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Spine Surgeries

ANTERIOR CERVICAL DISCECTOMY AND FUSION (ACDF)

Overview:
An anterior cervical discectomy and fusion is a surgical procedure to treat nerve root or spinal cord compression by decompressing the spinal cord and nerve roots of the cervical spine to stabilize the adjacent vertebrae.  Conditions which can be treated by this surgical intervention are cervical herniated disc, spondylosis, degenerative disc disease.  The surgeon takes a front (anterior) approach, either right or left, to access the spine.  The intervertebral disc is removed to free the nerve or spinal cord from compression and replaced with a cadaver bone graft.  The goal is for the bone graft to “fuse”  with the joining vertebrae.  This process of the fusion is a very slow process, therefore to instill stability, a titanium plate and screws are used to make the cervical spine stable and secure.

Procedure:
Patients are positioned in the supine (lying on the back) position, generally using a standard flat operating table. The surgical region (neck 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 environment.

A 2-4 centimeter (depending on the number of levels) transverse incision is made in one of the creases of neck, just off the midline. The cervical fascia is gently divided in a natural plane, between the esophagus and carotid sheath (area containing the blood vessels in the neck). Small retractors and an operating microscope are used to allow the surgeon to visualize the anterior (front part) vertebral body and discs. After the retractor is in place, an x-ray is used to confirm that the appropriate spinal level(s) is identified.

A complete discectomy (removal of the disc, including the protruding fragment) is typically performed, allowing the spinal cord and nerves to return to their normal size and shape when the compressive lesions are removed. Small dental-type instruments and biting/grasping instruments (such as a pituitary rongeur and kerrison rongeur) are used to remove the herniated disc. All surrounding areas are also checked to ensure no compressive spurs or disc fragments are remaining. The size of the empty disc space is measured; a graft size is chosen so as to restore the normal disc space height and the graft is then gently tapped into the disc space, in between the two vertebral bodies. A small titanium metal plate is frequently placed, affixed to the vertebrae with small screws, to impart immediate stability to the construct and allow for optimal bone healing and fusion. X-rays are then used to confirm appropriate position and alignment of the graft and hardware.

The wound area is usually washed out with sterile water containing antibiotics. The deep fascial layer and subcutaneous layers are closed with a few strong sutures. The skin can usually be closed using special surgical glue, leaving a minimal scar and requiring no bandage.

The total surgery time is approximately 2 to 3 hours, depending on the number of spinal levels involved.

This surgery can be performed at Cheyenne Regional Medical Center or Cheyenne Surgical Center.

Post-Op Care:
This surgery requires a short stay in the hospital, anywhere from 1 -3 days with a recovery period of 1 -2 weeks with restrictions and limitations.  Patients are instructed to avoid bending and twisting of the neck in the early postoperative period (first 2-4 weeks). Patients can gradually begin to bend and twist their neck after 2-4 weeks as the pain subsides and the neck and back muscles get stronger. Patients are also instructed to avoid heavy lifting in the early postoperative period (first 2-4 weeks).  Some patients are placed in a soft cervical collar for comfort to help decrease pain and to improve bone healing.

Showering/Bathing:
Patients can shower immediately after surgery, but should keep the incision area covered with a bandage and tape, and try to avoid the water from water hitting directly over the surgical area. After the shower, patients should remove the bandage, and dry off the surgical area. . Patients should not take a bath until the wound has completely healed, which is usually around 2 weeks after surgery.

Return to Work/Sports:
Patients may return to light work duties as early as 2-3 weeks after surgery, depending on when the surgical pain has subsided. Patients may return to heavy work and sports as early as 8-12 weeks after surgery, when the surgical pain has subsided and the neck and back strength has returned appropriately with physical therapy.

VIDEO (coming soon)


POSTERIOR CERVICAL FUSION (PCF)

Overview:
A posterior cervical fusion is a surgical technique repairing the cervical spine using a posterior (back of the neck) approach.  The PCF is most commonly performed on patients with cervical fractures or significant instability.  It can also be performed for spinal tumors, infections, or deformity.  PCF may also be used in conjunction with the anterior cervical surgery, especially when multiples levels of the cervical spine are involved. 

Procedure:
Patients are positioned in the prone (lying on the stomach) position, generally using a special operating table/bed with special padding and supports. The surgical region (neck 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 environment.

