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Anterior lumbar interbody fusion (ALIF)

Procedure Description

An anterior lumbar interbody fusion (ALIF) is performed to fuse two vertebral bodies together.  It is often done to improve low back pain.  Titanium alloy cages are generally used, and may be packed with the patient's own bone, or bone bank bone may be used.  The patient is taken to the operating room, and the surgeon may first harvest bone from the hip from the back or the front.  Next, the approach is made for the lumbar interbody fusion.  This is done from the front, through the abdomen.  The approach exposes the lumbar spine, and the aorta and vena cava or iliac veins and femoral arteries  are mobilized to provide access to the spine.  There is a plexus of nerves in front of the spine, which control sexual function in the male.  Once the spine is exposed, the surgeon will implant the cages, packed with bone, into the disc space, with the edges of the cage cutting into the bone of the vertebral bodies above and below.  C- arm fluoroscopy (real time x-ray) is used to help assist the surgeon in placement of the cages.  The surgeon may clean out the disc space, prior to placing the cages.  After this is completed, closure will be performed.  The patient is then taken to the recovery room.  The surgeon may elect to leave the ALIF as a stand alone procedure, or may supplement it with a posterior fusion (from the back). 

Procedure Risks

Anterior lumbar interbody fusion (ALIF)  is a frequently performed procedure.   Risks of the procedure can be broken down into two categories, 1) those related to the operative site, and 2) those related to the risks of anesthesia.

Risks related to the operative site: 

Surgical Exposure:  The patient is placed in a supine position (on their back).    In this position, despite great care, there can be pressure sores to the skin and pressure injuries to nerves.  Several large blood vessels are exposed and these may be injured.  If so, there may be significant blood loss.  In  men, injury to nerves located near the front of the spine may result in retrograde ejaculation.  If this is a concern, and the patient desires to still have children, he may choose to first donate to a sperm bank.  In addition, there is risk of damage to the ureters, which pass urine from the kidneys to the bladder.  The patient may experience pain in the hip where the bone graft was taken from.

Spinal Cord/Nerve Root injuries: If there is any injury to the spinal cord (in the upper lumbar area)  or nerve roots, the consequences may involve loss of sensation, increased burning sensation, paralysis, weakness, loss of bowel, bladder, sexual function.  There is a risk of disc material being pushed in the spinal canal, requiring surgery from the back, to decompress the nerves in the spine.  It is possible that due to the anatomy, only one cage (instead of the typical two) may be placed.  If there is significant scarring (possibly from previous abdominal surgery), or if the major blood vessels cannot be sufficiently moved, the surgeon may not be able to place the cages, and the intended levels may be left unfused.  There is also the possibility that the fusion may not heal and the two vertebral bodies surrounding the cage may remain unfused.  Surgery on the back of the spine may be necessary, either to decompress a nerve, or to fuse with bone graft and instrumentation.  There is a possibility that the cage may slip out toward the abdomen or spinal nerves.  The vertebral bodies may slip on each other. 

Fusion Risks:  When the hardware (instruments placed to hold the spine together) is placed, nerve roots or the spinal cord can be injured.  In addition, the bone may not properly fuse.  The propensity for non-fusion and continued pain is higher in smokers.  Cessation of smoking improves the chances of a successful fusion.  There can be pain and the standard risks of bleeding and infection associated with the site on the body from which the bone for grafting is taken (often the hip).  IIf bone bank bone is used for grafting, there is an extremely small chance of infection and HIV.  In addition, hardware can break and pull out from the spine.

General Risks:  These include  general difficulties, such as bleeding, infection, stroke, paralysis, coma and death.  Incisions on the abdomen and hip generally heal well, but there may be tenderness, or the wound may heal in an unpleasant manner.  There is also the possibility that the surgery may not relieve the symptoms for which the procedure was performed.  The problem for which the surgery was performed may recur, requiring additional surgery in the future.  In addition, although every attempt is made to protect all areas of the body from pressure on nerves, skin and bones, injuries to these areas can occur, particularly with prolonged cases.

Risks of Anesthesia: Blood clots in the legs, heart attacks, reaction to the anesthetic, reaction to blood transfusion, if it given.

Post-operative care:

There shall be no bending, twisting, or heavy lifting for several weeks after surgery.  Physical therapy may or may not be implicated.  Your doctor will gradually ease your work restrictions, depending on your progress.  You will likely be required to wear a lumbar brace or corset for three months after surgery.

Remember to keep the wound dry and clean.  Notify your surgeon of any drainage or temperatures greater than 101 Fahrenheit.

The goal of this surgery was to fuse the vertebral bodies in your  back.   We expect you to eventually do normal activities better because of the surgery.  Some continuuing back and leg pain is not unusual during the first few days and weeks following surgery.  Hurt does not necessarily mean harm.  You may experience numbness in the foot or leg, but this does not impair function.  The following is a list of suggestions that should help speed your recovery and give you every possible chance for the best results from your surgery.

  1. Immediately upon discharge, contact our office and set up an appointment for staple removal if one has not already been set up.
  2. Take it easy until seen by the physician.  This does not mean bed rest, but athletic activities during this period are definitely not recommended.  Please give your incision a chance to heal.  Avoid bending.
  3. Wear your lumbar brace or corset as prescribed by your surgeon.
  4. Lift nothing heavier than a half gallon of milk until seen by your doctor.
  5. Avoid sitting for periods of time longer than 45 minutes.  It is OK to sit in a lounge chair which is laid back, for as long as you wish.
  6. No jogging or running.
  7. After you get home, you may begin walking up to one mile per day.
  8. You may walk up or down steps as often as you like.  Please take them smoothly and slowly.
  9. No driving until OK with your physician.  Do not ride further than  50 miles at a time.  This applies during the first month after surgery.
  10. You may shower after you go home unless otherwise instructed.  Cover the incision with plastic wrap before the shower and remove it afterward.  Change dressing immediately.  Tub baths are not advisable.  You may shower without covering the incision one week after the staples are out.  Follow instructions concerning care of tapestrips, stitches or staples.  Your surgeon or his nurse clinician will explain the techniques used in the closure of your incision.
  11. Sexual activities are permitted.
  12. If you notice swelling, redness or opening of the incision, or if there is any clear fluid draining from it, please contact your surgeon immediately!  If you develop a fever, stiff neck or chills, contact the office immediately.  Take your temperature at 4:00 PM daily until the clips are removed.  Call if greater than 101 degrees Fahrenheit.
  13. If you have any questions, call our office, and for after hours emergencies, call the after hours number.
  14. Take your medications prescribed on discharge, as directed.
  15. It takes 6 - 12 months for a fusion to heal.  Be patient.
  16. Please avoid smoking, as it decreases likelihood of a successful fusion.

 

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