Posterior Lumbar Interbody Fusion (PLIF)

LUMBAR DISCECTOMY AND SPINAL FUSION

This is a surgical procedure that is designed to prevent abnormal movements within your spine. I will suggest this if you have instability of the spine or relative instability from degenerate disc disease. The aim is that by supposedly addressing the abnormal movements I would be able to reduce the amount of back pain that you would be experiencing and therefore improve the outcome of your operation. If you think that this is something that has not been discussed with you or you are not sure why this is not suitable for you please do discuss this with me. If your back pain is not that significant or you are able to control your symptoms by the use of your core muscles it may be better not to have the fusion.. There is no guarantee that having the fusion will result in a decrease of your back pain. It is often difficult to know exactly where the pain is coming from.

The fusion is achieved by encouraging two of the spinal bone to join together and become fused. Screws and rods will hold the two bones rigidly together. However to be certain of a long lasting effect we encourage bone to grow between the two bones. To help this occur a metal block is placed in the position where the disc was. This is promoted by bone graft, made up of your own bone, the bone removed during the operation and a bone graft substitute that has been shown to encourage bony fusion. There is a 40-50% chance that you will be very happy with the result of reduction of back pain after this operation. The fusion takes a long time to happen although the screws that I use will provide stability. It would not be uncommon for the pain to get better slowly and over a period of months.

Before the operation

You will be contacted by the hospital and invited to come for a pre-assessment. You will have some routine blood tests and have your pulse and blood pressure checked. You may also need to have an electric tracing of your heart activity. You will need to come into hospital on the day of your surgery. When you come in the nurses will check that you are ready for your surgery and will fit stockings on your legs to reduce the risk of getting a deep vein thrombosis. I will visit you in your room and check that you are prepared to have your surgery. You will also be visited by the anaesthetist who will review all the tests that you have had and discuss the anaesthetic with you. You will be escorted down to the operating theatre. Your anaesthetic will be administered and you will then be asleep.

The Operation

Once you have been anaesthatised and are asleep we will introduce a catheter to drain your bladder. It is quite a long operation and this will mean that you do not have to get up and get to the toilet during the night to pass urine. The catheter will be removed once you are able to get up and get to the toilet . We will carefully position you on to your front. Based on an x-ray I will localise the level that we will be operating at. The skin will be cleaned with a liquid to reduce the number of bacteria on the skin and reduce the risk of infection. An antibiotic will also be given to do this. A cut will be made in your back. The cut will be deepened through the fat and a cut will be made into the covering layer of the muscle. The muscle is then peeled away from the spine to expose the bones. The level at which I am operating is checked again to be totally certain that we are operating at the correct level.

I will identify the anatomical position through which I need to insert the bone screws. I will use x-rays during the operation to assist in this. The screws on either side are connected with rods and this stabilises the spine. Once this is done I will remove some of the bone to allow me access to the disc at the front of the spine.. I will move the nerves out of the way and I will be able to see the disc in front of me. I shall remove as much of the disc as is safe and then place a metal block into the space created. Removing the disc will hopefully remove that part which we think a significant part of your back pain is coming from. The cage that we put in maintains the space and encourages bone to grow to make this level fused and stable. This will prevent further painful movements at this level. I will then lay the bone that I had removed and the bone graft substitute between the two bones.

I will then give you an epidural to reduce the pain of the operation. I will hope to leave the epidural catheter within you to provide good pain relief after the operation. I will inject a gel that is designed to try to reduce the chance of scar tissue formation. I will then stitch up the small hole in layers. The stitch will be buried under the skin and paper stitches will be used. This will all be covered with a waterproof dressing.

Risks

The operation is designed to relieve your leg pain. Although this is a routine procedure it is important to be aware of the risks involved.

