Reducing motion between the vertebrae to correct alignment and restore disc height

Anterior Lumbar Inter-body Fusion (ALIF)

If surgical treatment is determined to be the best course of action, spinal restoration surgery can be done to reduce motion between the vertebrae, to correct alignment and to restore disc height. During the procedure, most of the disc between the two bones that are to be stabilized is removed and a spacer is placed to restore correct spinal alignment. I also implant bone-forming cells that multiply around the spacer to bridge the space between the vertebrae and allow the bones to grow together, resulting in a “fusion.” Increased stability and restoration of disc height and alignment often result in significant relief of pain down either leg.

The anterior lumbar inter-body fusion (ALIF) is a procedure in which the disc space is fused by approaching the spine through the abdomen instead of through the lower back. There is a small two-inch incision on the side of your lower abdomen and the abdominal muscles are retracted to the side. Since the anterior abdominal muscle in the midline (rectus abdominis) runs vertically, it does not need to be cut and easily retracts to the side. The abdominal contents lay inside a large sack (peritoneum) that can also be retracted, thus allowing me access to the front of the spine without actually entering the abdomen.

Advantages to ALIF Procedure

• Both the back muscles and spinal nerve roots remain undisturbed
• Placing the bone graft in the front of the spine puts it in compression; bone in compression tends to fuse better
• A much larger implant can be inserted through an anterior approach, providing for better initial stability of the fusion construction

Implants and Bone Grafts

Polyether-etherketone (PEEK) is a non-absorbable biopolymer that has been used in a variety of industries including medical devices. The PEEK cages are used as struts to replace the diseased disc between the vertebrae. The chemical make-up is compatible with our bodies and they do not interfere with X-ray, CT scan or magnetic resonance imaging, which is very helpful as it allows for better visualization of the healing bone. The elasticity is similar to that of bone. The PEEK implant is placed with allograft, which is cadaver bone that has been sterilized and molded to fit around the implant. It acts as a bridge for your own bone to grow into and eventually “fuses” into continuous solid bone between the vertebra above and below it.

If further stabilization is required from behind, such as placement of rods, plates or screws, then I might move you to a face-down position to perform a second procedure from the back to give added stability while the fusion heals over the next three to six months.

Before your surgery date, you will undergo a pre-operative medical evaluation and a surgical risk assessment by the hospitalist group where your surgery will take place. You will be instructed to stop taking weight loss supplements, herbals, aspirin, non-steroidal medications and blood-thinning medications several days prior to surgery to help reduce blood loss. Any dental work, including but not limited to routine dental cleaning, root canals or tooth extraction, should be done no closer than six weeks before or after your surgery.

After Surgery

Total recovery time is relatively short. Most patients are able to return to their normal activities within a few weeks or months after surgery. Most patients spend one night in the hospital following surgery if they are physically active prior to surgery. The surgical incision will be covered with a band-aid or small dressing. You may have a Foley catheter in your bladder for urination, which would have been placed when you were under anesthesia in the operating room. It is removed the next day following surgery. Patients are apprehensive about this, but it does not hurt.

Soon after surgery, if you can tolerate liquids, you may try regular food as tolerated. Go easy at first—it is normal to feel nauseated after having general anesthesia. Let your nurse know if you feel nauseated.

You will be provided physical therapy for walking while in the hospital and will even walk with nursing assistance in the hallway the night after your surgery. Most people are strong enough to go home directly from the hospital with assistance from friends or family the day after surgery.

Some people need a walker for the first few days following surgery until they are stronger and more confident with walking. If you already have a walker at home or plan to borrow one, please bring it with you on the day of surgery so that the hospital physical therapist can make any necessary adjustments. Be sure to label it with your name! If you don’t already have a walker, one will be provided for you to take home if needed.

