To understand spine surgery, you should be familiar with the structure of the spine. The spine consists of 33 bones called vertebrae that provide body structure and protect the spinal cord. Linking the vertebrae are intervertebral discs and facet joints that absorb shock and allow for movement and flexibility. As people age, the discs between vertebrae lose water, decreasing the ability of the discs to cushion the spine. This process is called disc degeneration and can reduce the space through which nerves exit, called the intervertebral foramen.
A bulging disc in spine occurs when one of discs between vertebrae develops a weak area which causes painful pressure on the spinal canal.
Pressure causes the outer rings of the disc to rupture and the soft nucleus to squeeze through. This compresses and irritates the spinal nerve root.
Aging, worn vertebrae and discs allow bone spurs to form. This causes or worsens narrowing of the spinal canal (stenosis), and irritates the nearby nerve, producing pain.
As a disc degenerates and flattens, vertebrae slip back and forth. This irritates the spinal joints and creates or worsens stenosis, irritating the nerve.
Spinal Stenosis is a condition that arises due to narrowing in and around the spinal canal, thus resulting in nerve pinching, which leads to persistent pain in the buttocks, limping, lack of feeling in the lower extremities, and decreased physical activity. There are several different types of spinal stenosis which can effect all regions of the spine (cervical, thoracic, and lumbar spine).
Scoliosis is a condition of the spine in which the spine curves to varying degrees in an "S" shape, either to the right or left side. There are three types of scoliosis: Idiopathic (of unknown origin); Congenital (in which the bones are asymmetrical at birth); or Neuromuscular (in which the scoliosis is due to a symptomatic condition, such as cerebral palsy, muscular dystrophy, or paralysis).
A discectomy is the surgical removal of disc material which has herniated, causing pressure on the nerve root or spinal cord. Your surgeon will remove the central portion of the disc, called the nucleus pulposis, thereby releasing the stress on the nerve.
A laminectomy is the removal of a portion of the lamina (the boney roof of the spine). This allows more room for the nerves of the spine and reduces the irritation and inflammation of the spinal nerves. The lamina does not grow back. Instead, scar tissue grows over the bone, replacing the lamina protecting the spinal nerves.
A laminotomy is decompression of only one side of the spinal canal (left or right). In this procedure, a small portion of the laminar roof over the spinal canal is removed, leaving the majority of the lamina intact.
A microsurgical laminoplasty is the decompression of the spinal canal using microsurgical techniques.
For people whose spines are not stable, the surgeon places bone graft between two or more vertebrae in order to promote the bone to grow or fuse together. The bone used for bone graft is usually taken from the bones of your own body (pelvis) at the time of surgery. This bone graft acts as the cement that fuses the vertebrae together. Occasionally rods, screws, or plates are used in addition to bone graft.
The anterior (or frontal) approach provides excellent access to the spine and enables your surgeon to restore a collapsed disc space. An incision is made in the left or right flank region of the abdomen and a portion of the disc space is removed and replaced with an implant. This can sometimes be combined with a Posterior Fusion (from the back) which would be used if a more rigid stabilization of the spine is required.
Surgery on the cervical spine may be performed to either decompress or relieve the pressure on the spinal cord or to help stabilize the cervical spine. There might be a need for a fusion to add stability to the cervical spine. Cervical fusion may be approached from the front of the neck (anterior) or the back of the neck (posterior). Bone graft may or may not be used to help stabilize the graft site. The bone graft may be allograft (donor bone) autograft (your own bone) or bone graft substitute.
.1. Before your spine surgery, the surgeon’s office staff will make an appointment for you with a medical physician at HSS who will:
2. Unless you are told otherwise, continue to take medicines already prescribed by your own physician.
3. The surgeon’s office staff will also make an appointment for you for pre-surgical testing approximately 7 to 14 days prior to surgery where:
You should bring a list of current medications and a detailed account of prior medical, surgical, and family health history. The nursing staff will request information as part of a comprehensive medical history to add to your patient database profile and will provide instruction on preparation for surgery.
4. The surgeon’s office staff will make an appointment for you to attend the pre-operative patient education class. The class is approximately 60 to 90 minutes long. During the class, patient educators will:
5. During your class you will instructed in muscle strengthening and clot prevention exercises. You should start these exercises one week prior to surgery.
6. You may be asked to donate your blood for the surgery. If a donation is recommended, the surgeon’s office staff will provide information and schedule one for you, usually 1 to 2 weeks prior to date of surgery.
7. You may wish to review and plan your post-hospital care with Case Management Services (212.606.1271) before admission. The Pre-Admission Program offers patients and their families the opportunity to receive assistance before the patient is admitted for surgery. This program enables you to begin understanding and planning your hospitalization and your discharge needs in a timely, comprehensive manner. It helps you maximize your options and make decisions in a more relaxed way.
