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Physical therapists and occupational thera‐ pists work with patients and instruct them on proper techniques of get‐ ting in and out of bed and walking independently. Patients are instructed to avoid bending at the waist, lifting (more than five pounds), and twisting in the early postoperative Figure 7. Use by breathing‐in deeply and measuring the period (first 2‐4 weeks) to volume of air your lungs can hold. Repeat this slowly, 10 avoid muscle strain injury. times every hour. Patients can gradually begin to bend, twist, and lift after 4‐6 weeks as the pain subsides and the back muscles get stronger. Dissolving stitches, sutures or staples are commonly used to close incisions. Surgical dressings that cover the incision may be removed prior to discharge from the hospi‐ tal. Some incisions are held closed with Steri‐Strips. These are small adhesive strips that are made to peel and fall on their own as the incision site heals. Normal wound care during the post‐operative period requires keeping the incisions dry. You usually are able to shower, but should avoid “soaking the wound” such as in baths, or swimming until you are seen by your physician at the follow up appoint‐ ment. Your first follow‐up appointment is usually within 2 weeks. Eat healthy foods, especially those high in protein unless indicated otherwise.
hospital or 2‐5 days depending on their condition. Once released from the hospital, patients who have undergone surgery may be given a prescription for pain medica‐ tions to be taken as needed, as well as a detailed post‐operative activity, physical therapy/exercise plan to help ease recovery and return to a healthy life. Patients can generally resume normal activity in about 6‐8 weeks after surgery, but this should be discussed with your physician. If you require outpatient physical ther‐ apy, you will probably need to attend therapy sessions for 2‐4 weeks. You should expect full recovery to take up to 3 months.
Colen Surgical Medi‐Card
What is an Anterior Lumbar Interbody Fusion (ALIF)?
Anterior Lumbar Interbody Fusion is a surgical procedure in which two or more verte‐ brae are joined or fused together. During this procedure the disc in between two vertebral bodies is removed and a bone graft or interbody spacer is inserted in its place. The goal of the procedure is to stimulate the vertebrae to grow together into one solid bone (known as fusion), (Figures 1 and 2).
Figure 1: Lumbar bony structures. The disc (labeled A) is removed and replaced with a spacer in between both vertebral bodies. This synthetic spacer is known as an interbody biomechanical device (labeled B).
______________________________________________________________________ I have read and understood the content presented in this brochure. All my questions regarding this surgical procedure have been answered satisfactorily. ______________________________________________________________________ PATIENT’S SIGNATURE DATE Disclaimer: The content presented in this brochure may vary slightly from the actual surgical procedure.
What are the possible complications?*
• Infection (post‐op infection is rare but may become a serious complication if left
untreated) • Bleeding
Figure 2: Interbody biomechanical spacer. Many types of biomechanical spacers are available on the market; this is an exam‐ ple of one that your physician may use.
• • • • • •
Complications from anesthesia (the anesthesiologist will discuss this with you) Continued pain Fusion may not occur (higher incidence of non‐fusion in patients who smoke) Hardware (i.e. screws, plates or cages) may break or come loose Numbness Nerve damage‐ surgery that is done near the spinal canal can potentially cause injury to the spinal cord or spinal nerves
Colen Publishing, L.L.C.
Authors: Chaim B. Colen, M.D., PhD. Roxanne E. Colen, PA‐C Illustrators: Chaim B. Colen, M.D., PhD. William Van de Putte Faculty Reviewer: Setti S. Rengachary, M.D. Editorial Formatting: Kathryn Schwartz Chelsea M. Smialek Katharine Van de Putte
There are 2 types of bony grafts that may be used in this procedure, one is an auto‐ graft (bone is taken from the patient’s own pelvic bone) or an allograft (bone ob‐ tained from another donor). Once the appropriate graft is chosen, it is packed be‐ tween the two vertebrae in order to “fuse” them together, providing increased spinal stability. This bone graft, or the biomechanical spacer implant, will take the place of the intervertebral disc, which is entirely removed in the process.
• Weakness • Thrombophlebitis (a condition in which the blood in the large veins of the leg
forms blood clots)
What are the indications? When is it used?
Spinal fusion surgery such as ALIF is most commonly indicated for patients suffering with chronic lower back and/or leg pain. Causative factors include degenerative disc disease and deformities in the curve of the spine causing spinal instability. Pain NOT relieved with conservative therapies (e.g. physical therapy, pain medication) may require surgery. Fusion surgery is done to stabilize and strengthen the spine as well as alleviate severe, chronic back pain. In cases where there is not a lot of instability, an anterior fusion (ALIF) alone can be sufficient.
*This is not intended to be a complete list of all possible complications.
Infinite possibilities to learning….
What is the recovery period?
Recovery time is different for every patient, however, most patients are up and walk‐ ing by the end of the first day after surgery. Most patients can expect to stay in the
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Generally, this is true in cases of one level degenerative disc disease where there is sin‐ gle disc space collapse (Figure 2). If, however, x‐ray films (prior to surgery) of the lumbar spine indicate abnormal movement of the spine suggesting instability (e.g. isthmic spondylolisthesis), an anterior approach to spine fusion may be accompanied with a pos‐ terior (from the back) fusion to provide addi‐ tional support to the fused level of the spine. The following is a synopsis of lumbar and sacral spinal nerve roots, along with their sensory and motor patterns (Figure 3):
(gastrocnemius, soleus muscles). Numbness, tingling or pain can radiate to the side and the sole of the foot. * This is not meant to be a comprehensive list of all the muscles and innervations.
