LUMBAR CORPECTOMY with cage and plate GOALS

LUMBAR CORPECTOMY with cage and plate GOALS
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The goals of a corpectomy are to remove any pressure from the adjacent spinal cord, and to stabilize the spine in a pain-free, normal alignment.

INTRODUCTION
Corpectomy, or vertebrectomy, refers to the removal and replacement of a vertebra and the intervertebral discs above and below it. This is usually done because they are compressing the spinal cord in the back. A length of bone or a synthetic cage containing bone fragments or artificial bone replaces the vertebra and discs to form a strut to maintain the normal height and alignment of the back. The bone graft will fuse with the vertebra above and below, to form a solid, stable mass. A corpectomy can be used to replace a number of adjacent vertebrae, in which case an additional posterior fusion with metal screws and rods may be required to maintain stability of the graft while it fuses.

INDICATIONS
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If a vertebra is damaged and needs replacing, or the front of the spinal canal is being compressed, causing pain, weakness or numbness in the legs, then a corpectomy may be required. The structures that can compress the anterior spinal cord include the vertebral body, the intervertebral disc and the posterior longitudinal ligament. The diseases that can cause this compression include infected, malignant or fractured vertebral bodies, degenerative disc disease and other diseases causing spinal instability.

ALTERNATIVES
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The non-surgical alternatives to corpectomy may be
– activity modification
– weight loss
– aerobic exercise, such as walking, cycling, and swimming
– strength and flexibility exercises
– physical therapy
– hydrotherapy
– heat and cold pads
– acupuncture
– pain-relieving medications such as acetaminophen or paracetamol, non-steroidal anti-inflammatory drugs, glucosamine, chondroitin.

The surgical alternatives to corpectomy may be
– steroid and local anesthetic injections
– surgical fusion
– disc replacement surgery, or arthroplasty.

INFORMED REFUSAL
It is your right to delay or refuse the recommended treatment for your condition. However, this delay or refusal may lead to the worsening of your symptoms, such as increased back pain or leg pain, pins and needles, weakness or numbness. You should ask your doctor what might happen should you choose not to undertake the recommended treatment.

BEFORE
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Before the corpectomy
- a doctor will perform a medical examination and any necessary tests to ensure that your general health will permit an anesthetic to be given and the procedure to be performed
- you will be advised when to stop any medications that will increase your bleeding risk ie aspirin, non-steroidal anti-inflammatories, anti-coagulants, vitamin E, glucosamine and some herbal medicines (including chamomile, danshen, garlic, gingko, devil’s claw, ginseng, fish oil, willow bark, feverfew, goji berries)
- you may be admitted into the hospital on the day before or on the morning of the procedure
- don't eat or drink anything for six hours before the procedure
- wear loose-fitting clothes that are easy to take off and put on. Do not wear any jewelry.
- before the procedure, the skin on your neck will be cleaned and you will be given a general health check.
- an intra-venous line will be placed in to a vein in your arm to administer fluid and medications
- you may be given a sedating medication to make you drowsy before being given your anesthetic
- you will be given a general anesthetic that will put you to sleep
- let your doctor know if you develop a fever, cold or flu symptoms before your scheduled procedure.

GOALS
The goals of a corpectomy are to remove any pressure from the adjacent spinal cord, and to stabilize the spine in a pain-free, normal alignment.

TECHNIQUE
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You will be lying on your back. Your abdomen will be cleaned. An incision will be made and the overlying muscles moved to the side. Your surgeon will confirm the correct vertebra for removal by using x-ray imaging. The inter-vertebral discs adjacent to the vertebral body to be replaced, will be incised and removed. Then the vertebral body will be channeled. The vertebral body end-plates will be prepared for the graft. Then the cage graft will be inserted. A plate will be screwed into position to assist immobilization of the spine, and bone chips will be added to assist bone fusion. X-rays will be performed to check the cage and plate’s position. The muscles will be replaced and the wound closed with sutures. A drainage tube will be left in the wound.

NO SMOKING
Smoking damages every part of your body and decreases the chance of a successful procedure. If you smoke, you should stop now.

