure on nerves or the spinal cord. Loss of the normal “shock absorber” function or arthritis around the damaged disc can also produce mechanical pain around the neck or shoulders with neck movement or awkward positions.

Q. What is required to fix the problem?

A. The best approach to your problem is to remove the damaged disc and bone spurs from the front, or anterior part, of the neck and to perform a fusion between the adjacent vertebral bodies. Certain conditions, however, require the surgeon to perform the fusion using a posterior approach instead.

Q. What is a spinal fusion?

A. A fusion is a bony bridge between at least two other bones; in this case, two vertebrae in your spine. The vertebrae are the blocks of bone which make up the bony part of the spine much like a child’s building blocks stacked on top of each other to make a tower. Normally each vertebra moves within certain limits in relationship to its neighbors. In spinal disease, the movement may become excessive and painful or the vertebrae may become unstable and misaligned putting pressure on the spinal nerves.

In cases like this, surgeons try to build bony bridges between the vertebrae using pieces of bone, which we call a bone graft. The bone graft may be obtained either from the patient himself, usually from the pelvis, or from a bone bank. There are advantages and disadvantages to either source. The bone graft is laid between the vertebrae. The bone graft has to heal and unite to the adjacent bones before the fusion becomes solid. Surgeons often use plates to protect the bone graft and stabilize the spine during the healing period, attaching them to the spine using screws.

Q. How is the operation performed?

A. An incision, usually about two inches in length, is made across the front of the neck. The windpipe, esophagus (food pipe), and other tissues are temporarily pushed aside and the abnormal disc or discs are removed completely. If your own bone is to be used for the fusion, another small incision is made over the front of the pelvis and one or more small bone grafts are removed to replace the disc or discs. In most cases this bone will heal or “fuse” to the vertebrae above and below it within six to nine months, creating a solid bony bridge between the two vertebrae and eliminating movement between them. For fusions involving more than one level or in the case of unusual spinal instability, internal plates and screws may be used to improve stability and conditions for bone healing.

11

Q. When is this operation necessary?

A. In most cases, the major indication for spine surgery is pain. Weakness, numbness, clumsiness, and gait instability may also be an indication for surgery. Often nonsurgical measures can control the pain satisfactorily. If the pain persists and interferes with daily activities or if other neurologic problems develop, then surgery may be necessary to relieve the problem. In most cases, the patient makes the final decision about surgery because of pain. If neurologic damage is occurring, your physician may strongly recommend that you proceed with the operation.

Q. Will I need a blood transfusion?

A. Rarely do we need to give a transfusion. Only in rare tumor or unusual reconstruction cases will a transfusion be needed.

Q. What can I do after surgery?

A. Please refer to the Cervical Fusion Discharge Instructions for details. You should try to walk and take care of yourself as much as you are able to. You should try to exercise each day. You may perform other low-impact activities not requiring lifting or neck movement as allowed by your brace. If a brace is not required, you may drive when allowed by your doctor.

Q. Will I need to wear a neck brace?

A. Most patients will wear some type of neck brace after this surgery. The type of brace and length of time you need to wear the brace will be determined by your surgeon.

Q. What shouldn’t I do after surgery?

A. You should avoid lifting heavy objects and avoid all overhead lifting. Twisting, repetitive bending and tilting your head back to look overhead are also stressful to the neck. If you are a smoker, you definitely should not smoke until your fusion is completely solid. Smoking interferes with bone healing.

Q. When can I go back to work?

A. That depends on the type of work you do. If a brace is required, you will not be able to drive until you no longer need the brace. For sedentary jobs, work may resume when you feel comfortable and can get to work.

Q. Will my neck be normal after surgery?

A. No. While most patients have excellent relief of arm pain after surgery, your neck will not be completely normal. While most patients with a one or two level fusion will not notice significant loss of motion, the stiffened segment of your spine puts additional stresses on adjacent discs, which may already be abnormal to some extent.

These other discs may cause symptoms. Although most patients can resume most of their normal activities after healing, you should take care of your neck.

12

Q. What are my chances of being relieved of my pain?

A. Ninety percent of patients obtain relief of their arm pain. Relief of neck pain is less predictable usually in the range of 75 to 80 percent.

Q. Could I be paralyzed?

A. The chance of neurologic injury with spinal surgery is low, but not impossible.

Injury to a nerve root with isolated numbness and/or weakness in the arm is possible.

Less than one in 1,000 cases may result in paralysis ― either complete or partial.

Q. Are there other risks there?

A. The risks of this operation include, but are not limited to, anesthesia, wound infection, uncontrollable bleeding, collection of blood clots in the wound or in the veins of the leg, pulmonary embolism (movement of a blood clot to the lungs), and heart attack. The chances of any of these complications occurring are two to three percent of the cases. Death may rarely occur during or after any surgical procedure.

Q. Could I have difficulty swallowing?

A. Most patients report mild discomfort with swallowing for a few days after surgery.

Occasionally, swallowing difficulties may be more significant and last for longer periods of time. Rarely, it may be necessary to place a feeding tube while swallowing returns to normal. If swallowing difficulty persists longer, notify your physician.

Q. Is the entire disc removed?

A. Yes. Q. Could this happen to me again?

A. Unfortunately, yes. Similar conditions which led to the disc damage being treated now may have already started in one or more of the other discs in your neck. A small percentage of fusions do not heal normally, which may require additional surgery. The chance of this happening increases if a fusion is attempted at more than one level, which is why spine plates are sometimes used for multilevel fusions. Over 90 percent of patients do well. Less than 10 percent have some recurring problems.

Q. Should I avoid vigorous physical activity?

A. No. Exercise is good for you! You should get some sort of vigorous, low-impact aerobic exercise at least three times a week. Walking either outside or on a treadmill, using an exercise bike and swimming are all examples of the type of exercise that is appropriate for spine patients. (See postop recovery sheet) Q. Who performs this surgery?

A. Both orthopedists and neurosurgeons are trained to do spinal surgery. It is important that your surgeon specialize in this type of procedure.

13

SECTION 1 Risk Factors and Complications Controlling Risk Factors With any major surgery there are certain risks. It is important that you understand the risks involved in having spine surgery, as well as what can be done to minimize those risks and prevent the incident of postsurgical complications.

Conditions that increase your risk of having a postoperative complication include:  Obesity  Heart and lung disease such as coronary artery disease and emphysema  Smoking  Diabetes  Osteoporosis  Tooth disease such as periodontal and tooth decay  Immunosuppressive diseases such as lupus and rheumatoid arthritis  History of depression, bipolar disorder requiring medication management  Bleeding abnormalities or anemia  Any sign of recent cold, flu, or sore throat By identifying potential problems before surgery, you can work with the healthcare team to prevent postsurgical complications.

Prior to your admission for surgery, you will be examined by a primary care physician and have routine laboratory tests either at your physician’s office or at Regional West Medical Center. After reviewing the results of your tests, physical exam, and medical history, the physician will be able to identify any particular health risk factors that you may have. If high risks are identified, your doctor may recommend additional tests or may discuss with you the need to delay surgery until the risks can be brought under reasonable control. Even now, before you have preadmission testing, there are things you can begin doing to reduce the risk of postoperative complications.

