Lateral Lumbar Interbody Fusion

What is a lateral lumbar interbody fusion?

Lateral: surgery will be done by going through the side or lateral aspect of your spine

Lumbar: lower part of your spine

Interbody: between 2 vertebrae

Fusion: process of stopping motion between two bones to improve stability

So, a lateral lumbar interbody fusion is a spinal fusion that fuses a part of your lower lumbar spine by going through the side (lateral).

There are many advantages of doing a lateral fusion vs a posterior fusion

1. Smaller incisions-typical incisions are 3-4cm in length as compared to posterior incisions which can be larger.
2. Less invasive-spares the posterior back muscles from major disruption associated with the traditional open back surgery.
3. Quicker recovery– varies from patient to patient but patients generally leave the hospital and recovery quicker.
4. Less postoperative pain-smaller incision means less pain
5. Quicker operation-as compared to the traditional posterior spinal procedures

The Procedure

Anesthesia & Induction

• Your anesthesiologist will talk to you about the specifics of his/her plan for the procedure. You will find out what medications and what type of anesthesia will be used to keep you pain free and comfortable throughout the operation.
• In general, most patients will undergo general anesthesia during spine procedures meaning you will be asleep and wont remember or feel any pain during the procedure itself. Patients may have pain upon waking up from anesthesia, but this will be managed with intravenous and oral pain medications.
  • After a breathing tube is placed and you are fully asleep, you will be positioned on your side on the operating room table.
  • Surgery will not begin until you are asleep and given pain medications so that you don’t feel any pain during the procedure.

Approach

A small skin incision is made on the side of your belly.  

Performing the Decompression

• Before removing the diseased/herniated disc, Dr. Webb will confirm that he is operating at the correct level by taking an x-ray while you are asleep. 
  • When the level is confirmed, Dr. Webb will then begin the decompression (removing the areas of compression from your spinal cord) portion of the procedure.
  • The disc that is pressing on your spinal cord/nerves will be removed with the use of special instruments and tools.
  • Dr. Webb will then ensure that your spinal cord and nerves are free from compression.

Performing the Fusion

• After the spinal cord has been decompressed and all the diseased disc material removed, this area/void needs to be replaced with something so that it can fuse together.
  • This area will now be replaced with bone graft material and a metal or plastic cage.
    • The bone graft will help this level to fuse.
    • The metal or plastic cage will indirectly decompress your spinal cord and nerves by “jacking open” your disc space.
      • This is similar to “jacking up” and changing your tires on your car after a flat tire. When your car is “jacked up”, there is more room for the tire to be placed and also relieves pressure off of the tire. Similarly, in spine surgery, when a metal or plastic cage is placed in between your bones, this “jacks up” the space that houses your spinal cord and nerves, giving them more room.

Closure

• The retractors that held the muscles apart will now be removed and will be allowed to fall back into their normal position.
• Dr. Webb uses absorbable sutures to close your wound. These sutures do not typically need to be removed and will absorb on their own.

Frequently asked questions

What can I expect after surgery?

After surgery you will be transferred to the recovery room, also called the PACU (post anesthesia care unit). After you have awaken from the anesthesia, you will then be transferred to your hospital room. This is typically when your family members can visit you.

Either the same day or the following morning after surgery, a physical and/or occupational therapist will begin your therapy. During your hospital stay, you will be given medications to help with pain and IV antibiotics to minimize the risk of infection. Most patients go home the same day of surgery but some patients may spend 1-2 nights in the hospital and are discharged home after:

1. You are tolerating a diet
2. Your pain is controlled
3. After you have worked with and passed physical therapy.

Walking after surgery is highly encouraged, even the same day of surgery!

What kind of recovery can I expect after surgery?

Recovery from a lateral spine surgery generally takes 12 weeks, but patients continue to heal for up to a year after surgery. This is because the bones have to fuse together which takes around 3 months. Every patient is different.

When can I return to work and/or activities?

Walking is highly encouraged, immediately after surgery and throughout your postoperative period. Most patients can return to a light desk job or household activities by 2-3 weeks after surgery. Patients with jobs that require heavy lifting, strenuous labor, or high impact activities such as running, biking, skiing, sports will not be allowed to return until Dr. Webb clears you, usually around 8-12 weeks.

What complications can I expect after surgery?

Inadequate relief of symptoms

• Dr. Webb is very particular about making sure we target the right level of your spine that may be causing your symptoms.
• Inadequate relief of symptoms after surgery could be due to a number of things including: multiple levels that are degenerated or worn out that will not be addressed in surgery, surgery done on the wrong level, or advanced and severe spinal cord compression that may be irreversible.
• Injections are confirmatory and are very predictive of how well you will do with surgery. These spinal injections, usually done before surgery in the conservative treatment period, are essential in determining which level of your spine is the cause of your symptoms.
• Just because you have multiple degenerated areas of your spine according to your imaging studies (MRI, X-ray, etc.), does not mean every level needs an operation.

Nerve damage, causing leg weakness or pain

• There are small nerves that control the muscles in your legs and foot that are close to where Dr. Webb will be working. 
• Dr. Webb carefully works around these nerves and ensures they are not damaged during surgery.
• If these nerves become irritated during surgery (sometimes just by touching or moving them), these nerves may cause pain for weeks to months after surgery until the nerve recovers. During this time, Dr. Webb may prescribe you nerve medication or steroids to help calm the inflammation down.
• Some patients may wake up with thigh pain and/or weakness because there are nerves overlying the psoas muscle that can become irritated or injured. In these cases, patients report weakness in flexing their hip (elevating their leg such as when marching). This usually gets better over time.

Dural tear

• The dura is the outer layer of the spinal cord. Sometimes, this layer can be especially thin in certain patients and very friable. During surgery, if there is a small tear in this layer, Dr. Webb will attempt to repair it. This is a not a very common complication, but definitely one that needs to be known.
• Sometimes after a dural tear is repaired, Dr. Webb may ask that you lay flat for 24 hours after surgery. This is done to give the repair time to heal and to ensure his repair does not come apart.
• Fortunately, multiple studies have shown that having a dural tear repair does not affect your outcome from surgery.

Infection

• Very low risk (<1%) but this risk is increased if you are overweight, immunosuppressed, on chronic steroids, or diabetic.
• Antibiotics will be given before surgery starts and also given for 24 hours after surgery while you are in the hospital to decrease the risk of infection.

Bleeding

• Very low risk, but increased if you are taking blood thinners, fish oil, herbal medications or have a clotting disorder.
• These medications will need to be stopped before surgery.
• Sometimes, a special tube called a drain will be placed during surgery. This tube is to collect any blood or fluids that can collect after surgery. This drain will be removed before you leave the hospital, usually the next day after surgery.

Spinal cord or Nerve damage

• Low risk
• A neuromonitoring technician is a professional trained in the monitoring of your nerves and spinal cord.
• This person (along with a Neurologist) is part of the team that will be taking care of you during surgery and will help Dr. Webb monitor your nerves and spinal cord throughout the procedure.
• You will be able to meet this person the morning of surgery and ask any questions about their role in your care.
• Generally, after you are asleep from anaesthesia, this technician will place small wires on your legs and arms so that the nerves and spinal cord and be monitored during surgery.

Lateral Lumbar Interbody Fusion