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Transforaminal Lumbar Interbody Fusion (TLIF)
Introduction
This is a guide to your upcoming operation. In it we explain what is likely to happen at each stage of the process. However your care will depend on your individual needs, so your progress may vary from this basic outline. Please become familiar with this guide and discuss any aspects you wish to with your surgeon or the nursing staff.
You will be admitted on the morning of surgery, unless this is impractical or you have some significant medical problems. You should expect to be in hospital for two days.
Before Surgery
You should stop taking anti-inflammatory drugs at least ten days prior to surgery as they can increase the risk of bleeding. These tablets include Voltaren, Nurofen, Brufen, Feldene, Naprosyn, Indocid, Celebrex and Mobic. If you are on low-dose aspirin, (eg. prescribed to prevent stroke or heart attack) you need to discuss this with your surgeon as you will likely need to cease this medication. If you are currently taking Warfarin (Coumadin or Marevan), Plavix or Iscover tablets, you should notify your surgeon as you will need to stop taking this medication under medical supervision. You should also stop taking any vitamin or mineral supplements ten days prior to your surgery.
You should keep the skin near the operation site clean. If you have a cut or pimple on the skin in the area, you should notify your surgeon prior to surgery.
Admission
You should not eat or drink 6 hours prior to surgery. This usually means from 2 am on the morning of your operation. (You may not be the first patient on the list, but the order may need to be changed unexpectedly)
You should bring with you:
- Personal effects (nightgown or pyjamas, slippers, dressing gown, toiletries)
- Any medication you are taking
- Medicare and private health fund membership cards
- Your medical consent and admission paperwork
Your x-rays and scans will be taken to the theatre on the morning of surgery by our staff.
Prior to going to theatre, you will:
- Have a shower with an antiseptic soap (Betadine)
- Be dressed in a theatre gown and disposable underwear
- Have special stockings fitted (to help prevent blood clots)
- Be asked to mark the painful arm (if applicable) with an indelible pen
If you wish, your surgeon will speak to a family member in person at the end of the day’s surgery list. Please notify the hospital nursing staff of the details.
The Procedure
You will be prepared for surgery by the nursing staff in hospital. You will be taken from the ward to the operating theatre on a trolley. The operation will take about three to four hours, but you may spend up to five hours in the theatre complex, by the time you wait in the preoperative area, have the surgery and wake up in the recovery area.
The anaesthetic
The anaesthetist will give you a general anaesthetic. A small needle will be placed in the back of your hand or in your forearm. This will be connected to a drip. You will be asked to breathe on an oxygen mask and the drugs to make you fall asleep will be injected through the drip. You will be asleep and not be aware of anything further until the operation is completed. Antibiotics are given to you at this stage and a catheter will be inserted into your bladder.
The surgery
You will be placed on the operating table lying with your back up (i.e., face down) resting on a frame. A needle will be placed in your back and an x-ray will be taken with an image intensifier (fluoroscopy). This will help identify the correct level at which to make the incision. Your back will be prepped (cleaned with antiseptic solution) and draped (covered with sterile sheets).
The incision will then be made. It is usually 10 to 15 cm long. A small incision is made over one buttock to insert a navigation probe to aid placement of the pedicle screws. The muscles covering the spine will then be detached and retracted to expose the laminae of the vertebrae. A small amount of bone is removed using special instruments from the side where the nerve is compressed. This allows us to see the dura, or delicate tube covering the spinal fluid and nerves. The compressed nerves are then freed of pressure and retracted (moved to the side) to expose the disc. The disc is then removed completely using special instruments. The correct cage is then used by measuring the space between the vertebrae. The small cage is packed with artificial bone and inserted into the space between the vertebrae. The fusion is performed by inserting screws into the vertebrae through the pedicles. Once the holes have been made through the pedicles into the vertebrae, the screws are inserted and the position is checked with the image intensifier. Rods are inserted to connect the screws. The navigation probe is removed.
Any bleeding is stopped and long-acting local anaesthetic (Marcain) is applied to the nerve and surrounding tissues. This provides pain relief for up to 12 hours. The wounds are closed with deep long-lasting dissolving stitches and more rapidly dissolving stitches are used to close the skin. These are just under the skin and do not have to be removed. A dressing is applied and you are transferred back to the trolley.
The recovery
The anaesthetist will reverse the anaesthetic. You will wake up in the recovery room. The nurses there will check your observations and the movement in your feet. Once you are sufficiently awake, you will be transferred back to the ward. Once in the ward, your progress will follow the clinical pathway.
After Surgery
When you return to the ward, you will be resting in bed. You will feel quite drowsy and the nurses will help you to move into a comfortable position. You will have a drip in your arm for fluids and for pain control, you will have a PCA. A PCA (patient-controlled analgesia) consists of another line attached to the drip in your arm and a pump that delivers a painkiller like Morphine, Pethidine or Fentanyl. You can control the amount of medication you receive by pressing a button. There is a safety lock-out mechanism built in to the PCA so that you cannot give yourself too much painkiller.