Nutrition Both poor nutrition and obesity increase your risk for infection and/or delayed healing both of a fusion and incision. While excessive weight can make your recovery period more difficult, a crash diet is not the answer. In fact, in the immediate postoperative period your caloric demands may increase, as your body deals with the additional stress placed on it by the surgery and recovery. If you are obese and would seriously like to lose weight before or after surgery, we recommend that you join a physician-supervised weight loss program. As you lose weight, you may see some improvement in your spine and a decrease in pain. When your weight is under control and you are preparing for spine surgery, it is important that your diet be nutritionally sound.

Infection It is important that you be free of infection before you have surgery and that you obtain immediate treatment for any infection that may occur after your surgery.

14

Although postoperative spinal infections are rare, particularly at Regional West Medical Center, they can have severe consequences if not treated promptly and appropriately. The most common areas that are sources of infection are the teeth and genitourinary tract. Poor hygiene is the leading factor in developing sources of bacteria in both locations. Any problems should be corrected before preadmission testing.

If you have not had a dental checkup within the last six months, you should schedule now prior to preadmission testing.

If you have any problems with urinating, frequency, burning or difficulty passing urine, you should see your urologist or family doctor for an evaluation.

Let your surgeon know if you have a cold, sores, cuts or inflamed areas anywhere on your body.

Making sure that you are free of infection may prevent having to delay your surgery.

Smoking If you are smoking, you should initiate steps to stop smoking immediately!

Smoking increases your chances of lung complications, delays wound healing and in the case of spinal fusion, delays or prevents successful bone growth of the fused area.

Allergies If you have any types of metal allergies or allergies to skin preps such as povidone or allergies to specific sutures or dressing materials, let your doctor know.

15

Possible Complications of Spinal Surgery Complications that can occur during or following spine surgery include:

Blood Clots Blood clots, which typically originate in the lower leg venous system, are surprisingly common after most types of surgery; as many of 50 percent of patients may develop venous clotting after surgical procedures. Fortunately, most of these are small and inconsequential. In some cases, however, the results of a deep vein thrombosis (DVT) can be devastating with clots that migrate and become emboli that can travel to the lungs, kidneys, heart, and brain.

Clots that travel to the lungs, known as pulmonary emboli or “PEs” are the most common and can result in sudden shortness of breath, cardiac disturbances, and even death. They can occur several weeks after a procedure. In the case of spinal surgery, the risks are less than for orthopedic procedures such as joint replacement or arthroscopy, with a published risk of approximately 0.6 percent. Risks reported at the Spine Center, are below the nationally published average. To prevent clots from occurring, there are several things that our staff and you, the patient, will do in the postoperative period. These include the following:  Early and aggressive mobilization. Getting up and walking are the most effective ways to prevent deep vein thrombosis.  Performing “ankle pumps” and range of motion exercises with the legs, even when supine and confined to bed.  Wearing TED hose (compressive stockings) in conjunction with the use of sequential compressive stockings (SCDs).  The administration of medication to prevent abnormal clotting while you are an inpatient. This is typically a warfarin or Lovenox type drug.

Nerve Damage Nerve damage is the one of the most dreaded complications of spinal surgery. Patients undergoing any of the various types of surgery, whether cervical, thoracic, or lumbar, are at risk. Damage can be caused by direct or indirect injury to the nerve roots or spinal cord. In addition, postoperative swelling around the spine and soft tissue can cause increased pressure on the nerve causing tingling, numbness, or weakness in the legs or arms. Patients undergoing cervical or thoracic spinal surgery are at risk for spinal cord injury with possible paralysis. The incidence of catastrophic injury resulting in quadriplegia or paraplegia is about one in 3,000 cases per year in the United States. Most of these cases are due to a lack of perfusion or blood flow to the spinal cord rather than to direct injury from a scalpel or other instrument.

It is for this reason that the Spine Center is so vigilant in monitoring blood pressure and other indexes of hemodynamics. We use Somatosensory Evoke Potential Monitoring (SSEP), which is the current standard of care for monitoring spinal cord function. This is used during those select cases in which we think the risks are high for nerve injury. This includes cervical, thoracic, and instrumented lumbar cases.

Included with SSEP monitoring is electromyographic monitoring (EMG), which allows recordings from specific individual nerve roots.

16

During the postoperative period members of the team will:  Check the muscle strength and sensation in your extremities  Remind you to begin active range of motion of the limbs It is important that you tell the nursing or the physical therapy staff immediately  If you sense new onset of muscle weakness  If you feel any tingling, numbness, or burning pain in the limbs, as these may be signs of pressure on the nerve(s).

In some cases, there will be a relative increase in numbness to a nerve distribution after surgery as a result of manipulation of the nerve during surgery to remove bone spurs and/or a herniated disc. These symptoms are usually transient and quickly resolve. The team will evaluate this in every case and give you immediate feedback as to the status of your nerve function.

Dural Leak The dura is a water tight sac of tissue that covers the spinal cord and nerves. Below the level of T12-L1, there is no longer a spinal cord, but rather a bundle of nerves located inside the dura with nerve roots branching off at their respective levels. This section of the spinal column could be best described as resembling a coaxial cable or fiber optic cable with an outer sheath and then multiple fibers running inside. A tear in the dura, this outer sheath, can occur during surgery. It is not uncommon to have a dural tear during spinal surgery; however, the incidence at the Spine Center is less than 1 percent annually.

Sometimes the dura needs to be cut intentionally to free up adhesions from bone spurs and scar tissue. This is called a durotomy. A tear of the dura or a durotomy needs to be repaired to achieve a watertight closure; otherwise, cerebral spinal fluid will leak out. These types of leaks cause severe postural headaches. This means that lying down, the patient has no headache, but as soon as they sit up or stand up, they have severe frontal or top of the head pain. After repair, the patients are instructed to lie flat with the head of the bed no higher than 15 degrees for a period of 24 to 48 hours, depending on the size and location of the leak. In some rare cases, the dural leak is delayed or not detected and symptoms may not present until several days to weeks after surgery. You need to inform your surgeon and the team as soon as you sense any postural headache so that prompt evaluation can be carried out.

Fortunately, in the vast majority of cases, a dural tear and repair has little to no impact on the overall outcome of a spinal surgery.

Infection Although it occurs infrequently, infection in a spinal surgery is one of our greatest concerns. It may necessitate returning to surgery for what is known as an “I and D” (Irrigation and Debridement) and, in some cases that are greater than six weeks out from surgery, removal of hardware. Treatment frequently requires six weeks of intravenous antibiotics, followed by oral antibiotics. In addition, a home antibiotic therapy regimen needs to be arranged with frequent lab checks. Infections from “flesheating, strep, and staph,” as well as “hospital-acquired” infections have been well publicized in the news media. These reports have highlighted that most infections are,

17

in fact, carried into the hospital by patients and therefore represent communityacquired infections. Methicillin-resistant Staph Aureus (MRSA) is one of the most dreaded of these bacteria and unfortunately many potential patients can be carriers of this bug. For this reason, inpatient spine surgery candidates are prescreened for MRSA colonization. If they are test positive, they are treated with special antibiotics and decolonized before entering the hospital.

Despite all of the efforts of surgeon, team, and patient, infections may still occur.

