Spine Surgery - Wallis Ligament Stabilisation

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1 Spine Surgery - Wallis Ligament Stabilisation An Information Leaflet Physiotherapy Department August 2011 Every Patient Matters

2 TO47 2 Introduction This booklet has been compiled by the physiotherapy department to help you understand lumbar Wallis ligament stabilisation procedures and post-operative rehabilitation. Anatomy The lumbar spine, or lower back, is composed of 5 bones, or vertebrae. These are numbered downwards from 1-5 and, because they are part of the lumbar spine they are prefixed by the letter L. Hence, you will hear medical professionals refer to L3 - L4 or L4 - L5, for example. At the very bottom of the lumbar spine is the sacrum. This bone is roughly the shape of an inverted triangle and the top part of this is referred to as S1. Diagram of the lumbar L1 L2 L3 L4 L5 Vertebral body Intervertebral disc Spinal canal - the spinal cord runs down from the top to the bottom of L1. The nerve roots continue to pass down the spinal canal until they exit at their designated level Nerve roots branch off the spinal cord and come out here Facet joints Sacrum lies here Each vertebra is connected to each adjacent vertebra by 3 joints, 1 at the front and 2 at the back. The larger one at the front is where the body of a vertebra is separated from its adjacent vertebral bodies by an intervertebral disc. The 2 joints at the back are called facet joints and these lie either side of the midline. These joints also serve to connect one vertebra with its adjacent vertebra. In addition to the bony

3 TO47 3 components, there are other important structures as well. The spinal canal is a bony tunnel which the spinal cord sits inside. At each level of the spine (that is between 2 individual vertebrae), a pair of nerve roots come out (one on each side). The nerve roots that come out at the levels of the lumbar spine go on to form the nerves of the leg. These nerve roots supply the skin and muscles in your legs. Each different level of nerve root supplies different muscles and different areas of skin. This helps medical professionals decide which part of your back may be causing the trouble. This also explains why people with low back problems can suffer with leg pain, numbness or tingling. These nerves also supply your bladder and bowel, which is why you may be asked about these. Diagram of a vertebra Vertebral body disc sits on top Spinal canal Nerve root branches off spinal cord and exits here Transverse process Facet joint Spinous process Mechanisms of injury There are 2 main conditions that may lead your surgeon to decide to operate. These are stenosis and disc prolapse. A Wallis ligament implant will be inserted in conjunction with the treatments for these which are surgical discectomy and/or decompression. The pathology leading to these is described below: Disc prolapse The intervertebral discs separate each of the vertebra. The principal functions of the disc are to allow movement between the vertebral bodies and to transmit weight from one vertebral body to the next. They are like shock absorbers.

4 TO47 4 Each disc has 2 basic components: a central nucleus pulposis a peripheral annulus fibrosus In a young healthy individual the nucleus of the disc is a semi-fluid mass, with a consistency similar to that of toothpaste. The annulus consists of tough fibres, arranged in highly organised layers. Whilst the nucleus is quite distinct in the centre of the disc, and the annulus is distinct at its edge, there is no clear boundary between the two. The ingenious and unique arrangement of the disc enables it to sustain and transmit weight, restrain excessive motion and stabilise the joint, and yet still allow the spine to move in all directions. A healthy disc is very resilient to injury. Problems can arise if there has been some disruption within the disc, which can be caused by repeated poor postures and/or movements or a specific task that has exposed the spine to an activity to which it is not accustomed e.g. lifting heavy objects when moving house. Changes can then take place within the disc. The nucleus is now less able to maintain its internal pressure which provides support to the disc s structure. As a result, extra load is borne by the annulus and the annulus can develop fissures or cracks in its organised arrangement of fibrous layers. These fissures tend to appear at the back of the disc, where the arrangement of fibrous layers is not as strong. The nucleus can then creep along these fissures, to the point where it can breach the entire thickness of the annulus. This is referred to as disc herniation. If the size of the herniation of the disc is sufficient, then it will press on the nerve root as the nerve root exits from the spinal canal to form the nerves of the leg. Compression of a nerve root can cause pain, tingling, pins and needles, numbness, weakness and loss of reflex action in the leg. These symptoms are still sometimes referred to as sciatica. Your surgeon will remove the part of the disc that is bulging (nucleus), not the whole disc, and remove any scar tissue or adhesions that may have formed around the nerve root. This is called a discectomy. Spinal stenosis Spinal stenosis is where there is a reduction of space or a narrowing either in the spinal canal (where the spinal cord passes to the bottom of L1) or around the nerve root as it exits the spinal canal. This narrowing, or stenosis, is often caused by degenerative or arthritic changes of the discs and the facet joints. When a joint becomes