You will have a bulky dressing over the wound on your back and a wound drain from your wound. You will have a catheter in your bladder so that you will not need to worry about getting up to pass urine. You will have sequential compression devices on your legs, which gently squeeze your calves to decrease the chance of clots in the legs.
You may feel nauseated after your anaesthetic but will be allowed fluids and a light diet if you feel well.
The Day After Surgery
You will have a wash in bed with the help of the nursing staff.
You will be able to progress to eating a normal diet.
You will be seen by the physiotherapist, who will stand you up and assist you to walk a short distance with the aid of a rollator (walking frame with wheels). The physiotherapist will give you instructions about your activities during the recovery period, including an exercise programme.
The Second Day After Surgery
You will be able to have a shower with the assistance of the nursing staff. Prior to your shower, the drip and PCA will be removed from your arm. The outer wound dressing will also be removed, leaving a small waterproof dressing that you can shower in. This inner dressing may need to be changed today if it is not sticking properly. The wound drain will be removed. The sequential compression devices will also be removed. Your stockings will be taken off for your shower and then reapplied.
You will have tablets available for pain relief. If necessary you can have an injection.
Your physiotherapist will visit each day and take you for a walk.
Once the pain drugs have worn off and you are able to get out of bed safely, the catheter in your bladder will be removed. This will usually be before lunchtime. The nursing staff will observe that you are able to pass your urine normally afterwards. You need to tell them if you have not passed urine within six hours after the catheter is removed.
The Next Couple of Days
You will be able to have a shower with less and less help.
You will progress to walking without the rollator and start taking walks yourself. Your physiotherapist will make sure you can cope with stairs and will supervise your progress.
The Day Of Discharge
Once you are walking safely and are able to look after yourself, and only need tablets for pain, you will be able to go home. You may travel home in a car seated in an upright position, but you should stop for a break if the trip is longer than half an hour or so. If you live more than one hour (100 km) from Brisbane, it may be better that you stay in Brisbane for up to a week after surgery depending on your mode of transport home. Alternatively, you may travel by plane 1 week after surgery.
Your wound will be reviewed prior to hospital discharge and the dressing will be changed.
When You Get Home
You can expect some pain around the wound area in your back and down your legs. The leg pain may come and go for several weeks after surgery but is not as severe as the pain was before surgery. This is normal and you should not be concerned. Your post-operative back pain will gradually decrease after the first few weeks. You should take your painkillers on a regular basis for the first two to three weeks and then you should be able to gradually decrease and cease these. If you become constipated, you may need to increase your fluid or fresh fruit intake or obtain appropriate medication from the chemist.
You should make an appointment with your GP to remove your dressing about ten days from surgery. If it falls off before this and the wound is clean, you should not worry. There are no stitches to remove as they are dissolving and under the skin. As the body dissolves the stitches, there is sometimes a mild reaction around the wound, seen as some redness and inflammation. You should wear your stockings for at least three weeks or until normal activities are resumed.
You should follow the guidelines given to you by your physiotherapist with regard to physical activity and your exercise programme. Generally, you should increase your activity level slowly with an aim to be back to most activities at six to eight weeks. You will usually find sitting to be the least comfortable activity and you will need to gradually build up your sitting, standing and walking tolerance.
You should endeavour to complete your exercise programme as directed by the physiotherapist and to take progressively longer walks building up to 30 minute sessions twice daily. Once your wound has healed, you may do pool work as advised by your physiotherapist.
You should avoid sudden twisting and bending movements of your spine and should not stretch past the point of pain. Reach for objects on the floor by bending your knees. Minimise work done with arms over your head. You should not lift, pull or push anything heavy (i.e. anything over 5 kg) until you have been reviewed by Dr Licina at seven to eight weeks post-op.
You should not sit in low or soft chairs. You should continue to sleep on your back or on your side with a pillow between your knees for the first month. If a fairly passive role is taken, you may resume sexual activity 4 to 6 weeks after your operation.
You should be safe to drive at three to four weeks. You may return to work at six weeks if you have a sedentary job such as administrative or clerical, or eight weeks if your job is more physical.
We will ring you during the following week after your hospital discharge to check how you are and remind you of your post-op appointment with Dr Licina. The appointment will be at seven to eight weeks after surgery and you will also have an x-ray on this day. The cost of this post-op visit (not the x-ray) is included in the surgical fee. Any subsequent visits pertaining to this surgery will be charged at the rebate rate.
You should see your local doctor or contact your surgeon if:
- You develop severe and constant leg or back pain
- You have bleeding or discharge from your wound
- You are unwell and have a fever
- You require a script for further painkillers