PREOPERATIVE SURGERY EDUCATION

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1 PREOPERATIVE SURGERY EDUCATION SURGERY NAME: INTERLAMINAR LUMBAR INSTRUMENTED FUSION (ILIF) PROCEDURE OVERVIEW: Lumbar Spinal Stenosis is the most common reason for back surgery in patients over 50 in the United States. Although the usual surgical procedure is a decompression procedure such as a laminectomy, surgeons sometimes find that a decompression procedure alone may create instability which in turn can create pain, however a full fusion surgery with rods and screws may be too extensive in certain cases. The ILIF procedure is a relatively new alternative to traditional fusion surgery. The ILIF procedure was developed to overcome some of the potential shortcomings of standard lumbar spinal stenosis surgery using a minimally invasive technique. The ILIF utilized a uniquely designed interspinous spacer to provide distraction, decompression and fusion. A precision- machined allograft bone is placed between the spinous processes (the bone you can feel when you run your hand down your spine) to permanently open areas that are pressing on the spinal cord and/or nerves, promote fusion between the spinous processes to provide long- term spine stabilization, provide a protective cover for the spinal cord to ehlp prevent scar tissue from pressing on the spinal cord and/or nerves. The ILIF utilizes a small plate is attached to both spinous processes to stabilize the segment of the spine and promote fusion, eliminating the need for more extensive surgery. Studies have shown that the plate is comparable to traditional pedicle screw fixation. During the ILIF procedure, the surgeon makes a small incision in the lower back and carefully creates an opening through the ligaments which allows access to the spinous processes. The damaged portion of the disc is removed and allograft bone is placed in the empty space which helps protect the spinal cord and nerves. A metal plate is inserted to stabilize the spine and secure the spinous processes until the fusion takes place. BENEFITS OF PROCEDURE: The ILIF procedure involves a minimally invasive decompression procedure called a laminotomy, which involves temporary distraction of the space between the spinous processes, and carefully removing only small sections of bone to relieve the pressure on the spinal cord and nerves. The benefits of an ILIF procedure include: Reduced operative time Reduced blood loss Smaller incision Less post- operative pain Minimal Scarring Reduced Hospital Stay Expedited return to normal activity ALTERNATIVES TO SURGERY: 1. Pain medications. A number of medications may be useful for pain. These include the standard opioid and non- opioid analgesic agents, membrane stabilising agents and anticonvulsants.

2 2. Pain injections. Local anesthetic may be injected through the skin of the neck, under CT scan guidance, around the compressed nerve. Patients frequently obtain a significant benefit from this procedure, and surgery can sometimes be delayed or even avoided. Unfortunately, the benefit obtained from this procedure is usually only temporary, and it tends to wear off after several days, weeks, or sometimes months. 3. Physical therapies. These include physiotherapy, osteopathy, hydrotherapy and massage. 4. Activity modification. Sometimes simply modifying your workplace and recreational activities, to avoid heavy lifting and repetitive neck or arm movements, allows the healing process to occur more quickly. 5. Other surgical approaches. These include: 1. lumbar microdiscectomy 2. lumbar decompression (also known as a laminectomy and rhizolysis) 3. non- instrumented fusion: where bone is laid down without using screws or cages to stabilize the spine 4. posterolateral instrumented fusion: where screws are placed but the disc space is not fused by inserting a cage 5. anterior lumbar interbody fusion (ALIF) 6. posterior lumbar interbody fusion (PLIF) 7. transforaminal lumbar interbody fusion (TLIF) 8. artificial disc replacement (arthroplasty) 9. disc nucleus replacement (nucleoplasty) 10. spinal cord stimulation GENERAL RISKS There are the risks of anesthesia and the general risks of surgery: Having a general anesthetic is generally fairly safe, and the risk of a major catastrophe is extremely low. All types of surgery carry certain risks, many of which are included in the list below: Significant scarring ( keloid ) Wound breakdown Drug allergies DVT ( economy class syndrome ) Pulmonary embolism (blood clot in lungs) Chest and urinary tract infections Pressure injuries to nerves in arms and legs Eye or teeth injuries Myocardial infarction ( heart attack ) Stroke Loss of life SPECIFIC RISKS Generally, surgery is fairly safe and major complications are uncommon BUT DO HAPPEN. The chance of a minor complication is around 3 or 4%, and the risk of a major complication is less than 1%. The specific risks of an ILIF include (but are not limited to): 1. Failure to fuse (non- union) 2. Fail to relieve the symptoms or to prevent deterioration

