A Guide to Surgery

What is Anterior Lumbar Interbody Fusion?

Anterior lumbar interbody fusion (ALIF) is a surgery performed to correct spinal problems in the lower back. The surgery can be implemented either as an open surgery or minimally invasive technique.

Indications for Anterior Lumbar Interbody Fusion

The common indications for ALIF include: 

• Severe lumbar (low back) or leg pain that is unresponsive to non-surgical treatment
• Degenerative disc disorder of the lumbar spine (pain due to damaged disc)
• Spondylolisthesis (slippage of one vertebra over another)
• Scoliosis (S-shaped curve of the spine)
• Fractures of the spine
• Tumors
• Spinal instability

Anterior Lumbar Interbody Fusion Procedure 

• ALIF surgery is usually performed under general anesthesia. You will be positioned supine (lying on the back).
• Your surgeon makes an incision on your abdomen and retracts the muscles and various structures to enhance the clarity and accessibility to the anterior aspect of the vertebrae.
• The surgical approach is from the front of the vertebral body in the lower back region.
• Your surgeon removes the whole or a part of the damaged disc between two adjacent vertebrae followed by fusion of the same with or without the use of bone grafts.
• External implant materials such as rods, screws, plates, and wires may be fixed to the treated vertebrae to deliver extra support and stability during the healing process.
• At the end of the procedure, the structures are re-approximated, and the skin is closed with sutures.

Recovery of Anterior Lumbar Interbody Fusion 

• The post-surgical hospitalization includes the rehabilitation program. If required, your surgeon may prescribe pain medications or a brace and follow-up physical therapy upon discharge. 
• The recovery period after ALIF surgery depends on your body’s healing capacity. The success of surgery depends on various factors such as age, spinal condition, overall health status and activity level of the individual.
• The period of your rest or inactivity depends on a few factors such as the type of surgical procedure and the approach used to access your spine, the size of the incision and presence of any complications.
• Return to work or normal activity depends on the type of work or activity you plan to perform. Usually, 3 to 6 weeks is the ideal time of healing. With the advanced and innovative techniques, it is now possible to achieve improved fusion rates, shorter hospital stay with an active and rapid recovery period.
• Strictly adhere to the postoperative instructions suggested by your spine surgeon to promote healing and reduce the possibility of postoperative complications.

Risks or Complications of Anterior Lumbar Interbody Fusion 

The complications of the ALIF surgery include infection, nerve damage, blood clots or blood loss, bowel and bladder problems and any problem associated with anesthesia. The underlying risk of spinal fusion surgery is the failure of fusion of vertebral bone and bone graft, which usually requires additional surgery.

What is a disc prolapse?

This is also referred to as a slipped disc or disc herniation and usually occurs between the ages of 25-50 years. The jelly-like central portion of the disc (nucleus pulposus) tears through the surrounding layers (annulus pulposus) and is displaced into the spinal canal, compressing the nerves extending from the spinal cord.

Disc prolapse symptoms occur as a result of compression on the spinal cord or the nerves going to the arms. Pain in the arms that increases on coughing and sneezing is a symptom of disc herniation. Numbness, the sensation of pins and needles, and muscular weakness in the arms and hands may also be present. When the prolapsed disc compresses the spinal cord (myelopathy), it can cause difficulty in walking, clumsiness of the hands and problems with urinating. The presence and severity of these symptoms vary from person to person.

Who needs surgery?

Surgery is reserved for those with:

• No relief of pain with non-operative forms of treatment;
• Increasing numbness and weakness in the arms and hands; or
• The presence of myelopathy, which indicates the need for early surgery.

About the surgery

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

Procedure: The surgeon makes a 2.5 to 5 cm incision in the skin in the front of the neck. The spine is exposed by retracting the muscles and blood vessels. The bulged disc is removed using special instruments and the pressure on the nerve roots and spinal cord is relieved. After the removal of the disc, the resultant gap is filled with a spacer (cage) made from a plastic material called PEEK and filled with an artificial bone graft substitute called VITOSS and OP-1. A titanium plate with screws is then used to fix the spine. A drain tube will remove the blood that collects at the surgical site. Skin sutures: Dissolvable sutures are used to close the skin. These will dissolve as your wound heals, however, the ends 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).