EXPECTATIONS
The expectations of a corpectomy are
– the procedure will take about one hour
– ninety percent of clients report a good or excellent relief of pain
– the hardware usually doesn't cause any problems, and is left in place permanently
– there may be some remaining back pain after the fusion from pre-existing degenerative disease elsewhere in the back.

REHABILITATION
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Rehabilitation from a corpectomy -
– you will spend about an hour in the recovery room before being taken to a high dependency or intensive care unit for overnight observation. Then you will return to your ward bed
– you will spend four or five nights in hospital
– your bowels may not open for a few days after the procedure
– use your prescribed pain medication, muscle relaxers and laxatives as directed
– you must avoid bending, lifting, twisting and sudden movements . Don’t lift anything heavier than a milk carton for two weeks. Most people can resume their normal daily activities after three weeks
– walking is the only exercise permitted in the first six weeks.
– your clinician will specify when you can start your daily exercise program. A physical therapist will guide you through the exercise program
– check your wound twice a day. If you notice any redness, swelling, green or yellow discharge, or opening of the wound, see your family doctor immediately and call your surgeon
– you may have small bandages called steri-strips on your incision. Keep these dry. These can be removed when they begin to peel off by themselves or after one week. Otherwise external sutures will be removed in one to two weeks.
– you should keep the wound dry. Otherwise showering is permitted, but avoid baths, swimming and creams for one week. The incision may be cleaned gently using regular soap and water. Only rub gently and don’t use perfumed soaps.
– you may be able to return to light sedentary work in six weeks
– you should have your wound reviewed by your family doctor one week after the procedure
- radiological imaging to confirm fusion has occurred, and a follow-up appointment with your clinician will be booked for six weeks after the procedure.

ON-GOING CARE
You have a weak spot in your back, and surgery can never return it to full strength. You will need to engage in lifelong back care to reduce the risk of further neck problems. You should always maintain correct posture, lose any excess body fat, continue your daily exercise program and avoid unnecessary stresses on your back.

POTENTIAL COMPLICATIONS OF A LUMBAR CORPECTOMY
ALLERGIC REACTION TO MEDICATION
An allergic reaction to the medications used can occur. This can cause a rash, swelling of the eyelids, hands, joints and throat, difficulty breathing, low blood pressure and death. These reactions are easily controlled with the right equipment and medications.

ADHESIONS - ABDOMINAL
Scar tissue formation is part of the natural healing process for all body tissues. In most people, scar tissue doesn't cause any problems. Adhesions however, are abnormal bands of scar tissue that take month or years to form. Abdominal adhesions often occur after abdominal surgery. They become attached to the abdominal wall and internal organs, and can cause pain. They can block the intestines, leading to an obstruction. Such adhesions may need surgical removal.

ADJACENT SEGMENT SYNDROME
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When one area of the spine has been fused and no longer allows any movement there, it transfers increased stress to the adjacent segments. This can increase wear and tear in these adjacent intervertebral discs, facet joints, pars articularis and ligamentum flava, and can lead to increased mobility and pain. These changes are called adjacent segment syndrome or transitional syndrome. Adjacent segment syndrome is more likely with instrumented fusion (pedicle screws, rods), multiple segments fused, abnormal fusion alignment, facet joint injury during surgery, increased age, and pre-existing degenerative changes. Some twenty percent of fusion patients will eventually need another operation to treat the adjacent segment degeneration symptoms by nerve decompression and extension of the fusion. Some pre-existing degenerative disease in the adjacent segments can be expected as part of the initial disease process, and it can be difficult to determine whether the degeneration is due to the progression of this pre-existing disease or due to adjacent segment disease. Only symptomatic adjacent segment disease requires treatment.

ANESTHESIA
Anesthesia is used so you will feel no pain during the procedure. Anaesthesia can be
Local – where the medication is injected into the skin around the site of the surgery to numb only surrounding tissues
Regional – where the body part is anesthetized by numbing a major nerve or part of the spinal cord.
Conscious sedation – where a full anesthetic is not given, rather, medications are used to create a near-sleep relaxed state.
General – where you are rendered unconscious and temporarily paralyzed. In this instance, medication is given to you through an IV line, and machines breath for you and monitor you, along with your Anesthesiologist. Most spinal operations require general anesthesia, so that you won’t move during the operation.