What are the benefits?
Anterior Lumbar Interbody Fusion (ALIF) is done to stabilize and strengthen the spine and may alleviate the symptoms of severe, chronic back pain.
How will I prepare for surgery?
The decision to proceed with surgery must be made jointly by you and your sur‐ geon. You should understand as much about the procedure as possible. If you have concerns or questions, you should talk to your surgeon before undergoing the operation. Once you decide on surgery, most surgeons will have you undergo a complete physical examination by your regular doctor. This exam helps evaluate whether you are physically fit to tolerate the upcoming operation. Before surgery you should avoid using antiplatelet agents (such as aspirin, Plavix) or blood thinners (such as coumadin, heparin) since these can increase bleeding during the operation. Smoking is frowned upon since it retards wound healing and should be stopped at least 2 weeks prior to the operation. On the day of your surgery, you will probably be admitted to the hospital early in the morning. You shouldn't eat or drink anything after midnight the night before your surgery. If you take any medications, discuss this fact with your doctor.
• Discs: L1‐L2; L2‐L3; L3‐L4
Figure 2: Lumbar spine x‐ray depicting degenerative disc disease at L5‐S1.
The wound is usually irri‐ A gated with sterile water containing antibiotics. The deep fascial layer and sub‐ B cutaneous layers are closed with a few strong sutures. The skin can usu‐ ally be closed using special surgical glue, leaving a minimal scar and requiring no bandage. The total surgery time is Figure 4: Typical location of the incision on the abdo‐ approximately 2 to 3 hours, depending on the number of spinal levels in‐ volved.
• Nerve roots: L1, L2, L3 ‐ Asso‐
ciated with weakness of hip flexion (iliopsoas muscle) and knee extension (quadriceps muscles – also L4). May cause numbness, tingling or pain in the front and the outside of the thigh.
What happens after sur‐ gery?
After surgery you are likely to experience pain at the incision site (incisional pain) that may be managed through the ad‐ ministration of oral analgesics or narcotics. Walk as early as possible after your surgery. This can help to prevent blood clots from forming in your legs and pneumonia by helping your lungs expand. Usually you will be given a small breathing de‐ Figure 5: Retraction and protection of the vascular structures in preparation for the insertion of the vice called an “incentive spi‐ interbody spacer. rometer” (Figure 7) which you can use to expand your lungs while in bed. Over time, normal healing pro‐ gresses and the pain subsides. Incisional pain accompanied by swelling, redness, discharge, numbness or flu‐like symptoms (e.g. fever/chills) should be reported to your physician im‐ mediately. Most patients are usually able to go home 3‐4 days after sur‐ gery. Patients will typically stay Figure 6: Construct in place. longer, approximately 4‐7 days, if a posterior spinal surgery is also performed. Before food and liquids are resumed after surgery, your doctor typically waits until you pass flatus (gas) or have a bowel movement. These are
What happens during surgery?
Patients are given a general anesthesia to put them to sleep during the surgery. A breathing tube (endotracheal tube) is placed and the patient breathes with the assistance of a ventilator. A ventilator is a device that controls and monitors the flow of air into the lungs. Preoperative intravenous antibiotics are given. Patients are positioned in the supine (lying on the back) position, generally using a special, radiolucent operating table. The surgical region (abdominal area) is cleansed with a special cleaning solution. Sterile drapes are placed, and the surgical team wears sterile surgical attire such as gowns and gloves to maintain a bacteria‐free environ‐ ment. A 3‐8 centimeter incision either transverse (A) or oblique (B) is made just to the left of the umbilicus (belly button), (Figure 4), this however is dependant on the num‐ ber of spinal levels to be fused. The abdominal muscles are gently spread apart, but are not cut. The peritoneal sac (containing the intestines) is retracted (moved to the side) to the side, as are the large blood vessels. Special retractors are used to allow the surgeon to visual‐ ize the anterior (front part) aspect of the intervertebral discs (Figure 5). After the retractor is in place, an x‐ray is used to confirm that the appropriate spinal level(s) is identified. The intervertebral disc is then removed using special biting and grasping instru‐ ments (rongeurs and curettes). Special distractor instruments are used to restore the normal height of the disc, as well as determine the appropriate sized spacer to be placed. A bone spacer (metal or plastic may also be used) is then carefully placed into the disc space. Fluoroscopic x‐rays are taken to confirm that the spacer is in the correct position. Titanium or stainless steel screws and rods may be inserted into the back of the spine to supplement the stability of the entire construct (Figure 6).
• Disc: L4‐L5 • Nerve root: L4 ‐ Associated
with weakness of knee exten‐ sion (quadriceps muscles). Numbness, tingling or pain can radiate to the kneecap and the inner side of the leg. The L4‐L5 disc is a common level for a lumbar disc herniation to oc‐ cur.
• Disc: L5‐S1 • Nerve root: L5 ‐ Associated
with weakness of knee flexion and upward flexion of the foot and toe (hamstrings, tibialis Figure 3: Pain from nerve roots has a anterior, extensor hallucis typical radiating pattern, known as a longus and extensor digitorum dermatome pattern.* longus muscles). Numbness, tingling or pain can radiate to the top and the outside of the foot. L5‐S1 is one of the most common levels for a lumbar disc herniation to occur. • Disc: S1‐S2 (typically part of the sacrum)
• Nerve root: S1 ‐ Associated with weakness of downward flexion of the foot
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