5 TO47 5 arthritic it tends to get a little bit bigger and thicker. If the facet joints get bigger and thicker then there is less room for the nerve roots to pass out from the spinal cord, and there is less room for the spinal cord itself. Wear and tear in the discs causes them to narrow and loose some of their shock absorbency. This brings the 2 vertebrae the disc is separating closer together. This also can reduce the room the spinal cord and nerve roots have. Arthritis is also accompanied by thickening of the soft tissues such as ligaments. There is a large ligament called the ligamentum flavum that sits inside the spinal canal. This can also become thickened and fibrous which will again limit the amount of room available for the spinal cord and the nerve roots. Your surgeon will widen the canal and release the pinched nerve root by trimming away the structures at fault. This is called a decompression. Some or all of the information above may apply to you - it is important to realise that everyone is different. The end result however, is similar for everyone. The nervous tissue is squashed so it is not able to send its messages properly to the skin and muscles of the legs. The result is leg pain, pins and needles, tingling, numbness, weakness and loss of reflexes. Why add a Wallis ligament implant? The Wallis ligament is a dynamic stabilizer it helps prevent excess movement of the spinal segments at fault whilst still allowing natural movements to occur. This is far less restrictive or severe than a spinal fusion and the implant can be removed if required. The aim is to prevent further wear and tear of the joints at the spinal level affected and may reduce the risk of any further disc prolapse at that level.

6 TO47 6 The Wallis ligament implant Bands. Body of implant (spacer) The implant is a spacer device which is inserted between the spinous processes of the level affected. It is made of polyetheretherketone (PEEK) material. It has 2 bands which pass around the spinous processes of the upper and lower levels and these are tightened and clipped securely into the body of the implant. The ligaments of the spine are not affected during the placement of the Wallis ligament. The implant in place (side view, as if lying on your tummy) ligaments of the spine Spinous process of lower vertebra Wallis ligament disc Treatment Almost everyone who comes into hospital to have a discectomy / decompression with Wallis ligament stabilisation procedure will have received some form of therapy intervention before the decision for surgery is taken. The reason for this is that the vast majority of back injuries can be completely resolved with conservative, or non-surgical treatment. However, in some cases therapy is not sufficiently beneficial and surgery is an option. Surgeons will operate to relieve leg pain only.

7 TO47 7 Surgery The operation is done under a general anaesthetic and usually takes about an hour. You are positioned on the operating table in a knee to chest position on your tummy. This stretches out the spine and makes access easier for the surgeon. The surgeon makes an incision usually 5-8 cm long down the centre of your lumbar spine with the middle of the incision over the troublesome area. The surgeon will examine the area and perform the required surgery as described above (discectomy/decompression), in order to relieve the pressure on the nerve. He will then insert the Wallis ligament implant as described above. Post-operatively - what to expect Most people come round from the anaesthetic and feel an immediate relief of their leg symptoms. Pain often settles fairly quickly. Numbness and tingling sensations usually take longer to settle though - this may be days, weeks or months. It varies considerably from person to person. Some people may always have an area of numbness that never fully recovers. Do not worry if your leg pain is still present though - it is not a sign the surgery has failed. Nerves take time to recover from being squashed. They also have a tendency to remember what has happened to them. Also, take into consideration your recent operation. Bruising and swelling will be present which will settle, but can also irritate the delicate nerve tissue initially. Following your surgery Day 1 The physiotherapist will come to see you and, if you are feeling well enough, then the plan will be to get you up and walking about, without the use of a walking aid. You will be taught a technique called log-rolling for getting into and out of bed. Starting from a supine position (lying on your back), log-rolling involves bending your knees a little then allowing your knees and your arms to go over to one side, so the body moves as a unit without too much twisting. From that position (lying on your side), allow your lower legs to drop off the edge of the bed and pivot yourself up with your