There are many possible complications from a general anesthetic.
Common complications (1-10% of general anesthetics) include
- post-operative nausea and vomiting – due to operation, anesthetic and pain-relieving drugs. May last a few hours to several days, but can be treated with medication.
- aches – due to lying still on a firm operating table for a long time.
- blurred vision, dizziness – due to low blood pressure from fluid loss or medications. Can be treated with fluid replacement and medications.
- bruising/pain – around injection and intravenous cannula sites. Usually settles by itself. Cannula can be moved if necessary.
- headache – due to the operation, the anesthetic, dehydration or anxiety. May last a few hours, but can be treated with medication.
- itchiness – due to an allergic reaction to drugs, sterilising fluid or sutures, or as a side effect of strong pain-relieving medication (opiates).
- memory loss/confusion – more common in older people who have had a general anesthetic. There are many causes, and may last a few days or weeks.
- pain from drug injection – some drugs cause pain when they are injected.
- shivering – caused by medications, stress or low body temperature during the surgery. Can be treated with a hot-air blanket.
- sore throat – from the breathing tube in your throat. May last a few hours to a few days. Can be treated with pain-relieving lozenges.

Uncommon complications (0.1% of general anesthetics) include
- anesthetic awareness – if you are ill, your Anesthesiologist my use more muscle relaxants and less general anesthetic to reduce your anesthetic risks. However this may lead to you being aware of your body and your surroundings during the operation. Anesthesiologists use monitors to observe your body’s reactions and adjust the medication doses. If you think you have been aware during the operation, your Anesthesiologist will want to know afterwards.
- bladder problems – depending on operation and medications, men may find it difficult to urinate, while women tend to leak urine after the operation. If necessary, a urinary catheter is used to drain the bladder until control returns.
- chest infection – may lead to breathing problems, but can be treated with antibiotics. More likely to occur in people who smoke.
- lip, teeth, tongue injury, jaw dislocation – can be caused by difficulty placing the breathing tube, or by clenching your teeth as you recover from the anesthetic.
- muscle pain – can be caused by a muscle relaxing drug (suxamethonium) used during emergency surgery if there may be food in the stomach, to prevent vomiting.
- slow breathing – can be due to some pain-relieving drugs or muscle relaxants. Can be treated with medications.
- worsening of existing medical condition – your Anesthesiologist will monitor your body closely and act to eliminate or reduce any medical complications.

Very rare complications (0.0005 to 0.01% of general anesthetics) include
- death – is very rare, and usually occurs when four or five complications occur simultaneously. Death from anesthesia occurs at one every 200,000 anesthetics.
- equipment failure – vital equipment can fail, but this is very rare, and monitors give immediate warnings.
- eye damage – eyelids are taped shut while you are asleep, to protect your eyes. Rarely, sterilising fluid may leak under the eyelids, or you may rub your eyes while waking from the anesthetic. Any discomfort is usually temporary.
- nerve damage – stretch, compression, incision or puncture. Usually recovers within three months.
- serious allergic reaction to medication – are noticed and treated quickly, but can very rarely cause death, even in healthy people.

You should discuss these with your Anesthesiologist.

ARTERY INJURY – COMMON ILIAC
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The common iliac artery in the lower abdomen supplies blood to the pelvis and leg on that side. Injury to the artery is uncommon, is usually obvious, and is repaired immediately.

ARTERY PERFORATION
Arteries are large blood vessels that can carry blood under pressure throughout the body. Your doctor will be very careful to avoid injuring arteries near your operation site. An artery perforation can result in significant bleeding and blood loss. This is very uncommon. If an artery is perforated, the artery can usually be repaired and the lost blood can be replaced by a blood transfusion. A specialist vascular surgeon is often asked to repair arteries. Late consequences of artery injury include fistula, hemorrhage, pseudo-aneurysm, thrombosis, emboli and death.

