Lumbar Spine Surgery

Lumbar Spine Surgery
A Guide to Preoperative and Postoperative Patient Care

AANN Reference Series for Clinical Practice
Committee on Reference Series
for Clinical Practice
2004 Committee
Kathy Baker, MBA BSN RN CCRN CNRN, Chair
Kirsten Featherstone, MS RN CCRN
Laura McIlvoy, PhD RN CCRN CNRN
Barbara Mancini, MBA BSN RN CNAA CNRN
2006 Committee
Janette Yanko, MN RN CNRN, Chair
Donna Avanecean, MSN RN FNP-C CNRN
Cathy Cartwright, MSN RN PCNS
AANN National Office
Barbara Schweizer, MBA BSN RN
Executive Director
Anne T. Costello
Senior Education Manager
Deborah S. Williams
Managing Editor
Sonya L. Jones
Graphic Designer
Lumbar Spine Task Force
Chair
Susan Ware, MSN RN ARNP CCRN CNRN
Author
Andrea Strayer, MSN AGNP CNRN
Contributing Authors
Angela Starkweather, PhD ANCP RN CNRN CCRN
Patricia Pagnotta, MSN RN CNRN
Dolores Emmons, BA RN
Joseph Haymore, MS RN CCRN CNRN ACNP
Content Reviewers
Karen Bouwman, MSN BC RN CNRN
Rich Jones, BSN CNRN NP RNFA
Pam Shadley, MS RN CNRN
Angela Starkweather, PhD ANCP RN CNRN CCRN
Acknowledgment
This publication was made possible through an unrestricted charitable contribution from
Medtronics Spinal and Biologics Division.
Publishers Note
The authors, editors, and publisher of this document neither represent nor guarantee that the practices described herein
will, if followed, ensure safe and effective patient care. The authors, editors, and publisher further assume no liability or
responsibility in connection with any information or recommendations contained in this document. These recommenda-
tions reflect the American Association of Neuroscience Nurses judgment regarding the state of general knowledge and
practice in their field as of the date of publication and are subject to change based on the availability of new scientific
information.
Copyright 2006 by the American Association of Neuroscience Nurses. No part of this publication may be reproduced,
photocopied, or republished in any form, print or electronic, in whole or in part, without written permission of the
American Association of Neuroscience Nurses.
Lumbar Spine Surgery
A Guide to Preoperative and Postoperative Patient Care
AANN Reference Series for Clinical Practice
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To meet its members needs for educational tools, the
American Association of Neuroscience Nurses (AANN)
has created a series of guides to patient care called AANN
Reference Series for Clinical Practice. Each guide has been
developed based on current literature and is built upon
best practices. The purpose is to help registered nurses, pa-
tient care units, and institutions provide safe and effective
care to patients who are undergoing lumbar spine surgery.
The personal and societal impact of low back pain is
signifcant. Between 70% and 85% of all people have back
pain at some time in their life (Anderson, 1999); low back
pain is the second most common reason for seeking care
from a primary care physician. Lumbar spine disorders are
the most common cause of disability in persons younger
than 45 years of age (Anderson, 1999). Of those with low
back pain, approximately 151,000 undergo a lumbar fusion
each year (Lipson, 2004). The direct and indirect costs of
low back disorders amount to billions of dollars annually.
Whether the patient experiences intermittent low back
pain or lumbar spine pathology refractory to conservative
management requiring a lumbar fusion, neuroscience
nurses are pivotal in assessment, treatment, and continuing
care. Resources and recommendations for practice should
enable the nurse to make decisions that will optimize pa-
tient outcomes.
This reference is an essential resource for nurses respon-
sible for the care of spine patients. It is not intended to
replace formal education but rather to augment the knowl-
edge of clinicians and provide a readily available reference
tool.
Neuroscience nursing and AANN are indebted to the
volunteers who have devoted their time and expertise to
this valuable resource, created for those who are commit-
ted to neuroscience patient care.
Preface
Contents
Lumbar Spine Functional Anatomy and Physiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Diagnostic Studies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Lumbar Spine Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Herniated Nucleus Pulposus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Cauda Equina Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Lumbar Stenosis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Spondylosis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Spondylolisthesis and Spondylolysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Degenerative Disc Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Degenerative Scoliosis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Treatment of Lumbar Spine Disorders. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Medical Treatment of Lumbar Spondylosis, Spondylolisthesis, Spondylolysis,
and Degenerative Disc Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Surgical Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Case Studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
Bibliography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
Lumbar Spine Surgery: A Guide to Preoperative and Postoperative Patient Care 3
1 AANN Reference Series for Clinical Practice
I. Lumbar Vertebrae
The lumbar spine is formed by fve vertebrae. The verte-
brae are commonly referred to as L1 through L5. L1 is the
most superior vertebra in the lumbar spine, and it abuts
the thoracic spine, whereas L5 is the most inferior vertebra
and abuts the sacral spine. The anterior or ventral element
of each vertebra is called the vertebral body. The vertebral
bodies of the middle and lower lumbar spine are more sub-
stantial in size to allow them to bear greater loading forces.
Posteriorly, or dorsally, each vertebra has a bony arch
that encircles the spinal canal. It is composed of two
transverse processes, two sets of facet joints, two pedicles,
two laminae, and one spinous process. The bony arch, also
referred to as the posterior elements, is quite bulky. It pro-
vides the necessary support for upright posture (Figure 1).
The noncompromised spinal canal has ample room for the
cauda equina and for cerebrospinal fuid (CSF).
Facet joints (bilaterally) are composed of a superior
articulating process and an inferior articulating process. The
superior articulating process forms a joint with the inferior
articulating process of the vertebra above (e.g., superior artic-
ulating processes of L3 forms two facet joints with the inferior
articulating processes of L2). They have a loose capsule and a
synovial lining; thus they are apophyseal joints (Figure 2).