Patients who have poor hygiene, diabetes, vascular disease or immunosuppression, as well as smokers, are at an increased risk of infection no matter what is done to prevent it. In addition to considerable expense, postoperative infection can cause additional pain, increase disability, and prolong recovery.

Your role is to safeguard yourself against infection and obtain immediate treatment if a problem occurs. In addition, you must be aware that certain routine procedures (e.g. dental cleaning, cystoscopy, colonoscopy) can stir up bacteria and present a risk to your spine. Unlike total joint replacement where antibiotics are recommended routinely before dental cleaning and other procedures, there are no guidelines for this type of treatment in spine surgery patients.

Mechanical/Hardware Instrumentation Problems  

Loosening, migration, or breakage or hardware: This may require revision surgery to correct the problem.

Nonunion or “pseudoarthrosis” of the fusion. This is when the bone graft does not consolidate and the fusion is not achieved. This may require revision surgery if the patient is symptomatic.

18

SECTION 2 Pre-operative Exercises Just as exercise is important in rehabilitation following spine surgery, it is advisable that you participate in a pre-operative exercise program as well. Exercising before surgery can help you build up the necessary strength and endurance for a more optimal recovery from spine surgery. The exercises below help to strengthen and condition the muscles in preparation for surgery and the post-rehabilitation phase. To enhance your recovery from this surgery, try to incorporate these exercises, as well as some aerobic exercise (walking, water exercise, bicycling) into your daily routine.

START POSITION: Lie on back with legs bent and feet together.

ACTION: Pull stomach up and in by hollowing lower lateral abdominal wall to flatten back gently onto floor. Assist this contraction by pulling up and in with the pelvic floor muscles. You should feel a pulling sensation in groin. Do not allow the upper lateral abdominal wall to lead or take over the hollowing contraction. Do not allow back to arch off floor (give into extension). Do not allow back to flatten too hard onto floor or let the stomach bulge forward (give into flexion). Hold and sustain a consistent contraction with minimal effort. Hold for 5 seconds. Repeat 10 times.

Lie on your back or sit Bend and straighten your ankles briskly. If you keep your knees straight during the exercise you will stretch your calf muscles. Repeat 10 times.

Lie on your back with legs straight Bend your ankles and push your knees down firmly against the bed. Hold 5 seconds, relax. Repeat 10 times.

Lie as shown with one knee bent partially Press heel to floor. Hold 5 seconds. Repeat 10 times.

19

Lie on your back Squeeze buttocks firmly together. Hold approximately 5 seconds. Relax. Repeat 10 times.

Lie on your back Slide heel towards your buttocks, bending the knee. Hold 2 seconds and slowly lower leg. Repeat 10 times.

Sit on a chair Pull your toes up, tighten your thigh muscle and straighten your knee. Hold approximately 5 seconds then slowly relax your leg. Repeat 10 times.

Support yourself in an armchair as shown Press shoulders downward, while concentrating on holding shoulder blades stable.

Support part of your body weight with legs as needed. Hold two seconds and slowly relax. Repeat 10 times.

Sit or stand.

Lift your shoulders. Relax. Repeat 10 times.

20

Stand with shoulders relaxed Move shoulder blade down and toward opposite hip. Hold 5 seconds. Repeat 10 times.

Stand with arms relaxed at your side Raise arm up overhead as far as you can. Repeat 10 times.

Stand with arms relaxed at your side Raise arm up to the side as far as you can. Repeat 10 times.

21

Preparation for Surgery Four to Six Weeks before Surgery Review “Exercise Your Right” The law requires that everyone being admitted to a medical facility have the opportunity to complete advance directives forms concerning future decisions regarding your medical care. Although Advance Directives are not required for hospital admission, we encourage you to consider completing the forms for the directives you desire. If you have advance directives, please bring copies to the hospital on the day of surgery.

Become Smoke-Free If you are a smoker, you should stop using tobacco products. The tar, nicotine and carbon monoxide found in tobacco products have serious adverse effects on your blood vessels and thus impair the healing of wounds and bone grafts. In addition, continued tobacco use damages the other discs in your spine leading to disease at other levels. Finally, we have found that smokers experience a greater degree of pain than non-smokers.

Spine Outcomes Program We are pleased to introduce the Spine Outcomes Program. We have instituted a process for collection of data that will help us measure our patients’ satisfaction with their surgical outcome. The program has two parts. The first data collection process occurs during the pre-op process. The second data collection process occurs six months after surgery. You will receive a short questionnaire that includes selected questions taken from the pre-op collection survey. This format allows us to form a comparison of a patients’ pre-op and post-op status. Collected information is kept strictly confidential throughout the data analysis process. We greatly appreciate your participation with our hospital-based study.

22

One Week before Surgery Stop Medications that Increase Bleeding 



Seven days before surgery, stop all medications containing aspirin and antiinflammatories such as aspirin, such as Motrin, naproxen, etc. These medications may cause increased bleeding. Your preoperative nurse and physician will tell you which ones.

If you are on Coumadin, you will need special instructions about stopping this medication. Please contact the prescribing physician for these instructions.

Plan Ahead to Ease Transition Back Home          

De-clutter your home. Temporarily put away area rugs that may be a tripping hazard.

Shop ahead! Have frozen dinners available to pop into the microwave and paper plates to limit washing. Also have plenty of liquids available. Pain medications can give you a very dry mouth.

Complete needed yard work and mowing or arrange to have this done for you.

Arrange for neighbors/family to collect mail and newspapers for a few days.

Change your bed and have fresh linens prepared.

Strategically place nightlights in bedrooms, hallways and bathrooms you may need to access at night.

Place essential and frequently used items at counter level in the kitchen. This may mean taking out the items from the lower or very upper cabinets out and storing them on the counter temporarily.

Have current bills paid so you do not have to worry about these immediately after the surgery.

Have support lined up especially if you live alone. Arrange for friends to call on certain days or stop by and make sure you do not need any extra assistance.

No special chair is needed, but use one that offers you support and comfort.

Pets   

Have help for the first few days to keep food and water available for pets.

Have a dog walker planned for the first week at least. You will not want to chance losing your balance or being jerked by your excited canine friend!

If you have cats, have the litter box up on a high table or counter so you do not have to bend down to clean it.

Points of Comfort 

You may want to bring extra pillows for the ride home to maximize your comfort.

23

Day before Surgery Find Out When to Arrive at the Hospital You will be asked to come to the hospital 1-1/2 hours before the scheduled surgery to give the nursing staff sufficient time to start IVs, prepare the surgical site and answer questions. It is important to arrive on time because sometimes the surgical time is moved up at the last minute and your surgery could start earlier. If you are late, your surgery could be moved to a much later time

Night before Surgery Chlorhexidine Shower You will receive chlorhexidine soap. Please follow the instructions for use as provided.

Please shower again with chlorhexidine soap the morning of your surgery.

NPO – Do Not Eat or Drink Do not eat after midnight unless otherwise instructed to do so.

You may have clear liquids until 4 hours before surgery.

If you must take medication the morning of surgery do so with a small sip of water.

  

Special Instructions You will be instructed by your physician or the preoperative nurse on which of your daily medications to take or omit the morning of surgery.