After the surgery

• In the recovery room: 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. A neck collar will be provided to prevent excessive neck movements and to keep you comfortable. When the medical staff in the recovery room is confident that you are comfortable, you will be transferred to your room.
• In the ward: You will be allowed to drink sips of fluids after surgery and gradually progress to a full diet. 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 to support your spine. You will stay in the hospital for 1-3 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.

Are there any risks involved in disc surgery?

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 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.

Talk to your surgeon

This is a brief overview and does not include all the known facts about your condition and the surgery. Feel free to seek any clarifications from your surgeon and his or her team. It is important for you to obtain a clear understanding of your condition, the surgery and the potential risks and benefits before you sign the consent form.

Anatomy of the spine

The spine consists of 33 bony blocks called vertebrae stacked one above the other with a soft intervertebral disc between each pair of vertebrae. The intervertebral disc consists of a soft jelly-like substance called the nucleus pulposus in the centre, which is surrounded by multiple layers of collagen called the annulus fibrosis (like an onion). The disc connects and allows movement between the vertebrae and acts as a shock absorber for the spine. The vertebrae surround and protect the spinal cord and nerve roots.

The neck, also called the cervical spine, consists of seven vertebrae with an intervertebral disc in-between each pair of vertebrae.

Who needs a posterior cervical (neck) spine surgery?

• When the problem causing symptoms is located in the posterior aspect of the spine;
• when the compression on the spinal cord is from the posterior aspect;
• when the cervical spine is excessively mobile and unstable; or
• in association with an anterior procedure to provide additional stability or to achieve additional decompression.

The compression can be on the nerves going to the arms or on the spinal cord. Compression of the nerves in the neck can cause pain radiating down the arm and forearm with numbness, pins and needles, and muscular weakness in the affected limb. When the compression is on the spinal cord (myelopathy), it can cause difficulty in walking, clumsiness of the hands and problems with passing urine. The presence and severity of these symptoms vary from person to person. Pain in the neck could arise from numerous structures. Degeneration of the intervertebral disc and arthritis of the facet joints are the common causes of neck pain.

Who needs surgery?

Surgery is reserved for those with:

• No relief of pain with the non-operative forms of treatment;
• Increasing numbness and weakness in the arms and hands;
• Or the presence of myelopathy indicates the need for early surgery.

After assessing your symptoms, examining your spine, and studying your x-rays and scans, the surgeon will decide whether you need a posterior spinal decompression, a spinal fusion or a combination of both.

About the surgery

• Anaesthesia: The surgery is usually performed under general anaesthesia, with the patient lying on the tummy. Occasionally, a frame is attached to the skull after anaesthesia, to maintain the position of the head during surgery.
• Procedure: The surgeon makes a 5-15cm incision in the skin on the back of the neck. The spine is exposed by retracting the muscles. Depending on the plan, a decompression, a fusion or a combination of both is performed. A decompression is performed by removing one or more bony laminae and any other structure overlying the spinal cord. A fusion is performed by inserting screws into the bones over the back of the spine and connecting the screws with rods. Occasionally, a combination of a decompression and a fusion is performed. At the end of the surgery a drain tube is inserted to remove the blood that collects at the surgical site.
• Skin sutures: Dissolvable sutures are used to close the skin. These will dissolve as your wound heals, however, the ends 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).

After the surgery

• In the recovery room: 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. A neck collar will be provided to prevent excessive neck movements and to keep you comfortable. When the medical staff in the recovery room is confident that you are comfortable, you will be transferred to your room.
• In the ward: You will be allowed to drink sips of fluids after surgery and gradually progress to a full diet. 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 to support your spine. You will stay in the hospital for 1-3 days and your surgeon will decide when you can go home safely.

Are there any risks involved in disc surgery?

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. Surgical complications can include bleeding, infection, spinal fluid leak, injury to the veins and arteries near the spine or injury to the nerve tissue of the spine 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 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.

Are there any risks involved in disc surgery?

This is a brief overview and does not contain all the known facts about your condition and the surgery. Feel free to seek any clarifications from your surgeon and his or her team. It is important for you to obtain a clear understanding of your condition, the surgery and the potential risks and benefits before you sign the consent form.