A 3-6 inch (depending on the number of levels) posterior (back of the neck) longitudinal incision is made in the midline, directly over the involved spinal level(s). The fascia and muscle is gently divided, exposing the spinous processes and spine bones. An x-ray is obtained to confirm the appropriate spinal levels to be fused. A laminectomy (removal of lamina portion of bone) and foraminotomy (removal of bone spurs near where the nerve comes through the hole of the spine bone) can be performed if necessary. Two small metal screws can be affixed to each spine bone, one on each side, which are then connected together with a titanium metal rod on each side of the spine. The bony surfaces and facet joints are then decorticated and bone graft is placed, which mends together over time (weeks and months).
The wound area is usually washed out with sterile water containing antibiotics. The deep fascial layer and subcutaneous layers are closed with strong sutures. The skin can usually be closed using sutures or staples. A sterile bandage is applied.

The total surgery time is approximately 2-4 hours, depending on the number of spinal levels involved.

This surgery can be performed at Cheyenne Regional Medical Center.

Post-Op Care:
Most patients go home in 3-5 days after surgery.  Patients are instructed to avoid excessive bending or twisting of the neck for the first 1-2 months following surgery.  Patients are instructed to avoid heavy lifting 2-4 months after surgery.  Most patients are required to wear a neck brace or collar after surgery to reduce the stress of the neck area, decrease pain, and improve bone healing. 

Showering/Bathing:
Patients can shower immediately after surgery, but should keep the incision covered with a bandage to avoid direct contact with water.  Patients are not advised to take a bath until granted permission by Dr. Beer at the 2 week follow up appointment.

Return to Work/Sports:
Patients may return to light work duties as early as 2-4 weeks after surgery, depending on when the surgical pain has subsided. Patients may return to moderate level work and light recreational sports as early as 3 months after surgery, if the surgical pain has subsided and the neck strength and mobility has returned appropriately with physical therapy. Patients who have undergone cervical fusion at only one level may return to heavy lifting and sports activities if the surgical pain has subsided and the neck strength and mobility has returned appropriately with physical therapy. Patients who have undergone cervical fusion at two or more levels are generally recommended to avoid heavy lifting, laborious work, and impact sports.

VIDEO (coming soon)


ANTERIOR LUMBAR INTERBODY FUSION (ALIF)

Overview:
Anterior lumbar interbody fusion (ALIF) is a type of spinal fusion that utilizes an anterior (front - through the abdominal region) approach to fuse (mend) the lumbar spine bones together. Interbody fusion means the intervertebral disc is removed and replaced with a bone (or metal) spacer, in this case using an anterior approach. The anterior technique is often favored when multiple spinal levels are being fused and multiple discs need to be removed. ALIF may be performed in conjunction with or without a posterior decompression (laminectomy) and/or instrumentation (use of metal screws/rods). The anterior ALIF approach is also ideal when only one spinal level is fused and a posterior decompression and/or instrumentation are not required. Although the anterior lumbar ALIF approach involves retracting (moving out of the way, temporarily) large blood vessels (aorta, vena cava) and the intestines, there is a wide exposure of the intervertebral disc without retraction of the spinal nerves and neurologic structures (and therefore, a decreased risk of neurologic injury).

ALIF is commonly performed for a variety of painful spinal conditions, such as spondylolisthesis and degenerative disc disease, among others.

Procedure:
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 environment.

A 3-8 centimeter (depending on the number of spinal levels to be fused) transverse or oblique incision is made just to the left of the umbilicus (belly button). 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 visualize the anterior (front part) aspect of the intervertebral discs. 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 instruments (such as a pituitary rongeur, kerrison rongeur, and curettes). Special distractor instruments are used to restore the normal height of the disc, as well as to determine the appropriate size spacer to be placed. A bone spacer (metal or plastic spacers may also be used) is then carefully placed in the disc space. Fluoroscopic x-rays are taken to confirm that the spacer is in the correct position.

The wound area is usually washed out with sterile water containing antibiotics. The deep fascial layer and subcutaneous layers are closed with a few strong sutures. The skin can usually be closed using special surgical glue, leaving a minimal scar and requiring no bandage.

The total surgery time is approximately 2 to 3 hours, depending on the number of spinal levels involved.

This surgery can be performed at Cheyenne Regional Medical Center.

