An anterior posterior fusion is performed through two incisions, one on the front (anterior) and one on the back (posterior). The front incision is made first. This is generally vertical and extends from the belly button to just above the hairline. A vascular surgeon will make the incision and perform the exposure for your spine surgeon. Once the spine is exposed, the diseased disc material is removed and replaced by one or twocages. These cages are filled with bone graft taken from your pelvis and/or bone graft substitute. The cages provide stability to the spine. The bone graft helps to stimulate the growth of bone from the vertebrae above to the vertebrae below. Once this process is completed, the wound is closed and you are turned onto your stomach.

The back incision is then made. The incision is vertical and varies in length. Once the spine is exposed, any bone or disc material compressing a nerve will be removed at this time if discussed prior to surgery. A screw is then placed on either side of each vertebra involved. The screws are connected by a rod on each side. Bone graft is then taken from your pelvis and placed alongside the hardware to promote fusion. Bone graft substitute may also be used.

The spine fusion is not actually completed at the time of surgery. Instead, the conditions for the spine to fuse are created. The hardware is put in place to temporarily stabilize the vertebrae until your own body has made enough bone to stabilize the vertebrae itself. As you heal, the bone graft and vertebrae will grow together to become one solid unit. It will take 6 to 12 months for the fusion to become solid. X-rays will be taken periodically to monitor healing.

WARNING: Patient’s who smoke or use other tobacco products DO NOT fuse. You must discontinue all tobacco products (including but not limited to chewing tobacco, cigarettes, cigars and the nicotine patch) prior to undergoing fusion surgery. Contact the office immediately if you need assistance to quit smoking.
Risks

Risks of spinal fusion surgery include but are not limited to nerve damage, blood vessel damage, blood clots, blood loss, dural tear, spinal fluid leak, infection, movement of the interbody cage and failure to fuse. Rare risks of surgery include weakness of an extremity, bowel or bladder dysfunction or incontinence, worsening of neurologic symptoms, worsening of low back pain and possible death. For males, there is a (rare) risk of retrograde ejaculation.

Pre-operative testing and any other necessary arrangements for your surgery are managed by the Surgical Coordinator. Please contact the Surgical Coordinator with any surgical questions you may have.

Prescreening

All patients that undergo surgery at the New England Baptist Hospital are required to go to the New England Baptist for a prescreening appointment prior to the date of surgery. At that visit you will undergo a complete physical examination by the anesthesia department. Blood work, special x-rays and an EKG will be taken. If you are required to see a specialist for surgical clearance (i.e. cardiologist), arrangements will be made to see that physician during your prescreening appointment. Please plan on spending a full day at the hospital.

Please report to the hospital 30 minutes prior to your appointment to register. Bring your insurance card(s) or workers compensation information with you to your prescreening appointment. Please bring a small snack and any medications (including pain medications) that you will need to take during the day to your prescreening appointment, as this may be a long day. There is a cafeteria and vending machines on site for your use.

You are required to bring all medications that you take on a regular basis to your pre-screening appointment at the New England Baptist Hospital in their original containers. This helps eliminate any confusion regarding your medications and will ensure that you will receive the appropriate medications during your stay at the hospital.

** On occasion, the pre-screening staff will detect a medical issue that needs to be either treated or further tested prior to the surgery date. If you are informed that additional testing and treatment is needed before surgery, please contact the surgical coordinator immediately. If the pre-screening staff has told you that you have not been cleared for surgery please alert the surgical coordinator immediately.

**You cannot have surgery without this pre-screening evaluation. If you miss your prescreening appointment your surgery will be canceled. If you cannot make your pre-screening appointment, you must call 617-754-5498 to reschedule as soon as possible. Contact the office immediately if you have any difficulty rescheduling this appointment.

To minimize time spent at prescreening, you may pre-register at www.onemedicalpassport.com. Your surgical coordinator will provide you will you surgeon’s ID number.
Conditions of Concern

**Please contact the office immediately if should develop any of the following conditions before your surgery date:

• Dental Infections
• Urinary tract infections
• Cuts that will not heal or that appear red
• Open wounds or sores
• Fever
• Any infection requiring antibiotics
• Cold or Flu
• Blood Clot
• Heart condition
• Any significant change in your overall health status
• Skin Rash
• New Allergies

Blood Donation

Most patients receive two blood transfusions following an anterior posterior fusion. Therefore, you will be asked to donate two units of your own blood preoperatively to be used for transfusion during or following surgery. One unit is generally donated at your prescreening visit. The Surgical Coordinator will make these arrangements.

Blood donations may also be scheduled at designated American Red Cross facilities. Most Red Cross locations do not provide this service.

Family members may donate blood for your surgery if their blood type is exactly the same. “Universal donors” are not acceptable.

The blood donated for your surgery may only be used by you. Any blood products not utilized will be discarded.

