Lumbar Fusion Surgery Information
We welcome you to the Excel Spine Center family and thank you for choosing us for your upcoming surgical procedure. Our team considers patient satisfaction to be of the upmost importance and we intend to exceed your expectations during this experience. As a leader in minimally invasive spine surgery, we take pride in offering the finest and most advanced spine care available. Our procedures offer the following benefits compared to traditional open spine surgery:
• Less muscle and tissue damage
• Decreased blood loss
• Reduced post-operative infection rate
• Less post-operative pain
• Shorter hospital stay
• Smaller scars
• Faster recovery time
• Quicker return to daily activities
You are the most important member of our team and are encouraged to take an active role in preparing for your surgery and recovery. You can make your surgical outcome safer and more successful if you are active, involved, well informed, and carefully follow your schedule and instructions.
Please take the time to carefully read this entire packet in order to understand your role in ensuring effective preparation and a smooth recovery. We highly recommend that you use this guide as a step-by-step tool throughout the entire surgery process. We also urge you to share this information your family/friends who will be helping you prior to surgery and throughout your recovery. Please note: This packet is just a guide. Dr. Kim or one of our Physician Assistants may give you different or additional instructions that are specific to your condition or procedure.
If you have any additional questions or concerns, please do not hesitate to contact us.
Sincerely,
Dr. Choll Kim and Team
What happens next? Kelsey, our surgery scheduler, will email you a pre-op questionnaire as well as a medication list to fill out. In the meantime, please schedule an appointment with your primary care physician (PCP) as soon as possible.
1. PRE-OPERATIVE APPOINTMENT WITH YOUR PRIMARY CARE PHYSICIAN
Please schedule an appointment with your PCP as soon as possible for a medical clearance and physical exam. Your PCP will perform an EKG and draw labs, after reviewing the results they will determine if you are healthy enough to undergo spine surgery. Please email Kelsey at Kelsey@excelspine.com when you have scheduled this appointment to give her the date. If you have other active medical problems, you may need to also obtain clearance from a specialist.
2. PRE-OPERATIVE APPOINTMENT WITH DR.KIM
Kelsey will contact you to choose a date for your surgery and to schedule your pre-op appointment with Dr. Kim, which will take place 1-2 weeks prior to surgery. She will also mail and email you a letter outlining these dates, in addition to other important information. We will be sending you consent forms; please review, sign and bring these with you to your pre-op appointment with Dr. Kim. If there are any parts of the consent that you wish to discuss prior to signing, please contact our office before your pre-op appointment. During this appointment, you will go over your “Journey to Recovery” and you will be given instructions for medication(s) to take after surgery. Please note, it is important to inform Dr. Kim if you drink alcohol every day. We will likely recommend that you have an alcoholic beverage with dinner while in the hospital to avoid alcohol withdrawal. Please email any questions or concerns to Kelsey at Kelsey@excelspine.com ahead of time.
3. HOSPITAL PRE-ADMISSION APPOINTMENT
Kelsey will schedule your hospital pre-admission appointment to take place on the same day as your pre-op appointment with Dr. Kim. During this appointment, you will verify your contact information and insurance. A nurse will also provide you with special antibacterial soap, instructions for the morning of surgery, and answer any questions regarding your hospital stay. Please bring a complete list of your allergies and medications, including the dosage, how often you take it, and the reason for the medication.
MEDICATIONS
Please email a complete list of your allergies and medications (prescription and non-prescription), including the dosage, how often you take it, and the reason for the medication, to Kelsey@excelspine.com. Some medications can affect blood clotting and increase the risk of excessive bleeding during and after surgery. Please follow these instructions for your safety and to avoid cancellation of your procedure. You should, however, NOT discontinue the bold medicines below without clearance from the provider who prescribes them (PCP/hematologist/cardiologist).
