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Posterior lumbar decompressive laminectomy with posterolateral fusion

Procedure description

A posterior lumbar decompressive laminectomy with a fusion is performed to decompress  nerve roots, and attempt to relieve lower extremity pain, while allowing the bones of the spine to fuse.  During the operation, the patient is put to sleep by the anesthesiologist, and is then gently turned to the prone (face and abdomen down) position, using cushions and gel rolls to protect and cushion the body.  The lower back is cleaned in a sterile manner, and the surgeon then makes a vertical (up and down).  The surgeon will dissect down to the spinous processes (bones protruding back from the spine) and then push the muscle away from the lamina ( the roof of the spinal  canal).  Often, an x ray will be taken at this point to confirm that the appropriate level is being operated upon.  The surgeon will then dissect the muscle off of the transverse processes (bones sticking out to the side of the spine) as these will be needed for the fusion later on in the operation.  Next, the surgeon will remove  the lamina in order to allow access to the spinal canal and nerve roots.  This is often done under magnification, usually using the microscope.  The surgeon will identify the nerves, and attempt to remove sufficient bone and ligament in order to adequately decompress them.  If there is also offending disc material compressing the nerves, the surgeon may remove that as well.  Sometimes quite a bit of the facet (joint holding the various vertebral levels together) needs to be removed to allow adequate decompression of the nerves.   After completing the decompression,  your surgeon  will begin the fusion portion of the operation.  Bone may be taken from the hip, or the bone from the back of the spine may be used.  Other types of bone growth stimulating substances may be used to supplement the bone.  Next, the cortex (outer surface of the bone) is removed from the transverse processes as well as the facets of the spine.  This allows a fresh "raw" surface of the spine to come into contact with the harvested bone, which is carefully laid over the transverse processes.  The goal is that over the next year, a "fusion mass" will develop, effectively fusing the spine at the intended levels.  Once completed, the retractors are removed and the muscle falls back into place. The muscle  is approximated with suture, and the deep fascia (firm fibrous tissue of the low back) is sewn closed, as is the subcutaneous tissue (tissue deep beneath the skin) and skin.  A drain may be left in to evacuate blood from the wound over the following 1-2 days.  The wound is dressed with a sterile dressing, and the patient is returned to the recovery room.

 

Procedure Risks

Posterior  lumbar  decompressive laminectomy with fusion is a frequently performed procedure.  Even though the risks of complications are relatively low, there are risks.  These 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 prone position (on their abdomen).      In this position, there can be pressure sores, pressure injuries to nerves, and injury to the eyes as a result of pressure to them.  During surgical dissection, injury to muscle surrounding the spine can occur.

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 may be a spinal fluid leak, which could occur after a tear of the covering of the spinal cord or nerve roots.  If this did occur, it may be necessary to have the patient flat in bed for several days after the surgery.  Even if everything goes as well as hoped, there is a risk of instability of the spine and disc herniation in the future,  requiring additional surgery on the lumbar spine.  The bone may potentially not fuse, and if so, slippage of the spine and additional pain may occur.
Smoking decreases the likelihood of a successful fusion.

General Risks:  These include such general difficulties, such as bleeding, infection, stroke, paralysis, coma and death.  Incisions on the low back generally heal well, but if could   be tender, or 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.  Bone can bleed quite a bit, and if sufficient amounts of blood are lost during the surgery, a transfusion may be performed.

 

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 relieve the pressure on the nerves in your back and reduce your leg pain.  We expect you to 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 in greater than 101 degrees Fahrenheit.
  13. If you have any questions, call our office, and for after hours emergencies, call the medical society.
  14. Take your medications prescribed on discharge, as directed.
  15. It takes 6 - 18 months for a nerve to heal.  During that time you may experience numbness, tingling, fleeting pain, or creepy/crawly sensations.
  16. NO SMOKING.

 

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