The nerve root canal, also called the lateral recess, is
adjacent to the pedicles and facet joints in the region of
the foramina. It encompasses the nerve root as it exits the
spinal cord (Figure 3). The neural foramina, also referred to
as the intervertebral foramina, is the actual far-lateral exit
opening of the nerve root canal (Benzel, 2001). The lumbar
vertebral, or spinal, canal is supported anteriorly by the
posterior edge of the vertebral body as well as the posterior
longitudinal ligament. This ligament lies on the posterior
vertebral body surface. The lateral elements of the vertebral
canal are the pedicles and the facet joints, with correspond-
ing articular capsules. Posteriorly, the vertebral canal is
formed by the laminae and ligamenta fava.
II. Intervertebral Disc
Each intervertebral disc in the lumbar spine provides
support and facilitates movement while resisting excessive
movement. The disc permits slight anterior fexion, posterior
extension, lateral fexion, rotation, and some circumduction
(Schnuerer, Gallego, & Manuel, 2003). The disc is the largest
avascular structure in the body (Anderson & Albert, 2003). It
is composed of the nucleus pulposus and the annulus fbro-
sus. In someone less than 35 years old, the nucleus pulposus
is soft, rather like crab meat in texture. With aging, the
nucleus pulposus dehydrates.
Surrounding the nucleus pulposus is the annulus fbro-
sus, which is tough and fbrous. The fbers of the annulus
fbrosus are concentric, like the layers of a radial tire. The
concentric arrangement provides great resistance and
strength. Each disc is bonded to the vertebral body below
and above it by a thin cartilaginous plate, referred to as the
endplate (Figures 4, 5). The endplate resists herniation of
the disc into the vertebral body and gives the disc its shape
(Benzel, 2001).
III. Ligaments
Each disc is reinforced anteriorly by the anterior
longitudinal ligament and posteriorly by the posterior lon-
gitudinal ligament. The laminae are connected by an elastic
yellow ligament called the ligamentum favum. Each facet
joint is connected to a capsular ligament. The transverse
processes are connected by intertransverse ligaments. The
rotator brevis and rotator longus ligaments connect the
transverse processes to the laminae of the superior two
Figure 1. Lumbar vertebra
Figure 2. Lumbar spine: Posterior view
Lumbar Spine Functional Anatomy and Physiology
vertebrae. The spinous processes are connected by the
supraspinous and infraspinous ligaments (Figures 6, 7, 8;
Yoganandan, Halliday, Dickman, & Benzel, 2005).
IV. Biomechanics
The functional unit of the spinal column is the motion
segment. A motion segment is composed of two adjacent
vertebrae, the disc between them, the facet joints con-
necting them, and the ligaments attached to the vertebrae
(Schnuerer et al., 2003). The geometry and health of the
functional units help a surgeon determine which patients
will beneft from surgery, as well as the most appropriate
surgical intervention for a given patient.
V. Spinal Cord
The spinal cord ends at approximately the L1L2 level
in an adult. The conus medullaris is the end of the spinal
cord. The flum terminale is an extension of the pia mater,
which descends below the conus medullaris and is an-
chored to the coccyx.
VI. Nerve Roots
The cauda equina is a fanning bundle of lumbar and
sacral nerve roots exiting off the spinal cord at the conus
medullaris. This mass of nerve roots provides communica-
tion with the lower extremities and controls bowel, bladder,
and sexual function (Figures 9, 10). The cauda equina is
relatively resistant to neurologic insults, compared with
the spinal cord (Benzel, 2001). The exiting nerve root in the
lumbar spine is numbered according to the pedicle above it.
For instance, the L5 nerve root passes below the L5 pedicle.
(See Table 1.)
VII. Vasculature
The abdominal aorta follows the left side of the spine
until L4, where it bifurcates into the left and right common
iliac arteries (Figure 11). The femoral arteries arise from the
common iliac arteries. The middle sacral artery, iliolumbar
artery, and internal iliac artery supply blood to L5 and the
sacrum. Segmental arteries branch off the aorta and sup-
ply the vertebral body, posterior elements, and paraspinal
muscles of the lumbar spine. Near the posterior wall of the
vertebrae, each segmental artery bifurcates into a posterior
branch and spinal branch. The spinal branch enters the
vertebral canal through the intervertebral foramen and
supplies portions of the posterior vertebral body. It joins
other spinal branches at other levels to form the anterior
spinal artery. The anterior spinal artery supplies the ante-
rior two-thirds of the spinal cord.
Segmental veins drain into the inferior vena cava, which
originates at the convergence of the left and right common
iliac veins at the L4 level (Schnuerer et al., 2003). The inferior
vena cava terminates in the right atrium of the heart.
Figure 3. Lumbar spine: Lateral view Figure 4. Intervertebral disc in relation to endplate and vertebral body
Figure 5. Intervertebral disc
Figure 6. Ligaments of the lumbar spine
Figure 7. Ligaments of the lumbar spine: Posterior view Figure 8. Ligaments of the lumbar spine: Lateral view
Lumbar Spine Surgery: A Guide to Preoperative and Postoperative Patient Care I
Figure 9. Termination of spinal cord at conus
medullaris; cauda equina; and termination of
dura in coccyx
Table 1. Nerve Roots and Corresponding Sensory, Motor, and Reflex Functions
Nerve Root Sensory Motor Reflex
L2 Groin area Hip Flexor (iliopsoas) None
L3 Groin, anterior thigh Knee extension (quadriceps) None
L4 Anterior thigh, knee, medial calf Knee Extension (quadriceps) Patella (knee jerk)
L5 Lateral thigh, lateral calf, top of foot EHL (extensor hallicus longus)
raise great toe
Foot dorsiflexion (anterior tibialis)
Knee flexion (hamstrings)
none
S1 Posterior thigh, posterior calf, lateral
aspect of foot
Foot plantarflexion (gastrocnemius) Achilles (ankle jerk)
Figure 10. Dermatomal distribution of lumbar nerve roots
Figure 11. The abdominal aorta and its
branches
Common diagnostic studies utilized to evaluate the
lumbar spine patient are outlined below. In general, imag-
ing is not used during the frst 6 weeks of acute back pain if
the following conditions are met:
no other neurologic signs or symptoms
no trauma
no history of malignant tumor
no constitutional symptoms
patients age is between 18 and 50 (Winters, Kluetz,
& Zilberstein, 2006).