ARTERY THROMBOSIS
Arteries are large blood vessels that carry blood throughout the body. Sometimes they need to be moved to the side or compressed to allow access to the operation site. This pressure can lead to a clot forming within the artery, a process known as thrombosis. This is most likely in older patients with pre-existing blood vessel disease. A large clot can block the artery, while a small clot can dislodge, becoming an embolus, which travels and eventually blocks a small artery. Blocked arteries lead to insufficient blood flow, or ischemia in the tissues supplied by the artery. This can cause damage to these tissues, which may be permanent, depending on the duration of the blockage. Ischemia in the brain can cause a stroke. In the spinal cord it can cause paralysis and altered sensation. In the legs, it can cause pain and gangrene.

BACK PAIN
Back pain after the procedure is to be expected. This may be similar or different to the original back pain. It is usually temporary. Sometimes the original back pain can persist, or it can be worse.

BONE GRAFT DISPLACEMENT
During a bone graft, fragments of bone are placed in the space between two bones. If the space is kept still, the bone fragments will fuse together and to the adjacent bone to form one solid, stable, pain-free piece of bone. However, if excess movement occurs between the adjacent bones before the bone fragments have fused, the bone graft can become displaced. This can cause or risk causing pain, injury to adjacent tissues, mal-alignment (of bones) or non-fusion of bone (non-union, pseudoarthrosis). This may require another operation to correct.

BONE GRAFT MISPLACEMENT
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During a bone graft, fragments of bone are placed in the space between two bones. If the space is kept still, the bone fragments will fuse together and to the adjacent bone to form one solid, stable, pain-free piece of bone. Your surgical team uses all available equipment and techniques to ensure the bone grafts are placed in the best possible position. Rarely, because of anatomical variations, equipment limitations or system failures, the implants are not optimally placed, and a further procedure may be required depending upon the results of the initial procedure.

CAUDA EQUINA SYNDROME
The cauda equina is the bundle of nerves below the spinal cord in the spinal canal. They transmit movement and sensation information to and from the lower body and also manage the bladder, bowels and sexual function.  Cauda equina syndrome occurs when pressure is applied to these nerves, and they are inhibited. If the pressure is not removed quickly, permanent nerve damage can occur. Cauda equina syndrome can cause leg paralysis and numbness, impaired bladder or bowel control, loss of sexual sensation and other problems. The pressure on the nerves can be due to damaged disc or bone, tumour, infection or bleeding. The longer and more severe the compression, the longer and less likely the recovery. Severe compression greater than 24 hours may never recover. Milder compression may take several years to recover. Post-operative cauda equina syndrome is usually due to an epidural haematoma, and requires an urgent procedure to remove the collection of blood.

CEREBROSPINAL FISTULA
A tear in the dura, which contains the spinal cord and the cerebrospinal fluid, can allow cerebrospinal fluid to leak out through the wound, and onto the skin. This is called a cerebrospinal fistula. It may cause headache when standing, back or limb pain, nausea, vomiting, dizziness, ringing in the ears or eye pain from bright light. There is a risk of infection and meningitis. The dural tear may reseal spontaneously, or it may require bed rest, a blood patch procedure, drainage, or surgery to repair.

DEATH
No surgeon can guarantee a risk-free operation. All operations have some risks. Some risks are minor inconveniences, while some are major disabilities. The risks increase with repeat operations on the same area of your body. Your entire medical staff will do their best to eliminate all risks to you, before, during and after your surgery. However sometimes, even after the surgery goes well, serious problems can arise that can result in death. These include pneumonia, pulmonary emboli, heart attack and stroke. You should discuss these risks with your Surgeon and your Anesthesiologist.