3 3. Fracture of spinous process 4. Mechanical failure of the spinous process plate 5. Movement of the allograft spacer out of proper position 6. Worsening of pain 7. Infection 8. Blood clot in wound requiring urgent surgery to relieve pressure 9. Cerebrospinal fluid (CSF) leak: this risk is much higher in revision (re- operation) surgery 10. Surgery at incorrect level (this is rare, as X- rays are used during surgery to confirm the level) Specific Risks Continued. 11. Blood transfusion surgery is performed very close to the large blood vessels that go to the legs injury to these large blood vessels may cause substantial blood loss 12. Screw and/or cage breakage, movement, or malposition, sometimes requiring further surgery 13. Cage or graft dislodgement (expulsion) 14. Nerve damage (weakness, numbness, pain) occurs in less than 1% 15. Major neurological problems are fortunately rare, but include: paraplegia (paralysed legs) incontinence (loss of bowel/bladder control) impotence (loss of erections) 16. Chronic pain (may require further surgery) 17. Adjacent segment disease (deterioration of the disc above or below due to the extra stress caused by the fusion) 18. Injury to the bowel, ureter (the tube running from your kidneys to the bladder), or spermatic cord 19. Retrograde ejaculation in men occurs in less than 5% of cases (the real figure is probably closer to 1%) the nerves (known as the superior hypogastic plexus) that control ejaculation are draped over the front of the L5- S1 disc these nerves are very sensitive, and ejaculation can be disrupted ejaculation then occurs into the bladder, rather than out through the penis erection and sex drive are rarely affected it often resolves with time (several months to a year) 20. Incisional hernia (this may require corrective surgery) 21. Post- operative ileus (slowing of the bowels, which usually settles over a few days) 22. Injury to sympathetic nerve 23. Injury to the diaphragm or kidney 24. Deep venous thrombosis and pulmonary embolism (formation of blood clots in the leg veins, and these may break off and travel to the lungs, which can be life- threatening) 25. Death (this s extremely rare)

4 SIGNATURE / ACKNOWLEDGMENTS PAGE E PATIENT ACKNOWLEDGMENTS: I have read or have had read to me the above educational information on my prescribed procedure and have had the opportunity to ask questions about the procedure, the alternatives and risks, both general and specific. By signing below I agree to the prescribed procedure and I do not wish to pursue any of the alternative listed treatments. Patient Name (Printed) Date Patient Signature Witness Name(Printed) Date Witness Signature

5 PREOPERATIVE SURGERY INSTRUCTIONS 1. ACTIVITY: Activity as tolerated. 2. DIET: Diet as tolerated. Nothing to eat or drink after midnight on the night before your surgery. 3. MEDICATIONS: If you are taking BLOOD PRESSURE MEDICATION, you may take it with a very small sip of water the morning before you go to the hospital or surgery center. If you are DIABETIC, do not take your diabetic medications the morning of surgery because you will not be eating. Taking such medications may cause your sugar to bottom out and surgery may have to be cancelled or postponed. NOTE: Hold off on taking diabetic medications for 24 hours prior to and for 48 hours after surgery. If you are taking: ASPIRIN, IBUPROFEN, GARLIC, VITAMIN E, FISHOIL, GINGER, GINKGO, NSAID S, PLAVIX or COUMADIN medication, you need to stop taking it two weeks prior to surgery. These medication increase your bleeding and should not be taken before a surgical procedure. Additionally taking these medications prior to surgery can affect scarring from your incisional area. NOTE: If you are on Plavix or Coumadin, you will need to be cleared by the prescribing physician. 4. MORNING OF SURGERY: a) Shower using antibacterial soap. Dress in clean, loose fitting clothes. b) Remove make- up, contacts, jewelry (including body piercings), nail polish, etc. c) Do NOT wear deodorant, oil or any type of body lotion or perfume/cologne. 5. TIME OF SURGERY: A representative from the hospital will call you the evening prior to your surgery and will let you know what time to be there. Due to fluctuations in length of surgery times and/or cancellations, you may be asked to be there earlier or later than your original scheduled time. Usually 2 hours prior to surgery.