8. Prepare for your return home from the hospital.
9. Before your admission, please complete the Health Care Proxy form authorizing another person, designated by you, to make decisions with your physician about your care, should this become necessary.
10. A nurse from the Same Day Surgical (SDS) unit will contact you one business day prior to your surgical date, between the hours of 1pm and 7pm (Friday for Monday surgical cases) with more detailed instructions.
11. The night before your surgery and two hours after your dinner, administer your Fleet enema (per your doctor’s direction).
12. The surgical area should be washed with the antiseptic soap solution at the end of your last bath or shower before surgery. The solution should be rinsed and removed after application. Specific instructions will be provided through the pre-surgical screening appointment, the pre-operative education class, and pre-operative phone call.
13. The SDS nurse will review when you should stop eating and drinking, but realize that it is likely that only clear fluids (no milk products) after midnight (i.e., water, ginger ale, black coffee or tea) will be allowed on the day of your surgery and nothing should be consumed three hours prior to your surgical time. A detailed pre-operative nutritional guideline is described in this booklet and will be reviewed during the pre-operative education class.
14. For patients who have Sleep Apnea and use a Sleep Apnea device, please bring your mask attachment and a record of the settings you normally use. Please DO NOT bring the Sleep Apnea machine. Patients with Sleep Apnea are generally required to stay overnight in the Post-Anesthesia Care Unit (PACU) to be monitored and observed.
15. The use of nicotine products (i.e., cigarettes, cigars, gums, or patches) has been shown to increase risk of complications following surgery. They can inhibit bone and wound healing by decreasing blood flow to the surgical site. They can also increase the risk of deep vein thrombosis (DVT, a.k.a. blood clots). Please discuss smoking cessation with your doctor. You will be provided with a pamphlet in the class and you can also find it online at: http://www.hss.edu/conditions_smoking-cessation-for-healing.asp
16. You and your family will be instructed to go to the Family Atrium on the 4th Floor of the hospital.
17. If you wish to have a private nurse during your hospital stay, the hospital can arrange this service for you. Please call 212.774.7187.
Be sure you understand all pre-operative instructions. If you have questions or concerns, please discuss them with your surgeon or call the HSS Patient Education team at 212.606.1263.
Nutrition is an important part of your overall health, and is even more important at this time. Your nutritional status, in part, determines your ability to recover and heal properly from surgery.
In order to maximize nutritional status, a variety of foods should be eaten daily and in accordance with USDA Guidelines (see choosemyplate.gov). A nutritionally balanced diet consists of whole grains, fresh fruits and vegetables, lean meats, and dairy products on a daily basis.
There will be some level of pain following all orthopedic and spine surgeries. The Anesthesia Department works closely with patients and uses a multidisciplinary approach to aggressively manage post operative pain. This includes a variety of different pain medications and physical therapy.
With the exception of some of the less extensive spine surgeries, your orthopedic spine surgeon will request the consult of our Department’s Acute Pain Service (APS). The APS is a specialized team consisting of an anesthesiologist, a nurse trained in pain management, and a pharmacist. A combination of different pain treatments are incorporated, depending on the type of discomfort you experience as well as the side effects to which you may be sensitive.
Pain management begins with you. Since no objective tests exist to measure what you are feeling, you must help the staff by describing the pain, pinpointing its location, and judging its intensity, as well as reporting any changes. Pain may be constant or sporadic, as well as sharp, burning, tingling, or aching. A pain scale is used to help you and the staff gauge the level of pain and effectiveness of treatment.
People used to think that severe pain after surgery was something they “just had to put up with.” While it is reasonable to expect some discomfort following surgery, the current treatment options greatly reduce the level of pain most patients have.
Your description will help us provide you with a plan of care. Even under your personal Pain Management Program, your pain level may change at times. Be sure to tell your nurse if it becomes worse.
It is extremely important to perform deep breathing exercises after surgery to rid your airway and lung passages of mucus. Normally, you take deep breaths almost every hour, usually without being aware of it, whenever you sigh or yawn. When you are in pain or are drowsy from anesthesia or pain medication, your breathing may be shallow. To ensure that you take deep breaths daily, the nursing staff will provide you with a device called an incentive spirometer, along with instructions on its use.
Gentle exercises to improve your range of motion can help prevent circulation problems as well as strengthen your muscles. Very soon after surgery, a physical therapist will teach and review your exercise program, as outlined in the “Mobility Throughout Your Hospital Stay” section of this book.
Your rehabilitation program will begin once you are medically stable and there are orders from your doctor to begin post-operative mobility. This is based on the type of spinal surgery you have had. You might be getting out of bed a few hours following surgery. For some patients, rehabilitation will begin the day of surgery, for others it will start the day after surgery. Everyone will begin rehabilitation within 24 hours of surgery or per your surgeon’s plan.