DEEP VEIN THROMBOSIS
A blood clot that forms inside the large deep veins of the legs is called a deep vein thrombosis, or DVT. Any surgery can put you at an increased risk of deep vein thrombosis because the blood’s clotting mechanism is switched on by the body trying to stop the bleeding associated with the operation. As well, injury to blood vessels, immobility and anesthetic effects during and after the surgery make it easier for clots to form and grow. Also some people have additional DVT risks such as age greater than fifty years, varicose veins, previous heart attack, cancer, atrial fibrillation, ischemic stroke, diabetes, previous DVT, heart failure, combined oral contraceptive pill use, smoking, obesity, leg weakness, and inherited clotting abnormalities. You should tell your doctor if you think you have any clotting problems.
A DVT can cause two problems. It blocks the blood flow from the legs back to the heart, causing swelling of the legs and pain. If the clot doesn’t dissolve properly, the swelling and discomfort can become permanent. Secondly, and more seriously, a part of the clot in the leg can break off and travel up the veins to the lungs, where it blocks the smaller lung blood vessels and stops the blood flow. This is called a pulmonary embolus, or PE. If the PE is large enough or there are many of them, it can cause death. It is important to minimize your risk of deep vein thrombosis and pulmonary embolism. Two preventative techniques are used. The first applies mechanical means to increase the blood flow through the legs, and includes support stockings, sequential compression devices, leg exercises in bed, and getting out of bed as soon as possible. The second technique uses chemical means to slow down the blood’s clotting process. These include heparin, heparinoids, low molecular weight heparin and coumadin. However medications that thin the blood to prevent clotting will also increase the risk of bleeding and hematoma formation. Your doctor will discuss the use of these medications with you. It is normal to use some method to minimize clot formation during and immediately after spinal surgery.

DUROTOMY
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The dura is a thin layer of tissue that forms a sac containing the brain, spinal cord and nerve roots. The sac is filled with cerebrospinal fluid or CSF. The dura can be torn during spinal surgery leading to a leak of the fluid from the sac. This complication is more difficult to avoid during repeat surgery at the same location, or when operating on severe spinal narrowing or a large disc herniation. A dural tear with the leakage of cerebrospinal fluid, can cause a headache when standing, back or limb pain, nausea, vomiting, dizziness, ringing in the ears or eye pain from bright light. A continuing leak can lead to a cerebrospinal fluid cyst under the skin, or a leakage of fluid from the wound. Dural tears can reseal spontaneously, or it may require bed rest, a blood patch procedure, drainage, or an additional operation to repair.

DYSESTHETIC LEG PAIN
Sometimes a burning hypersensitivity leg pain occurs after the procedure. This is called dysesthetic pain. This pain may resolve over a few days, but can be permanent. The cause is not clear.

EPIDURAL HEMATOMA
If bleeding occurs into the epidural space around the spinal cord, it may form a collection of blood, called an epidural hematoma. If the hematoma is large, it can compress the spinal cord and nerve roots leading to pain, weakness, numbness and bowel and bladder problems. A surgical procedure may be required to stop the bleeding and remove the hematoma.

EYE INJURY
During the general anesthesia, all care is taken to protect your eyes. They will be taped closed to reduce the risk of drying or scratching the surface of the eye. Should this happen, it usually heals over a day or two. A more serious, and much more rare complication is blindness from pressure on the eyeball or decreased blood flow through the eye, known as ischemic optic neuropathy. Blindness due to ION is a 0.1% risk, and is associated with emboli, prolonged spine surgery in patients greater than seventy years old, prone (face down) position, diabetes, intra-operative blood loss/hypotension, and ankylosing spondylitis (poor position because of neck deformity). Your Anesthesiologist will do all they can to eliminate risk of these problems.

FLUOROSCOPY
Fluoroscopy uses X-rays to obtain instant pictures of the inside of a patient during a surgical procedure. This is very useful when devices need to be accurately positioned. X-rays are a form of ionising radiation. They can potentially cause cancer, reproductive abnormalities, cataracts and radiation dermatitis. Any effect depends on the amount and duration of exposure to the X-rays. During surgical procedures, the exposure is usually not significant. Your doctors will minimize the radiation dose to yourself and themselves by minimising the intensity and duration of exposure and by using lead shields. Pregnant women can wear extra shielding. By way of comparison, a pelvic (AP) x-ray gives a radiation dose of 0.7 mSv, and a pelvic CT gives 10.0 mSv. The world average background radiation level is 2.4 mSv per year.