I. X Ray
The advantages of using X ray are that it is inexpensive
and noninvasive. It shows the general changes of arthritis
and bony alignment. However, it reveals only bony struc-
tures, and the patient is exposed to radiation.
Serial X rays aid in the evaluation of bone healing and
maturation of surgical fusion.
II. Computed Tomography
In the lumbar spine patient, the computed tomography
(CT) scan may be utilized either as an adjunct to magnetic
resonance imaging (MRI) studies or in patients who
cannot undergo MRI evaluation. A CT scan shows the
bony elements of the spine very well, as well as the discs,
nerves, and ligaments. Although it provides excellent
visualization of the bony components, the CT scan is less
sensitive to changes in the soft tissues of the spine. The use
of contrast agents may be useful for highlighting masses
and abnormal tissue/fuid collections. The CT scan also is
occasionally used in conjunction with computerized neuro-
navigation for intraoperative three-dimensional (3-D)
image guidance during lumbar fusions.
III. Magnetic Resonance Imaging
Utilizing strong magnetic felds and radio frequencies,
magnetic resonance imaging (MRI) can provide useful
information on all tissues in the spine (e.g., bones, soft
tissues, spinal cord, nerves, ligaments, musculature,
discs). MRI is superior to CT for evaluation of soft tissue
structures. Contrast agents may be used for highlight-
ing masses, epidural scarring as a result of prior spine
surgeries, and abnormal tissue or fuid collections. MRI
is contraindicated for patients who have many metallic
implants or a cardiac pacemaker.
IV. Bone Scan
Radioactive tracers are injected into the patient. These
tracers then attach themselves to areas of increased bone
production or increased vascularity associated with tumor
or infection. It is often utilized when evaluating for spon-
dylolysis (i.e., destructive lesion of the vertebra), occult
fractures, or suspected bony metastasis.
V. Discogram
Discogram may be used to evaluate for degenerative
disc disease. Under fuoroscopic guidance, a contrast
agent is injected into the nucleus pulposus. The clinician
performing the procedure assesses the amount of contrast
agent administered and at what point the patient experi-
ences pain. It is then noted whether the patients typical
pain is elicited. Radiographs are taken to assess whether
the contrast agent stays within the nucleus pulposus or
leaks out of the disc. All of these data may be useful in de-
termining whether a specifc degenerated disc seen on MRI
or CT scan is the cause of the patients symptoms. The util-
ity of this test is controversial (Resnick, Malone, & Ryken,
2002; Resnick et al., 2005a). See Degenerative Disc Disease
for further discussion.
VI. Myelogram/Postmyelogram CT
A contrast agent is injected under fuoroscopy into the
intrathecal space through either lumbar puncture or cis-
ternal puncture. The contrast agent is then visualized with
radiographs, commonly with CT. The resulting images are
useful for evaluating patients who cannot undergo MRI
studies (e.g., people with pacemakers) or as an adjunct to
MRI. This test also is useful in evaluating for suspected
cauda equina syndrome (any mass lesion or infection that
is within or impinging upon the thecal sac; arachnoiditis;
or nerve roots lesions).
VII. Electromyography/Nerve Conduction Velocities
Small needles are inserted into specifc muscles to as-
sess muscle activity and nerve conduction time, as well as
amplitude of electrical stimulation along specifc nerves.
Electromyography (EMG) may be indicated for patients
without a clear radiculopathy (i.e., pain in the anatomic
distribution of the affected nerve root) to further assess and
diagnosis their pathology. This test is typically not used to
evaluate acute radiculopathy.
Diagnostic Studies
Herniated Nucleus Pulposus
I. Description and Etiology
Intervertebral disc herniation is also known as herniated
nucleus pulposus (HNP). HNP may be asymptomatic despite
radiographic evidence of bulging, protrusion, or extruded disc
(Figures 12, 13, 14). The etiology may be either nonspecifc or
attributable to a precipitating event. Even when the patient is
symptomatic, surgical intervention often is not required. An
HNP may be symptomatic due to a combination of direct nerve
root compression, the release of infammatory chemicals (e.g.,
matrix metalloproteinases, prostaglandin E2, interleukin-6,
nitric oxide), and hypoxia of the nerve root and basal ganglion
(Carette & Fehlings, 2006). Radicular pain can be accompanied
by paresthesias or paresis (i.e., weakness) in the anatomic dis-
tribution of the affected nerve root. The patient may complain
of low back pain. The back or leg pain may be aggravated by
coughing, sneezing, or assuming certain positions.
II. Incidence
Most HNPs occur at the L4L5 or L5S1 levels. The peak
incidence is among people 3555 years of age (Benzel, 2001).
The majority of HNPs occur in a posterolateral direction, com-
pressing the ipsilateral nerve root as it exits the dural sac.
III. Supporting Data
A. MRI studies are the best test to evaluate the
spinal structures, HNP, and nerve root com-
pression. A CT scan may be required to further
evaluate the bony structures in some patients.
B. Motor weakness, sensory changes, or alteration
in deep tendon reflexes are noted. (Please refer
to Table 1 for more information.)
C. Preoperative diagnostic studies are consistent
with HNP-induced neurological dysfunction or
symptoms.
D. Lumbar nerve root tension may be tested with
a straight leg raise test or other provocative
maneuvers.
E. Gait, forward flexion, and general mobility are
noted.