Anatomy of the spine

The spine consists of 33 bony blocks called vertebrae stacked one above the other with a soft intervertebral disc between each pair of vertebrae. The intervertebral disc consists of a soft jelly-like substance called the nucleus pulposus in the centre, which is surrounded by multiple layers of collagen called the annulus fibrosis (like an onion). The disc connects and allows movement between the vertebrae and acts as a shock absorber for the spine. The vertebrae surround and protect the spinal cord and nerve roots.

The neck, also called the cervical spine, consists of seven vertebrae with an intervertebral disc in-between each pair of vertebrae.

Who needs a posterior cervical (neck) spine surgery?

• When the problem causing symptoms is located in the posterior aspect of the spine;
• when the compression on the spinal cord is from the posterior aspect;
• when the cervical spine is excessively mobile and unstable; or
• in association with an anterior procedure to provide additional stability or to achieve additional decompression.

The compression can be on the nerves going to the arms or on the spinal cord. Compression of the nerves in the neck can cause pain radiating down the arm and forearm with numbness, pins and needles, and muscular weakness in the affected limb. When the compression is on the spinal cord (myelopathy), it can cause difficulty in walking, clumsiness of the hands and problems with passing urine. The presence and severity of these symptoms vary from person to person. Pain in the neck could arise from numerous structures. Degeneration of the intervertebral disc and arthritis of the facet joints are the common causes of neck pain.

Who needs surgery?

Surgery is reserved for those with:

• No relief of pain with the non-operative forms of treatment;
• Increasing numbness and weakness in the arms and hands;
• Or the presence of myelopathy indicates the need for early surgery.

After assessing your symptoms, examining your spine, and studying your x-rays and scans, the surgeon will decide whether you need a posterior spinal decompression, a spinal fusion or a combination of both.

About the surgery

• Anaesthesia: The surgery is usually performed under general anaesthesia, with the patient lying on the tummy. Occasionally, a frame is attached to the skull after anaesthesia, to maintain the position of the head during surgery.
• Procedure: The surgeon makes a 5-15cm incision in the skin on the back of the neck. The spine is exposed by retracting the muscles. Depending on the plan, a decompression, a fusion or a combination of both is performed. A decompression is performed by removing one or more bony laminae and any other structure overlying the spinal cord. A fusion is performed by inserting screws into the bones over the back of the spine and connecting the screws with rods. Occasionally, a combination of a decompression and a fusion is performed. At the end of the surgery a drain tube is inserted to remove the blood that collects at the surgical site.
• Skin sutures: Dissolvable sutures are used to close the skin. These will dissolve as your wound heals, however, the ends 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).

After the surgery

• In the recovery room: 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. A neck collar will be provided to prevent excessive neck movements and to keep you comfortable. When the medical staff in the recovery room is confident that you are comfortable, you will be transferred to your room.
• In the ward: You will be allowed to drink sips of fluids after surgery and gradually progress to a full diet. 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 to support your spine. You will stay in the hospital for 1-3 days and your surgeon will decide when you can go home safely.

Are there any risks involved in disc surgery?

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. Surgical complications can include bleeding, infection, spinal fluid leak, injury to the veins and arteries near the spine or injury to the nerve tissue of the spine 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 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.

Talk to your surgeon

This is a brief overview and does not contain all the known facts about your condition and the surgery. Feel free to seek any clarifications from your surgeon and his or her team. It is important for you to obtain a clear understanding of your condition, the surgery and the potential risks and benefits before you sign the consent form.

What is the cause of a spinal deformity?

Scoliosis (abnormal sideward bending of the spine) and kyphosis (abnormal forward bending of the spine) can result from numerous causes. In a majority of adolescents, the exact cause is unknown (idiopathic) and in others it can be caused by congenital vertebral anomalies or as a manifestation of some other disease (eg neurofibromatosis, paralytic disorders etc). In adults, spinal deformity can be due to degenerative conditions, previous spinal surgery or even childhood deformities that have persisted. Some of these deformities can progress and need treatment.

When is surgery indicated for a spinal deformity?

In adolescents and children, surgery is indicated when curve progressive occurs or is anticipated, or to correct a cosmetic deformity that is unacceptable to the patient. In adults, pain relief and improving function may be additional considerations.

What are the surgical options for the correction of spinal deformities?

