Lateral Lumbar Interbody Fusion (LLIF or XLIF)
NOTE: PLEASE DO NOT TAKE ANY NON-STEROIDAL ANTI-INFLAMMATORY DRUGS (NSAIDs like Advil, Aleve, Ibuprofen, Motrin, Naprosyn, Mobic, etc) OR ASPIRIN PRODUCTS FOR 2 WEEKS BEFORE SURGERY. These medications can increase bleeding during surgery. If you absolutely need to be on these medications until the date of surgery, check with your surgeon.
Your Spine Problem:
There may be two separate problems in your spine. First is spinal stenosis, a condition in which the spinal nerve roots or spinal cord is compressed by degenerated (“worn out”) portions of the spine. Bone spurs, disc degeneration/herniations, and soft tissue hypertrophy (overgrowth) may all contribute to spinal stenosis and arises from arthritis (“wear and tear” or “degeneration”) of the spine. The compression of the nerve roots can cause symptoms such as pain, numbness,
tingling or weakness of the buttocks and legs. These symptoms are called radiculopathy, myelopathy, or neurogenic claudication, depending on the location of compression within the spinal canal. These areas of nerve compression need to be decompressed to allow maximal recovery of nerve function to improve ambulatory function, strength and balance and to relieve pain, numbness, and tingling. The second problem may be instability of one vertebra on another and further spinal degeneration, which can result in spinal deformity. This instability can make the spinal stenosis with nerve
compression worse and/or cause back pain and progression of deformity. These areas may need to be fused to allow for restoration of alignment, correction of spinal deformity and resolution of back pain. This is all done to improve a patient’s quality of life.
Your surgery - general considerations:
The surgery is designed to address all of the problems present. Not every patient has the same problems – the surgery is tailored to your particular problems.
If you have spinal stenosis, the surgeon will remove the portions of the lumbar spine (typically bone spurs and/or disc herniation) that are causing the compression of the nerves. This is called a “decompression” and in your particular case can be done in a minimally invasive fashion. The entire spine is not removed, only the areas compressing the damaged nerve roots are removed. The decompression helps to free up space for the nerve roots so that they are no longer “pinched.” If you have instability, a fusion may be performed. This is done using metal screws and rods to connect the problem vertebrae. The disc at the affected level will also be removed to help take pressure off the nerves, improved fusion success, restore the alignment of the diseased spinal segments, and correct the deformity to restore normal body alignment. The disc is then replaced with an implant and bone graft. Using the implants and the bone graft, a proper environment is created so that the problem segments will fuse together and heal into one bone. The entire spine is not fused! Only those segments causing the problem are fused. It can take up to one year for the fusion to completely heal. During that time, you may progressively increase your activities under our surgeon’s guidance. However, you should always be careful to ensure that the fusion heals properly. You will be given information on what you can and can’t do after surgery.
Your minimally invasive surgery (MIS) specific to you: XLIF or LLIF
Fortunately because of your particular pathology and anatomy you are amenable to surgical treatment in a minimally invasive fashion. Through the use of specialized surgical instrumentation and implants, intraoperative microscope, as well as advanced intraoperative imaging techniques, your surgery can be performed through small “windows” using tubes for retractors as opposed to traditional spine surgery requiring large extensive surgical incisions for visualization. This allows for minimal tissue and muscle disruption, with faster recovery and less blood loss and less post-operative pain. We no longer need to strip off muscle and create extensive scar tissue surrounding the spinal nerves with a traditional large incision which involved substantially more bleeding, higher risks of spinal fluid leaking, higher infection rates, and more muscle pain with muscle scaring. Rather with a MIS approach, rehabilitation and mobilization are much quicker after surgery, recovery time and return to work is expedited, hospital stay is shortened, there is less intra-operative blood loss and less post-operative pain. In your particular case, a small incision will be made on your side to provide working windows. Through this working window, a tubular retractors will be utilized to remove disc material from a collapsed and degenerated disc. This allows for placement of a much larger implant and bone graft material to indirectly decompress the spinal nerves by distracting and restoring normal disc height and restoring a more normal alignment when abnormal to begin with. A plate and screws through the same incision or placement of screws and rods through two separate small incisions on the back will be done percutaneously, guided by real time navigation using intraoperative fluoroscopy as well as
intraoperative neurological monitoring to safely monitor nerve function during the surgery. This technique allows for maximal surface area for robust fusion mass. Furthermore, it is an excellent surgical approach to indirectly decompress nerves in patients with leg pain from sciatica or difficulty walking from neurogenic claudication from nerve compression within the central spinal canal or foramen. It is also a great technique to correct spinal deformity; including scoliosis, kyphosis, and spondylolisthesis to more anatomically realign the spine.