Figure 12. Progression of disc herniation
A. Normal disc
B. Bulging disc; pressure placed on exiting nerve root
C. Disc extrusion; disc material outside of annulus
From AANN Core Curriculum for Neuroscience Nursing (4th ed.), edited
by M. K. Bader and L. R. Littlejohns, 2004, St. Louis: Saunders. 2004
Elsevier Inc. Reprinted with permission.
Figure 13. Lumbar spine: MRI, sagittal view (L5S1 herniated disc)
Figure 14. Lumbar spine: MRI, axial view (L5S1 disc bulge with left
lateral recess stenosis)
Lumbar Spine Disorders
IV. Definitions
A. Bulge: Symmetrical extension of the disc
beyond the endplates
B. Protrusion: Focal area of bulge/disc exten-
sion that is still attached to the disc (annulus
fibrosis)
C. Extruded fragment: Nucleus pulposus no lon-
ger connected to the disc
D. Sequestered fragment (i.e., free fragment):
Nucleus pulposus in the posterior longitudinal
ligament
E. Radiculopathy: Pain in the distribution of a
nerve root resulting from irritation/compres-
sion on that nerve root
V. Nonsurgical Medical Treatment
Nonsurgical treatment is important in the care of the
patient with an HNP. Surgery usually is not indicated until
symptoms have persisted for at least 6 weeks.
A. General recommendations
1. Promote general well-being, such as the
benefits of smoking cessation, weight man-
agement, and adequate physical activity.
2. Prolonged bed rest is not recommended.
If necessary, bed rest should be limited to
no more than 2 days (Thorson, Vaneck,
Campbell, Kuku, & Marshall, 2005).
3. Physical therapy often is indicated; exercises
may help reduce pain and improve function.
(Henwood, Adams, Sypert, & Benzel, 2005)
B. Medications
Medications may provide short-term relief
of pain, which would enable the patient to
participate in therapies. Effective strategies for
symptom management include the use of the
following:
muscle relaxants to reduce muscle spasm
nonsteroidal antiinflammatory drugs
(NSAIDs) to reduce inflammation of the
nerve root
narcotics for short-term acute pain relief.
C. Epidural corticosteroid injection (ESI)
ESI is a caudal, translaminar, or interlaminar
injection of a corticosteroid (e.g., methylpred-
nisolone). The mechanism of action is its ability
to inhibit prostaglandin synthesis and decreased
immunologic responses. Additionally, it is
thought to promote membrane stabilization,
suppress neuropeptides, block phospholipase
A2 activity, and block nociceptive C-fber con-
duction (Ngu, DeWal, & Ludwig, 2003). In a
randomized, double-blind, controlled trial, Ng,
Chaudhary, and Sell (2005) found that transfo-
raminal injections may localize preferentially
to the peripheral perineural space, especially
if there is severe foraminal stenosis. McLain,
Kapural, and Mekhail (2005) noted that no study
has shown a clear advantage of one approach,
type, or volume of cortisone. Thus, the approach
for the ESI needs to be individualized to each
patients symptoms and radiographic fndings.
Wilson-MacDonald, Burt, Griffn, and Glynn
(2005) evaluated ESI for nerve root compression
and found that a single injection provided short-
term pain relief. Ngu et al. (2003) noted that the
current data on ESI and patient outcomes are
inconclusive. Resnick et al. (2005c) concluded
that there is no meaningful evidence in the
medical literature that the use of ESI is of any
long-term value in the treatment of patients
with chronic low back pain. The literature does
indicate that the use of lumbar ESI can provide
short-term relief in selected patients with chronic
low back pain (p. 713).
D. Acupuncture
Acupuncture is considered an alternative
treatment. It originated in China more than 2,000
years ago (National Center for Complementary
and Alternative Medicine, 2004). Very fne
needles are placed into specifc trigger points to
stimulate anatomic points in the body. It is theo-
rized that acupuncture works by infuencing the
electromagnetic feld of the body, which can alter
the chemical neurotransmitters within the body.
There is insuffcient published data to judge its
effcacy in the treatment of low back pain, and
further study is needed (Ngu et al., 2003).
E. Spinal manipulation (chiropractic or
osteopathic)
Spinal manipulation is used to relieve symp-
toms and help the patient progress toward an
active exercise program (Thorson et al., 2005).
There is insuffcient published data to judge its
effcacy in the treatment of low back pain, and
further study is needed (Ngu et al., 2003).
VI. Surgical Treatment
Surgical treatment may be indicated when conservative
management has failed to alleviate the patients symptom-
atology or for patients who have cauda equina syndrome or
progressive neurologic defcits. Atlas, Keller, Wu, Deyo, and
Singer (2005a) found that surgically treated patients with
a herniated lumbar disc had more complete relief from leg
pain and improved function and satisfaction than nonsurgi-
cally treated patients at 10-year follow-up. Of note, however,
was that improvement in the patients predominant symp-
tom and the patients work and disability outcomes at 10
years was similar regardless of the treatment (i.e., surgical
or nonsurgical). Although microdiscectomy is the gold-
standard operative approach, minimal-access techniques are
gaining in popularity.
A. Microdiscectomy
1. Microdiscectomy is performed under gen-
eral or regional anesthesia.
2. The patient is in a prone position.
3. Following deep dissection, the correct disc
space is confirmed radiographically. Once
confirmed, the ligamentum flavum and
lamina are dissected to expose the nerve
root. The opening in one lamina is termed a
semihemilaminectomy.
4. Once the nerve root is identified, all liga-
ments obstructing the view of the disc and
nerve roots are cleaned away. A nerve root
retractor is used to gently bring the nerve
root structures medially.
5. The disc is often excised and the disc frag-
ments, which will vary in size, are carefully
removed.
6. The area is then irrigated, hemostasis is
achieved, and the wound is closed.