Download Discharge Instructions

Pain Medications: In the hospital, your pain control will be transitioned from intra-venous self-administered medication (push button) to pain pills the next morning. You will be provided a prescription for the oral pain medication that works for you, which may be obtained on the way home from the hospital. Please remember that narcotic pain medications cause the intestines to move more slowly, which allows more time for your body to reabsorb water from your intestines. This can cause your stool to become dry and hard, thus causing constipation. It is recommended to take an over-the-counter stool softener (Colace, Miralax, Senekot-S, Dulcolax or Milk of Magnesia) while you are taking narcotic pain medication and to drink plenty of fluids. Your pain medication may contain an ingredient called acetaminophen or APAP. That is the generic name for Tylenol. Keep track of how many tablets you take a day and do not exceed 4,000 mg of acetaminophen in a 24-hour period. Excessive Tylenol intake causes liver damage. After your surgery, do not take non-steroidal medications, such as, Motrin, Aleve, ibuprofen, Relafen, Indocin, Naprosyn or Naproxen for three to six months. These medications inhibit bone fusion healing. I will let you know when it is safe to resume this class of medication. If in doubt about taking any pain medications, please call my office to check. You should no longer require narcotic pain medication for longer than four weeks after surgery.

Wound Care: Keep your incision clean and dry. There will be sutures at the top and bottom of your incision that may need to be removed at your first post-op appointment. At times, I choose to use “skin glue” called Dermabond that does not require external sutures. If you feel the edges of this clear coating, do not peel or pick. It will come off over time. There may also be strips of tape across your wound called Steri-Strips. Please leave these in place, even if they begin to curl up at the edges. They will be removed by me or my assistant at your first post-op appointment. Once you no longer notice drainage on the dressing or band-aid, you don’t need to continue wearing it. Do not apply any ointments, peroxide or betadine to the incision, as these may inhibit new skin cell growth and delay complete healing of your incision. If your incision lies directly underneath your pant waistline, you may wish to keep a dressing on it to avoid friction from the waist band.

Bathing: No tub bathing or swimming for six weeks, but you may shower two or three days following your surgery. Let water run over the incision, while turning away from the full force of the stream, pat it dry and then let it air dry.

Nutrition: Drink a can of Boost or Ensure nutritional supplement at each meal until you are back to eating three regular, nutritious meals per day. Proteins are the building blocks of healing.

Initial Activity at Home:

• No bending, twisting, stooping or lifting over five to ten pounds for at least eight weeks after surgery
• Sleep on your back or side opposite the surgery with pillows under or between the knees for support
• First week: Walk short amounts in the house every 10 to 15 minutes. Stairs are okay with help.
• Second week: Repeat first week but outside, weather permitting
• Third week: Walk up to a half mile per day, divided doses
• Fourth week: Walk up to one mile per day, divided doses
• Third month: Walk up to three miles per day
• No driving for the first two weeks and must be off narcotic pain medications before driving
• Use good body mechanics (always bend with your knees to lift or to pick something up from the floor)
• Physical therapy may be prescribed for you later in your recovery, depending on your progress

Follow-up: Your first post-op appointment will be about two weeks after surgery; however, if you have concerns prior to this date, I will see you back sooner as needed. The tiny suture knots at each end of your incision will be painlessly removed and X-rays may be taken. Subsequent follow-up appointment intervals will be based on how you are progressing.

Return-to-Work: Status is determined on each individual’s progress, depending on the type of work you do and depending on the baseline of your health and activity level prior to the surgery. In general, you may expect to be off work for the first two weeks following your surgery. You may then qualify for light duty sit-down work depending on your progress. It may take three to six months before you can return to physically demanding work, such as construction or heavy lifting. You should not drive a car, operate heavy machinery or make important decisions while you are still taking narcotic medications.

Informed Consent

Prior to surgery, you will be asked to sign a form that is called “Informed Consent.” After considering the chances of benefit from surgery with the chances of a complication, you must be the one to make the final decision of proceeding with surgery. By signing, you are acknowledging that you understand the potential risks, complications and benefits to the procedure and that you wish to proceed. Below is the list of potential risks and complications of this procedure:

• Heart attack
• Stroke
• Death
• Vascular or organ injury
• Pulmonary embolism (a blood clot in the lungs)
• Deep venous thrombosis (a blood clot in the veins)
• Ileus (a temporary slow-down of the intestines causing constipation, vomiting, and bloating)
• Dural tear (a tear in the lining of spinal cord resulting in spinal fluid leak and headache)
• Paralysis
• Failure to improve the painful symptoms
• Continued back pain
• Failure of the fusion
• Implant failure
• Loss of blood requiring a blood transfusion with the associated risk of AIDS or hepatitis
• Re-operation for mal-positioned hardware or inadequate decompression of the nerve root
• Difficulty with flexion of the hip