The purpose of this letter is to explain what is involved when a fusion is performed on your lower back. We have found that the more knowledgeable the patient, the more successful the outcome. This letter is intended to answer some of the most commonly asked questions. Please feel free to raise any other questions with your doctor.

1. What is the basic structure of the spine?
   The spine is composed of vertebrae, disks, a spinal cord, and nerves. Typically, the vertebrae are referred to as the “spine”. These vertebrae are strong and bones that support the trunk and protect the spinal cord and nerves. The disk is the soft structure located between the vertebrae. These disks act as cushions which enable the vertebrae to move.
   
   
2. What is a lumbar fusion?
   A lumbar fusion is when two or more vertebrae in the low back are “fused” together to create a solid bridge of bone between the vertebrae and across the disk space. A fusion is usually performed to eliminate movement between vertebrae and stabilize a painful or unstable segment of the spine. Once a segment of the spine is stabilized the patient usually experiences some relief of pain. Surgery is not recommended unless there is almost a 70% chance of improving your level of pain. This approximately 70% chance of improvement does not necessarily mean that you will be completely pain free but rather that your level of pain should be significantly improved. It means that there is a 30% chance your pain will not improve. However, each situation is unique. There is also at least 5% chance that you may become significantly worse.
   
   
3. Will I lose mobility once a portion of my spine becomes solid bone?
   It depends in part on how much of the spine is fused. The spine will not move as much but you will not notice it as it is only a small amount. Most people believe that the spine enables you to bend over at the waist; this motion actually occurs mostly at the hips. There are patients that have their entire spine fused yet are still able to touch their fingertips to the floor.
   
   
4. What happens during a lumbar fusion?
   At the hospital you are given a general anesthetic to put you to sleep. Once you are asleep, padding is placed between your body and the table and you are carefully positioned face down. An incision is made over your lower back and your muscles are gently pulled away from your spine to expose the lumbar vertebrae. If your nerves are under any pressure they are decompressed. Once the nerve work is completed the surgeon begins the grafting process. This entails removing small pieces of bone from the outside part of the back of your pelvis. These pieces are used to stimulate the fusion. The bone on the lower part of your spine is then roughened up. This enables the bone chips to have a better surface area with which to bond. The graft is then placed closely against the roughened up bony surfaces. It is this combination of Posterior Lumbar Fusion small pieces of bone with a raw bony surface which stimulates the body to form a solid piece of bone.
   
   
5. Why are screws, plates, or rods used in my spine?
   Screws, plates, and rods (also known as instrumentation) are used to immobilize the spine which thereby enhances the healing process. Instrumentation acts as an internal splint, or, like a rebar in concrete. Historically, braces or casts were used. However, research has found that they are not as effective in immobilizing the spine. If too much motion occurs the vertebrae may not fuse together. This is known as a pseudarthrosis or non-union. The incidence of pseudarthrosis ranges from 15 to 40% without hardware. If this occurs, further surgery may be required to stimulate the bone to fuse. Screws, rods, and plates have been shown to significantly decrease the rate of non-union.
   
   Once the fusion process is completed, it is the fusion that holds the spine stable, not the hardware. Therefore, if the fusion is solid the hardware serves no purpose, but we do not recommend the routine removal of the hardware as that would require an additional operation with no benefit to the patient.
   
   If the fusion is not solid, there is a high probability that the hardware will loosen or break. This is not dangerous and will not cause nerve damage as the hardware is buried deep within the fusion mass, similar to steel rods buried in concrete for reinforcement.
   
   The benefits of the screws, rods and plates are as follows:
   
   1.They help correct deformity of the spine.
   2.They give immediate stability and earlier relief of pain.
   3.They give rise to a higher fusion rate than non-instrumented fusions.
   
   Complications associated with placement of the screws include dural tear, bone breakage, nerve damage, vascular injury, and infection. Screws may also loosen or break. However, this is not typically thought of as a complication but rather as an indication that the fusion has not healed.
   
   
6. What are the risks of using screws, rods, or plates in my spine?
   Complications associated with placement of the screws include dural tear, bone breakage, nerve damage, vascular injury, and infection. Screws may also loosen or break. However, this is not typically thought of as a complication but rather as an indication that the fusion has not healed.
   
   
7. Does smoking have an effect on the outcome of my fusion?
   Research shows that the healing rate is greater than 90% in non-smokers and less than 50% in smokers. Many surgeons frown on performing a fusion in patients who smoke because of the higher rate of non-union and infection. Physicians have also found that in smokers it is sometimes necessary to go in through the front and the back of your spine in order to obtain a successful fusion. If you smoke, be prepared to discuss the situation in detail with your physician.
   
   
8. What will my hospital stay be like?
   Several nurses and doctors will ask you questions regarding your medical history. It is important to bring a list of medications that you are currently using. You will wait in the holding area of the operating room for about 30 minutes before surgery. This is where you will meet your anesthesiologist and have your IV’s initiated.
   After surgery you will wake up in the Recover Area where you will remain for two hours. There will be a catheter in your bladder. The catheter is usually removed on the second day, however, if you are unable to urinate you may need to be recatheterized. Due to the anesthesia and medications, many patients have a poor recollection of this time period.
   
   The first two days will be difficult. We will try very hard to keep you as comfortable as possible with IV pain medicine. You will be able to control the amount of pain medication you receive by using a small push button. You can push the button as often as you need; the machine will control the dose. We have been very happy with the amount of pain control we can obtain with this machine.
   