B. Open discectomy
Open discectomy is the same procedure as
microdiscectomy, except the surgeon does not
use an operative microscope. Thus, a larger
incision is required.
C. Minimal-access/minimally invasive discectomy
This technique permits a discectomy to be
performed through a very small incision and with
minimal disruption of adjacent tissues (Figure
15). It is often performed on an outpatient basis or
with a 23-hour observation stay. This technique is
increasing in popularity in all settings, but specif-
cally in freestanding surgery centers.
1. The surgeon utilizes a tubular retractor sys-
tem and Loupes magnification or an operat-
ing microscope.
2. The tubular retractor is placed through a
small incision and deep dissection.
3. The discectomy is performed, as described
above, through the tubular retractor.
D. Potential complications
1. Intraoperative bleeding
2. Dural tear
3. Nerve injury (spinal cord or nerve root) dur-
ing surgery, resulting in changes in motor or
sensory function
4. Infection
VII. Nursing Assessment, Interventions, and Monitoring
A. Preoperative
1. Describe the surgical procedure to patient
and family.
2. Informed consent obtained by surgeon.
3. Describe the expected outcomes, both post-
operative and long term.
4. Arrange for required preoperative testing.
5. Advise patient to discontinue medications
such as herbal products, NSAIDs, antico-
agulants, aspirin, warfarin, and clopidogrel
bisulfate.
6. Encourage patient to anticipate and arrange
for perioperative and postoperative care needs.
B. Perioperative
1. Explain to patient where and when to
arrive, as well as surgery time.
2. Instruct patient as to eating and drinking
restrictions.
3. Instruct patient about medications to be taken
the morning of surgery with a sip of water.
4. Remind patient to wear comfortable clothing
and to leave jewelry and valuables at home.
5. Tell patient to remove dentures, partial plates,
eyeglasses, contact lenses, nail polish, and sculp-
tured nails.
C. Intraoperative
1. Time Outright patient, right surgery,
right site
2. Proper patient positioning
a. Table options are surgeon specific.
b. If patient is obese, consider using a
Jackson table.
3. Intraoperative needs anticipation
a. Equipment
b. Patient-specific needs (e.g., latex allergy)
Figure 15. Minimal-access microdiscectomy
D. Postoperative
1. Neurological assessment
a. Strength and sensation assessment, as
compared with preoperative status.
b. Special attention to neurological assess-
ment and correlation with the operative
intervention.
2. Mobility
a. Patient should mobilize quickly unless
ordered differently due to complication
(e.g., CSF leak).
b. Instruct and help patient to roll to side
and bring legs down while simultane-
ously rising up with the torso from the
bed. This minimizes twisting at the
waist.
c. Instruct and help patient to rise from a
chair using the legs, rather than pushing
off with the back.
3. Pain control
a. The degree of pain varies considerably.
b. Intravenous hydromorphone or mor-
phine sulfate may be used as needed
until the patient is able to take oral med-
ications.
c. Codeine, hydrocodone, or oxycodone,
with or without acetaminophen, may be
prescribed as needed when the patient is
able to take oral medications.
d. NSAIDs, as needed, can be very beneficial.
e. Neuropathic pain medications
(e.g., gabapentin) may be beneficial.
f. Antispasmodics may be prescribed if
muscle spasms are present.
g. Heat may be applied for spasms and
muscular tension.
h. Ice may be applied for radicular pain for
no more than 20 minutes per hour.
i. Gentle massage may be used away from
the incision.
j. Have patient change positions frequently.
k. Modest activity may be conducted as
tolerated.
4. Constipation prevention
a. Consider initiating techniques preopera-
tively.
b. Ensure adequate water intake.
c. Diet should include adequate fresh
fruits, vegetables, and fiber.
d. Stool softener (e.g., docusate) may be
used two to three times per day.
e. Motility agents (e.g., senna) should be
used only as needed.
5. Urination
a. Urinary hesitancy, especially in the
immediate postoperative period, is usu-
ally transient.
b. Assess urinary output, frequency, and
volume.
c. Assess to be sure there is adequate emp-
tying. Bladder scanning or intermittent
bladder catheterization may be neces-
sary to assess for retention or incomplete
emptying.
6. Discharge planning
a. Discharge planning should be initiated
preoperatively.
b. Reinforce the following: no lifting, bend-
ing, or twisting; no sitting for long peri-
ods of time.
c. Remind patient to change positions fre-
quently.
d. Remind patient not to drive while using
narcotic pain medications.
e. Explain to patient that sexual activity
may be resumed 2 weeks after surgery
and when it is comfortable.
f. Ensure that the patient is aware of
return-to-work and activity recommen-
dations.
7. Reinforce alternative planning and problem
solving for practical everyday activities (e.g.,
vacuuming, doing laundry, and performing
child care).
8. Incision care varies with the type of closure.
9. Ensure the patient is aware of postoperative
follow-up recommendations.
VIII. Expected Outcomes
A. Patients with mild symptoms will usually
improve regardless of the type of treatment. Sur-
gical intervention for moderate to serve sciatica
results in greater improvement. Surgical inter-
vention provides faster relief from an acute sciatic
attack. According to Angevine and McCormick
(2002), Lumber discectomy is generally per-
formed to reduce pain or disability and thereby
improve quality of life. Important surgery-related
results, therefore, include the patients percep-
tions of the effect of surgery on their health and
ability to perform daily tasks (p. E8).
B. As noted above, Atlas et al. (2005a) completed
a 10-year follow-up study of the long-term out-
comes of surgical and nonsurgical management
of sciatica secondary to a lumbar disc hernia-
tion and found that surgical treatment (mostly
open discectomy) led to more complete leg
pain relief, improved function, and improved
satisfaction.
