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PEDICULAR SCREW FIXATION / FUSION SURGERIES

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Spinal fusion is a surgical procedure used to correct problems with the small bones of the spine (vertebrae). It is essentially a "welding" process. The basic idea is to fuse together the painful vertebrae so that they heal into a single, solid bone.

Spine surgery is usually recommended only when your doctor can pinpoint the source of your pain. To do this, your doctor may use imaging tests, such as x-rays, computed tomography (CT), and magnetic resonance imaging (MRI) scans.

Spinal fusion may relieve symptoms of many back conditions, including:

  • Degenerative disk disease
  • Spondylolisthesis
  • Spinal stenosis
  • Scoliosis
  • Fracture
  • Infection
  • Tumor

Description

Spinal fusion eliminates motion between vertebrae. It also prevents the stretching of nerves and surrounding ligaments and muscles. It is an option when motion is the source of pain, such as movement that occurs in a part of the spine that is arthritic. The theory is if the painful vertebrae do not move, they should not hurt.

If you have leg pain in addition to back pain, your surgeon may also perform a decompression (laminectomy). This procedure involves removing bone and diseased tissues that can put pressure on spinal nerves.

Fusion will take away some spinal flexibility, but most spinal fusions involve only small segments of the spine and do not limit motion very much.

Procedure

Lumbar spinal fusion has been performed for decades. There are several different techniques that may be used to fuse the spine. There are also different "approaches" your surgeon can take for your procedure.

Your surgeon may approach your spine from the front. This is an anterior approach and requires an incision in the lower abdomen.

A posterior approach is done from your back. Or your surgeon may approach your spine from the side, called a lateral approach.

Minimally invasive techniques have also been developed. These allow fusions to be performed with smaller incisions.

The right procedure for you will depend on the nature and location of your disease.

Bone Grfting

All spinal fusions use some type of bone material, called a bone graft, to help promote the fusion. Generally, small pieces of bone are placed into the space between the vertebrae to be fused.

A bone graft is primarily used to stimulate bone healing. It increases bone production and helps the vertebrae heal together into a solid bone. Sometimes larger, solid pieces are used to provide immediate structural support to the vertebrae.

In the past, a bone graft harvested from the patient's hip was the only option for fusing the vertebrae. This type of graft is called an autograft. Harvesting a bone graft requires an additional incision during the operation. It lengthens surgery and can cause increased pain after the operation.

Most autografts are harvested from the iliac crest of the hip.

One alternative to harvesting a bone graft is an allograft, which is cadaver bone. An allograft is typically acquired through a bone bank.

Today, several artificial bone graft materials have also been developed.

Demineralized bone matrices (DBMs).

Calcium is removed from cadaver bone to create DBMs. Without the mineral, the bone can be changed into a putty or gel-like consistency. DBMs are usually combined with other grafts, and may contain proteins that help in bone healing.

Bone morphogenetic proteins (BMPs).

These very powerful synthetic bone-forming proteins promote a solid fusion. They are approved by the U.S. Food and Drug Administration for use in the spine in certain situations. Autografts may not be needed when BMPs are used.

Ceramics.

Synthetic calcium/phosphate materials are similar in shape and consistency to autograft bone. Your surgeon will discuss with you the type of bone graft material that will work best for your condition and procedure.

Immobilization

After bone grafting, the vertebrae need to be held together to help the fusion progress. Your surgeon may suggest that you wear a brace.

In many cases, surgeons will use plates, screws, and rods to help hold the spine still. This is called internal fixation, and may increase the rate of successful healing. With the added stability from internal fixation, most patients are able to move earlier after surgery.

Complications

As with any operation, there are potential risks associated with spinal fusions. It is important to discuss all of these risks with your surgeon before your procedure.

Infection.

Antibiotics are regularly given to the patient before, during, and often after surgery to lessen the risk of infections.

Bleeding. A certain amount of bleeding is expected, but this is not typically significant.

