The spine consists of 24 individual vertebrae, the sacrum and the coccyx. Intervertebral discs separate each vertebra. The discs consist of a firm fleshy centre, the nucleus pulposus, which is surrounded and held together by a cartilaginous ring of fibres, the annulus fibrosis. The intervertebral discs act as shock absorbers and hinges. The vertebrae are also linked together by ligaments and muscles. Between each two vertebrae there is a small opening on either side, through which a nerve passes. In the lower part of the spine, the lumbar region, some of the nerves combine to form the sciatic nerve, supplying the legs.
Important Muscles of the Spine
The spine is supported by muscles, which provide a natural corset around it. These muscles consist of Transversus Abdominus, Erector Spinae and Multifidus, the pelvic floor muscles and the diaphragm. These muscles act together like guy ropes of a tent. The stronger the muscles, the more support it gives the spine. People suffering with low back pain often have weaker muscles and therefore a less stable spine.
Spinal Fusion Surgery
A spinal fusion can be carried for several reasons. In many cases it is performed to relieve back pain and increase stability. This procedure can prevent motion at one or more of the vertebral segments. Decreasing the motion should decrease pain at that segment. Spinal fusions can also be carried out to correct deformity and relieve pain from a scoliosis (a spinal curvature). A spinal fusion often involves the use of a metal prosthesis and/or a bone graft. The bone graft may be taken from the hip. The surgery can be performed, approaching from the front or back (anterior or posterior), or from both.
Before and Immediately After the Operation
Before the Operation
You will be admitted to the hospital the day before your operation. It is very important that you bring with you any relevant x-rays and scans, and a list of your current medications and any medical allergies you may have. On admission you will be assessed by the ward nurse, who will ask details of your past medical and surgical history and arrange some routine blood tests. You may also require a chest x-ray and an Electrocardiograph (tracing of you heart). Before your operation you will be seen by your surgeon and he will obtain your consent for the procedure. You will also be seen by your anaesthetist. The physiotherapist will explain your postoperative rehabilitation and exercises. If you are required to wear a brace postoperatively, you may be seen by the orthotist the evening before surgery to take measurements and a fitting for your brace.
Immediately After the Operation
You will be escorted back to your room from the recovery area by a member of the ward nursing team.
You will have an intravenous infusion (drip) in progress via a cannula in one of the veins in your arm. Once you resume eating and drinking, these IV fluids will stop. You will also receive antibiotics through your IV line to prevent infection.
In addition there may also be a separate smaller drip providing you with pain relief, the use of this pain relief drip is controlled by you using a button. This is a very safe and effective way of ensuring you get analgesia as you need it.
There will be a surgical dressing over the wound-site. There will often be a drain coming from the wound attached to a small plastic collection bottle. This is usually removed within 24 hours post-operatively.
The nursing team will be checking your blood pressure, pulse and circulation very regularly during the immediate postoperative period. The time span will reduce as you become more awake.
You will remain in the hospital for several days after surgery. During this time we aim to help you become more independent so you can return home.
General Exercises and Mobility
Following an anaesthetic the normal cough reflex, that keeps the lungs clear, is reduced. Post-operative pain and immobility can also affect your respiratory function.
These exercises are to be done hourly. Breathe in gently, so you feel your lower ribs expanding. Hold for a count of three and then breathe out slowly. Repeat this 4 times followed by a cough, hourly.
While you are less mobile or on bed rest, it is important to maintain the circulation in your legs. This is to prevent a deep vein thrombosis (DVT), a blood clot, from forming while you are resting in bed.
- Pump your feet up and down for 30 seconds, hourly
- Circle your ankles in both directions 10 times, hourly
- You should keep your compression boots on while in bed.
It is important to maintain muscle strength while you are less mobile or on bed rest. Do both these exercises hourly.
- Tighten your thigh muscles by pushing your knees down into the bed. Hold for 5 seconds, relax and repeat 10 times
- Clench your buttocks. Hold for 3 seconds, relax and repeat 10 times.
It is important that you know how to move in bed and how to get in and out of bed correctly. This is to avoid putting unnecessary strain on your back.
Bend the knee on the opposite side that you are rolling to and turn onto your side. Keep your back completely straight.
Getting In/Out of Bed
You may need some help getting in and out of bed for the first time.
- Log roll onto your side
- Using your arms, slowly push yourself up, lowering your legs at the same time
- Ensure that you keep your back straight
- Sit on the edge of the bed
- Lower your body onto your elbow and shoulder, at the same time as lifting your legs on the bed
- Gently roll onto your back.
You may be required to wear a brace or corset following your surgery. The brace should be put on before you get out of bed and removed once back in bed. Your consultant will tell you how long you need to wear the brace for.
You will be encouraged to gently start walking as soon as you are able. It is important to stand straight and to walk early.