Surgery always carries with it a risk of infection although this is rare. This may lead to a temporary increase in back pain and an antibiotic may need to be prescribed. An increase in back pain may occur for up to a year may be permanent. The risks of infection are approximately 1%.
Damage to nerves. Numbness, pins and needles and weakness may improve after surgery but recovery may be slow. If there are severe symptoms before surgery, there may be some ongoing numbness and weakness after the operation which if the nerve has been permanently damaged may not recover. On very rare occasions, the nerve may be damaged at the time of the operation leading to an increase in pins and needles, numbness and weakness. This happens in less than 1% of patients.
Damage to the nerves to the bladder and bowel and both legs ( Cauda Equina Syndrome)
This is extremely rare and happens in less than 1% of spinal surgery.
Dural tear. A tear to the lining of the sac containing the nerves (dura) can cause a nasty headache. This is due to a small leak of the fluid that surrounds the nerves and brain. The tear is stitched or patched during the surgery and you may have to lay flat for a while after the operation to allow it to seal over. It can cause headaches which may last for a few days but should wear off completely. It does not seem to change the final outcome of the surgery
Ongoing back pain. On occasions, back pain can be the same or even a little worse after back surgery. The main aim of spinal decompression surgery is to improve your leg pain. The stabilisation will hopefully help the back pain but that may only happen in about 50- 60 % of cases. Everyone is different and I will be able to give you some indication as to how likely this is.
Recurrance. Not all the bone, ligament or joint is removed. These are living tissues and it is possible that they will grow and become enlarged again. This could result in further tightness to the nerves and a recurrence of your pain.
Wrong level. It would be easy to be operating at the wrong level of the spine as the bones look very similar. That is why I take multiple x-rays during the operation to be sure that I am working at the correct level.
Although the insertion of the screws is performed with the aid of x-rays, studies have shown that as many as 25% of screws may have been placed so that they are breaking through the bone. This sounds common and only rarely does it cause any problems to the nerves. In the rare event that this may have happened it is possible to perform a further operation to correct this. Damage to the nerves from screw placements occurs in less than 1% of cases.
Adjacent segment disease. This condition refers to a possible change that could happen because one segment of the spine has been made stiff. If one level is fused then the level above may have increased stress through it. This may cause increased wear and result in degeneration which could produce pain from this level above the previous surgery. There are on going studies to find out if this in case the fact or whether this is the natural degeneration that has been occurring in your spine.
The aim of the fusion is to encourage the two spinal bones to fuse. However in some instances this does not happen and the two bones may become joined with scar tissue rather than bone. This could result in the instability continuing. However the screw fixation is often strong enough to provide enough stability that the spinal instability is reduced and the symptoms may still be improved.

Risks Related to Anaesthetics

Modern anaesthetics are extremely safe. However, as with all general anaesthetics, there is a very small risk of complication concerning the anaesthetic during the procedure. Any existing medical conditions will be taken into consideration.

General Risks

There are a number of complications that can occur in any operation e.g. blood clots, heart attacks, and chest infections. The risk of these complications in a person of average good health is low. If you have any medical conditions or are taking any medicines it is very important that you inform the pre-assessment nurse, surgeon and the anaesthetist. Constipation is common after any spinal surgery and I will encourage you to take laxatives if you have any difficulty opening your bowels. Some people find that they are left with a tender scar, to prevent this I will suggest that once the wound has healed, at about two weeks, you start to massage the scar itself. You can use a cream or oil if you want.

After the Procedure

You will then be placed back in your bed, woken up and taken to the recovery area. Here your pulse, blood pressure and breathing will be closely monitored. Once the staff are sure that you have woken up fully from the anaesthetic and that your pain is well controlled they will organise for you to transferred back to the ward. Later the same day either the physiotherapists, nurses or myself will get you out of bed and start you standing and walking. So long as you have fully recovered from the anaesthetic and your blood pressure is normal, we will encourage you to walk.

Although it may even be the same day, it is usually the next day that the physiotherapists will ensure that you are able to walk a reasonable distance and over the next few days safely manage the stairs. Once you have done this you will be ready to go home.

Your spine is still stable after the operation. It is absolutely fine for you to start to move around after the operation as much as is comfortable. The speed with which you get moving again is largely determined by how comfortable you are. Most people are able to leave hospital after two nights. Some people are well enough to leave the next day and some need three nights. You sholld be self caring when you leave hospital but will obviously need help with cooking, shopping and cleaning. I tend to advise against driving for 4 weeks.. The idea is to be comfortable enough behind the wheel of a car such that you would have full confidence that you would be able to cope in an emergency.