Pain at graft site. A small percentage of patients will experience persistent pain at the bone graft site.

Recurring symptoms. Some patients may experience a recurrence of their original symptoms.

Pseudarthrosis. Patients who smoke are more likely to develop a pseudarthrosis. This is a condition where there is not enough bone formation. If this occurs, a second surgery may needed in order to obtain a solid fusion.

Nerve damage. It is possible that the nerves or blood vessels may be injured during these operations. These complications are very rare.

Blood clots. Another uncommon complication is the formation of blood clots in the legs. These pose significant danger if they break off and travel to the lungs.

  • Soon after the surgery, the physiotherapist will see you in the room.
  • Exercises are started to improve your body circulation, circulation of the operated part.
  • This helps to reduce the swelling, lung complication and prepares you to start your movements and early ambulation.
  • A) Physiotherapist will guide you to perform simple lower limbs exercises in bed.
    • Calf pump exercises.
    • Straight leg raising.
    • Taking your leg sideways.
    • Bending your knees.
    • Back press exercises in bed.
    • Tummy tuck exercises in bed
    • B) Nursing staff and physiotherapist will help you to turn on either sides with pillows kept in between the legs and avoid twisting movements at back.
      C) Ice Packs / cryotherapy  around the site of reduce pain.
      D)    Deep Breathing exercises in Bed.
      These exercises should be done in set of 5, twice in a day along with application of iace packs twice-thrice / day.

      Day  1

      A)    Same set of exercises are continued. B)    Buttock lifting exercise. C)    Turning to either sides with helps of pillows is reviewed and eased. D)    Prop-up upto 600 of the bed is permitted today during meal sessions for about 10 minutes each time. E)    Ice packs / cryotheraphy continued.

      Day  2

      A)    Same set of exercise is continued.

      B)    Turning to either sides is reviewed.

      C)    If your drain tubes are out, you would be made to sit upright with helps of lumbar brace.

      If there are no complications, you would be allowed sit upright with help of lumbar brace for two meal sessions for about 10-15 minutes each time.

      D)    Ice packs / cryotheraphy continued in accordance with pain.

      Day  3

      A)    Same set of exercise is continued.

      B)    You would be made to walk today with abistance of walker with lumbar brace once or twice a day.

      C)    You would now be allowed to sit up right for all meal sessions for about 10-15 minutes with lumbar brace.

      D)    Ice packs / cryotheraphy continued.

      Day  4/5

      A)    Same set of exercise is continued.

      B)    Independent sitting for about 20 minutes advices.

      C)    Independent walking and increase in walking distance in encouraged. You may be advised to walk at least three-four times a day in hospital corridor.

      D)    Toilet –Training on commode with lumbar brace.

      E)    Stair case climbing with lumbar brace is given.

      F)    Ice packs / cryotheraphy is in accordance with your pain.

      DISCHARGE  : Usually after 5 post-operative Day

      A) Discharge is planned after

      ·         You are able to get out of bed unaided.

      ·         You are able to walk to the toilet.

      ·         You are able to sit and get up comfortably on your own with lumbar brace.

      ·         You do not have any other complaints.

      B) On discharge, you are allowed to ride in a regular car but make sure it is easy to get in and out of it. It goes without saying that you are not be allowed to drive your own vehicle home.

      At home upto 2 weeks post-surgery

      A) Home modifications :-

      Put things that you think you will need close to where you can get them without stressing your back i.e. without bending forwarded.

      B) Exercises :-

      ·         You will be spending half of your time resting is bed and other half up and around.

      ·         Same set of exercises as told to you during your discharge should be continued in set of 10, twice-thrice / day  till 2 weeks post-surgery.