There are a number of alternatives in spine deformity surgery:

• An anterior procedure (from the front through the chest wall or abdomen) removes discs and corrects the deformity and maintains the correction with rods and screws inserted into your vertebral bones.
• Posterior surgery (from the back) can also be performed using rods, screws and hooks to correct the deformity and fuse the spine.
• Occasionally, a combination of an anterior and posterior procedure is needed, which can be done in one or more stages. Bone may be taken from your pelvis to assist in the spinal fusion. Your surgeon will discuss these options with you and decide which option is best suited in each case. Your surgeon and clinical co-ordinator will explain the surgical procedure to you in detail with the help of models and diagrams. Do not hesitate to clarify all your doubts prior to surgery so that you have a better understanding of and realistic expectations for the surgical procedure. Since there are many surgical options for the correction of spinal deformities, the precise surgical procedures will not be detailed here.

After surgery

• In the recovery room: Following surgery, you will usually be transferred to the Intensive Care Unit (ICU) 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. You may have a drainage tube from your surgical site or from you chest to help prevent the collection of blood in these areas. You may remain in the ICU for 24-48 hours and will be transferred to your room in the ward when the surgical team is satisfied with your progress.
• In the ward: You will be allowed to drink sips of fluids after surgery and gradually progress to a full diet. The drainage tube, urinary catheter and pain pump will be removed in 24-48 hours and you will be encouraged to walk around. You will stay in the hospital for 5-7 days and your surgeon will decide when you can go home depending on your wound healing, ambulation and pain status.
• Pain relief: Medications will be provided to reduce your pain after surgery and for the first 2 to 3 weeks at home. However, if you have excessive pain while you are in the hospital, the attending nurses should be informed.

Are there any risks involved in disc surgery?

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. The surgical complications include bleeding, infection, spinal fluid leak, injury to the veins and arteries near the spine, or injury to the nerve tissue or its surrounding protective layer.

Injury to the nerves may occur during surgery, resulting in paralysis of certain muscles in the legs and loss of sensations. Loss of bowel and bladder control can also occur following nerve injury. An injury to the covering layers of the nerves (dura) can result in leakage of spinal fluid and may occasionally require a repeat surgery to control the leak.

Although antibiotics are given before and after surgery, there is a 1-5% incidence of wound infection. Superficial 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, although we do not routinely use medications. However, if you have had an episode of DVT in the past, let your surgeon know.

The insertion of the screws can potentially cause nerve injury, resulting in weakness and abnormal sensations in the legs. Great care is taken to ensure the accurate placement of the screws, including the use of intra-operative fluoroscopy (x-rays). Correction of the deformity can also cause stretching of the nerves and spinal cord and may result in nerve injuries.

Another potential risk is that the fusion may not become solid, resulting in non-union, or pseudarthrosis. This may require a repeat surgery after a few months to supplement the bone graft to obtain a solid bony fusion.

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.

Talk to your surgeon

This is a brief overview and does not include all the known facts about your condition and the surgery. Feel free to seek any clarifications from your surgeon and his or her team. It is important for you to obtain a clear understanding of the surgery and potential risks and benefits before you sign the consent form.

Anatomy of the spine.

The spine consists of 33 small bones called vertebrae stacked one above the other with a soft intervertebral disc between each pair of vertebrae. The intervertebral disc consists of a soft jelly-like substance called the nucleus pulposus in the center, which is surrounded by multiple layers of collagen called the annulus fibrosis (like an onion). The disc connects and allows movement between vertebrae and acts as a shock absorber of the spine. The vertebrae surround and protect the spinal cord and nerve roots.

What does posterior spinal decompression mean?

Compression on the nerve roots exiting from the spinal canal can cause leg pain. A posterior spinal decompression includes either a partial (laminotomy) or complete (laminectomy) removal of the lamina along with the removal of the ligaments and new bone (osteophytes) that are compressing the nerve roots. The lamina is the bony portion of the vertebra that lies behind the spinal cord.

Spinal decompression is performed to relieve the compression on the nerves. The surgery is effective for the relief of the leg pain; however, weakness, numbness and pins and needles in the legs (if present) may take a few months to resolve and occasionally may not resolve completely, depending on the duration of symptoms.

What does spinal fusion mean?

