Neurosurgery - Spinal fixation surgery (single level) - Physio advice

Introduction

This advice leaflet will describe some of the basic ways you can manage your back post operatively.

The spine is made up of 33 small bones, called vertebra, stacked on top of each other in an ‘S’ shape. Not all spines are the same ‘S’ shape, but they are usually curved at the neck and lowest part of the back.

This shape should be kept in mind when you move to maintain the natural curves in your back whatever you are doing. Each of the vertebrae has a disc in between them which acts like a shock absorber (see diagram on page 4).

Spinal nerves pass between each vertebra next to the disc and travel to the arms and legs.

These nerves allow us to move our muscles and feel things in different parts of our body. The muscles in the back support the vertebrae and the discs.

The lumbar region of the spine bears the most weight of the body. It is capable of bending and twisting more than any other part. This can lead to excess wear and tear and is therefore more prone to degeneration.

What is a disc?

Discs are tough yet flexible and allow the spine to bend and twist.

Discs have a central part filled with a rubbery substance called the nucleus.

The outside wall is called the annulus which is made from tough and flexible fibres.

What has happened to my disc and spine?

Disc degeneration

Disc degeneration is due to the aging process. Cracks can occur in the annulus and the nucleus dehydrates.

Continuous mechanical strain on the disc causes fragments of degenerate disc material to be pushed through the crack, creating a hole in the annulus. This is sometimes referred to as a prolapsed disc.

Stenosis

Spinal stenosis is when the spinal canal, through which the spinal cord runs, is too narrow and the spinal cord/nerves become compressed in the narrowed space. This can be due to congenital narrowing or degenerative changes. This causes the spinal nerves in the back to be irritated or trapped.

This can also be due to extra bony growths (osteophytes) pressing on nerves.

Spondylolisthesis

This is a forward slip of one of the bones of the spinal column on another. This can occur due to a developmental condition, degeneration changes or trauma.

It can cause narrowing of the spinal canal in which the spinal cord runs and as a result can put pressure on the nerves.

The aims of the operation are:

1. Improve the alignment of your spine by correcting any deformity - e.g. a forward or sideways slip of the vertebra
2. Free any trapped nerves
3. Remove the pain source - the degenerate and inflamed disc
4. Fuse the disc- by packing the space between the vertebra with a cage containing graft. This encourages new bone growth which will eventually fuse the vertebra together

What happens during surgery?

Spinal fusion is a surgical technique to stabilise the vertebra and the disc between the vertebrae.

Fusion surgery is designed to create solid bone between the adjoining vertebrae thus eliminating any movement between the bones. Metal implants are attached to the spine and then connected to rods.

The metalwork is used to hold the spine in the correct position until the spinal segments fuse together.

Bone grafts are placed along the length of the corrected spine. The bone graft does not form a fusion at the time of the surgery. Instead, the bone graft provides the foundation and environment to allow the body to grow new bone and fuse a section of the spine together.

Drains will be inserted during surgery to drain any excess blood that may collect following the operation. Drains will be removed 24-48 hours post operatively.

At the time of the fusion surgery and for the first six months after surgery, the metalwork provides the stability for the section of the spine that was operated on. Over the long term a solid fusion of bone that has healed will provide the stability.

Possible complications:

• No improvement in your back or leg pain (or worse pain)
• Infection - signs of infection may be discharge from the wound or any swelling, redness or heat from the wound. If you notice this symptom, please contact your spinal team.
• Nerve damage - this is damage to the nerves in your back which can result in altered sensations to your legs, pins and needles, weakness including foot drop, loss of control to your bowel or bladder. These changes can be temporary or permanent
• Bleeding or haematoma - collection of blood
• Dural tears or leaks – this is when the membrane covering the spinal cord (the dura) is damaged during surgery. This may lead to sickness and headaches after surgery. It is usually treated with bed rest but occasionally may require more surgery
• Non-union - this is when the bone does not fuse as planned. This is only determined when reviewed in clinic as the development of the bony bridge between the vertebrae occurs over weeks and months. The risk is higher for patients who smoke, are obese or have been treated with radiation for cancer. It is important that you stop smoking prior to your surgery. Smoking and the use of nicotine containing products has shown to be detrimental to the healing of the bone and therefore can affect the fusion of the spine

After a spinal fixation surgery, it takes about three months for the vertebrae to begin to fuse, although 1-2 years are required before fusion is complete.

We recommend you have a BMI of less than 30 prior to surgery.

What to expect after the surgery

You may experience discomfort in your back and hips as a consequence of spending time in one position during your operation. This should resolve over time, usually within 3-6 months.

It is normal to be in some discomfort post op but let the nurses know if your pain stops you from doing normal activities such as eating, sleeping, walking and going to the toilet.

Following the surgery, a nurse or physiotherapist will assist you to get out of bed and walk to the bathroom. The nursing staff will monitor your wound; you are advised not to shower for the first 10 days until the wound dressing is removed. You will be assessed by a physiotherapist and in some instances may be referred to an occupational therapist.

You will receive your post op clinic appointments through the post following your discharge. If you experience any of the following symptoms following your surgery and after discharge home, you should seek medical advice.

• Numbness around your back passage or genital region
• New onset of bladder or bowel incontinence
• New numbness, pins and needles or weakness in your legs

Following your surgery you should avoid excessive bending, lifting and twisting and use a common-sense approach.

Advice for the following 3 months:

• Avoid excessive bending
• Avoid heavy lifting and twisting and use a common-sense approach
• You should not lift anything heavy for a period of 3 months
• It is advised that you should not lift anything heavier than a full kettle of water

Getting in and out of bed

When getting out of bed, roll onto your side with your knees bent and slide your feet over the edge of the bed.