** If you have any religious beliefs or medical issues that that prohibit you from receiving blood or blood products, please notify your surgeon or the surgical coordinator immediately.
Bowel Prep

The prescreening unit may give you a prescription for bowel medication take prior to surgery to help reduce post-operative bowel discomfort.

Medications

You must discontinue all anti-inflammatory medications (other than Celebrex), aspirin products and other anticoagulation medication one week prior to surgery. If you are currently taking Plavix, Coumadin, Warfarin or any other blood thinners, please contact the office immediately.

Bracing

All patients undergoing spine fusion surgery are required to wear a back brace post-operatively for a minimum of three months. The brace helps to stabilize the spine while it is healing. You will be measured pre-operatively for this brace. If a custom brace is needed arrangements will be made for a fitting before your surgery date.

Bone Stimulators

An external electrical bone stimulator is a lightweight, battery powered, portable device that is used as an adjunctive therapy to enhance the chances of obtaining a solid spinal fusion. It is recommended for use in patients undergoing a multi-level or revision fusion. Bone stimulators are also recommended for patients who smoke, patients who are diabetic and for those with severe instability in the spine.

On occasion, the surgeon recommends that an implantable bone stimulator device be used. This is placed at the time of surgery.

Our office, with your permission, will attempt to obtain insurance approval for the bone external stimulator if needed. Insurance approval and the amount covered by the insurance company will vary from plan to plan.

** The use of bone stimulators is contraindicated in patients with implantable pace-makers or defibrillators.
Hospital Guest Hotel Services

New England Baptist Hospital offers hotel services on the hospital grounds exclusively to patients and their family or friends. This program was put in place to help eliminate the stress of traveling to and from the hospital for appointments or surgery.

Guests have the option of a twin, double or queen bed. Some rooms include a sleep chair for an additional person.

All guest rooms have:

• A private bath with shower
• Cable TV
• Telephone
• Clock radio
• Daily housekeeping

Other amenities include:

• Complimentary parking
• Use of the common room, with complimentary coffee service, microwave, refrigerator and sitting area
• Discounts at the hospital cafeteria

Room rates range from $75 to $105 per night

For reservations, please call Guest Services at 617-754-5173 between 8 am and 4 pm Monday through Friday. It is recommended that you call for reservations as soon as possible to ensure availability.

Other Suggestions for Pre-Operative Planning

• Place items in your home that you use on a daily basis between waist and shoulder height. That way you can safely avoid reaching or bending.
• Make small meals or grocery shop before your surgical date so you will have little need to do so post-operatively.
• Find someone to help with chores or errands.
• If you live alone it may be helpful to stop mail for a period of time while you are in the hospital.
• Buy a pair of slip on shoes so that you will not have to bend to put them on post-operatively.
• Make arrangements for your pets to be fed or cared for.

Please do NOT eat any food or drink after midnight the night before your surgery. Do NOT eat candy or gum. You may have your morning medications with a sip of water. If you use insulin, do not administer your morning injection. Bring your insulin with you to the hospital.

Hospital Arrival

You are expected to arrive at the hospital at the time provided to you by the surgical coordinator. This will be approximately 1 ½ to 2 hours prior to your surgical time.

Please leave early to allow time for any traffic delays.

Please report to the admitting office immediately to check in. Bring your insurance card(s) with you. Once you are admitted, you will be escorted to the Bond Center.

Bond Center

Once you arrive at the Bond Center, your will meet the nurse who will be taking care of you that morning. You will be asked to change into a hospital gown. The anesthesiologist will put in an IV in your arm for medications. Your surgeon will see you before surgery.

Length of Surgery

The length of your surgery is dependent on how many vertebrae are involved. The average length of surgery is 5-7 hours. You will be transferred to the recovery room after the surgery is completed. Once you are awake and alert, you will then be transferred to your hospital room. The surgeon will speak to your family once surgery is completed at your request.



In-Patient Post-Operative Care


Pain

Your low back and abdomen will be very sore post-operatively. Pain medication will be utilized to keep you as comfortable as possible. Do NOT expect to be pain free.

Bowel Discomfort

Your intestines will be manipulated during the anterior portion of your surgery to allow for good exposure of the spine. As a result, your bowels may not work normally for a few days following your surgery. You will be slowly introduced to food as tolerated. We recommend small meals for the first few days, gradually increasing to your normal portions.

Breathing

Breathing exercises are incorporated into your post-operative program to help prevent pneumonia from developing. You will be given a device called an incentive spirometer to assist you with these exercises.

Bladder Care

You may have a catheter placed during your surgery to help you to urinate pos-operatively.

Clot Prevention

When you are inactive, precautions are taken to avoid the development of blood clots. You may be required to wear elastic stockings post-operatively.