8 TO47 8 arms. You should now be sat on the edge of the bed. If needed, you will be given support to stand up. You may feel a little light-headed or shaky on your legs initially, but this should quickly pass. You will also be shown some exercises by the physiotherapist. It is important that you try to do these, about 4 times a day You will also be advised to avoid long periods of sitting. We advise that you sit for meals and using the toilet only. Aim to sit for no longer than minutes in the first week. Gradually build this up so you are able to sit for 1 hour by the sixth week. Be aware of your sitting posture - do not allow yourself to slump. Your physiotherapist will advise you on good sitting posture, and the importance of maintaining good sitting posture. Day 2 The physiotherapist will review your exercises and ensure there are no problems. You will also be assessed on using the stairs to ensure you are safe. Once the surgeon has inspected your wound, you may be discharged. Most patients are discharged home on Day 2 or 3. You may need to see your GP / practice nurse if wound dressings are required. The first 2 weeks The physiotherapy department will contact you with an appointment in the out-patient physiotherapy department for 2 weeks after your operation. In the meantime, you need to continue with your exercises at home. Aim to do them 4 times a day. Gradually increase your walking. A few shorter walks a day can be more comfortable than one longer one in the first few days.

9 TO47 9 After week 2 Your exercises will be progressed by the physiotherapist in out-patients. Most patients are back to work by week 6 (unless it s a very strenuous job). Avoid heavy work / lifting for up to 12 weeks post-operatively. Your progress will be reviewed in your consultant s clinic as an out patient at around 6-8 weeks post-op. Trouble shooting! Below are some common complaints, questions and answers I ve had back surgery - surely I must rest completely? No, most definitely not! Your back is designed to move and it s important to get it moving well again as soon as possible. The surgery wound will heal with scar tissue and it is important that the scar tissue is not allowed to become a disorganised tangle of fibres. By stretching and moving you will encourage the scar tissue fibres to line up where they are needed. You may need to reassure your family as well, as some well-meaning family members can treat you like an invalid! When can I drive? If the surgery and recovery has been routine, you may resume driving at 3-4 weeks. Check with your insurance company and avoid long distances initially. I assume I can t bend forward Why ever not! Your back is designed to bend - it goes further forward than it does in any other direction. However, what you must try and avoid is repeated bending or prolonged bending. You wouldn t hold your elbow bent for several hours, yet people will happily sit for ages in a poor position with their back bent! Be sensible. Be aware of your posture and try to bend your knees when lifting. When can I return to sport? Once your wound is clean and dry, swimming is excellent exercise for your back. You can return to the gym after 2 weeks for gentle exercise on the treadmill, x-trainer and recumbent bike. Avoid conventional static bikes, steppers and rowers initially because of the amount of flexion required. Avoid heavy weights as well. It may be worth asking your

10 TO47 10 gym instructor for a review to ensure good technique. Discuss returning to particular sports with your out-patient physiotherapist. What are the risks of surgery? Your consultant will discuss these with you individually in clinic, at your pre-operative assessment. General surgical complications apply such as the risk of stoke, DVT, blood clots in lungs, wound infection. It is unlikely the implant itself will cause any problems but it can be removed if necessary. There is also a chance your symptoms will remain unchanged / worsen, but again this is unlikely. Our smoke free policy As per the smoke free law, smoking is not allowed by anyone anywhere on the hospital site. For further information, please read the patient information leaflet 'Policy on Smoke Free NHS Premises'.

11 TO47 11 Produced by Stockport NHS Foundation Trust Review Date: August 2013 If you would like this leaflet in a different format, e.g. in large print, or on audiotape, or for people with learning disabilities, please contact PCS. Your local contact for more information is Patient and Customer Services at Poplar Suite, SHH, Tel: or

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