The purpose of these exercises is to increase mobility of the spine and to re-educate the stabilising muscles. This will not happen straight away and may take several weeks to achieve good mobility and muscle strength. It is very important to continue these exercises for several months.
These exercises should be painfree although mild discomfort can be experienced if starting these exercises for the first time. If the exercises are painful, stop them and discuss with your surgeon or physiotherapist. The exercises should be performed 4 times a day.
To achieve a position where minimal stress is taken through the spine, we need to achieve a neutral position. Find a comfortable position where the spine is neither flattened nor arched. This position should be the starting point for the following exercises.
1. Abdominal Setting
In lying, gently pull your lower abdominal muscles towards your spine (away from a belt). Hold the contraction for 3 seconds, relax and repeat 10 times. Try to increase the contraction time to 10 seconds. Do not hold your breath while doing this exercise. When you are able to sit, you can perform this exercise in an upright sitting position. Ensure that your spine is in neutral. Repeat 10 times.
2. Straight Leg Raising
In lying, set your abdominals as in exercise 1. Tighten your thigh muscles on the straight leg, pull your toes towards you and lift the leg a few inches off the bed. Hold for 3 seconds and then lower down slowly. Keep the knee straight during this exercise. Repeat 5 times and then perform on the other leg.
3. Pelvic Tilting
In lying, set your abdominals as before. Flatten your back down into the bed, hold for 2 seconds and relax. Then arch your back away from the bed and again hold for 2 seconds. During this exercise you should feel your pelvis tilt backward and forwards. Do not hold your breath while doing this exercise. Repeat 5 times.
In lying, with your knees bent up, squeeze your buttocks together and set your abdominal muscles in the neutral position. Curl your bottom off the bed, vertebra by vertebra, as high as possible, until eventually the pelvis is in line with the knees and shoulders. Hold for 3 seconds and gently lower, maintaining the abdominal contraction. Repeat 5 times.
5. Neural Mobilisation
This exercise is to prevent the nerve becoming tethered within the spinal canal and to enable the nerve to move freely throughout the lower limb. This exercise should be done gently to prevent irritation. In lying, holding the neutral position, bring one knee up towards your chest. With the hip at 90º, hold behind the thigh. Gently straighten the leg until a stretch is felt. Pull the toes down and towards you, hold for 3 seconds. Bend the knee back down and once comfortable, repeat the exercise 5 times on each leg.
On Discharge from Hospital
The aim is for you to avoid doing things that aggravate your pain. Once recurrence of back and leg pain has occurred, it is much more difficult to alleviate it. It is much simpler to avoid it in the first place. If in doubt, err on the side of caution.
The aim is to do small amounts and often. For most of the first week you will either be in hospital or should be pottering about at home. For the second week, the amount of activity undertaken should essentially be unchanged. It would be perfectly reasonable to fix your own meals and look after yourself, though you should not be doing housework or looking after others.
From the second week onwards, light exercise may be taken. You may go on very short car journeys (10-15 mins) and go out for short walks. Prolonged outings, lengthy or frequent trips to the office are not advised. Problems most often arise when patients do a little too much, a little too often.
After surgery it is advised not to sit for more than 30 minutes, for the first two days, except for during meals. It is important to alternate your position between lying, sitting and walking. If you wish to sit, a high upright dining room style chair would be the most appropriate. Do not sit on low, soft sofas or chairs.
Gradually increase the time that you spend sitting. You should be back to normal around about the 6-12 week mark. However, it will always be advisable to avoid prolonged periods in very soft armchairs.
You should not sit in a bath as this will put strain on your back. You should use a shower instead if you have one. If you do not have a shower you will need to obtain a bath seat.
You will feel some degree of pain postsurgery, which will obviously lessen as time goes by. You will be provided with pain relieving medication to take home with you. Repeat prescriptions can be obtained from your GP if necessary. Regular rest periods will also aid with pain relief.
Include fresh fruit, vegetables, and bran cereal in your diet. Drink at least 6-8 glasses of water and juice each day. Avoid straining to have a bowel movement. You may use prune juice, Lactulose or stool softeners on an as need basis.
It is very important to keep your wound dry until at least 24 hours after the suture(s) have been removed. Prior to suture removal it is perfectly reasonable to have a shower, providing the wound is covered with a waterproof dressing. On discharge the ward nurses will provide you with an adequate supply of wound dressings until suture removal around the 10th day post-surgery. In general, it is better if the dressings are changed as infrequently as possible to reduce the risk of introducing infection.
You should contact the Spinal Nurse Specialist or the ward if you experience any of the following:
- Temperature of 37ºC or higher
- Yellow, green or blood stained discharge from your incision
- Redness, swelling or warmth around your incision.
- New or unusual pain, numbness or tingling
- Shortness of breath or chest pain
- Calf pain or pressure in your leg(s).