It is vital that you play an active part in your recovery. You may feel some discomfort but you are not harming yourself. Your exercises will help you return to normal more quickly and to feel better in yourself. It is quite safe to take painkillers to help you to do this. If leg pain recurs, you should ease off and rest until symptoms settle. Gradually increase the level of strenuous activity and lifting and generally by 2-3 months you should be back to normal.

Generally I would want you to have a minimum of four weeks off work after your surgery. Depending on how you travel to work and the duties you are required to perform will determine how long it will be before it is advisable for you to return to work. If you are able to return to work with reduced hours and on lighter duties this will be quicker than if you have to wait till you are fully fit.

If you perform any particular sports please discuss this with me so that I can advise you as to what would be safe. I will be able to give you guidance as to what would be considered safe and how to gradually increase the activites so that you are able to return to your sport in a safe manner.

THE FIRST WEEK

Pain relief

A local anaesthetic is injected into the wound at the time of surgery, which should help with pain relief.
You will be given painkillers as required on the ward and for you to take home if needed.
It is important to start moving and if pain is preventing you from doing this let us know and we may be able to alter you pain medication to help you to be able to become independent.
You may find that your leg pain is still very much the same as before. In some cases the nerve irritation does take a while to settle down. In addition you will have the pain of the operation. Although this is a different pain you may find that you need to take just as many pain killers as before to keep this under control. Do not expect to be completely pain free.
If you do not feel significant pain it may still be important to take the pain killers that you have been given. It is better that while you are increasing your level of activity you do not feel inhibited by increasing pain.

BED MOBILITY AND EXERCISES

You can lie on your side if you wish. Whichever position is most comfortable to allow you to sleep well is fine.
Whilst in bed, you can lie on your side or sit slightly propped up as comfort allows.
Early mobility is very important and the physiotherapists will start you walking within 24 hours of surgery, the same day if possible. You will also be encouraged with your exercise programme.
You will be encouraged to be as mobile as possible. This will include going up and down stairs within a couple of days of surgery.
Generally if it is comfortable to do it is safe to do. Remember to build up gradually.

DISCHARGE HOME

Discharge from hospital is normally within 1-3 days after your operation.
You will be given a sheet of exercises by the physiotherapists to continue at home. If you are comfortable you can increase these, but build up in small amounts. It is a slow recovery and is not meant to be a race.
Becoming constipated is painful after back operations. Take laxatives as necessary.

WEEKS 2 - 6

For the first couple of weeks it is recommended that you avoid:

Sitting in low chairs you will do no harm but it may increase your back pain.
Sitting for a long time – for example longer than 20 minutes. The length of time that you will be able to sit and stand for will gradually get longer over this time.
Getting into the bath until your wound is clean and dry.
Driving for the 2-4 weeks – you can be a passenger for short journeys.
Prolonged rest – you will get stiff and your muscles will get weaker.

Return to Normal Activity

Housework

You can start back to normal activities, as you feel able to do so.
You may want to ask someone else to do the hoovering in the early stages.
Avoid lifting heavy furniture.
After 12 weeks it is expected that you can lift as you normally would do but use your common sense.

Return to work

If your job involves sitting at a desk, you may return after 5- 6 weeks, depending on how you are progressing. It is often possible to return to working from home with reduced hours as early as 2 weeks. Working from home or for reduced hours and lighter duties are ways that you may be able to return to work sooner and should be discussed with your employer.
Your ability to get to work, such as being able to drive a car, and how long you can sit for any length of time may actually determine when you can return to work.
If your job involves heavy lifting, you may need to delay your return for 3 months. It is recommended that you discuss your job with the Consultant.

Sport

I will advise you when you can start to return to your normal sports after the operation. If you tell him which sports you do he will advise you accordingly.

Sexual Activity

This may be resumed once you feel comfortable to do so.
You can try different positions to find out which is most comfortable for you.

YOU SHOULD CONTACT US IF YOU EXPERIENCE ANY OF THE FOLLOWING AFTER YOUR OPERATION:

A loss of sensation or change in your ability to move your bowels or empty your bladder.
Any significant leg pains and pins and needles.
Any redness, oozing or discharge from your wound.
Feeling unwell with a raised temperature.