GASTROINTESTINAL PERFORATION
The intestines are adjacent to the surgical site, and must be moved to obtain access during surgery. Your surgeon will be careful to avoid perforating the intestine. Perforations are difficult to detect, but can be repaired. If not detected, they can lead to serious infection after a few days with pain, fever and bloating. An unseen perforation may need another operation to clean and seal the perforation.

HEMATOMA
During any surgery, some blood vessels will be cut. Your surgeon will stop all significant bleeding before suturing the wound shut. Sometimes bleeding recommences after the operation, forming a collection of blood in the tissues, called a hematoma. The hematoma can cause pain, pressure on adjacent tissues or become infected. It may need to be removed by inserting a drainage tube or performing a surgical operation.

HEMORRHAGE
During surgery, blood vessels must be cut to access the desired location in your spine. Your surgeon will plan the surgical route to avoid large blood vessels, and will ensure bleeding has stopped before finishing the operation. Sometimes, one of these cut blood vessels begins re-bleeding after the operation. If the amount or location of the bleeding is causing you a problem, your surgeon may need to perform a further procedure to stop the bleeding and remove the accumulated blood.

HERNIA - INCISIONAL
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A hernia is a protrusion of tissue through the muscle or tissue that normally contains it. An incisional hernia is when the area of weakness through which the hernia occurs is a previous surgical wound. They can occur at any time, usually due to excess tension applied to the wound before it has healed, or poor healing due to infection, poor nutrition, diabetes, obesity or prior disease. Incisional hernias commonly occur in the abdominal wall. Hernias are covered by skin, and may cause pain and a lump consisting of fatty tissue or an internal organ. They usually become larger and more painful, in which case they are surgically repaired.

ILEUS
Post-operative ileus refers to temporary paralysis of the bowel, usually caused by intra-abdominal, spine or chest surgery and narcotic pain-killing medications. Symptoms include abdominal discomfort and bloating, constipation, nausea or vomiting. Most cases settle within three days by fasting and minimizing the use of narcotic medication. Occasionally, emptying of the stomach by naso-gastric suction tubes and intravenous feeding and fluid is required.

IMPLANT FAILURE
Spinal fusion operations use screws, plates, rods and spacers to hold the vertebrae in correct alignment while the bone fuses together over the first few months. Once the bone fuses, these implants are not necessary. They are left in place if they are not causing any problems because of the surgical risks involved in removing them. Sometimes, before the bone has fused, an implant may break or migrate from its correct position. This can cause or risk causing pain, injury to adjacent tissues, mal-alignment (of bones) or non-fusion of bone (non-union, pseudoarthrosis) and may require a second operation to remove or replace the implant.

IMPLANT MISPLACEMENT
Spinal fusion operations use screws, plates, rods and spacers to hold the vertebrae in correct alignment while the bone fuses together over the first few months. Your surgical team uses all available equipment and techniques to ensure the implants are placed in the best possible position. Rarely, because of anatomical variations, equipment limitations or system failures, the implants are not optimally placed, and a further procedure may be required depending upon the results of the initial procedure.

INFECTION
Infections occur in less than one percent of spinal operations. If the wound becomes more painful or tender, red, hot or swollen, oozes a clear or yellow fluid and doesn’t heal, or if you have fever or chills, the wound may be infected. Your Surgical Team will use sterile instruments, aseptic techniques, antibiotics and regular wound care to minimize this risk. Infections can be :
superficial, involving the skin. These infections usually respond to oral antibiotics and washing the site. Sometimes the wound needs cleaning and re-suturing in the operating theatre.
deep, involving the vertebrae or spinal cord. This is more serious and may require intravenous antibiotics, and further operations to drain the infection. Rarely, infected bone graft or hardware may need to be removed.
Wound infections are more likely if you smoke, have diabetes, are overweight, or if the wound took a while to heal or there was a hematoma.
If you have any concerns, you should contact your doctor immediately.