Physical Therapy

Physical therapy begins the day after your surgery. The therapists will assist you in getting out of bed and walking. They will help you to regain your strength so that you may be discharged to home safely.

Your hospital case manager will review your post-operative plan with you before you are discharged. The hospital case manager is responsible for arranging the following services for you if needed:

• Home Physical Therapy
• Inpatient Rehabilitation Transfers
• Home Nursing
• Transportation to Home or a Rehab Center
• Home Health Aides;

Rehabilitation Hospital Transfer

You may be transferred to an inpatient rehabilitation center for a short period of time
following surgery if you are not ready to go home. If inpatient rehabilitation is needed, the necessary arrangements are made by the hospital case manager. If you would like to go to a specific rehabilitation hospital, please inform your case worker as soon as possible.

Home Services

If you have been told you will receive home care services post-operatively and you are not contacted by the home care agency within two days of your discharge, call the agency’s number that is listed on your discharge papers. If they do not respond, contact the office immediately.

Medications

You will receive prescriptions for pain medications upon discharge. The prescriptions are provided to you by the hospital. Please review your medication instructions prior to leaving the hospital.

You will need to contact the office for medication refills. Please keep in mind that many medications cannot be called in to your pharmacy and must be mailed to your home. It is important to call the office several days in advance so that you can receive your medications on time. Pain medications will NOT be refilled after business hours or on the weekends.

Pain medications are designed to make your pain more tolerable. Do NOT expect to be pain
free.

Medical Equipment

Arrangements for medical equipment such as a cane, commode, walker, shower chair, etc. are made by the hospital if needed.

Length of Stay

You will be expected to spend 4-5 days in the hospital.
Questions?

** If you do not understand your discharge instructions, ASK QUESTIONS before you leave the hospital.

Please contact the office immediately if you develop any of the following symptoms after discharge from the hospital:

• a significant increase in pain
• new numbness, tingling or weakness of legs
• fever over 100°F
• new back or leg pain
• severe headaches
• redness or discharge from the incision site

Office Phone Number: 617-730-9814

After 4 pm on weekdays and on the weekends, the on-call physician will be paged


Post Op Visits

1st Post-Op visit

Your first post-operative visit will be scheduled by the surgical coordinator. You must be seen in the office between the 10th and 14th post-operative day for suture/staple removal and a wound check. If you are unable to come to the office for this visit, please contact our office as soon as possible.

2nd Post-Op visit

Your second post-op visit will be scheduled by the surgical coordinator. This will be approximately 6 weeks after the date of surgery. You will see your surgeon on this date and x-rays will be taken.


Immediately After Surgery

Pain

Post-operative pain is normal and to be expected. Be sure to take your medications as prescribed. Contact the office with any significant increase in your pain.

Incision Care

Dressing: A dressing will be applied to your incision following surgery. This dressing should be left on until your first office visit unless otherwise specified by your physician or physician assistant. Your visiting nurse may receive instructions to remove or change this bandage before your first post-operative visit.

Do not be alarmed if the dressing becomes moist or bloodstained. However, if the area continues to bleed, you should call the office immediately.

Wound Care: Your wound should be kept clean and dry. You should not allow your incisions to get wet in a shower unless otherwise specified by your physician.

Incision: Initially the incision appears pink. Over time, with proper care, it will heal into a fine white line. This may take up to one year. For best results, put vitamin E directly onto the incision once it has healed. Keep the incision out of the sun or cover with sunscreen.
Exercise

You are expected to walk daily for exercise. Begin with short distances and try to walk two times per day.
Precautions/Limitations

Avoid prolonged sitting. Avoid bending or twisting at the waist. Do not lift anything greater than 5 pounds. You are restricted from household chores such as laundry, vacuuming, cleaning, raking, shoveling, etc. If you have a question regarding a certain activity, contact the office beforehand.

3-6 Weeks After Surgery

Driving: You should not drive for 6 weeks unless told otherwise by your surgeon.

Intercourse: You should avoid sexual activity for 3-4 four weeks following surgery. Before you resume sexual activity, make your partner aware of your pain and any concerns that you may have. Limit activity and positions that cause pain. The dependent (supine) position is recommended. Avoid twisting and excessive bending of the hips and sudden movements.

3 Months After Surgery

Work: You are expected to be out of work for a minimum of 12 weeks. This of course varies from person to person. Return to work is dependent upon the rate of healing, symptoms, work demands, etc. If you need disability paperwork completed, please contact the office at the earliest possible date.

Rehabilitation: You will begin an outpatient physical therapy approximately three months after the surgery unless advised otherwise by your surgeon. This allows for healing.

Bracing: You are expected to wear your low back brace at all times (except when sleeping) for a minimum of three months.

Bone Stimulators: You should wear your stimulator post-operatively as advised. Please call the office with questions.