What to Bring to the Hospital            

Patient Guidebook Advance directives and living will Insurance card and co-pay (if applicable) List of your regular medications and dosages Personal hygiene items (toothbrush, powder, deodorant, razor, etc.)

Shorts, tops and culottes Well-fitting flat shoes Loose fitting warmup suit for the ride home Battery operated items For safety reasons, DO NOT bring electrical items A favorite pillow with a pillowcase in a pattern or color so it will not end up in the hospital laundry Any braces for your back or for walking. Cane or walker if you already have one. Have a family member bring equipment to the hospital room the day after surgery for proper adjustment if needed.

24

SECTION 3 Hospital Care Day of Surgery What to Expect In the Outpatient Surgery area you will be prepared for surgery. This includes starting an IV and fitting you with TED stockings. The operating room nurse and your anesthesiologist will interview you in the prep room. They will escort you to the operating room where you will see your surgeon. Following surgery you will be taken to a recovery area where you will remain for approximately one hour. During this time, pain control will be established and your vital signs will be monitored.

For the rest of this day, you may walk around in the room or try a short walk in the hallway, eat soft foods and drink what you like. We will instruct you on breathing exercises, ankle pumps, TED stockings and the benefits of ambulation.

Please, do not get up unassisted until the therapy or nursing staff has cleared you to do so.

Initially, your pain will be managed with IV medication. When you are able, the nurse will transition you to oral medication. There will be a dressing over your neck incision.

If you require evaluation and treatment by a member of physical or occupation therapy, these services will begin the day after surgery.

Please read the following information about the day of surgery very carefully.

Ask any questions about these instructions in advance of your surgery day. 

    



Do not eat solid food after midnight the night before you are scheduled for surgery. If your surgery is after 2 p.m., a pre-op nurse will provide specific instructions. You may have clear liquids up to four hours before surgery; then nothing to drink. IF YOU HAVE A DRINK WITHIN FOUR HOURS OF SURGERY, WE WILL HAVE TO CANCEL YOUR SURGERY! Do not smoke, chew gum, or take hard candy or breath mints on the day of your surgery.

Do not take any medications before surgery that your physician or the POC nurse did not approve beforehand. Bring a list of your medications, but leave the medications at home.

Please come to the hospital at the time given to you at your pre-assessment meeting.

If you suddenly catch a cold or other ailment or suffer changes in your physical condition, please notify your surgeon immediately.

On the night before and the morning of surgery, take a shower with the antibacterial soap given during the pre-op visit. Please follow the bathing instructions given. Wash your hair with at least the morning shower. Do not apply makeup, lotions, powder or deodorant after showering.

Bring an extra set of soft, stretchable pants (like sweatpants) with you to wear home after discharge. Wear loose comfortable clothing and flat-heeled shoes to the hospital.

25

  

Remember, no jewelry or piercings (including wedding rings), contact lenses or money. Leave your valuables at home or give them to a relative or friend for safekeeping.

Bring this book with you on the day of surgery, along with your driver’s license and your insurance card for identification.

Under most circumstances, one person may accompany you to the Outpatient Surgery area. Your family and friends are welcome to wait in the lobby waiting area until you are taken to your room.

Examples of clear liquids that you may drink:  Clear apple juice, cranberry juice, white grape juice  Black coffee or tea (no cream or milk)  Chicken or beef broth  Water  Gatorade  Clear carbonated liquids (soda) Examples of liquids NOT TO DRINK:  Orange juice  Milk  Any liquid with a nectar or pulp  Alcohol  Coffee or tea with cream or milk

Post-op Routine through Discharge Each day starts with blood work obtained early in the morning with the 6 a.m. vital signs. A post-op X-ray of your cervical spine will be done so your doctor may see the surgical area before you are discharged. The staff will assist you to a wheelchair for transport to the radiology department. After X-rays, our staff will help you to a chair for breakfast.

26

Understanding Pain Management Your home exercise program is designed and modified with you in mind. The exercises will speed your recovery and make you mobile more quickly. It is important that you devote time each day to the exercises. The exercises should be done at least two to three times per day. You will begin outpatient physical therapy as soon as you are able to tolerate being away from home and can get in and out of the car easily.

It is our goal to make your surgery as pain-free as possible. Having said that, we realize pain management is not perfect and you will have some discomfort after your surgery. It is important to note that pain medications have side effects. These include respiratory depression (decreased ability to breathe normally), hypotension (low blood pressure), nausea and constipation. Other less common side effects include itching, urinary retention and abdominal distention (collection of gas within the intestines).

These side effects mean that the amount of medication will have to be reduced at times to avoid creating dangerous or uncomfortable conditions.

Medication tolerance is another factor. This is the body’s tendency to become less responsive to the pain reducing action of narcotics after being exposed to them for periods of time. In other words, your body can become used to having these drugs.

Unfortunately, the side effects can still be present.

Patients who have taken large doses of narcotics for months or years have a much harder time keeping comfortable after surgery. For this reason, it is very important for you to provide accurate information to your surgeon about the amount of pain medication you have been taking. Inaccurate information could result in a needlessly painful and stressful post-operative course. It may be necessary to taper or discontinue your use of narcotics prior to surgery. This may even require inpatient detoxification. It may be necessary to delay your surgery while this is accomplished.

Once you have had surgery, we will rely heavily on your own assessment of your pain, and work with you to relieve it. Most patients will receive intermittent low doses of pain medication into their IV, which they control with a small pump. After 12 to 24 hours, you will transition to oral pain medications. Generally, these are the same medications you will take at home once you are discharged from the hospital.

Throughout your hospital stay, your surgeon and your bedside nurses will assess your physical condition and look for signs of pain and side effects. Pharmacologists are available for consultation to help optimize your treatment program. Using this approach, most of our patients have very satisfactory pain control after surgery.

27

Discharge Plans and Expectations When patients are ready for discharge from the hospital, certain criteria are generally met. Patients will be able to move independently with a walker, eat and drink well, and take oral medication to control discomfort.

We suggest that you not go home alone, but have someone with you to be your caregiver for two to three days. This can be a friend or family member who can change your dressing and help you with your TED stockings. This caregiver will also help out with meals and household activities. During these first few days at home, we want you to concentrate on your recovery.

If equipment (rolling walker, bedside commode) is needed, the case managers will order this for you while you are in the hospital. While most patients go directly home, sometimes the services of home physical therapy or sub-acute rehabilitation is needed. If so, the case manager will make these referrals for you, as well.

The general length of hospitalization for a cervical laminectomy and anterior cervical fusion is one to two days. Posterior cervical fusion patients generally stay one to three days while anterior/posterior patients can be at the hospital for two to three days.

28

SECTION 4 Post-operative Care Caring for Yourself at Home When you go home there are several things you need to know to ensure your safety and steady recovery and comfort.

Control Your Discomfort 1. Medication Management  Take your pain medicine at least 30 minutes before activity to control incisional pain.  Gradually wean yourself from prescription medication to Tylenol. You may take two Extra-Strength Tylenol® in place of your prescription medication up to four times per day.  During the first three months after surgery (if you have a cervical fusion) do not take over the counter anti-inflammatory medication such as ibuprofen (Motrin or Advil) and Aleve. This type of medications can interfere with bone healing and thus jeopardize the success of your surgery. If you have prescription antiinflammatory medication at home, consult your physician before taking these.