   The combination of pain medicine, anesthesia, and spine surgery may cause you to experience some nausea. We allow only ice chips or small amounts of liquids until you are passing gas. If fed too soon, you may become distended and even more nauseated. About 20% of our patients are fairly nauseated within the first 24 hours. This problem is usually resolved by the second or third day.
   
   We encourage you to get out of bed on the first day. By the third day we insist that you are ambulating. We have found that there is a lower incidence of lung, bladder, and vascular complications the earlier the patient is mobilized.
   
   
9. When can I shower?
   The drains are usually removed from your back on the first or second day. You may shower with the dressings in place or off, depending on the preference of your doctor, on the second or third day. There are small tapes on your skin that you will need to pull off after the tenth day. The sutures do no need to be removed as they will eventually be absorbed into the skin. We ask that you not soak in a bath or pool for seven days.
   
   
10. When can I go home and what will I be able to do?
    You may go home once your pain can be controlled with pills, your incision is not draining, and your bowel and bladder are functioning normally. Most patients are ready to go home by the fourth day after surgery.
    
    We encourage you to begin walking the day after surgery. Initially these walks may only be a few steps, but each day you should increase the distance/time of your walks. We would expect you to be able to walk for 10-15 minutes at a time by four weeks after surgery.. You should be able to go up and down stairs, drive, and perform basic daily activities without too much of a problem. You should avoid bending at the waist as that increases the stress across the fusion site. It usually takes a minimum of four months for the fusion to heal. The time frame in which you can return to work depends on your recovery. Each patient has a unique set of work-related issues which will need to be discusses with the doctor.
    
    The first office visit should be scheduled two to four weeks after you are discharged. The purpose of this visit is to check your incision and make sure you are progressing as planned. The second visit is typically scheduled two to four months after surgery. During this visit the status of your fusion is assessed. Each physician has his own approach to rehabilitation, some more vigorous than others. Your physician will prescribe a rehabilitation program based on your specific needs.
    
    
11. Do I need a blood transfusion?
    A spinal fusion is a major surgery which may require a blood transfusion. If you have had prior surgery you are more likely need a transfusion. Each case is different and the risks should be discussed with your surgeon before surgery. The blood bank is very safe; the risk of contracting Aids is less than one in 500, 000. The risk of contracting Hepatitis is one in 100,000.
    
    
12. What are the specific risks of this operation?
    Every surgical procedure carries significant risks. These include major risks which may have long term or negative side effects and minor risks which do not have any long term effects.
    
    Major Risks
    
    Deep Infection: 2-3%
    These include infections which may show up several months after surgery and require prolonged use of antibiotics. Future surgeries may also be necessary.
    
    Pseudarthrosis: 5-30%
    A pseudarthrosis or non-union is a term used to describe a fusion that has not healed. This means that a solid bridge of bone has not formed between the vertebrae. A non-union does not necessarily mean that the surgery must be redone; many patients with a non-union are quite happy with their pain relief. However, in cases where the pain persists, the fusion may have to be redone. We have found that smokers have a higher incidence of pseudarthrosis(>50%) that non-smokers. Therefore, you should be aware that smoking can significantly affect the outcome of your surgery.
    
    Dural Tear: 2-5%
    The spinal cord and nerves are surrounded by a sac of clear fluid called the dural sac. This sac is not routinely entered. However, if the sac is torn during surgery, it is sewn tightly together to prevent any cerebral spinal fluid from leaking. Small tears require no further treatment. Larger tears may require you to remain flat on your back for 24 to 72 hours to enable the leak to seal. If the leak persists you may require further surgery or special drains.
    
    Nerve Damage: 1-2 %
    Nerve damage can occur due to excess traction, a screw placed too close to the nerve, or a nerve inadvertently cut during the procedure. Symptoms include numbness, weakness, and/or pain. Nerve damage is usually a temporary problem which is isolated to only one nerve however, it can occasionally involve multiple nerves and remain permanently. In rare instances bowel and bladder function may be lost. Paralysis is possible but very rare.
    
    Re-operation:15%
    Further surgeries may be necessary if the hardware breaks or loosens. Other reasons include nerve impingement from a screw, pseudarthrosis (non-healing of the fusion), infection, or persistent pain. There is about a 10% chance that the fusion may transfer stresses to the adjacent disks, resulting in disk disease and requiring surgery.
    
    Other:
    Other major complications are rare but include perforation of a major blood vessel, kidney damage, or death.
    
    Minor Risks
    Complications which are less serious include bladder infection, superficial wound drainage, inability to urinate for a few days, nausea, headache, constipation, abdominal bloating, sore throat, pneumonia, and reactions to medications. If your body is unable to replenish its blood supply or if too much blood is lost during surgery, a blood transfusion may be necessary. As with any surgery, there are also unanticipated major and minor risks.
    
    
    
13. What is your overall philosophy regarding spinal fusion?
    Lumbar fusion is generally an elective surgery. Therefore, it is your choice to proceed based on your current level of discomfort and disability. We recommend that you do not have surgery if you can live with your current level of pain or can make changes in your lifestyle to decrease the pain. If you have made a valiant effort and the pain still persists, surgery should be your next step.
    
    The rate of surgical success varies greatly depending on your exact problem, overall health, and the magnitude of surgery necessary. We hope that by providing you with as much information as possible about the surgery, you can determine if the pain you are experiencing is worth the risk of surgery.

Final Comments
Patients often ask if the purpose of this letter is to provide the surgeon with legal and medical protection. This is true; however, the main goal of this letter is to provide you with as much information as possible to assist you during your decision-making process. We believe that patients who are more informed about the procedure are less anxious and apprehensive with their surgery. These patients usually experience less pain and have a better outcome overall.