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Anterior lumbar interbody fusion (ALIF)

Surgery :: Anterior Cervical Decompression Fusion :: Lumbar Disc Replacement
Posterior Cervical Spine Surgery :: Spinal Deformity Surgery :: Lumbar Decompression and Fusion
Lumbar Discectomy :: Surgical Risks :: FAQ

The ALIF approach has the advantage that, both the back muscles and nerves remain undisturbed.

About the surgery

Anaesthesia: The surgery is usually performed under a general anaesthetic with the patient lying on the back.

Procedure: In the anterior lumbar interbody fusion (ALIF) approach, the disc space is fused by approaching the spine through the abdomen. A 7-10cm incision is made in the abdomen and the abdominal muscles are retracted to the side.

The anterior abdominal muscle in the midline (rectus abdominis), is retracted to the side. The abdominal contents lay inside a large sack (peritoneum) that can also be retracted, thus allowing the spine surgeon access to the front of the spine. The large blood vessels that continue to the legs (aorta and vena cava) lay on top of the spine, so your spine surgeon may perform this surgery in conjunction with a general surgeon who mobilizes the large blood vessels. After the blood vessels have been moved aside, the disc material is removed and a cage filled with bone morphogenic protein (BPM) is inserted. The incision is closed with dissolvable sutures and a drain tube removes the blood that collects at the surgical site.

After surgery

Following surgery, you will be transferred to the recovery room and may feel some pain at the operated site when you wake up. A patient controlled analgesia (PCA) pump will be provided which releases a small dose of pain medication every time you press the button, thereby putting you in control of your pain. You will be given intravenous fluids to keep you hydrated and a urinary catheter will empty your bladder. When the medical staff in the recovery room are confident that you are comfortable, you will be transferred to your room.

In the ward: Since the abdomen was opened during surgery, you will be advised not to eat or drink anything for the first 12 -24 hours. You will then be commenced on a clear fluid diet and gradually progress to a light diet. On the day after surgery, the drain tube, urinary catheter and pain pump will be removed and you will be encouraged to walk wearing a brace for support. You will stay in the hospital for 3-5 days and your surgeon will decide when you can go home.

Pain relief: Although we expect that you will be in pain or discomfort, we recommend that you take regular pain relief following surgery. Medications will be provided to reduce your pain after surgery and at home for the first 1-2 weeks. If pain persists after discharge please seek advice from Spine Service or your General Practitioner.

Skin sutures: Dissolvable sutures are most often used to close the skin. These will dissolve as your wound heals, however, the tip of the suture on either end of the incision will need to be cut on your first visit to the surgeon's office 7-10 days after surgery.

What to expect following surgery

Pain: You will feel discomfort and pain at the operative site immediately after surgery. You will be given pain medications; however, the soreness and stiffness in your back and/or limbs will continue for some time. Please ensure you take regular pain relief.

Tingling / Numbness: A degree of tingling and/or numbness in your limbs may be experienced after surgery and may take some time to subside.

Drains: Some patients may return to the ward with a drain tube near the surgical site to help prevent any collection of fluid at the operation site. The drain is usually removed in 24 to 48 hours.

Drips: You will have a small plastic needle (cannula) to receive fluids and antibiotics during and after surgery. The cannula will be removed when you are drinking sufficient fluids and after the doctor has stopped the prescribed antibiotics.

Catheter: A catheter will be inserted into your bladder under anaesthesia to drain you bladder during and immediately after surgery. This catheter will keep you comfortable, so you will not have to get out of bed to go to the toilet on the first day. The catheter is usually removed the day after surgery.

Calf compressors: Following your surgery, you will have inflatable compressors on your calves to reduce the risk of deep vein thrombosis (DVT). You may also be given a pair of anti-thrombotic stockings.

Coping with the Blues: It is not uncommon for patients to feel a little depressed or emotional after your surgery. The doctors and nurses will help you through this vulnerable phase.

Diet: You will be Nil by Mouth initially allowed only sips of fluid and crushed ice to suck. Once bowel sounds are present, you will start on a post-operative diet and gradually increase to a full diet. To avoid constipation, you should include plenty of roughage, cereals, fruit & vegetables in your diet. You should also aim to drink 2-3 litres of fluid daily.

Bowels: It is common not to have bowel movements for the first few days. Once you have started on a full diet, you will be given medications to help with bowel movements.

ALIF surgery potential risks and complications

All surgical procedures are associated with a risk of complications and all risks should be discussed with your surgeon. The risks may be associated with the anaesthesia given or the surgical procedure per se. Surgical complications can include bleeding, infection, spinal fluid leak, injury to the veins and arteries near the spine or injury to the spine's nerve tissue or its surrounding protective layer.

Injury to the spinal cord or the nerves may occur during surgery and can result in complete paralysis of all four limbs or paralysis of certain muscles in the arms or legs, with loss of normal sensation. Loss of bowel and bladder control can also occur following injury to the nerves. An injury to the covering layers of the nerves (dura) can result in a leak of spinal fluid and this may occasionally require a repeat surgery. Great care is taken to ensure the accurate placement of the screws, including the use of intra-operative fluoroscopy (x-rays).