It is critical to understand that motivation and participation in your physical therapy program is a vital element in the success of your surgery and your overall recovery. It is imperative that you play an active role in your recovery and rehabilitation from the start!
Walking is the #1 exercise following any spinal surgery. Your therapist will assist you in sitting up with your feet over the bedside (we call it dangling). You will then stand with the use of a walker and the continued help of your therapist. As the days progress, you will increase the distance and frequency of walking. Most patients progress to a straight cane within a few days after surgery.Before leaving the hospital, you will be instructed in a home exercise program. Remember, you make the difference! Your participation in a physical therapy program is essential to the success of your surgery. The more committed and enthusiastic you are, the quicker your improvement will be.
Precautions are in effect during your recovery period, which is approximately six weeks. Maintain your precautions until they are discontinued by your surgeon.
1. Do listen to your body while performing functional movements or activities. Gradually increase your activity level, being sure to also rest as needed during the day. Know what your limits are.
2. Do walk and gradually progress the distance and frequency as tolerated.
3. Do wear your brace if prescribed by your surgeon.
4. Do sit in a sturdy chair with arms in order to ensure good posture.
1. Do not lift heavy objects. Be sure object weighs less than five lbs (e.g. one gallon of milk).
2. Do not force any extremes of motion, especially with bending, twisting, or rotating.
3. Do not sit for for more than 30-45 minutes at a time.
4. Do not spend a prolonged time in any position during the day. Change positions frequently to avoid discomfort and strain on your back.
5. Do not sit in low, soft chairs or recliners.
Please do not hesitate to contact your surgeon with any questions you have about the following instructions. Consult with your internist about duration and dosage of iron (ferrous sulfate) after your discharge.
1. A clean, dry dressing can be applied over the incision until your staples, sutures, or steri-strips are removed. The surgical wound may be open to air, unless a brace is ordered. A light gauze dressing with paper tape may be placed over the wound to protect it.
2. After suture or staple removal, leave the incision uncovered unless instructed otherwise.
3. Please inform your surgeon if you notice increasing redness or drainage from your incision.
1. Take your pain medication as prescribed.
2. To control pain, take your pain medication before the pain becomes severe.
3. If your pain medication seems weak or you are experiencing unpleasant side effects, do not hesitate to call your surgeon’s office.
4. If you are taking pain medication, avoid alcoholic beverages.
5. It is important to notify your surgeon’s office if you require additional pain medications. It will take a few days to mail you a new prescription, so call the surgeon’s office before your supply runs too low. Call when you have one week’s supply, to be safe.
If you experience discomfort during your ongoing physical therapy, take your pain medication at least 45 minutes prior to your subsequent therapy sessions. This will allow enough time for the medication to take effect.
1. Walking is the main exercise when you leave the Hospital; monitor the walking distance and gradually progress distance and frequency as tolerated.
2. Use long-handled devices if you need to, in order to avoid excessive strain on your body.
3. A referral will be made for a home physical therapist on an as-needed basis.
4. At your follow-up visit, your surgeon will determine if you need to have outpatient physical therapy. This can be provided at HSS, if you can arrange transportation to our physical therapy center on 70th Street. If this is not convenient, we can make a referral for outpatient physical therapy at a physical therapy center in your community. To obtain services at these facilities, you will need a prescription from your surgeon, and in most cases, authorization from your insurance provider.
A raised toilet is recommended for ease of getting on and off the toilet and to ensure you’re comfortable.
You are allowed to shower once your surgeon has cleared you to do so. Please follow the instructions provided by your surgeon’s team in order to protect your incision. Your physical therapist will be able to provide you with instructions and tips on showering according to your bathroom set-up.
Rubber-soled shoes that can be slipped on are recommended because you will be unable to bend over to tie your shoes after surgery. Elastic laces are available for sneakers so that they can be more easily slipped on.
The use of adaptive equipment for dressing may make you feel more comfortable and will allow you to maintain your precautions.
Swelling is common after spine surgery. The more swelling you have, the more pain you may have, and the more difficult it may be to move. Therefore, it is important to minimize the harmful effects of swelling to enhance your recovery. To reduce swelling, apply cold therapy to the surgical site for the first two weeks for 20 minute intervals. After two weeks, ice for 20 minute intervals before and after walks, when soreness or pain is present, or after exercise. If you advance your activity too quickly or overdo it, your neck or back may become more swollen.
This guidebook is a comprehensive, essential overview of everything having to do with spine surgery at HSS, from an overview of the procedure and hospital maps to nutrition tips and illustrated physical therapy exercises. Please note: patients and their partners may have concerns about sexual activity after spine surgery. This information and more is available in the downloadable PDF below. For more detailed information not covered here, please download the PDF.