2. Use of Ice and Heat  It cannot be emphasized enough how valuable icing of the incisional area can be in the post-operative period. All inpatients will receive various forms of this therapy and outpatients are encouraged to use ice packs or other similar products during the first month after surgery. The first 10 to 14 days are key in effective ice/cold therapy. A slurry of water and ice is the most effective method of transferring cold. We recommend cold therapy for the first 10 to 14 days, six to eight times per day, for 15 to 20 minutes per session. Obviously, the patient needs to prevent potential frostbite or irritation of the skin so check the integrity of the skin periodically.  Apply heat to areas of muscle spasm only. Do not use heat around your incision; this will cause swelling.

3. Positioning  Change your position every 45 minutes throughout the day.  Muscle strain and spams can often be reduced by elevating the arms with pillows. Using this positioning technique along with pain medication will optimize your comfort. See Section 5 for pictures.

4. Muscle Spasm  If your doctor has prescribed a muscle relaxer, take this to help muscle spasms.  Gentle stretching may ease muscle spasm. The idea is to “lengthen” the muscle that is in spasm. Remember to avoid the B.L.T.s.  Gentle massage applied to the muscle spasm may help to reduce discomfort.

29

5. Breathing  Take slow, controlled, deep breaths. Cough deeply and use your incentive spirometer (I.S.) several times each hour. This helps to expand your lungs after surgery and prevent pneumonia or respiratory complications. Deep breathing can also assist in relaxing your muscles and body. Breathing and relaxing while you move will help reduce muscle tension.

6. Body Changes  Your appetite will be poor. Drink plenty of fluids to prevent dehydration. Your desire for solid food will return.  You may have difficulty sleeping at night. This is not abnormal. Do not sleep or nap too much during the day.  Your energy level will be decreased for the first month.  Pain medications contain narcotics, which promote constipation. Use stool softeners like Senokot® or laxatives such as Milk of Magnesia if necessary while using narcotics. Do not let constipation continue. If the stool softener and Milk of Magnesia do not relieve your discomfort, contact your pharmacist, family doctor, or surgeon for advice.  Pain, limited mobility, medication side effects, and reliance on others can lead to depression after surgery. With time, this should improve. Seek medical attention if these symptoms persist.

7. Caring for Your Incision  You may shower (not tub bathe) after 48 hours.  Remove dressing before shower, pat incision dry after shower and replace dressing as instructed.  Notify your surgeon if there is increased drainage, redness, pain, odor or heat around the incision.  Take your temperature daily at 8 a.m. and 4 p.m. Call your surgeon if it exceeds 100.5 degrees.

8. Signs of Infection  Increased swelling, redness at the incision site.  Change in the color, amount or odor of drainage.  Increased pain around the incision.  Fever greater than 101 degrees.

9. Prevention of Infection  Take proper care of your incision as explained on the previous page.  Bathing: Take sponge baths for the first two days.  After that, you may shower as long as your wound is clean, dry and not red.

AVOID tub bathing for at least three weeks after surgery. Keep your wound clean and dry as much as possible to avoid potential infection until it fully heals.

30

Dressing Change Procedure This procedure is the same for the neck and hip bone graft incision.

1. Wash hands.

2. Prepare all dressing change material (open gauze pad and tape).

3. Remove old dressing and dispose old dressing.

4. Wash hands.

5. Inspect incision for the following:  Increased redness  Increase in clear drainage  Yellow/green drainage  Odor  Surrounding skin is hot to touch 6. Pick up gauze pad by one corner and lay over incision. Be careful not to touch the inside of the dressing that will lay over the incision.

7. Place the dressing over the incision and tape it in place.

8. Wash hands.

Occlusive Dressing If the incision has the clear occlusive dressing please follow these instructions:  If dressing remains dry, remove occlusive dressing on post-op day #2. You may leave the incision open to air or re-dress as described above. Continue to inspect the incision daily as instructed above.  If dressing becomes wet with a collection of fluid or blood, remove promptly and follow the instructions at the top of the page. Change dressing daily and as needed until incision remains dry. Gauze pads may be obtained from a medical pharmacy.

Dermabond® If the incision has been treated with Dermabond (skin glue) please follow these instructions:  If dressing remains dry, remove occlusive dressing on post-op day #2. Carefully try to lift gauze from the incision. If the gauze adheres to the incision, do not pull it loose. Just trim away the loosened gauze as needed. After a few days the gauze should come free.  If the dressing becomes wet with a collection of fluid or blood, remove promptly and follow the dressing change instructions for “gauze dressing.” Change dressing daily and as needed until incisions remains dry.

Stockings You will be asked to wear TED stockings while in the hospital. These stockings are used to help compress the veins and decrease the chance of blood clots. You will wear the stockings most of the day, taking them off for one hour in the morning and one hour in the evening.

31

Blood Clots in the Legs Surgery may cause the flow of blood to slow and clot in the veins of your legs. If a clot develops, you may need to be admitting to the hospital to receive intravenous blood thinners. Prompt treatment usually prevents the more serious complication of pulmonary embolus. Moving around through the day, especially walking, will reduce the chance of a blood clot.

Signs of blood clots in the Legs  Swelling in thigh, calf or ankle that does not go down the elevation of the legs.  Pain and tenderness in the calf.

These signs are not 100 percent certain, but are warnings. If they are present, promptly notify your surgeon.

Prevention of blood clots  Frequent foot and ankle pumps  Walking  Stockings/TED hose  Elevating your feet/legs

Pulmonary Embolus An unrecognized blood clot could break off in the vein and go to the lungs. This is an emergency and you should call 911 if suspected.

Signs     

of an embolus Sudden chest pain Difficulty and/or rapid breathing Shortness of breath Sweating Confusion

Prevention of embolus  Prevent blood clot in the legs.  Recognize a blood clot in the leg and seek medical care immediately.

32

SECTION 5 Post-operative Activity Guidelines Physical Therapy: What to Expect While You are in the Hospital After surgery, you may find that your mobility is limited due to pain and to certain restrictions placed by your doctor. If this is the case, your doctor may order physical therapy to assist your recovery.

Physical therapy will generally begin on the first or second day after surgery. Therapy will focus on functional mobility (getting in and out of bed, transfers, and walking), instruction in proper body mechanics (to protect your spine), and simple exercises to help decrease pain and enhance your recovery. Medications will be used to help manage your pain and will be used in conjunction with physical therapy to make activity more comfortable.

The physical therapy staff is committed to making your post-surgical recovery and transition to home as easy and smooth as possible.

Occupational Therapy: Learning Proper Body Mechanics The purpose of occupational therapy is to teach you how to do routine/daily activities while following your back precautions.

The occupational therapist will teach you how to use tools (adaptive equipment) to bathe and get dressed without hurting your back. Additionally, you will be taught how to use proper body mechanics to complete the routine things you do every day.

Precautions: “No Bending. Lifting. Twisting.”

DON’T  Twist your back to reach for anything  Bend over at the waist  Reach out to pick up objects

DO  Turn your entire body to face the item you want to pick up  Squat down (bend at the hips and knees) or use long-handled tools  Move close to item before picking it up

33

Body Mechanics and Positioning The following pictures provide examples of how to use these principles in everyday life.