Post-Op Care:
Most patients are usually able to go home 3-4 days after surgery. Patients will typically stay longer, approximately 4-7 days, if a posterior spinal surgery is also performed.  Patients are instructed to avoid bending at the waist, lifting (more than five pounds), and twisting in the early postoperative period (first 2-4 weeks) to avoid a strain injury. Patients can gradually begin to bend, twist, and lift after 4-6 weeks as the pain subsides and the back muscles get stronger.  Occasionally, some patients may be issued a soft or rigid lumbar corset that can provide additional lumbar support in the postoperative period, if necessary.

Shower/Bathing:
Patients can shower immediately after surgery, but should keep the incision area covered with a bandage and tape, and try to avoid the water from water hitting directly over the surgical area. After the shower, patients should remove the bandage, and dry off the surgical area. Patients should not take a bath until the wound has completely healed, which is usually around 2 weeks after surgery.

Return to Work/Sports:
Patients may return to light work duties as early as 2-3 weeks after surgery, depending on when the surgical pain has subsided. Patients may return to moderate level work and light recreational sports as early as 3 months after surgery, if the surgical pain has subsided and the back strength has returned appropriately with physical therapy. Patients who have undergone a fusion at only one level may return to heavy lifting and sports activities when the surgical pain has subsided and the back strength has returned appropriately with physical therapy. Patients who have undergone fusion at two or more levels are generally recommended to avoid heavy lifting, laborious work, and impact sports.


POSTERIOR LUMBAR INTERBODY FUSION (PLIF)

Overview:
Posterior lumbar interbody fusion (PLIF)  is a type of spinal fusion procedure that utilizes a posterior (back area incision) approach to fuse (mend) the lumbar spine bones together (using an interbody fusion technique). Interbody fusion means the intervertebral disc is removed and replaced with a bone spacer (metal or plastic may also be used), in this case using a posterior approach. The posterior technique is often favored when one or two spinal levels are being fused in conjunction with a posterior decompression (laminectomy) and instrumentation (use of metal screws/rods). There are two different types of posterior interbody fusion procedures. The traditional PLIF procedure involves placing two small bone graft spacers, with gentle retraction of the spinal nerves and neurologic structures, one graft on each side of the interbody space (right and left).

PLIF is commonly performed for a variety of painful spinal conditions, such as spondylolisthesis and degenerative disc disease, among others.

Procedure:
Patients are positioned in the prone (lying on the stomach) position, generally using a special operating table/bed with special padding and supports. The surgical region (low back 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 environment.

A 3-6 inch (depending on the number of levels) longitudinal incision is made in the midline of the low back, directly over the involved spinal levels. The fascia and muscle is gently divided in the midline, and retractors are used to allow the surgeon to visualize the posterior (back part) vertebral arches. After the retractor is in place, an x-ray is used to confirm that the appropriate spinal level(s) is identified.

A complete laminectomy (removal of lamina portion of bone) and foraminotomy (removal of bone spurs from the opening where the nerves leave the spinal column) is typically performed, allowing the nerves to return to their normal size and shape when the compressive lesions are removed. The nerve roots and neurologic structures are protected and carefully retracted, so that the bone spurs can be visualized and removed. Small dental-type instruments and biting/grasping instruments (such as a pituitary rongeur and kerrison rongeur) are used to remove the arthritic, hypertrophic (overgrown) bone spurs and ligamentum flavum. All surrounding areas are also checked to ensure no compressive spurs or disc fragments are remaining.

The PLIF technique includes performing a wide laminectomy and bilateral partial facetectomy to allow visualization and removal of the intervertebral disc. The intervertebral disc is then removed using special biting and grasping instruments (such as a pituitary rongeur, kerrison rongeur, and curettes). Special distractor instruments are used to restore the normal height of the disc, as well as to determine the appropriate size spacer to be placed. A bone spacer (metal or plastic spacers may also be used) is then carefully placed in the disc space. Small metal rods and screws are placed in the upper and lower vertebral bodies, which will provide immediate stability while the bone mends and to increase the fusion rate (percentage of patients where the bone successfully mends together). Fluoroscopic x-rays are taken to confirm that the spacer is in the correct position.

The wound area is usually washed out with sterile water containing antibiotics. The deep fascial layer and subcutaneous layers are closed with a few strong sutures. The skin is closed using stitches or surgical staples. A sterile bandage is applied, and is changed daily while in the hospital.

The total surgery time is approximately 3 to 6 hours, depending on the number of spinal levels involved.

This surgery can be performed at Cheyenne Regional Medical Center.