30 DAYS PRIOR TO SURGERY, DISCONTINUE:
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7 DAYS PRIOR TO SURGERY, DISCONTINUE:
- Aspirin
- Coumadin/Warfarin
- Effient/Prasugrel
- Pradaxa/Dabigatran
- Aggrenox/Dipyridamole
- Non-steroidal anti-inflammatory drugs (NSAIDs), such as Mobic/Meloxicam, Motrin/Ibuprofen/Advil, Naproxen/Naprosyn/Aleve, Ketorolac, Voltaren/Diclofenac, Celebrex (Note: Tramadol, and Tylenol/Acetaminophen are ok to take for pain control during this time)
- If you take a GLP-1 Agonist weekly, stop 1 week prior to surgery. These include: Dulagutide/Trulicity, Exenatide/Byetta or Bydureon, Liraglutide/Saxenda or Victoza, Lixisenatide/Adlyxin, Semaglutide/Ozempic/Wegovy/Rybelsus
5 DAYS PRIOR TO SURGERY, DISCONTINUE:
- Plavix/Clopidogrel (Restart 72 hours after surgery)
2 DAYS PRIOR TO SURGERY, DISCONTINUE:
- Eliquis/Apixaban (Restart 72 hours after surgery)
- Xarelto/Rivaroxaban (Restart 72 hours after surgery)
THE DAY BEFORE SURGERY, DISCONTINUE:
- Metformin
- If you take a GLP-1 Agonist daily, stop 1 day prior to surgery. These include: Dulagutide/Trulicity, Exenatide/Byetta or Bydureon, Liraglutide/Saxenda or Victoza, Lixisenatide/Adlyxin, Semaglutide/Ozempic/Wegovy/Rybelsus.
DO NOT TAKE THESE MEDICATIONS AFTER 5PM THE NIGHT BEFORE SURGERY, OR THE MORNING OF SURGERY:
- ACE inhibitors (Lisinopril, Captopril, Enalapril, Sacubitril)
- Angiotensin II Receptor Blockers/ARBs (Losartan, Valsartan, Candesartan, Irbesartan)
ON THE NIGHT BEFORE SURGERY, DO NOT EAT OR DRINK AFTER MIDNIGHT.
- This includes gum and candy. It is ok to brush your teeth the morning of surgery and take medicine with a small sip of water, but do not drink a full cup.
FAMILY, FRIEND OR CAREGIVER SUPPORT
A family member, close friend or other designated caregiver will become an important member of your extended team to help you prior to surgery and throughout your recovery. Please introduce these individuals to Dr. Kim. Please also make arrangements to have a family member or friend drive you home from the hospital, stay with you for the first few days at home and drive you to your post-op appointment with Dr. Kim. If this is a problem, please notify our office.
BEFORE THE PROCEDURE
• Please arrive to the hospital/facility at the time designated by the facility. This is usually 2 hours prior to scheduled surgery.
• Remain NPO (no food and no water) as instructed.
• After checking in, you will be asked to complete any remaining admission or consent forms.
• You will then be escorted to the pre-operative holding area to be prepared for your surgery.
• You will be asked to change into a hospital gown.
• An IV line will be started, and an initial set of vital signs will be taken.
• The anesthesiologist will review your chart and answer any of your questions.
• Dr. Kim will meet with you to answer any last-minute questions and exchange/verify contact information
with you or your family/friends.
DURING THE PROCEDURE
• When the surgical team is ready, you will be taken to the operating room.
• The anesthesiologist will manage your vital signs and adjust your anesthetic as needed to ensure your
comfort and safety throughout the entire time you are in the operating room.
• While you are sleeping, a small tube called a foley catheter may be inserted into your bladder to drain urine
during your surgery. This catheter is either removed while still in the operating room or may remain in place
until you are up and out of bed if you are expected to stay in the hospital overnight.
• A neuromonitoring technician will apply electrodes to your arms and legs to monitor nerves intraoperatively.
• The surgical team will prepare you and place drapes to ensure a sterile environment.