Although antibiotics are given before and after surgery, there is a 1-5% incidence of wound infection. Superficial mild infections can be treated with antibiotics, while deep infections may require a wound wash-out under anaesthesia. If you have had an infection in any other region (urinary bladder, chest and skin) immediately prior to surgery, you may be at a higher risk of post-operative infection in the spine, so let your surgeon know.

Venous thrombosis (DVT: clotting of blood in your calf muscles) and pulmonary embolism are uncommon after an elective spine surgery, particularly when you are out of bed and walking within 24 hours after surgery. We use calf compressors and TED stockings to prevent the clotting of blood in legs; we do not routinely use medications. However, if you have had an episode of DVT in the past, let your surgeon know.

There is a major risk that is unique to the ALIF approach. The procedure is performed in close proximity to the large blood vessels that go to the legs. Damage to these large blood vessels may result in excessive blood loss. Quoted rates in the medical literature put this risk at 1% to 15%.

For males, another risk unique to this approach is that approaching the L5-S1 (lumbar segment 5 and sacral segment 1) disc space from the front has a risk of creating a condition known as retrograde ejaculation. There are very small nerves directly over the disc interspace that control a valve that causes the ejaculate to be expelled outward during intercourse. By dissecting over the disc space the nerves can stop working, and without this coordinating innervation to the valve, the ejaculate takes the path of least resistance, which is up into the bladder. The sensation of ejaculating is largely the same, but it makes conception very difficult (special harvesting techniques can be utilized). Fortunately, retrograde ejaculation happens in less than 1% of cases and tends to resolve over time (a few months to a year). This complication does not result in impotence as these nerves do not control erection.

In general, the principal risk of this type of spine surgery is that a solid fusion will not be obtained (nonunion) and further surgery to re-fuse the spine may be necessary.

Nonunion rates are higher for patients who have had prior lower back surgery, patients who smoke or are obese, patients who have multiple level fusion surgery, and for patients who have been treated with radiation for cancer. Not all patients who have a nonunion will need to have another fusion procedure. As long as the joint is stable, and the patient's symptoms are better, more back surgery is not necessary.

Other than nonunion, the risks of a spinal fusion surgery include infection or bleeding. These complications are fairly uncommon (approximately 1% to 3% occurrence). In addition, there is a risk of achieving a successful fusion, but the patient's pain does not subside.

There are certain warning signs you should look for after surgery that may indicate a problem, such as excessive bleeding, redness or discharge from the wound, fever, weakness or numbness of the legs, or problems urinating. If you notice any worrisome symptoms, notify your surgeon at once.

Commonly asked questions:

Will I need a blood transfusion?

Although some blood loss occurs during surgery, a blood transfusion is not generally required. More extensive surgeries may occasionally require a blood transfusion.

How long will I stay in hospital?

The length of your stay in the hospital will depend on the surgical procedure that you have had and can vary from an overnight stay to a week. It will also depend on how your wound is healing. You will be given a rough idea regarding the length of your stay during the pre-surgical education session. However, your surgeon will make a final decision after the operation.

When can I walk?

You will usually be encouraged to begin walking the morning after surgery.

Do I have to wear a back/neck brace?

Yes, you will be required to wear your brace when sitting, standing and walking after surgery. Your physiotherapist will wean you off as appropriate.

When can I have a shower after my surgery?

You can have a shower the day after your surgery. If your dressing gets wet, a new one can be applied.

When do I see my doctor after my surgery?

During your pre-surgical education session, the clinical co-ordinator will make an advance appointment for you to visit the rooms after you have been discharged from the hospital. This date can be changed depending on the length of your hospital stay.

Do I have stitches to come out?

The wound is usually closed with dissolvable sutures under the skin and these do not need to be removed. Metallic staples or non-dissolvable sutures, if used, will need removal. On your first appointment (10 days post-op) the surgical wound will be examined and the sutures/staples will be removed.

Do I need to attend physiotherapy sessions?

Following surgery a physiotherapy programme will be started to retrain you to maintain good posture and teach you the correct way of moving your spine.

Is there a certain position that I should sleep in at night?

The most important thing is for you to be comfortable. Some people find it comfortable to sleep with a pillow between their legs or under their thighs.

When is it safe to engage in sexual relations?

This is a very personal domain and is left up to you; whenever you think that you and your partner are ready. Clinically, a two-week period is recommended, provided you are the less active partner.

How long should I wait before driving a car?

The recommendation is to wait 3-4 weeks before driving a car. This may vary depending on your surgery and your progression during rehabilitation.

When can I go back to work?

This is assessed on patient-to-patient bases. If you have a physical occupation, it may take up to 3-6 months. With a sedate occupation, you could be back at work as soon as 3 weeks. Do not commence work until you speak to your doctor and physiotherapist.

When is it safe to bend and/or lift items heavier than a bag of sugar?

During the post-surgical physiotherapy sessions, you will be taught the correct way to bend and lift. Bending from the hips is fine if carried out in a controlled manner, but avoid heavy lifting objects (more than 3kg) till your physiotherapy commences.

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