34

35

36

37

38

Using a Cane Keep the cane away from your feet so you don’t trip. A walking aid, such as a cane or walker, can help you stay more independent and avoid falls. Remember to keep your walking aid within easy reach when you’re in a chair or in bed. Learn how to use it safely so you don’t injure yourself. Be sure the cane or walker is the correct height.

Hang your arm loosely at your side, and measure the distance from your wrist to the floor. The distance should be the same as the height of your cane or walker.

Walking with a Cane If you have a stronger side, hold the cane on the side of your stronger leg.

1. Get your balance.

2. Move the cane and your weaker leg forward.

3. Support your weight on both the cane and your weaker side.

4. Step with your stronger leg.

5. Start again from step 1.

39

Using a Walker

1. Roll the walker (lift it if you’re using an un-wheeled walker). Move it forward about 12 inches.

2. If you have a weaker side, step forward with that foot first.

Use the walker to help you keep your balance as you take the step.

3. Bring your other foot forward to the center of the walker.

To Sit Down

1.

2.

3.

Back up until you feel the chair behind you. If you have an injured leg, knee, or hip, extend that leg out in front of you.

Bend forward at your hip.

Reach behind you with one hand and grab the armrest or the side of the chair. Do the same with the other hand.

Lower yourself onto the center of the chair, then slide back.

40

Up Stairs

1. Turn the walker sideways so the crossbar is next to you. Place the first 2 legs on the step above you.

Hold the walker with one hand and the handrail with the other.

2. Support your weight evenly between the handrail and walker.

Step up with your good leg.

3. Bring your injured leg up. Then lift the walker to the next

Down Stairs

1. Turn the walker sideways so the crossbar is next to you. Place the back two legs on the step beside you. Hold the walker with one hand and the handrail with the other.

2. Support your weight on your good leg. Step down with your injured leg.

41

3. Support your weight evenly between the handrail and your walker. Slowly bring your good leg down.

Then move the walker down to the next step.

To Get Up 1. To get up, do the reverse of the three steps above.

2. Hold the crossbar of the walker with one hand, and the arm of the chair with the other.

3. Don’t try to use only the walker to stand — it could tip over.

42

SECTION 6 Discharge Plans and Expectations Planning for your hospital discharge is an important aspect of your surgical success.

We suggest that you do not go home alone, but have someone available to assist in your care for the next two or three days. This can be a friend or family member who can help with meals and household activities, which will allow you to concentrate on your recovery. If you do not have this support available, please let us know as soon as possible so the spine team can connect you with community resources that can provide assistance. Such services may or may not be covered by your health care insurance.

While most patients go directly home, in the event the spine team recommends further rehabilitation following your hospital stay, options for this level of care will be provided. Each level of rehabilitation has specific functional and financial criteria that must be met depending on your health care coverage. If you do not meet this criterion but strongly wish to pursue rehabilitation, you have the option to pay privately for your stay.

43

Cervical Laminectomy 1. Immediate Post-op to Discharge from Hospital You may get out of bed as soon as comfortable. Walk as desired. Keep wound clean and dry. Wear brace or collar as instructed.

2. Discharge to First Office Visit If you were given a brace or rigid collar, wear this when you are out of bed and the soft collar at rest. Continue to walk as desired. Gradually increase your distance. You may shower, but do no bathe in a tub or swim. You should remove any dressings from the surgical incision before showering. If you are not wearing a brace, you may drive short distances as soon as you are comfortable.

Driving is not advisable while wearing a neck brace. You should plan to take it easy and rest for the next week at home and then gradually increase your activity as tolerated.

3. First Visit (approximately ten days to six weeks post-op) Gradually increase activities. Remain on your feet for longer periods of time and increase your walking distances. You may return to a sedentary job in as little as two weeks if your commute is less than 20 minutes and you are pain free.

You may tub bathe and swim. No bending, twisting, or lifting more than ten pounds.

4. Six to 12 Weeks You may return to light duty or physical labor if pain free. You may lift up to 25 pounds but continue to avoid bending and twisting of the neck. At your six week visit, you will be shown specific exercises to strengthen your neck muscles.

5. Twelve to 24 Weeks Continue to avoid heaving lifting or repetitive bending and twisting of the neck.

Continue these restrictions until advised further.

Swimming: Refrain from pool activity that causes repetitive twisting of the head and neck. Even the simple activity of walking in the water can be therapeutic during this time of recovery.

44

Cervical Fusion 1. Immediate Post-op to Discharge from Hospital You may get up as desired wearing a rigid collar or brace. Use the soft collar in bed.

Instructions for Removal of Soft Collar, Skin Care, and Re-application:  Before taking off your collar, gather the supplies you will need: soap, wash cloth, towel, and pads.  Stand or sit in front of a sink with a mirror. Release the strap on one side. Remove the collar and set it aside.  Keep your head and neck straight and still. Use a wash cloth to clean your face and neck.  Rinse away soap and gently dry your skin.  Remove moist and/or dirty pads. If needed, clean and towel dry the plastic and straps. Attach the clean pads  Place the front of the collar so your chin comes to the front edges of the chin piece.  Place the back panel behind your neck.  Connect the straps on both sides and tighten.

2. Discharge to first office visit Try to be up as much as possible using a hard brace when up and the soft collar when in bed. You may shower, but do not tub bathe or swim. You should remove any dressings from the surgical sites before showering and replace, if desired, after showering. You should avoid driving at this time, but you may be a passenger. Avoid strenuous activity. You may walk as much as you can comfortably, but no other exercise is advisable for now.

3. First visit (approximately ten days to six weeks post-op) Gradually increase activities using brace or collar as before. You may shower, tub bathe, swim, and participate in any desired low impact aerobic activity such as walking, exercise bike or StairMaster™. You may return to work as instructed by your physician. Do not drive if you are still wearing a brace.

Continue to avoid lifting anything over ten pounds.

4. Six to 12 weeks You may be weaned from brace or collar depending upon your X-rays. Drive only if you are out of the brace. No running, contact sports, or lifting of weights over 25 pounds. Use soft collar as desired for comfort.

5. Twenty to 24 weeks Continue to avoid heavy lifting (over 25 pounds), repetitive bending and twisting of the neck. Continue these restrictions until your X-rays indicate that you are completely healed and your physician releases you to full activity.

Swimming: Refrain from pool activity that causes repetitive twisting of the head and neck. Even the simple activity of walking in the water can be therapeutic during this time of recovery.

45

Lumbar Laminectomy 1. Immediate Post-op to Discharge from Hospital You may get out of bed as soon as comfortable. Keep wound clean and dry.

2. Discharge to First Office Visit If you were given a back brace, wear it when you are out of bed. Continue to walk as desired gradually increasing the distance. You may shower 48 hours after surgery. Remove dressing, shower, dry off incision, and replace dressing if desired. Do not bathe or swim. You may drive short distances as soon as you feel comfortable. For the next week, you should rest at home. Avoid strenuous activity. Avoid bending, lifting and twisting for the next month. You can walk as much as is comfortable, but no other exercise is advisable for now. Call if there is any incision drainage, redness, or fever. It is not unusual to have some leg pain and/or numbness. Please contact your surgeon if these symptoms are severe.

