In some instances, a minimally invasive procedure can be performed. Minimally invasive PLIF involves making several small incisions in the skin to place the pedicle screws percutaneously. This is done with the assistance of intraoperative navigation or Stealth. The interbody cages are normally placed through one side (as a TLIF). The procedure relies on indirect decompression of the nerve roots. This may work well in some patients but in other patients an open procedure may be more appropriate for their condition. The aim of performing the surgery using this technique is to reduce the operative trauma to the spinal muscles, thereby reducing blood loss and post-operative pain and speeding recovery.
The hospital stay is normally around 4-7 days in total, but varies depending on the patient and their underlying condition.
After discharge, it is advisable to rest for 2 weeks which should consist of normal daily activities. One should maintain a good posture as advised by the physiotherapists, for example, you should not slouch in a chair. You should not spend too long in any one position.
Once you feel more confident then activities such as driving can resume. Normally one can drive after 2 weeks from the date of surgery. But most of all you need to feel confident.
A return to work depends on the work environment. Those with sedentary jobs can usually begin to go back to work after 4-6 weeks. Those with more manual jobs should wait at least 6-8 weeks but it should be discussed with Prof Owler prior to surgery and again at the follow-up appointment.
We will make an appointment to see Prof Owler 6 weeks from the date of surgery or thereabouts. At that visit any concerns can be discussed and the wound will be checked. If there are any significant problems, then you should contact his office earlier. At that time a follow-up CT scan is arranged.
A second follow-up appointment is normally scheduled for 3 months. Prof Owler will review the post-op CT scan and inform the patient of the result.
Further follow-up may be arranged to ensure that you are progressing well and answer any questions.
All surgical procedures have risk. There are risks common to all surgeries such as infection, bleeding, deep vein thrombosis (DVT), pulmonary embolism and those associated with a general anaesthetic.
In relation to PLIF surgery, most infections that occur are superficial and easily treated with antibiotics. However, very occasionally, a deep-seated infection can occur and this may require removal of the pedicle screws and may result in further surgery and chronic pain. Pre-existing diabetes increases the risk of this complication.
Bleeding can be significant with PLIF surgery. In most patients, the operation is at one level only and the risk of requiring a blood transfusion is low (<5%). However, when two or more levels are involved, the risk of requiring a blood transfusion will increase.
The spinal cord is normally well clear of the site of the surgery. In the lower lumbar spine, the spinal cord has changed into a group of nerve roots called the cauda equina. While patients commonly worry about complications such as paraplegia and incontinence, such problems are very rare. More common is the chance of injuring one nerve root at the site of the surgery and the risk of this is approximately 1% and may result in numbness or weakness of the leg which may be permanent.
Persistent or recurrent pain in the leg can occur for several reasons. Some patients will experience leg pain because of changes that occur in the nerve itself after it has been compressed severely or for an extended period, i.e., neuropathic pain. Some patients will develop scar tissue around the nerve.
In relation to the fusion itself, there is a risk of the bones not healing together as one, i.e., non-union / failure of fusion. The risk of this is small and most patients will not have symptoms but it may result in back pain and revision surgery.
There is a risk of adjacent segment disease. As the spine is fused at the level(s) of the pathology, more stress is placed across the levels above and below the level of the fusion. This may accelerate changes at those levels and cause similar problems, sometimes requiring surgery.
During the procedure, a small tear may occur in the covering of the nerves (dura). This dural tear will result in leakage of spinal fluid. Therefore, when it occurs it is repaired with sutures. The tear happens because the spinal canal can be very tight and because adhesions may develop between the degenerative structures and the dura. If this occurs, it is repaired at the time. The patients are normally asked to stay flat in bed for 24 hours after surgery and the drain will be kept in for a longer period. In most cases, there are no other consequences and the recovery proceeds as normal. However, in some patients the leak will continue and this may necessitate a return to the operating theatre to re-suture or repair the leak.
This is not an exhaustive list of potential complications but this information provides an overview of the more common complications that patients may be exposed to.
There are numerous other very rare complications that may also occur including those associated with a general anaesthetic such as reactions to medication.
The outcome of surgery is dependent on the indication for surgery and often the severity and duration of symptoms prior to surgery. No guarantees can be given in relation to the surgery.
Pain is the most common symptom of radiculopathy and, in most cases, is the first symptom to improve; often immediately after the surgery. Pins and needles may take longer but tend to improve quickly. Numbness takes the longest period to recover, perhaps even over 12 months and some patients may not experience full recovery of numbness. Weakness has variable recovery depending on severity and duration before surgery. Some patients will experience recovery immediately while others may have persistent weakness despite the surgery. Normally physiotherapy is required to treat weakness.
Overall, about 90% of patients will experience significant improvement in pre-operative symptoms while a further 10% will not improve as much as is hoped and 1-2% percentage will be worse off in relation pain or some other problem. Neurogenic claudication normally responds well to surgery. Over 90% of patients are expected to improve significantly with surgery. With successful surgery, they can normally begin to increase their fitness and increase the distances that they can walk and the time that they can stand for. Back pain associated with spondylolisthesis normally also improves. About 80% of patients will experience significant improvement in their back pain allowing them to reduce their analgesic requirements and resume their normal activities.
When a PLIF is performed for mechanical back pain, the expectations are different. We would expect that 70% of patients will experience a significant improvement in their pain such that they can reduce their analgesics and begin to return to their previous activities. However, this will vary depending on the nature of the underlying problem, as well as the duration of symptoms prior to surgery.
As mentioned earlier, there are several points that are emphasised to patients undergoing spinal fusion surgery for back pain. These are that the aim of surgery is to reduce the pain to a level where the patient can function more effectively, but that the surgery will not cure their pain; that the surgery is not a stand-alone treatment, that it is expected that the patient will need extensive spinal physiotherapy and treatment to recondition the muscles and other regions of the spine; and that as previously mentioned, the rate of success is significantly lower with surgery for this indication than for others.
The main reason for on-going care of the spine after fusion surgery is to avoid injuring the levels adjacent to the site of a fusion. However, it also helps reduce the chance of long term lumbar spinal pain. Prof Owler’s philosophy is to attempt to return the patient to a normal active life rather than place onerous restrictions on the patient. However, there are two aspects of spinal care that are important to patient’s that have undergone surgery.
The first, and somewhat obvious, advice is to avoid activities that may reinjure the spine. In the simplest form this includes not lifting heavy or awkward objects. As a general rule, no-one should generally be lifting weights above 20Kg. In the short term the lifting restrictions are much less (see above). When lifting, good technique should be used such as keeping the knees bent and back straight while keeping the object being lifted close to the body. People should avoid simultaneous lifting and twisting. Those who are golf enthusiasts should wait 3 months after surgery before resuming golf.
The second aspect to long term care is maintaining spinal fitness. This includes weight loss, core strengthening and on-going exercise. The best exercises are those which are non-impact such as swimming and cycling. All patients are normally taught core-strengthening exercises. These should be continued independently by the patient at home indefinitely.