      Do’s and Dont’s *****until 2 weeks post-surgery

      Do’s

      a)    you are allowed to sit upright with lumbar brace for about 20-30 minutes according to your comfort level.

      b)    Change your position from sitting after every 30 minutes.

      c)     You are allowed to stand for sessions of about 30 minutes with lumbar brace.

      d)    Walking should be carried out 4-5 / day.

      e)    Slowly increase the frequency and distance of walking.

      f)     Sleep either on your back or either sides with pillows for support.

      g)    You are recommended to sue shower while bathing. You can remove the brace when in shower. Use Rubbermaid chair while bathing.

      h)    Use of commode is must.

      Don’t’s

      a)    Avoid forward bending in sitting for about 6 weeks.

      b)    Avoid crossed legged sitting for 6 weeks.

      c)     Twisting movements at back are to be avoided while getting in and out of the bed.

      d)    Lifting of heavy weights more than 10 pounds by bending forwarded is avoided.

      e)    Avoid sleeping on stomach for 4-6 weeks.

      f)      Complete  No to Indian toilet.

      2  – 4 weeks post surgery

      As week program, you can gradually increase your amount of activities but your restrictions do not change at this point.

      Exercises :

      Set of exercises is modified to progressive exercises programme here

      a)    Stretching of tight strucheres and strengthening of back and limb muscles is started.

      b)    Abdominal strengthening   exercises       - upper

      - lower

      c)     Unilateral buttock lifting with one leg straight raising.

      d)    Knee to chest position exercises.

      e)    Sitting and waling should be progressed as per comfort level.

      f)     As a guide, you likely to be off work for about 4-6 weeks.

      g)    Driving can be initiated by end of 4 weeks for shorter distance only. Long journeys should be avoided. If at all unavoidable, should be done with pillows to support your back and change in position frequently.

      4-6 weeks post spinal fusion surgery

      Activities :

      ·         You will now begin to increase your level of activities at home.

      ·         But at any event exercise motion at lumbar spine and pelvis is to be avoided.

       

      Exercises :- Vigorous and male dynamic exercise protocol

      ·     Abdominal exercises       1.  Upper     2.  lower

      ·     Stretching of tight strucheres

      Till 2 weeks post-operative surgery

      I) Home modifications :-

      Put things that you think you will need close to where you can get them without stressing your back i.e. without bending forwarded.

      II) Activities :-

      As the time progresses, you can gradually increase your amount of activities at home are to your comfort level, forward bending and lifting heavy weights being only the restrictions.

      III) Exercises :-

      Continue the same set of exercises told you during the discharge in set of 10, twice a day.

      IV) Sitting, standing, walking can be done for more than 30-40 minutes according to your comfort level at least 4-5 times a day.

      V)  While bathing, shower is recommended. You can remove the brace when in shower room.Sit  on a chair while in shower. Use of commode is recommended. Complete No to Indian toilet.

      VI) Sexual activities can be resumed back by end of 2 weeks according to comfort level.

      2  weeks – 4 weeks post surgery

      I.             Activities

      Increase in activities at home all to comfort level.

      Lifting of weights upto 20 pounds  permitted.

      Side bending, rotations, multi-directional activities as tolerated.

      II.            Exercises : Vigorous physical therapy exercises regimen started.

      a)    Dynamic upper and lower abdominal extension exercises.

      b)    Knee to chest position exercises.

      c)     Stretching of tight strucheres.

      d)    Dynamic back exercises.

      e)    Cat-Camel exercises.

      f)     Core stabilization exercises.

      g)    Dynamic exercises on ball.

      h)    Can start with gym protocol.

      III.       Return to your work

      IV.           Jobs requiring prolonged sitting or sedentary job can be resumed.

      V.            Avoid sitting for prolonged hours at a stretch. Get up & walk around to change your position.

      VI.           Heavier work can also be resumed with modifications in work place and working style .

      VII.         Sitting, walking should be increased in respect of strengthening the muscles. Treadmill, stationary, bicycle can be used. Swimming can be resumed.

      VIII.       Sports can be resumed by end of 6 weeks.

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