3. First Visit (approximately ten days post-op to six weeks) Gradually increase activities. Remain on your feet for longer periods and increase your walking distances. You may return to a sedentary job at two weeks if commute is less than 20 minutes and you are pain free. You may tub bathe and swim. No bending, twisting, or lifting. Sit only in chairs with good lumbar support. Sexual intercourse if desired (patients on bottom or side). May start regular aerobic activity such as vigorous walking (work up to three miles in 45 minutes), StairMaster™, swimming and low impact aerobic classes.

4. Six to 12 Weeks You may return to physical labor or light duty if pain free, lifting 25 pounds or less. No bending and twisting. You may drive up to one hour. Continue your exercise program. You will be shown specific therapeutic exercises at your six week visit.

Swimming: Refrain from pool activity that causes repetitive twisting of the head and neck. Even the simple activity of walking in the water can be therapeutic during this time of recovery.

46

Lumbar Fusion 1. Immediate Post-op to Discharge from Hospital You may get out of bed as soon as comfortable. Keep wound clean and dry.

2. Discharge to First Office Visit If you were given a back brace, wear this when out of bed. Continue to walk as desired. Gradually increase your distance. You may shower after 48 hours or per your physician’s instruction. Remove dressing, shower, pat incision dry and replace dressing if desired. Do not tub bathe or swim. Avoid riding in a car.

3. First Visit (approximately ten days to six weeks post-op) Gradually increase activities. Remain on feet for longer periods of time and increase walking distances. You may drive short distances for necessities at three weeks and return to a sedentary job at three to six weeks if commute is less than 20 minutes and you are pain free. You may tub bathe and swim. No bending, lifting or twisting. Limit sitting and use good lumbar support to avoid placing undue pressure on the spine. Sexual intercourse if desire (patient on bottom). Wear back brace whenever up.

4. Six to 12 Weeks You may return to non-strenuous work if you are pain free. Avoid bending, twisting, or lifting anything over ten pounds (equals a gallon of milk). Start regular low impact aerobic activity such as vigorous walking (work up to three miles in 45 minutes), StairMaster™, or low impact aerobic classes. You may drive up to 30 minutes. You will be shown specific therapeutic exercises at your six week visit. You should wear your back brace whenever up.

5. Twenty to 24 Weeks Continue to avoid heavy lifting (less than 10 pounds) or any repetitive bending or twisting of the back. Wear back brace until your physician advises you further. Continue these restrictions until advised that fusion has healed.

Swimming: Refrain from pool activity that causes repetitive twisting of the head and neck. Even the simple activity of walking in the water can be therapeutic during this time of recovery.

47

48

Reasons to Call Your Doctor Following discharge to your home if you experience any of the following call your doctor immediately: 1. Excessive redness around your incision.

2. Temperature greater than 100.5 degrees.

3. Pus-filled drainage from the wound.

4. Worsening pain not relieved by pain medication 5. _______________________________________ 6. _______________________________________ 7. _______________________________________ 8. _______________________________________

49

SECTION 7 Home Setup after Spine Surgery Rearranging a few items in your home, assessing what equipment you will need, and understanding how to adapt to your environment will help facilitate a smooth transition from the hospital setting back to home.

Kitchen 1. Make sure all frequently used items are taken out of low storage places and placed on the counter for easy access.

2. Move all food in refrigerator to the top shelves.

3. Remove all throw rugs as they present a tripping hazard.

4. On cooking days, cook three to four meals instead of one so that cooking is kept to a minimum.

5. Place a high stool or chair in the kitchen area to sit on while working (chopping food, washing the dishes, stirring on the stove, or using the microwave).

6. Use a reaching tool to grab items of less than two pounds in high and low places.

7. Empty trash when only half full.

Living Room 1. Do not sit on low couches without arm rests, as they are difficult to get out of.

2. Place a pillow on a low surfaced chair or recliner to increase the seat height.

3. Before sitting down, make sure all items are within reach (i.e. telephone, remote control, water, snacks).

Bedroom 1. Sleep on the side of the bed that is closest to the bathroom.

2. Place a nightlight in the room for easy visibility when getting up.

3. If using a commode, place it at a 90 degree angle to the bed and keep mobility assistive devices nearby.

Bathroom 1. If a tub/shower is the only option for showering, consider a tub transfer bench with or without legs. (If a shower stall is an option, it is recommended to use a commode for both the toilet and as a shower chair.)

2. Place the bench in a position so that water controls are within reach. It is best if the bench is placed on the side of the faucet and a handheld shower head is used.

3. A high raised toilet seat is recommended if there are places next to the toilet to hold onto when standing up. A commode is recommended if there is nothing next to the toilet to hold onto when standing up or lowering down.

50

Nutrition Good nutrition before and after surgery is important for post-surgical healing. Your wounds may not heal well if you eat a diet that is low in nutrients. Calories, protein, vitamins such as vitamin C and vitamin A, and minerals such as iron and zinc are important nutrients to help heal wounds.

Eating Well Following a well-balanced eating plan with a variety of foods from each food group helps to ensure adequate amount of nutrients to prepare your body for the stresses of surgery. You can get more information from the MyPyramid website – www.mypyramid.gov.

A well balanced eating plan includes:  Grains: Choose a variety of food made from wheat, rice, oats, cornmeal, barley or another cereal grain. Make half your choices whole grains. Food from this food group offers a good source of fiber, zinc, and B vitamins.  Fruits and vegetables: Choose a variety of fruits and vegetables to get an abundant of color and nutrients in your diet. Focus on a minimum of five servings of fruits and vegetables per day. Food from these food groups are a good source of vitamin C and vitamin A.  Milk or milk alternates: Aim at getting two to three servings of milk or alternate dairy products each day. Choose milk, cheese, yogurt or fortified soy or rice milk. Foods from this food group provide a good source of protein, calcium, vitamin D and B vitamins.  Meat and beans: Foods from this food group are good sources of protein, iron and zinc. These foods help our body heal from surgery, infection and injuries.

Foods in this group include beef, chicken, fish, seafood, pork, tofu, nuts, and nut butters. Focus on eating five to six ounces of meat or the equivalent in a meat alternate per day.

Calories help to provide your body with energy and having enough energy supports the healing process. After surgery you may find that you are struggling with a poor appetite and you are eating less. This may slow the healing process.

The following are some ideas to help you eat enough calories and protein to help your recovery after surgery:  Eat smaller more frequent meals. Eat five to six meals per day.  Keep snacks such as nuts, fruit, cereal, yogurt and milk handy.  Choose nutrient dense drinks in place of water or coffee. Nutrient dense drinks include milk, fruit juice, fruit smoothies and even lattes.  Add fruit, nuts, cream or half and half to cereals.  Use milk to make soups.  Have cheese or peanut butter with crackers or fruit.

The following are suggestions to help you eat more protein:  Add one tablespoon dry milk powder to one cup of milk, hot cereal, soups or gravies.  Spread peanut butter or another nut butter on crackers or toast.  Add extra chopped meat or shredded cheese to soups, salads or casseroles.

51

   

Have yogurt with fruit and nuts.