Whilst doing this use your arms to help push the top part of your body into a sitting position as your legs lower to the floor (see diagram).

There are 2 basic sleeping positions which may be helpful if you are experiencing back pain.

It may be more comfortable to sleep on your side.

Posture

Good posture is vital as it helps to reduce strain on the joints and ligaments in your spine, therefore reducing the risk of neck and back pain. Sit well supported in a chair, with a pillow or rolled up towel in the lowest section of your back, if needed, so you are using your natural curves.

Try this to avoid a slouched posture or slumped sitting position.

You should avoid sitting on furniture that is low, this is to avoid over bending and over stretching after your surgery.

Changing your posture and taking frequent walks will help keep your muscles working, prevent stiffness and promote your recovery.

For the first three months of recovery, you should sit for no longer than thirty-minute periods. It is advised that you get up, stand and have a walk.

Personal care

To avoid over bending when washing and dressing below your knees, you should bring your foot up and rest it on your knee (see diagram).

If you are unable to do this, long handled aids such as a shoehorn, a long-handled sponge or a helping hand grabber may be privately purchased.

If you are having difficulties with personal care including washing and dressing, an Occupational Therapist may will assess this.

If you have access to a cubicle shower this should be utilised.

If you have a shower over the bath, we recommend the use of a bathmat, so you don't slip. Alternatively having a strip wash at the sink is advised if there are no alternative facilities. If you feel you may struggle with bath transfers, you will require a referral to your community occupational therapist.

If you have difficulties getting on and off the toilet, you may need to be assessed by an Occupational Therapist. They can assess if toileting equipment is required on discharge.

Alternatively, get someone to help you during the period of time you have post-operative pain.

Domestic activities

Precautions you need to take after your surgery will require you to change the way you carry out everyday tasks for a period of three months.

You can engage in light household activities (i.e. dusting, ironing) when you go home from hospital if you wish but nothing strenuous until you have seen your consultant. Use a common-sense approach, remembering no heavy lifting (more than a kettle filled with water) for 3 months, correct lifting posture for lighter tasks and pacing of activities.

Carry only things that you are comfortable carrying with one hand and do this close to your body. Aim to store frequently used items at waist height to avoid bending and overstretching.  Alternatively, you could try sliding objects across the work surfaces. Vacuuming, washing windows, carrying shopping etc. should be avoided.

Traveling/driving

If you have recently had spinal fixation surgery, you can restart driving at 6 weeks dependent on your symptoms.

You must feel you can control the car, are able to turn your head to view your blind spot effectively and manage an emergency stop with no pain.

You may travel in a car but make sure you don’t travel for longer than half an hour before getting out and having a walk around to relieve any stiffness.

This applies for the first three months following your surgery.

Return to work

You can return to work between 6 weeks to 3 months dependant on whether you feel able to manage your job role; remembering heavy lifting must be avoided for the first 3 months. Your doctor or Physiotherapist may be able to advise you further.

The nursing staff can provide a sick note when you leave hospital and your G.P can provide any further sick notes. It may be useful to speak to your employer/occupational health about your absence, potential for a graded return and for any changes/work- based assessments.

Return to exercise/leisure

Everyone wants to know how soon they can start doing things, timescales can be helpful, but everyone is different and will recover at a different rate after an operation.

A common-sense approach is best. Being mobile as soon as possible improves your circulation and will help with the healing process.

Activity and exercises should not increase any back pain or symptoms. If you have concerns regarding worsening back pain or weakness, contact your GP, Complex spine specialist nurse or surgeon’s secretary.

You will not be given specific exercises post operatively because your spine needs time to heal.

You may or may not require additional physiotherapy on discharge dependent on your needs. This will be provided locally to where you live.

Regular daily walks are a good way to increase your general fitness and activity level.

Walk for as long as is comfortable. If your discomfort increases too much, your back is telling you to take a short rest, and then carry on.

Make a note of how far you walked and try and improve next time.

Make sure you take your painkillers at regular intervals; this will help keep you mobile.

You may return to sex when your back is comfortable. At first choose a position based on comfort.

You may return to the gym after 3 months starting with light cardiovascular exercise such as treadmill walking, static supported bike and cross trainer.

Keep all exercises low resistance and no inclines. No running or rowing. No weighted exercises for 3 months.

Any classes must be low impact and started after the 3 month period.

Pilates type exercise classes can be beneficial following the 3 month post-operative period.

Road cycling can be re-commenced after 3 months.
 
You can commence swimming at 3 months utilising any stroke but avoiding prolonged breaststroke. Stop after each or every few lengths to give your back a change of position.

Returning to hobbies, recreation or sport will need to be discussed with your surgeon at your clinic appointment.

As a general rule, you may not be able to return to impact sports/ hobbies for 12 months.

Useful addresses

Back Care
National charity providing information, support, promoting good practice
0845 130 2704
www.backcare.org.uk

NHS Direct
www.nhsdirect.nhs.uk

NHS 111 Service
When its less urgent than 999 – telephone 111

Arthritis Research UK
St. Mary’s Court St. Mary’s Gate, Chesterfield, Derbyshire, S41 7TD
+44 (0) 300 790 0400
www.arthritisresearchuk.org/

Disabled Living Centre
Disabled Living, Burrows House, 10 Priestley Road, Wardley Industrial Estate, Worsley, Manchester, M28 2LY
0161 607 8200
www.disabledliving.co.uk

The Care Team
6 Allen Road, Urmston, Manchester, M41 9ND
0161 746 7566
www.thecareteam.co.uk

Back Pain Charity
Tel: 0845 130 2704