Post-Op Care:
Most patients are usually able to go home 3-5 days after surgery.  Patients are instructed to avoid bending at the waist, lifting (more than five pounds), and twisting in the early postoperative period (first 2-4 weeks) to avoid a strain injury. Patients can gradually begin to bend, twist, and lift after 4-6 weeks as the pain subsides and the back muscles get stronger.  Occasionally, patients may be issued a soft or rigid lumbar corset that can provide additional lumbar support in the early postoperative period, if necessary.

Shower/Bathing:
Patients can shower immediately after surgery, but should keep the incision area covered with a bandage and tape, and try to avoid the water from water hitting directly over the surgical area. After the shower, patients should change the bandage, and dry off the surgical area. The dressing should otherwise be changed every 2-3 days when at home. Patients should not take a bath until the wound has completely healed, which is usually around 2 weeks after surgery.

Return to Work/Sports:
Patients may return to light work duties as early as 2-3 weeks after surgery, depending on when the surgical pain has subsided. Patients may return to moderate level work and light recreational sports as early as 3 months after surgery, if the surgical pain has subsided and the back strength has returned appropriately with physical therapy. Patients who have undergone a fusion at only one level may return to heavy lifting and sports activities when the surgical pain has subsided and the back strength has returned appropriately with physical therapy. Patients who have undergone a fusion at two or more levels are generally recommended to avoid heavy lifting, laborious work, and impact sports.

VIDEO (coming soon)


MICRODISCETOMY (MLD)

Overview:
Microdiscectomy, also called Microlumbar Discectomy (MLD), is performed for patients with a painful lumbar herniated disc. Microdiscectomy is a very common, if not the most common, surgery performed by spine surgeons. The operation consists of removing a portion of the intervertebral disc, the herniated or protruding portion that is compressing the traversing spinal nerve root. Years ago, most spine surgeons would remove a herniated disc using a rather large surgical incision and surgical exposure without the use of a microscope or telescopic glasses, which would often involve a long hospital stay and prolonged recovery period. Today, many surgeons use a microscopic surgical approach with a small, minimally-invasive, poke-hole incision to remove the disc herniation, allowing for a more rapid recovery.

Procedure:
Patients are positioned in the prone (lying on the stomach) position, generally using a special operating table with special padding and supports. The surgical region (low back 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 environment.

A 1-2 centimeter longitudinal incision is made in the midline of the low back, directly over the area of the herniated disc. Special retractors and an operating microscope are used to allow the surgeon to visualize the region of the spine, with minimal or no cutting of the adjacent muscles and soft-tissues. After the retractor is in place, an x-ray is used to confirm that the appropriate disc is identified.

A few millimeters of bone of the superior lamina may be removed to fully visualize the disc herniation. The nerve root and neurologic structures are protected and carefully retracted, so that the herniated disc can be removed. Small dental-type instruments and biting/grasping instruments (such as a pituitary rongeur) are used to remove the protruding disc material. All surrounding areas are also checked to ensure no additional disc fragments are remaining.

The wound area is usually washed out with sterile water containing antibiotics. The deep fascial layer and subcutaneous layers are closed with a few strong sutures. The skin can usually be closed using special surgical glue, leaving a minimal scar and requiring no bandage.

The total surgery time is approximately 1 hour.

This surgery can be performed at Cheyenne Regional Medical Center or Cheyenne Surgical Center.

Post-Op Care:
Most patients are able to go home the same day or early the next day after surgery.  Patients are instructed to avoid bending at the waist, lifting (more than five pounds), and twisting in the early postoperative period (first 2-4 weeks) to avoid a strain injury or recurrent disc injury. Patients should try to avoid sitting in the same position for more than 45-60 minutes in the first few weeks after surgery. After sitting for 45-60 minutes, patients should get up and stretch or walk for a little bit, then sit down again if desired.

Shower/Bathing:
Patients can shower immediately after surgery, but should cover the incision area with a small bandage and tape, and try to avoid water hitting directly over the surgical area. After the shower, patients should remove the bandage, and dry off the surgical area. Small surgical tapes affixing the suture should be left in place. Patients should not take a bath until the wound has completely healed, which is usually around 2 weeks after surgery.

Return to Work/Sports:
Patients may return to light work duties as early as 1-2 weeks after surgery, depending on when the surgical pain has subsided. Patients may return to heavy work and sports as early as 4-6 weeks after surgery, if the surgical pain has subsided and the back strength has returned appropriately with physical therapy.

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