• The total time required for surgery differs from patient to patient depending on the complexity of the
procedure.
AFTER THE PROCEDURE
• You will be taken to a recovery area where you will remain for 1-2 hours.
• Dr. Kim will update your family and/or friends.
• You may feel groggy from the anesthesia.
• A nurse will monitor your vital signs and check your pain level. You should tell the nurse when it hurts,
where it hurts and how much it hurts on a pain scale of 0-10.
• You will then be taken to the spine unit to begin the post-operative and rehabilitation phase of your
recovery. Friends and family can see you in your room at this time.
POST-OP HOSPITALIZATION
• After your surgery, the nursing and surgery teams will closely monitor you.
• Generally, each day starts with a blood draw for routine monitoring.
• You will be introduced to physical therapists, the two of you will work together to achieve important goals outlined in the “Journey to Recovery”, which was given to you at your pre-op appointment with Dr. Kim. These goals include regaining independence and mobility, developing a program for walking at home, and understanding proper body mechanics and spine precaution.
• A provider from Excel Spine will visit you.
• Most patients go home the afternoon of post-operative day #1.
LENGTH OF STAY
Your stay at the hospital will depend on your individual condition, your tolerance to pain medication, and the extent of your surgery. Your individualized treatment “pathway” (also known as the “Journey to Recovery”) will outline your plan of care during your hospital stay. Most patients go straight home but some patients may need to recover in a skilled nursing facility (SNF) about 1-3 days after surgery.
After 3 days, remove the dressing and leave the incision open to air. Wash your hands before and after caring for your incision. Your incision has medical glue that dries purple and acts like a barrier to protect your incision. Let the glue flake off over the next few weeks; do not pick at the flakes. Wear a clean, loose cotton T-shirt to keep the area dry. Do not apply creams, lotions, or ointments to the incision for the first 6 weeks. To avoid infection or scarring, do not scratch or scrub the incision.
Please notify us of any discharge from the wound and email a photo of your wound and dressing if this occurs to Choll@excelspine.com, or call us. Please include the time of your last dressing change in the email so we can assess the quantity of discharge and recommend appropriate wound care. If you have been prescribed antibiotics, finish the entire prescription as directed.
• Change positions at least every 30-45 minutes.
• Stay active throughout the day, taking breaks when necessary.
• Take pain medication as directed and at least 30 minutes before planned activity or exercise.
• Apply a covered ice pack 2-3 times a day, for 15-20 minute intervals to help swelling or discomfort.
• Use relaxation techniques such as meditation, deep breathing, reading or listening to music.
• Perform simple stretches and gentle range of motion exercises. See our YouTube video on gentle back
exercises that may be started before physical therapy: https://www.youtube.com/watch?v=FB5G_o0DRIQ
Some pain is to be expected as you recover. The amount and intensity of pain you may experience varies by the extent of the surgery and your tolerance to pain medications. Some patients find significant pain relief right after surgery and may only need to take Tylenol/Acetaminophen, while other patients experience a fair amount of residual pain and soreness that persists and slowly improves over time. These patients may need to take prescription pain medications for a few weeks after surgery. Be sure to take your medications as instructed and understand that some medications are to be taken only as needed. Common side effects of narcotic pain medications include constipation, nausea, drowsiness, and dizziness. It is important to wean off of all narcotic pain medications and transition to Tylenol/Acetaminophen as soon as possible to prevent narcotic dependence. However, do not take narcotic pain medication and Tylenol/Acetaminophen together because the narcotic medication may already have Tylenol/Acetaminophen in it. Do not take more than 3,000 mg of Tylenol/Acetaminophen in one day. Also, do not drink alcohol or drive while you are taking pain medication. Lastly, do not take aspirin-like products or non-steroidal anti-inflammatories (NSAIDS, outlined on pg. 4) for 3 months after surgery, unless Dr. Kim instructs you to do otherwise.