MALIGNANT HYPERTHERMIA
Malignant hyperthermia is a rare life-threatening condition that is triggered in genetically-predisposed people by some drugs used for general anesthesia. In susceptible people, the drugs cause an uncontrolled increase in skeletal muscle calcium levels and muscle contraction, leading to decreased blood oxygen and increased blood carbon dioxide and body temperature. This can lead to circulatory collapse and death if not quickly treated. Susceptible people may have multiple episodes of anesthesia without developing malignant hyperthermia. Symptoms usually develop within one hour of drug administration. There is no simple test to diagnose susceptibility to malignant hyperthermia. It is usually found during drug administration or suspected if a family member develops the symptoms. While treatment is effective, if you or a family member have experienced malignant hyperthermia, you must avoid the potential trigger drugs. There are safe alternative medications available.

NERVE INJURY – LATERAL FEMORAL CUTANEOUS
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The lateral femoral cutaneous nerve supplies sensation to the front of the thigh. It usually passes under the inguinal ligament in front of the hip, however in 10% of people it passes over the anterior iliac crest. near the site of bone graft removal. It can be injured during bone graft removal or by prolonged pressure while lying on your front during the surgery. Injury causes pain, pins and needles or numbness on the front of the thigh, called meralgia paresthetica. Pressure injuries usually resolve within three months. If the nerve has been cut, the symptoms may be permanent. Anesthetic injections can help with pain management. Occasionally surgery may be required.

NERVE INJURY – LUMBAR
Because the vertebrae surround the spinal nerve roots, operations on the vertebrae can injure the nerve roots within the spinal canal or as they leave the spinal canal through the intervertebral foramen. The nerves can be bruised, stretched, torn or cut while accessing or repairing the damaged vertebra. Locating, protecting and mobilizing the spinal nerves are the most difficult and time-consuming part of most spine surgeries. Your surgeon will be very careful to avoid any injury to the spinal nerves. If a nerve is damaged, the injury can cause temporary or permanent pain or bladder and bowel dysfunction as well as partial or complete loss of sensation or movement in your leg.

NERVE INJURY – LUMBAR SYMPATHETIC PLEXUS
The lumbar sympathetic nerves are located near the lumbar spine. Injury to these nerves during anterior surgery can lead to pain and increased blood supply to the leg on that side. This leg appears redder, drier and warmer. Most people interpret this as coldness of the opposite leg. These symptoms usually resolve over time.

NERVE INJURY – ULNAR
While under anesthesia, your body will be immobilized in a certain position to allow access to the injured region, and to keep your arms out of the way. Sometimes the ulnar nerve in your arm can be inadvertently compressed or stretched at the elbow, leading to pain, numbness or weakness in the hand after the procedure. These symptoms can appear one to four days after the procedure, and usually disappear over a few weeks. Your medical and nursing staff will take all care to minimize risk of this complication.

NON-UNION
Failure of the two vertebrae to fuse into one solid bone is called non-union or pseudo-arthrosis. This occurs in about ten percent of spine fusion operations. Nicotine products, including chewing tobacco, and cigarette and cigar smoking, can slow bone healing and significantly increase the likelihood of non-union. Consuming high doses of non-steroidal anti-inflammatory drugs after the operation can also increase the risk of non-union. Other causes are excessive alcohol intake, the location and number of segments fused, osteoporosis and some medical diseases. Non-union can cause worsening pain, and may cause the supporting hardware to break. Additional surgery may be required to add more bone graft, replace the hardware or add an electrical stimulator to encourage the fusion to heal.

OSTEOMYELITIS
Osteomyelitis is a bacterial infection of bone or the bone marrow. It can occur as a result of surgery, especially after the placement of foreign material in the bone, or as a result of an adjacent infection. It can take up to four weeks after the surgery to cause symptoms, and most commonly causes worsening pain after an initial period of relief. Risk factors include age, smoking, obesity, diabetes, malignancy, chemotherapy, immune suppression, malnutrition, indwelling venous catheters, concurrent infections and extended hospitalization. It is difficult to treat, often requiring weeks or months of intravenous antibiotics. A surgical procedure to clean the area may also be required.