If you have been provided with a spinal brace please ensure that you are confident in its application and removal before you leave the hospital. It is important that you are comfortable wearing it. Continue to wear your brace until you are advised otherwise by your consultant at your follow-up appointments. If you experience any problems after you go home you may contact the ward or the orthotist for advice.
Outpatient Physiotherapy will usually begin after your follow-up appointment 4-6 weeks post-operatively when the back will be stable enough to allow real progress to be made. Pilates classes may also be appropriate.
You will be able to return to work from home at short periods after the first few weeks. Most light office-based jobs may be returned to at around 4-6 weeks providing that the commute is reasonable. Heavy manual work will take about 12 weeks to return to. It may not be advisable to work long days when first returning to work.
You should not return to sports until your surgeon has reviewed your progress and you have completed your physiotherapy programme.
You should be the passive partner initially, with your back well supported. Stop if it becomes painful or if you think it may hurt.
Back Care Advice
One of the most common causes of low back pain is poor postural habits. This may involve standing, sitting, lifting or even lying in a poor position.
The spine consists of a series of natural curves that act as shock absorbers and give it maximum strength.
In the standing position, there is an inward curve in the small of the back, immediately above the pelvis, known as the lumbar lordosis. Frequent or prolonged loss of this curve may cause excessive strain on the back, leading to the development of back problems.
Correct Standing Posture
- Stand with your weight equally distributed on both legs. You should feel your lumbar curve correct itself into a more neutral position
- Pull in your stomach muscles, as described earlier under abdominal setting
- Tuck your chin in, as if making a double chin
- Draw your shoulder blades down, increasing the distance between your ears and shoulders. This may feel unnatural to begin with but with continued correction your muscles will build endurance.
Correct Sitting Posture
The lumbar lordosis is more easily lost in sitting. It is therefore important that adequate support is given to maintain a good sitting posture, particularly if sitting for long periods.
Try not to sit on sofas or deep easy chairs that would cause you to slouch. Whenever possible, use a lumbar roll for the small of your back, to maintain the lumbar curve.
- Ensure that your desk is at the correct height to prevent you slouching. A chair with adjustable height and back is advisable
- Sit with your feet resting flat on the floor, thighs supported and at right angles to your hips
- If your chair does not have adequate support, use a lumbar roll
- Have the chair close to the desk, to prevent you leaning over
- If working at a computer, it is important to look slightly down at the screen. If necessary tilt the level of the screen and avoid glare. Ensure that the screen is directly in front of you and not to one side, so that you need to turn your head to look at it
- When sitting for long periods, regular interruption of sitting is advisable. Getting up and moving around will help relieve muscle stiffness
- When sitting reading, you can use a sloped surface. This can be achieved by simply propping a board on some.
You should avoid lifting for 4-6 weeks after surgery. If you have to lift, be very careful. Let someone else to do the lifting or carrying if possible. It is important to learn the correct lifting technique, whether it involves small or heavy objects. Keep lifting to a minimum.
NEVER – bend or twist your back
ALWAYS – bend your knees and keep your back straight, bracing with your lower abdominal muscles
NEVER – attempt to lift too heavy an object on your own
- Carry objects as close to your body as possible. If a weight can be broken down, do so
- When shopping or travelling, use two lighter bags rather than one heavy bag, or better still use a trolley
- Be careful when lifting objects out of your car, not to twist round while lifting. Deep car boots can be a hazard.
- For the first few weeks you should try to avoid doing any strenuous household tasks
- Vary your tasks, taking regular breaks
- Kneel or bend your knees if you have to reach down. Use both hands to avoid twisting
- Kneel on a pad when washing floors, or use a long-handled mop
- When using a vacuum cleaner, keep the handle close to the body
- Dusting or polishing shouldn’t be done at a level higher than the shoulder
- Use steps/blocks to reach higher places, rather than trying to reach it by stretching
- When making a bed, go round to the other side rather than leaning over it.
- Working in the garden can be a danger area for back pain sufferers.
- Vary your work, not doing any one job for too long at a time
- Kneel on a pad or sit on a low stool
- Never bend down suddenly to pick up that odd weed
- Mow the lawn with the handle of the mower’s handles close to the body
- Use long-handled implements to avoid bending
- If you have to dig, dispose of the soil a little at a time to avoid twisting whilst lifting.
In the first few weeks avoid driving and in the weeks that follow limit journeys to short distances. It is important to have a car seat that is comfortable and can be adjusted.
If the seat has little or no lumbar support, use a small cushion or lumbar support in the small of your back.
Adjust the seat for maximum comfort so that your hips and knees are well-supported and your arms relaxed. During longer journeys, stop and get out of the car at regular intervals.
Whilst this page aims to provide you with useful advice and information it must be noted that it should act only as a guideline. Should you have any further concerns about the surgical procedure it is advisable that you discuss them with your consultant.