Avoid lifting more than 10 pounds for 4 weeks after surgery (a gallon of milk weighs about 9 pounds). When lifting, use proper body mechanics, try to only lift objects that can be easily lifted with one hand, and do not lift above your elbows. Do not participate in sports or activities that require frequent or strenuous bending, twisting, pushing or pulling (such as gardening, mowing the lawn, etc.) for about 2-3 months after surgery. When bending, try to use your knees rather than your waist, but you should try to bend and twist gently to avoid stiffness. Also, try to avoid climbing full flights of stairs until you are steady on your feet, and have enough strength and balance to do so safely. You should have help going up and down the stairs for the first few attempts. Start with one step at a time and use a railing. Listen to your body and be mindful of your limits.
You may walk around without restriction but be aware that your muscles are weaker after spine surgery and you may be more susceptible to falls. You should change positions throughout the day to help control pain, prevent blood clots and improve circulation. It is helpful to sit for a while, lie down for a while and take short walks periodically throughout the day. You should gradually increase your activity level and rest as needed. You should also perform gentle stretches and exercises on a consistent basis in order to increase flexibility, strengthen muscles and maintain an active lifestyle. Use common sense regarding activity. Do not push yourself to the point of fatigue or pain – moderation is the key.
You may sleep in any position you find comfortable. You should try sleeping on your back with a pillow under your knees, or on your side with a pul
You should try sleeping on your back with a pillow under your knees, or on your side with a pillow behind your body slightly tucked under your back and hips. To maintain good posture, avoid using more than two pillows under your head and try to keep your back straight.
A healthy, well-balanced diet will help strengthen
your immune system, give you energy, increase your tolerance to activity, and help your incision heal. Be sure to increase fluid intake to six, 8 oz. glasses of water each day, and eat fresh fruits and vegetables high in fiber. This will help the common constipation caused by pain medication and inactivity. You should also take the bowel medications (Colace, Dulcolax) that were prescribed at your pre-operative visit to stay ahead of constipation or until you have your first bowel movement (then as needed).
It is always our goal that patients return home after spine surgery. Though, in some cases, patients may need help beyond what a family member or friend can provide. These patients may benefit from home health services including nursing care, physical therapy, and occupational therapy, which are brought to the patient’s home for a short period of time. During each visit, a nurse will check and record vital signs, examine the incision, assist with dressing changes, and teach the patient or the caregiver to do the same. The nurse will also go over medications, nutrition, fluid intake, and the regularity of bowel movements. In other cases, some patients may benefit from a short stay at a skilled nursing facility (SNF), especially patients who need help walking, caring for themselves, or do not have someone at home to assist them. Dr. Kim will determine if you may benefit from either of these services and they will be arranged for you prior to surgery.
You may shower with the dressing. The dressing should be removed 3 days after your surgery and you may continue to shower with the incision uncovered. Let the soapy water run over the incision freely, but afterwards, make sure to dab it dry with a towel. It is important that you do not submerge the incision site in water, including bathtubs, pools and hot tubs, until the incision is completely closed (usually 6 weeks after surgery).
Around 3 months after surgery, you can begin chipping and putting. If chipping and putting are not painful, you may move to the driving range. Start with short-irons, move to mid-irons, and then to long-irons and clubs, as long as you are not experiencing pain at each level.
Your motivation and participation in physical therapy are essential elements of your recovery; you must play an active role in every step of your rehabilitation. You will receive a prescription for physical therapy at your first or second post-operative appointment with Dr. Kim. Outpatient physical therapy usually starts 4-6 weeks after surgery and continues for about 6 weeks. The goal is to establish and optimize an individualized home/gym exercise program that can be continued on a consistent basis even after your formal physical therapy is completed. This program will focus on improving functional mobility non-impact aerobic exercises, coordination and balance, proper body mechanics, and overall conditioning. As your physical therapy sessions draw to an end, the transition to your home/gym program should be seamless. Your dedication to physical therapy and exercise will set the pace for your recovery.