Wear and tear (degeneration) of the spine can cause a loss of normal spinal alignment, excessive movement between vertebrae and arthritis of the spinal joints, all of which can cause low back pain. This can be treated by spinal fusion, where bone graft substitutes (VITOSS and OP-1) are placed around the vertebrae to form new bone connecting adjacent vertebrae so that they behave and move as one block.

The fusion is supplemented with rods (or plates) and screws to provide immediate stability. The screws are made of either titanium or stainless steel and are well tolerated by the body.

Which surgery will you need?

After assessing your symptoms, examining your spine and studying your x-rays and scans, the surgeon will decide whether you need a posterior spinal decompression, a spinal fusion or a combination of both.

About the surgery

• Anaesthesia: The surgery is usually performed under general anaesthesia, with the patient lying face down.
• Procedure: The surgeon makes a 5-10 cm incision in the skin over the affected area of the spine. The muscle is detached from the bone to expose the laminae, which are the portion of the bony vertebrae that lies behind the spinal cord. A portion of the lamina is removed (laminotomy) along with the surrounding ligaments to expose the compressed nerve roots. Occasionally, the whole lamina (laminectomy) is removed. The ligaments, intervertebral disc and new bone (osteophytes) that are pressing on the nerve roots are removed. This procedure is called a spinal decompression. Next, the surgeon may decide to fuse your spine using screws connected with rods or plates. A bone graft substitute (VITOSS and OP-1) is placed across the joints and bone at the back of the vertebrae to allow new bone to form (over 3-6 months) between the two adjacent vertebrae so that they now start behaving as one block. A drain tube removes the blood that collects at the surgical site. Skin sutures: Dissolvable sutures are used to close the skin. These will dissolve as your wound heals, however, the ends 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).

After surgery

• In the recovery room: 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: You will be allowed to drink sips of fluids after surgery and gradually progress to a full diet. 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 to support your spine. You will stay in the hospital for 1-3 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.

Are there any risks associated with this surgery?

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. Surgical complications can include bleeding, infection, spinal fluid leak, injury to the veins and arteries near the spine or injury to the nerve tissue or its surrounding protective layer.

Injury to the nerves may occur during surgery, resulting in paralysis of certain muscles in the legs and loss of sensations. Loss of bowel and bladder control can also occur following nerve injury. An injury to the covering layers of the nerves (dura) can result in leakage of spinal fluid and may occasionally require a repeat surgery to control the leak.

Although antibiotics are given before and after surgery, there is a 1-5% incidence of wound infection. Superficial 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.

The insertion of the screws can potentially cause nerve injury resulting in weakness and abnormal sensations in the legs. Great care is taken to ensure the accurate placement of the screws including the use of intra-operative fluoroscopy (x-rays).

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.

Talk to your surgeon

This a brief overview and does not contain all the known facts about your condition and the surgery. Feel free to seek any clarifications from your surgeon and his or her team. It is important for you to obtain a clear understanding of your condition, the surgery, the potential risks and benefits before you sign the consent form.

Disease Overview

The lower back or lumbar region is often the site of pain due to its high mobility and weight-bearing. Spongy discs present between the vertebral bones of the spine help cushion the spine during stress and movement. These intervertebral discs in the lumbar region may undergo damage due to stress, causing them to herniate or rupture, and compress adjacent spinal nerves. This can lead to lower back pain, as well as pain, weakness, and numbness in the lower legs. 

What is Lumbar Discectomy?

A lumbar discectomy is a surgical procedure performed to treat a herniated or ruptured disc and relieve pressure on the spinal nerves.

Lumbar Discectomy Procedure

To perform lumbar discectomy, your doctor makes a small incision in your lower back over the affected spinal disc. Some vertebral bone and ligament may need to be removed to expose the disc. A microscope is used to visualize the disc and the adjacent spinal nerves. The spinal nerves are protected, and the affected disc is completely removed. The surgical site is then irrigated with antibiotic solution and closed.

Postoperative Care following Lumbar Discectomy

Following surgery, activities such as bending, lifting and sitting for prolonged periods should be avoided for four weeks. Your doctor will advise you about the exercises that will improve the strength and flexibility of the lower back. You may be able to return to work in 2-6 weeks depending on the level of activity involved.

Risks and Complications of Lumbar Discectomy

Lumbar discectomy, as with any invasive surgery may be associated with certain complications such as include nerve and spinal cord injury, infection and ongoing pain.