The clinical symptoms of cauda equina syndrome (CES)
are low back pain; sciatica; saddle and perineal hypoesthesia
or anesthesia; a decrease in anal tone; absent ankle, knee, or
bulbocavernous refexes; and bowel and bladder dysfunc-
tion. Not all criteria are required for the diagnosis to be
established. However, symptoms of urinary dysfunction
and saddle hypoesthesia with varying degrees of motor and
sensory loss in either of the extremities are necessary for the
diagnosis (Fehlings, Zeidman, & Rampersaud, 2005). Sacral
root lesions manifest more subtle clinical symptoms than
those of lumbar root involvement. Sensory assessment of the
perineal area distribution should be documented. A com-
plete perineal examination should include the perianal area,
the natal cleft, and the posterior scrotal or labial areas.
The cauda equina consists of peripheral nerves, both
motor and sensory, below the level of the conus medullaris
and within the spinal canal. The conus medullaris contains
the myelomeres of the fve sacral nerve roots. Damage to
any part of this structure may result in CES.
Damage to the structures of the conus medullaris,
usually by compressive forces, can cause CES. The most
common cause is midline prolapse of the intervertebral
disc, and the most common levels reported are in the lower
part of the cauda, particularly L4L5. Most lumbar disc
herniations causing CES are midline prolapse, causing
bilateral symptoms.
Other conditions that may cause CES include tumor,
trauma, spinal epidural hematoma, chiropractic manipula-
tion, pneumococcal meningitis, Pagets disease, laminar
hooks, and free fat graft following discectomy. CES often
occurs with no precipitating event.
Symptom onset can occur suddenly without previous
history of backache, with acute onset of bladder dysfunc-
tion following a long history of low back pain; or gradually
from a background of chronic low back pain and sciatica.
Compressive lesions may create a partial block, causing
a varying degree of impairment in addition to asymmetry
of the disturbance. A complete block is not required to
produce a CES. Clinical evidence
has demonstrated little correlation
between the degree of block and the
development of CES (Fehlings et al.,
2005).
Signifcant neurologic changes can
occur with 75% restriction of the cauda
equina. Neural tissue damage includes
an infammatory response and axonal
and Wallerian degeneration followed by
proliferating Schwann cells and regener-
ating axonal buds.
II. Incidence
CES is rare, affecting an estimated 1% secondary to disc
herniation (Fehlings et al., 2005).
A. Radicular pain is often described as stabbing,
shooting, or burning.
B. The patient may have hypoesthesia or hyperes-
thesia in the same region.
C. The patient may describe difficulty urinating
or the absence of or decreased feeling in the
perineal region.
D. Healthcare providers should assess motor
weakness (specific motor nerve root), sensory
changes (numbness or tingling along a spe-
cific distribution), and reflexes (decreased or
absent).
E. If CES is suspected, an examination and evalua-
tion of perianal sensation is warranted. Sensory
assessment of the perineal region should include
the perianal area, the natal cleft, and the pos-
terior scrotal or labial areas. (See Table 2 for
possible symptoms related to specific functions.)
F. MRI and CT studies not only determine the
level of pathology but also aid in the diagnosis
of the primary pathologic lesion.
G. The diagnosis of CES is primarily based on
clinical examination.
IV. Surgical Management
Although controversy exists as to the value of early
decompression, expeditious surgery continues to be
recommended within 48 hours after the patient presents.
Transcanal approaches include standard open lumbar
laminectomy for resection of compressive lesion or
discectomy/microdiscectomy for herniated disc.
V. Nursing Assessment, Interventions, and Monitoring
Please refer to the recommendations for herniated lum-
bar disc.
Table 2. Symptoms Related to CES
Involvement Symptoms
Motor Limb weakness or weakness of movements; hypotonia in the limb or
muscle group; diminished or absent reflexes
Sensory Hypoesthesia or hyperesthesia with objective signs of sensory loss in
a dermatomal or myotomal distribution
Urinary sphincter control Difficulty initiating micturition, retention, stress incontinence; loss of
urethral sensation
Bowel dysfunction Constipation, loss of appreciation of rectal distension; loss of anal
tone and sensation
Sexual dysfunction Sudden onset of difficulty achieving an erection or orgasm
Cauda Equina Syndrome
VI. Outcomes
A. In a study by Kennedy et al. (1999), early
decompression was a significant factor in pre-
venting poor outcome due to CES. The mean
time to decompression in the group with a
satisfactory outcome was 14 hours, whereas the
time in the group with the poor outcome was
30 hours.
B. In many cases, early intervention may prevent
the progression of partial sphincter disturbance
to complete lesions. This progression has been
documented to occur even within the first 24
hours (Kennedy et al., 1999).
C. Predictors of residual dysfunction are the pres-
ence of significant sphincter disturbance and
complete perineal anesthesia at presentation.
D. The goal of surgery is to prevent progression of
neurological dysfunction; resolution of present-
ing symptoms of neurologic dysfunction is
unknown.
Lumbar Stenosis
A. Central canal stenosis
The normally triangular-shaped spinal canal
becomes fattened, compressing the thecal sac
(Figure 16). As it progresses, the cauda equina
is compressed. This can be caused by any
of the following, or any combination of the
following:
facet hypertrophy
thickening and bulging of the ligamenta
flava
outward disc bulging
disc degeneration
spondylosis (Figures 17, 18)
degenerative spondylolisthesis.
The condition is aggravated by positions of
extension, which produce more central-canal
and lateral-recess narrowing.
B. Lateral-recess stenosis
Lateral-recess stenosis is a narrowing in the
area where the nerve roots exit the spinal canal.
It can also be caused by facet hypertrophy, disc
bulging, loss of disc height, spondylosis, or
degenerative spondylolisthesis.