If Dr. Kim orders you a brace, it will either be given to you at your pre-op appointment with Dr. Kim or a representative will deliver it to your home and fit it for you. A back brace is a temporary support and should only be used as needed for comfort. You should wear a clean loose cotton T-shirt under the brace to protect skin and absorb sweat. Do not wear the brace in bed. If Dr. Kim orders a walker, cane, toilet seat or commode, the hospital case manager or home health coordinator will order it for you at the time of discharge from the hospital. In many cases, patients do not need any equipment.
Most patients wait to resume intercourse for about 4 weeks. You should situate yourself in a position that supports and takes pressure off the lumbar region. You can achieve this by lying flat on your back, placing a small pillow or hand towel under your low back, and placing a pillow under your knees to make them slightly bent. The bottom or missionary position is usually the safest and most comfortable; however, use your pain and discomfort as a guide.
Driving will depend on the extent of your surgery and your recovery progress. Your pain must be managed so that you no longer need any narcotic pain medication, such as Percocet, Oxycodone, Vicodin, etc. These medications can affect your ability to drive. Generally, many patients can start driving after 4 weeks, but you should consult Dr. Kim. Try to limit initial driving to short, local distances.
This will depend on the extent of your surgery, your recovery process and the specific requirements of your job. If you have a relatively sedentary job and can comfortably sit, you may resume working around 6 weeks after surgery. If your job is physically demanding, and you are able to perform controlled exercises and lift weights, you may return to work around 3 months after surgery; however, more time may be needed. Dr. Kim recommends returning to work on a part-time basis with limited duties before returning to full-time work without any restrictions. If you need to take time off work, please contact your employer for FMLA forms. For more information about FMLA, visit: www.dol.gov/whd/fmla/.
You may start a pool exercise program, go swimming, take baths and go in hot tubs around 6 weeks after your surgery. Please be sure to wait until your incision has completely healed before submerging it in water. If you are unsure, please email or text a picture of your incision to our office or Dr. Kim.
You will follow-up with Dr. Kim or a Physician Assistant periodically throughout the next year to ensure that you are continuing to heal appropriately. Your first post-op appointment will be 1-2 weeks after surgery. During this appointment, a provider will discuss your medication regimen, examine your incision, and assess your muscle and nerve function. You will likely receive a prescription to start physical therapy, a prescription for x-rays and you will schedule your future post-op appointments. X-rays will be ordered at 6 weeks, 3 months, 6 months and 1 year after surgery. Patients with active medical problems should schedule a follow-up appointment with their PCP about 4 weeks after surgery.
If you experience any of the following symptoms:
• Persistent, severe or uncontrollable pain
• Increasing weakness or numbness in your extremities
• Incisional redness, drainage, or increased swelling
• Difficulty breathing, fever or chills
• Problems controlling your bladder or bowel
• No bowel movement for 5 days
• Calf or lower leg swelling
Following a Fusion
1-2 WEEKS AFTER SURGERY
• Take several short walks and perform posture exercises throughout the day.
• Do not lift more than 10 pounds until 4 weeks post-op (a gallon of milk is about 9 lbs).
• Drink six, 8 oz. glasses of water per day, and eat fresh fruits and vegetables high in fiber.
• Do not participate in sports or activities that require frequent or strenuous bending, twisting, pushing or pulling.
• Limit initial car rides to short, local distances (around 1 hour or less).
3-4 WEEKS AFTER SURGERY
• Try to stop wearing your brace, if applicable.
• You may resume intercourse, as tolerated.
• Wean off of all narcotic pain medications and transition to Tylenol/Acetaminophen.
• If you are no longer taking any narcotic pain medication, you may start driving.
• You may go on longer car rides and take short, local flights.
5-6 WEEKS AFTER SURGERY
• Do not lift more than 15-20 pounds.