Bone graft:
A bone graft is necessary to perform the fusion. Most cases local bone graft will be used in combination with a synthetic graft material or banked allograft bone material. A number of factors influence whether your own bone, banked allograft bone, synthetic bone graft substitute or some combination is appropriate for you. In some cases Bone Morphogenic Protein (BMP) will be used to supplement and encourage bone growth for a robust fusion mass. Based on these factors, you and your surgeon will discuss and decide together the type of bone graft to be used for your surgery.
Incision:
Usually, one incision will be made o n y o u r s i d e a n d two small incisions on either side of the back will be made to access your spine. The size of the incision depends on many factors including the number of levels requiring decompression and your body weight. There will generally not be any stitches to remove.
There may be a small plastic drain that comes out of your skin near the wound, depending on the type of surgery you have. Its purpose is to keep blood clots from pooling in the wound. Usually, your surgeon’s team will remove the drain on day two to three after surgery.
Your Hospital Stay:
After surgery, you will be taken to the anesthesia recovery room. When you are awake after anesthesia, usually about 1-3 hours later, you will then go to your hospital suite. In most cases, your family may be able to see you once you have suf ficiently awakened from anesthesia in the recovery room, as well as once you arrive in your suite.
Diet:
Initially, you will not have much of an appetite, however, you will be allowed to eat regular food whenever you feel up to it. Don’t force yourself to eat. Eat only as much as you are comfortable with. It is common for your GI tract t o not function normally immediately after surgery due to anesthesia, narcotics, and physical inactivity but generally resolves within a few days. On the other hand, getting off IV pain medications as soon as it is reasonable, staying well hydrated, and walking as much as possible will help w i t h G I m o t i l i t y .
Physical Therapy:
You will participate in physical therapy as early as the day of surgery while in the hospital. This is
extremely important to your overall recovery from surgery for a number of reasons. Getting out of bed is
good for your lungs; it prevents blood clots from forming in your legs, and speeds your recovery.
However, until your surgeon says otherwise, the only physical therapy you should do initially when discharged home is walking. No strengthening or stretching of the lower back is necessary. These may
actually be harmful unless prescribed to you later at an appropriate time by your surgeon. Some people will need to use a walker during their initial recovery period, others may not.
Pain Medications:
You will be given a PCA pump for pain control after surgery. The PCA is a machine that allows you to push a button to receive pain medication (usually morphine) when you feel pain. You can push the button as often as you wish, however, the machine limits the amount of medication you get every hour. Use the machine to make yourself feel comfortable. However, because using the PCA for long periods of time can have side effects, it is best to switch to oral pain medicine as soon as possible. Your surgeon will do this for you in the hospital at the appropriate time (usually the day after surgery). Oral pain pills are advantageous in that they provide a more constant level of pain control than does a PCA pump
Going home:
Your length of stay in the hospital depends on many factors, including your general medical condition and the severity of your spine problem. Most patients who have a one-level decompression and fusion can go home in one to three days. If more levels need surgery or if you have had a previous spine surgery, your hospital stay may be longer.
You can go home when: 1) you are taking oral pain pills; AND 2) you can eat and drink enough to sustain yourself (don’t worry -- most people will not feel like eating and drinking too much after surgery, and that is ok); AND 3) you are able to get out of bed and walk around. The physical therapist will help in determining when you are safe to go home. Having a bowel movement is not necessary before going home.