Figure 16. Central and lateral-recess stenosis: MRI, axial view
Figure 17. Spondylosis in the lumbar spine
Figure 18. Spondylosis: Posterior view
C. Neurogenic claudication
Compression of the microvasculature of
the lumbar nerve roots, resulting in ischemia
and pain, is believed to be a major contribut-
ing factor in the development of neurogenic
claudication. In addition to ischemia, postural
changes can cause stenosis. Postural neurogenic
claudication is induced when the lumbar
spine is extended and lordosis is accentu-
ated, whether at rest or during exercise in the
erect posture. With extension of the spine,
degenerated intervertebral discs and thickened
ligamenta fava protrude posteriorly into the
lumbar canal, producing transient compression
of the cauda equina. In the ischemic form, it
is theorized that transient ischemia occurs in
compressed lumbosacral roots when increased
oxygen demand occurs during walking (Garfn,
Rydevik, Lipsen, & Herkowitz, 1999).
II. Definitions
A. Congenital stenosis: The patient was born
with a small narrow spinal canal.
B. Acquired stenosis: The spinal canal has nar-
rowed because of degenerative changes.
III. Incidence
A person with severe congenital lumbar stenosis may
become symptomatic as early as 20 years of age, whereas
someone with acquired lumbar spinal stenosis becomes
symptomatic at 6070 years of age (Dimar, Djurasovic,
& Carreon, 2005). Males have a higher incidence than fe-
males. There does not appear to be any correlation between
race and lumbar stenosis.
Although L4L5 is the most frequently involved level,
lumbar stenosis may be found focally over one or two seg-
ments or at multiple levels.
IV. Supporting Data
A. Symptoms
1. Lower extremity symptoms may be
described as burning, cramping, aching,
numbness, tingling, or dull fatigue.
2. Early stenosis may present with nonspecific
back pain.
3. Leg fatigue, pain, numbness, and weakness
occur sometimes several months to years
after the back pain was first noticed.
4. Symptoms are usually exacerbated by walking.
5. Symptoms are generally bilateral but can be
more pronounced on one side.
6. Pain radiates from the buttocks to the poste-
rior or posterolateral thighs and occasionally
spreads distally to the calves and feet.
7. Symptoms are immediately relieved by sit-
ting down.
8. Symptoms are often improved with a forward
flexed posture. Patients may describe increased
walking tolerance if using a supportive device
such as a grocery cart, walker, or cane.
9. Walking distance usually gradually declines
over time due to the onset of symptoms at
shorter and shorter distances.
10. The degree of pain does not always correlate
with the severity of stenosis.
B. Examination
1. Posture is often stooped forward (i.e., for-
ward flexion). This sort of stooped posture,
referred to as the Simian stance, is more pro-
nounced with ambulation.
2. Patients strength is generally intact.
3. Patients deep tendon reflexes may be
decreased or absent.
4. Sensation is usually normal but may be
temporarily affected after ambulation. If
comorbidities are present, such as diabetes,
the patient may have decreased sensation in
a stocking distribution.
IV. Nonsurgical Medical Treatment
As with HNP, nonsurgical management can provide
symptom relief and is of utmost importance. Unlike those
of HNP, symptoms progress slowly in most patients, af-
fording them ample time to participate in a multimodal
nonsurgical program. A comprehensive program includes
not only structured therapy but also general personal well-
being and commitment to daily activities to promote good
back health.
The patients age and other comorbidities often will
necessitate the coordination of care with the primary care
provider.
Options include the following:
A. General recommendations
1. Promote general well-being, such as educat-
ing patient about the benefits of smoking
cessation, weight management, and ade-
quate physical activity.
2. Physical therapy often is indicated; exercises
may help reduce pain and improve function.
Flexion exercises and low-impact aerobic
conditioning should be emphasized. The
use of recumbent bicycles, elliptical train-
ers, treadmills, and warm water pools can
be very beneficial for overall conditioning.
A home flexion exercise program should be
followed daily.
B. Medication
Medication may be benefcial for short-term
pain symptom relief to allow patients to par-
ticipate in therapies. There are several effective
strategies for symptom management, including
1. muscle relaxants to reduce muscle spasm
2. NSAIDs to reduce inflammation of the
nerve root
3. narcotics for short-term acute pain relief.
C. Bracing
In this population, braces may be used to
decrease lumbar lordosis, which may decrease
pain. However, prolonged use may cause
muscle atrophy, which can increase back pain.
The effcacy of lumbar braces for treating acute
and chronic low back pain is unknown (Ngu et
al., 2003).
V. Surgical Treatment
Laminectomy and partial facetectomy (typically medial
one-third) is the standard surgery. The number of levels
decompressed is dependant upon the number of levels
suspected of causing the patients symptoms. Great care
is taken to avoid dural tear, nerve root injury, or complete
facetectomy, which can lead to segmental instability or
acquired spondylolisthesis (Figure 19).
A. Following deep tissue dissection, localization is
confirmed with X ray.
B. Bony removal begins with the spinous process.
The amount of bone removed depends on the
amount of stenosis.
C. The lamina is thinned with a drill. The thinned
lamina is then removed; the spinal canal is
carefully decompressed.
D. The ligamentum flavum lies between the lamina
and the thecal sac. Often with spinal stenosis,
the ligamentum flavum is thickened. The dura
is often physically protected while the ligamen-
tous and bony dissection is completed.
E. The lateral recesses are then checked, and
ligamentous or bony material is removed,
with particular attention to the medial aspect
of the foramen. This ensures good nerve root
decompression.
F. The wound is irrigated and closed. A drain
may be utilized.
VI. Nursing Assessment, Interventions, and
Monitoring
A. Preoperative
1. Surgical procedure
2. Preoperative history and physical
3. Informed consent (obtained by surgeon)
4. Anticipation of perioperative and postop-
erative care needs
a. Initially, patient will not be able to be
alone and must make arrangements for
a care provider.
b. Patient should arrange for help with
household chores, yard work, pets, and
other tasks.