PARAPLEGIA
The spine surrounds and protects the spinal cord. Surgery to the spine can damage the spinal cord. Damage to the thoracic, lumbar or sacral spinal cord can cause loss of movement and sensation in the lower half of the body, known as paraplegia. Paraplegia may be complete, with no movement or sensation below the level of the spinal cord injury, or incomplete with some movement or sensation. Some people with incomplete paraplegia can work unsteadily, but most require wheelchairs or other supports. Urinary and fecal incontinence and impotence are common, and require the use of urinary catheters and a bowel management program (suppositories, enemas, digital stimulation). Paraplegics are at increased risk of pressure sores, thrombosis and pneumonia. Your surgeon and staff will take the utmost care to protect your spinal cord during and after your procedure.

PERITONEAL TEAR
The peritoneum is a thin membrane that lines the inside of the abdominal wall. It can be torn during abdominal surgery, but any tears can be repaired during the surgery. Unseen tears can lead to bowel adhesions or intestinal herniations.

PRESSURE SORES
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Prolonged lying down during the procedure and the post-operative recovery can lead to skin pressure sores over prominent bones. Your medical and nursing staff will carefully place, pad and move you, to prevent this occurring.

RESIDUAL PAIN
Some pain remaining after the procedure is very common. In most cases, surgery can not restore the spine back to a pre-diseased state. Some pain should be expected to come from the area of the operation. In addition, pain from adjacent areas already damaged by the disease, or by their own degenerative problems will most likely continue. Usually any residual pain is mild, but it may be severe or even worse than the original problem.

RETROGRADE EJACULATION
During male ejaculation, the sphincter muscle at the outlet of the bladder contracts to prevent the semen entering the bladder, thus forcing the semen down the urethra. If the sphincter muscle is weak or the nerves that control it are damaged, semen can enter the bladder. This is called retrograde ejaculation. The nerves that control the bladder can be damaged during spine surgery, causing retrograde ejaculation. Retrograde ejaculation is not dangerous, but can decrease male sensation during orgasm and decrease male fertility. If you are male and contemplating having more children, talk to your surgeon about storing your sperm in case this complication occurs. Should this complication occur and pregnancy be desired, the sperm can also be centrifuged from the male’s urine, and the female partner can be artificially inseminated.

URETER INJURY
The ureters drain urine from the kidneys in the loins, to the bladder in the pelvis. The ureters pass near the lumbar spine and can be injured during spine surgery, causing leakage of urine. Injuries can be immediately repaired during surgery. Unseen injuries can cause blood in the urine, abdominal pain, distension, ileus and infection. These may recover spontaneously, or require further surgery.

URINARY TRACT INFECTION
While under a general anesthetic during the surgery, and when confined to bed after the surgery, you will not be able to go to the toilet to urinate. A urinary catheter will be passed along your urethra to freely drain the bladder and avoid bladder discomfort. The presence of a urinary catheter does increase the risk of bacteria entering the bladder and causing a urinary tract infection. Treatment usually requires the catheter to be removed, followed by a course of antibiotics.

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This article was written with the assistance of the following surgeons.

Dr Paul Licina. Dr Licina is spinal orthopedic surgeon, and co-founder of Brisbane Orthopaedic Specialist Services in Brisbane, Queensland, Australia. www.brisbaneorthopaedics.com.au/paul_licina.html

Dr Matthew McDonald. Dr McDonald is a spinal neurosurgeon based at Wakefield Hospital, Adelaide, South Australia, Australia. www.wakefieldneurosurgery.com.au

Dr Richard Parkinson. Dr Parkinson is a spinal neurosurgeon based at St Vincent's Clinic, Sydney, New South Wales, Australia. www.svph.com.au/index.php?option=com_content&task=view&id=145&Itemid=178

Dr Lali Sekhon. Dr Sekhon is a spinal neurosurgeon, and founder of Nevada Neurosurgery in Reno / Carson City, Nevada, USA. www.nevadaneurosurgery.com