On occasion, some patients may need to go to a rehabilitation facility first before going home, depending on how large of a surgery you have and what your particular support system is at home. If rehabilitation is recommended, you will build up your strength in a more supervised setting until ready to go home.
What to do when you get home:
WHAT TO DO AFTER YOU GET HOME
LUMBAR OR THORACIC FUSION & DECOMPRESSION
POST-OPERATIVE INSTRUCTIONS
Wound Care:
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Keep your incision clean and dry.
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There are no stitches to remove, unless you have been told otherwise. All of the
stitches are “inside.”
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If the wound is dry, no further dressings are needed and the incision can be left
open to air. If there is some drainage, the wound can be covered with a clean
dressing as needed.
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You may shower when the wound has been clean and dry for 24 hours. However,
do not soak the wound in a bathtub or pool. Gently clean your wound – do not scrub
it vigorously until it is completed healed.
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If you have them, let the Steri-strips (the tape on your incision) fall off by
themselves. If some are still there by the end of two weeks, you may peel them off.
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Do NOT put any ointments or antibacterial solutions over the incision or
Steri-strips.
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If you notice any drainage, redness, swelling, or increased pain at the incision, call
the office.
Activities:
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Walking is the best activity. Walk as much as you like. It is good for you and will
help you recover more quickly.
!
AVOID the BLTs: Bending, Lifting, and Twisting of your lower back. However,
you may exercise your arms and legs with light weights (5-10 pounds) if desired as
soon as you feel like it -- as long as those activities do not cause you to perform
BLTs on your lower back.
!
Do not try to do too much too early (e.g. heavy housework such as making beds,
laundry, vacuuming). Use your common sense. Again, walking is the best activity,
and we encourage you to walk.
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If you have been given physical therapy visits at home, these are for safety and help
Medications:
!
PLEASE DO NOT TAKE ANY NON-STEROIDAL
ANTI-INFLAMMATORY DRUGS (NSAIDs like Advil, Aleve, Naprosyn,
Ibuprofen, Motrin, Mobic, etc) FOR 3 MONTHS AFTER SURGERY. These
medications can adversely affect fusion. If you absolutely need to be on these
medications sooner, please check with your surgeon first.
!
If you were on a baby aspirin prior to surgery, you may generally resume
that after surgery.
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If you were on a blood thinner (like Coumadin/ Lovenox/ Heparin products/ or
Plavix), check with your surgeon as to when that may be resumed after
surgery.
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You may have been given prescriptions for several different pain medications, or
your surgeon may have provided you with one type of pain medication. Take the
narcotics for moderate to severe pain. Try to take the appropriate medication for the
level of pain you are having. Take the pain medicine only when you need to.
!
Pain medications are helpful around the time of surgery, but they can cause problems
if taken for too long. The goal is to try to get you off of the medications by 4-6
weeks or earlier, if possible. Some people may need medications for longer than 4-6
weeks, and that’s ok. But try to wean yourself off of them if you can.
!
If you find that your pain is really mild, try taking plain extra strength
Tylenol instead.
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The pain medicines may tend to make you somewhat constipated. You should
drink plenty of water and drink prune juice if needed. You may take Colace to
keep your bowels regular. Feel free to take any over the counter laxatives if you
need to.
Diet:
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Eat whatever you like. You may not feel like eating too much for a few days, and
that’s ok. Foods high in fiber (fruits, vegetables) are good in that they can help
reduce constipation.
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Drink plenty of fluids.
Follow up:
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If you have not already been given a postop follow up appointment, call the office
within the first few days after you get home. Tell the office staff that you had surgery
and need a two-week follow up appointment.
Questions:
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Feel free to call the office with any questions.
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If you are having an urgent concern, call the office immediately. During business
hours, you will be connected to your surgeon’s medical assistant, who reports urgent
concerns to your surgeon. After business hours, you will be connected to the surgeon
on call who can help you. If it is an emergency, call 911 or go to the ER for