Melt cheese on bread, English muffins or tortillas.

Add shredded cheese to vegetables.

Choose desserts that contain eggs such as egg custard, bread pudding, or rice pudding.

A diet with an adequate amount of vitamins and minerals helps with healing too.

Vitamin C and zinc are especially important for healing. Good sources of vitamin C include orange juice, strawberries, tomatoes, cantaloupe, broccoli, cranberry juice, green peppers, and potatoes. Foods high in zinc include meats, cereal and dried beans.

If you are not able to eat enough food you may not be getting enough calories, protein, vitamins or minerals. In this case, a liquid supplement may be suggested by your doctor or registered dietitian. Liquid supplements such as Ensure Plus®, Boost Breeze®, Carnation Instant Breakfast®, and Enlive® can help supplement your diet when you are eating poorly.

52

Glossary Annulus – The outer rings of rigid fibrous tissue surrounding the nucleus in the disc.

Anterior – A relative term indicating the front of the body.

Bone Spur – An abnormal growth of bone usually present in degenerative arthritis or degenerative disc disease.

Cartilage – A smooth material that covers bone ends of a joint to cushion the bone and allow the joint to move easily without pain.

Computed Tomography Scan (also called a CT or CAT Scan) – A diagnostic imaging procedure that uses a combination of X-rays and computer technology to produce cross-sectional images, both horizontally and vertically, of the body. A CT scan shows detailed images of any part of the body including the bones, muscles, fat and organs. CT scans are more detailed than general X-rays.

Congenital – Present at birth.

Contusion – A bruise.

Cervical Spine – The part of the spine that is made up of seven vertebrae and forms the flexible part of the spinal column. The cervical spine is often referred to as the neck.

Corticosteroids – Potent anti-inflammatory hormones that are made naturally in the body or synthetically for use as drugs. The most commonly prescribed drug of this type is prednisone.

Degenerative Arthritis – The inflammatory process that causes gradual impairment and loss of use of a joint.

Degenerative Disc Disease – The loss of water from the discs that reduces elasticity and causes flattening of the discs.

Disc – The complex fibrous and gelatinous connective tissues that separate the vertebrae in the spine. They act as shock absorbers to limit trauma to the bony vertebrae.

Discectomy – The complete or partial removal of the ruptured disc.

Dura – The outer covering of the spinal cord.

Dural Tear – A laceration or tear of the dura that can occur during surgery. Leakage of spinal fluid occurs at this site. This is often treated with bed rest for 24 to 48 hours, thus allowing the tear to heal.

Facet – The small plane of bone located on the vertebra.

53

Foramina – Plural form of foramen (a natural opening or passage through a bone).

Foraminotomy – The surgical procedure that removes part or all of the foramen. This is done for relief of nerve root compression.

Fracture – A break in a bone.

Fusion – The surgical procedure that joins or “fuses” two or more vertebrae together to reduce movement at this joint space. As a result, pain is lessened.

Herniated Disc – The abnormal protrusion of soft disc material that may impinge on nerve roots. Also referred to as a ruptured, bulging, or protruding disc.

Inflammation – A normal reaction to an injury or disease which results in swelling, pain, and stiffness.

Joint – Where the ends of two or more bones meet.

Lamina – The bone that lies posterior to the vertebrae.

Laminotomy – The removal of a small portion of the lamina.

Laminectomy – The removal of the entire lamina.

Ligaments – Flexible band of fibrous tissue that binds joints together and connects various bones.

Lumbar Spine – The portion of the spine lying below the thoracic spine and above the pelvis. This part of the spine (also called the lower back) is made up of five vertebrae.

Magnetic Resonance Imaging (MRI) – A diagnostic procedure that uses a combination of large magnets, radiofrequencies, and a computer to produce detailed images of organs and structures within the body.

Myelopathy – A condition that is characterized by functional disturbances due to any process affecting the spinal cord.

NSAID – An abbreviation for nonsteroidal anti-inflammatory drugs, which do not contain corticosteroids and are used to reduce pain and inflammation. Aspirin and ibuprofen are two types of NSAIDs. Nerve Root – The portion of a spinal nerve that lies closest to its origin from the spinal cord.

Neuropathy – A functional disturbance of a peripheral nerve.

Nucleus Pulposus or Nucleus – The relatively soft center of the disc that is protected by the rigid fibrous outer rings.

54

Osteoporosis – A condition that develops when bone is no longer replaced as quickly as it is removed.

Osteophyte – A bony overgrowth.

Pain – An unpleasant sensory or emotional experience primarily associated with tissue damage.

Pain Threshold – The least experience of pain that a person can recognize.

Pain Tolerance Level – The greatest level of pain that a person is prepared to tolerate.

Paresthesia – An abnormal touch sensation such as burning or tingling.

Posterior – A relative term indicating that an object is to the rear of or behind the body.

Radiculopathy – A condition involving the nerve root that can be described as numbness, tingling, or pain that travels along the course of a nerve.

Sacral Spine – The last section of the spinal column located below the lumbar spine. It is made up of several semi-fused pieces of bone.

Sciatica (also called Lumbar Radiculopathy) – A pain that originates along the sciatic nerve.

Scoliosis – A lateral, sideways curvature and rotation of the back bones (vertebrae), giving the appearance that the person is leaning to one side.

Soft Tissues – The ligaments, tendons, and muscles in the musculoskeletal system.

Spine – A column in the body consisting of 33 vertebrae.

Spinal Stenosis – A narrowing of the vertebral canal, nerve root canals, or intervertebral foramina of the spine caused by encroachment of bone upon the space. Symptoms are caused by compression of the nerves and include pain, numbness, and/or tingling.

Spine – The flexible column of 24 vertebrae, discs, ligaments and muscle that lie between the head and pelvis and behind the rib cage. Also referred to as the spinal column.

Spinous Process – The part of the vertebrae that you can feel through your skin.

Spondylosis (Spinal Osteoarthritis) – A degenerative disorder that may cause loss of normal spinal structure and function. Although aging is the primary cause, the location and rate of degeneration is individual. The degenerative process of spondylosis may impact all of the spine creating overgrowth of bone and affecting the intervertebral discs and facet joints.

Spondylolisthesis – A forward displacement of one vertebra over another.

Sprain – A partial or complete tear of a ligament.

55

Stress Fracture – A partial or complete tear of a muscle or tendon.

Tendon – The tough cords of tissue that connects muscles to bones.

Thoracic Spine – The portion of the spine lying below the cervical spine and above the lumbar spine. This part of the spine is made up of twelve vertebrae.

Torticollis (also called Wryneck) – A twisting of the neck that causes the head to rotate and tilt on an angle.

Transverse Process – The wing of bone on either side of each vertebra.

Trigger Point – Hypersensitive area or muscle or connective tissue usually associated with myofascial pain syndromes.

Ultrasound – A diagnostic technique which uses high-frequency sound waves to create an image of the internal organs.

Vertebra(e) – The bone or bones that form the spine.

X-ray – A diagnostic test which uses invisible electromagnetic energy beams to produce images of internal tissues, bones and organs onto film.

56

Medical Plaza North Two West 42nd Street Scottsbluff, NE 69361 308.630.1947 PhysiciansClinic.net