• Start physical therapy.
• You may perform light chores, such as cooking, dusting, sweeping or folding laundry.
• You may participate in non-contact sports and activities such as yoga or cycling.
• If you have a relatively sedentary job, you can likely return to work.
3 MONTHS AFTER SURGERY
• Gradually increase activities as tolerated by pain.
• You may perform household chores, such as gardening and mowing the lawn, as tolerated by pain.
• You may participate in more non-contact sports and activities such as running, golfing or tennis.
• You may start taking frequent or long distance flights.
• If your job is physically demanding, you can likely return to work.
6 MONTHS AFTER SURGERY
• You may participate in contact sports, ride a road bicycle, and go downhill skiing, snowmobiling, waterskiing, or horseback riding, as tolerated by pain.
Q: What if I’m not ready to proceed with surgery?
A: You should never feel pressured to proceed with surgery. If you are unsure, we encourage you to review our educational materials, get a second opinion, speak to one or more of our previous surgery patients, or talk with your family and friends.
Q: What can I do before my surgery to help with my recovery? (See page titled “Preparing For Surgery”)
A: Dr. Kim recommends maintaining a healthy diet and getting enough sleep each night to strengthen your immune system. You should continue to perform simple stretches and exercises that increase flexibility and
strengthen muscles. Keeping your muscles toned and endurance high will help you to recover faster after surgery. Also, you can try to reduce alcohol consumption and try to stop smoking or cut back on the number of cigarettes you smoke each day.
Q: Why should I quit smoking prior to surgery?
A: You should try to stop smoking or cut back on the number of cigarettes you smoke each day, in order to help your bones fuse, wound heal, and minimize the risk of infection. There is a higher chance your fusion will not heal if you continue to smoke because smoking disrupts the normal function of the body’s system, decreases blood flow to healing tissues, limits bone growth and accelerates arthritic changes. Stopping even for a short period of time will be helpful.
Q: Will I see Dr. Kim or a Physician Assistant if I stay overnight in the hospital? (See page titled “Day of Surgery”) A: Yes! Dr. Kim or one of our Physician Assistants will visit you.
Q: When will I be able to return to my normal activities? (See page titled “After Surgery Do’s and Don’ts”)
A: You can expect to experience less post-operative pain, a shorter hospital stay, a faster recovery time, and an earlier return to work and daily activities than is associated with traditional open back surgery. Nonetheless, it is
still surgery. While most procedures successfully relieve pain and improve function, recovery does take time. Returning to your normal activities will be a slow process. Each surgery is different, and the healing and recovery time will vary.
Q: When will I be able to travel? (See page titled “Recovery Guidelines”)
A: You may travel as soon as you feel comfortable, but Dr. Kim recommends avoiding long distance travel for at least 3-4 weeks. During these first few weeks, try to only take short car rides that are 1 hour or less. If you need to take a long care ride, you should stop at least once an hour to stretch and walk around. However, it is okay to fly home after surgery if needed, 24 hours after discharge if you live out of town. Please make sure to get assistance with carrying luggage and consider using a wheelchair support. On the flight, please make sure to walk and stretch every hour.
Q: Will my spinal implant(s) set off metal detectors?
A: Most implants are made of titanium and will not set off metal detectors. If for some reason an alarm does go off, you should inform security of your spinal implant(s) and consider showing them your surgical scar. In some situations, a security guard may wave a wand along your back to confirm your fusion instrumentation.
Q: Why must I take antibiotics for dental work or other surgical procedures?
A: Dental work or other surgeries increases the chance of infection. If an infection spreads to your spinal instrumentation, it must be surgically removed and replaced. Therefore, taking antibiotics reduces the risks of
new hardware getting infected. Please inform your dentist and other physicians of your spine surgery. We recommend oral antibiotics prior to invasive dental work for the first year after surgery. Prophylactic antibiotics are not needed after the first year.