6 Pre- Operative Instructions Continued: 6. WHAT TO BRING: a) Bring some very comfortable clothing to go home in. Something like sweats that can just be slipped on is recommended. Nothing that needs to be pulled over the head. Wear comfortable shoes or slippers (no heels). b) Leave all valuables and jewelry at home (including wedding rings/band). c) Bring a list of all medications your are taking including prescriptions, over- the- counter medications, and/or supplements, including herbal vitamins. 7. LENGTH OF STAY: a) IN- PATIENT: If your procedure is being done at a hospital, your surgeon will give you an estimated length of stay. Your actual length of stay will be determined how well you do postoperatively. For an ILIF surgery, most patients will go home on the third or fourth day after surgery. b) OUT- PATIENT: Certain surgeries can be done on an out- patient basis where you can go home the same day of surgery. Occasionally, patients may have to stay overnight (23 hours) and go home the next day. If it is determined that you need additional time, we will have you stay in a nearby after- care facility.

7 POSTOPERATIVE (AFTERCARE) SURGERY INSTRUCTIONS The first 2 days will be difficult. The most painful part of recovery is usually the abdominal incision and if used, the site of the bone graft harvest. In order to obtain an adequate amount of graft, the muscles inserting into your iliac crest had to be dissected. As you walk these muscles will pull on the graft site. This area will be painful until the scar matures, which may take anywhere from 4 to 6 weeks. Before patients go home, physical therapists and occupational therapists work with patients and instruct them on proper techniques of getting in and out of bed and walking independently. 1. ACTIVITY: Spine precautions: a) No lifting anything over 5 lbs. b) Light housework only (no hanging laundry, no vacuuming, no mowing) c) No driving until you are cleared by your surgeon. d) No exercising or playing sports until you are cleared by your surgeon. e) Frequent short walks are encouraged (1-2 hours per day or as suggested by your surgeon. f) Traveling by car is allowed for short distances. Longer trips should be broken into shorter segments (30 min intervals), stopping to take short walks. 2. BRACE: You may be given a brace to wear to provide lumbar support. Wear your brace during the day at all times. Your brace can be removed to sleep and shower or as directed by your surgeon. 3. DIET: Diet as tolerated. Maintain normal healthy diet, high in fiber to avoid constipation. 4. MEDICATIONS: The medications that will be given to you by your physician/surgeon will vary depending on patient. Your surgeon will discuss these with you prior to your surgery. Please advise your surgeon of any drug allergies so that your medications may be issued correctly. 5. INCISIONAL CARE: Leave dressing on to prevent rubbing of clothing unless directed by your physician.

8 6. SCAR CARE: Approximately 10 days after your first post- op visit or when you have the sutures removed, massage your incisional area with Vitamin E oil or prescribed scar gel. This will help break up the scar tissue and prevent it from expanding. **Avoid aspirin, NSAIDS, and medications that cause bleeding until the incisional area has healed. 7. SHOWERING: Patients can shower immediately after surgery, but should keep the incision area covered with a bandage and tape, and try to avoid the water from water hitting directly over the surgical area. After the shower, patients should remove the bandage, and dry off the surgical area. Patients should not take a bath until the wound has completely healed, which is usually around 2 weeks after surgery. 8. COMMON CONCERNS: a) Having a fever a couple of days post- op is not uncommon. It is usually due to being less active and is pulmonary in nature. If the fever persists a week after surgery, it may be a sign of infection and you should call the office for an earlier follow- up appointment. c) Having numbness and some similar pre- op symptoms after surgery is common. This is due to swelling from the surgery itself or sometimes may be a result of your nerves just healing. d) Often times, after surgery, patients get to feeling better and increase their activity. Patients need to be mindful that they are still healing and that increased activity may lead to symptoms similar to the ones prior to surgery. You may just need to take it easy and see if the symptoms subside. 9. CALL DOCTOR IF: You should notify your surgeon and should also see your GP if you experience any of the following after discharge: Increasing arm or leg pain, weakness or numbness Worsening back pain Increasing swallowing problems Fever after one week Swelling, redness, increased temperature or suspected infection of the incisional area. Leakage of fluid from the wound Pain or swelling in your calf muscles (ie. below your knees) Problems passing urine or controlling bladder or bowels Chest pain or shortness of breath

9 10. FOLLOW UP VISIT: YOUR FOLLOW UP APPOINTMENT TO SEE: IS ON AT

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