In case of abnormal and excessive motion at vertebral segment results in severe pain and disability seen in

• Lumbar Degenerative Disc Disease-spinal stenosis
• Lumbar Spondylolisthesis (isthmic, degenerative, or postlaminectomy spondylolisthesis)
• Other conditions such as weak or unstable spine (caused by infections or tumors), fractures, scoliosis, or deformity

• Posterolateral fusion: bone graft between the transverse processes in the back of the spine

Interbody Fusion: graft where the intervertebral disc between vertebrae is removed and a bone graft is placed in the space between the vertebrae. A plastic or titanium device may be placed between the vertebrae to maintain spine alignment and disc height. The types of interbody fusion are:

• Anterior lumbar interbody fusion (ALIF) – the disc is accessed from an anterior abdominal incision
• Posterior lumbar interbody fusion (PLIF) – the disc is accessed from a posterior incision
• Transforaminal lumbar interbody fusion (TLIF) – the disc is accessed from a posterior incision on one side of the spine
• Transpsoas interbody fusion (DLIF or XLIF) – the disc is accessed from an incision through the psoas muscle on one side of the spine
• Oblique lateral lumbar interbody fusion (OLLIF) – the disc is accessed from an incision through the psoas muscle obliquely

Anesthesia

• Surgery is performed in general anesthesia, the patient will be fully asleep.

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Patient position

• Patients are positioned in the prone (lying on the stomach) position, generally using a special operating table with special padding and supports.

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Procedure

• A 2-3 inches longitudinal incision is made in the midline of the low back, directly over the correct level of the herniated disc, confirmed with intraoperative fluoroscopy. Retractors are used and muscles are dissected subperiosteally to expose the targeted spinal level. A portion of the lamina partial or whole lamina (complete laminectomy) is removed along with the surrounding hypertrophied ligaments and osteophytes with or without discectomy to decompress the nerve root and dural sac adequately. The bone graft will be placed between the affected vertebrae to join them. Sometimes, the graft material is inserted between the vertebrae in special cages. Followed by the insertion of pedicle screws and connection with rods bilaterally. The added stability provided by screws, and rods helps the spine to heal faster and with a higher rate of success. The wound area is usually washed out with sterile water containing antibiotics. The deep fascial layer is closed with strong non-absorbable sutures, while is closed with subcuticular self-absorbable sutures leaving a minimal scar. The total surgery time is approximately 2 hours for a single-level surgery.

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Post-Operative Care

• After 1-2 hours of monitoring in the recovery room, patients are shifted to ward. Oral fluid intake started after 4 hours and gradually switched to a full diet. Most of the patients can stand and walk by the next morning with good pain tolerance and can be sent home accordingly in 2-3 days.

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Home Care

• To follow proper techniques of getting in and out of bed and walking independently. Should walk and stay active as much as possible. Can climb stairs if required. The patient should avoid prolong sitting (>45-60 min) and avoid bending at the waist, lifting (more than 2-3 kg)

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Brace

• Usually not required to wear a back brace after surgery, however, one can wear it if found comfortable and getting some support while standing and walking.

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Wound Care and follow up

• Before leaving the hospital, dressing is changed and surgical drain is removed and a waterproof dressing is applied to the surgical wound. the patient can take shower and will be called on the 5th post-op day for a dressing checkup and change of medication if needed.

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Return to work

• The patient can resume light work or driving once the pain is tolerable, usually in a week to 10 days. Avoid bending and twisting and no strenuous activity including yard work, housework for the next 2-3 weeks.

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Complications

Lumbar fusion surgery is generally considered a very safe procedure, however, like any other surgery, there are several risks and complications associated with the procedure are:

• Operative wound infection
• Hoarseness of voice and difficulty in swallowing
• Dural tear and CSF leakage
• Bleeding
• Implant related complication- loose screw, broken implant
• Adjacent segment disease
• Pseudoarthrosis or non-union
• Nerve root damage
• Bowel/bladder incontinence
• Deep vein thrombosis, which occurs when blood clots form in the leg

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Result of surgery

• The success rate for lumbar fusion is variable depending upon the diagnosis and type of fusion technique done, however, approximately 90% of patients experience significant long-term functional outcomes. The overall success of the procedure also depends upon the adequate decompression of nerves and dural sac which inadvertently needed along with the fusion surgery.

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