5. Potential risks and complications
6. Expected outcomes, both postoperative and
long term
a. Realistic patient expectations
b. Mutual patient and physician expecta-
tions
7. Required preoperative testing: For this
patient population, special attention needs
to be paid to preoperative medical clearance
because of advanced age or other medical
conditions.
8. Discontinuation of medications, including
herbal products, NSAIDs, anticoagulants,
aspirin, warfarin, clopidogrel bisulfate
B. Perioperative
1. Explain to patient where and when to
arrive, as well as surgery time.
2. Instruct patient on eating and drinking restric-
tions.
3. Instruct patient on medications to be taken
the morning of the surgery with a sip of
water. Be aware of the institutions anesthe-
sia guidelines.
4. Remind patient to wear comfortable cloth-
ing and to leave jewelry and valuables at
home.
5. Tell patient to remove dentures, partial
plates, eyeglasses, contact lenses, nail polish,
and sculptured nails.
Figure 19. Decompression laminectomy
Lumbar Spine Surgery: A Guide to Preoperative and Postoperative Patient Care 1I
C. Intraoperative
1. Prone position is generally used.
2. Patients abdomen should hang free to
reduce intraoperative bleeding by minimiz-
ing vena cava compression and epidural
venous pressure.
3. Pressure points and genitalia should be
checked to avoid positioning injuries.
4. Lateral position is difficult.
D. Postoperative
a. Strength and sensation assessment should
be compared with preoperative status.
b. Pay special attention to the neurological
assessment and correlation to the opera-
tive intervention.
c. In the event of significant nerve root
manipulation intraoperatively or neuro-
logical deficits postoperatively, the phy-
sician may order postoperative steroids
for 2448 hours. Antibiotics may be con-
tinued for 24 hours.
2. Mobility
(e.g., CSF leak).
b. Instruct and help patient to roll to side
and bring legs down while simultane-
ously rising up with the torso from the
bed. This minimizes twisting at the waist.
chair using the legs, rather than pushing
off with the back.
d. Patient may benefit from a walker if he
or she is deconditioned, had a multi-
level laminectomy, or has difficulty with
mobility.
e. Evaluate the patient for need for an
inpatient physical therapy referral for
gait training and walker evaluation.
f. Instruct patient to take short walks to
avoid excessive fatigue; note preopera-
tive walking endurance.
g. If a CSF tear has occurred, physician
may order flat bed rest. This is often
dependent on degree of tear, ease of
repair, and surgeon preference. For a
persistent CSF leak, a lumbar drain may
be implemented.
3. Pain control
a. The degree of pain varies considerably.
b. Intravenous hydromorphone or mor-
phine sulfate may be used as needed
until the patient is able to take oral medi-
cations.
c. Codeine, hydrocodone, or oxycodone,
with or without acetaminophen, may be
prescribed as needed when the patient is
able to take oral medications.
d. NSAIDs, as needed, can be very beneficial.
e. Neuropathic pain medications
(e.g., gabapentin) may be beneficial.
f. Antispasmodics may be prescribed if
muscle spasms are present.
g. Heat may be applied for spasms and
muscular tension.
h. Ice may be applied for radicular pain for
no more than 20 minutes per hour.
i. Gentle massage may be used away from
the incision.
j. Have patient change positions frequently.
k. Note geriatric considerations when
administering medications.
4. Constipation prevention
a. Consider initiating techniques preopera-
tively.
b. Ensure adequate water intake.
c. Diet should include adequate fresh
fruits, vegetables, and fiber.
d. Stool softener (e.g., docusate) may be
used 2-3 times per day.
e. Motility agents (e.g., senna) should be
used only as needed.
f. Geriatric patients are prone to chronic
constipation problems.
5. Urination
a. Urinary hesitancy, especially in the
immediate postoperative period, is usu-
ally transient.
b. Assess urinary output, frequency, and
volume.
c. Assess to be sure there is adequate emp-
bladder catheterization may be neces-
sary to assess for retention or incomplete
emptying.
d. Patient may have long-standing urinary
retention.
6. Incision care
a. Assess incision to be sure it is clean and dry.
b. Care varies widely depending on the type
of closure (staples, sutures, skin glue).
c. In general, incision needs to be moni-
tored daily for redness, drainage, and
signs of infection. Patient and caregiver
need to be instructed on specific incision
care, evaluation for signs and symptoms
of infection, and when and who to call
with questions or problems.
7. Postoperative teaching
a. Avoid heavy lifting (anything heavier
than a gallon of milk) for the first 46
weeks.
b. Avoid prolonged sitting or standing for
the first 46 weeks, including long car
trips.
c. The need for outpatient therapy is
decided on individual basis.
d. Patient will gradually be weaned from
pain medication.
8. Discharge planning
a. Discharge planning should be initiated
preoperatively.
b. Talk to patient about how to gradually
return to activities of daily living (ADLs)
and lifestyle.
c. Reinforce to patient the following: no
lifting, bending, or twisting; no sitting
for long periods of time.
d. Remind patient to change positions fre-
quently.
e. Remind patient not to drive while using
f. Explain to patient that sexual activity
may be resumed when it is comfortable.
g. Ensure that the patient is aware of
return-to-work and activity recom-
mendations. Return to work will vary
depending on type of work (sedentary
roles earlier than heavy labor). Return to
work may be a gradual progression to
full time.
h. Reinforce alternative planning and
problem solving for practical everyday
activities (e.g., vacuuming, doing laun-
dry, performing child care).
i. Explain incision care.
j. Ensure that the patient is aware of post-
operative follow-up recommendations.
9. Patient comorbidities may affect postopera-
tive recovery.
VII. Expected Outcomes
Atlas, Keller, Wu, Deyo, and Singer (2005b) found that
patients with lumbar spinal stenosis treated surgically
and nonsurgically had similar low back pain relief, pre-
dominant symptom improvement, and satisfaction at 810
years. However, the surgical treatment group experienced
greater improvement in leg pain relief and back-related
functional status.
Spondylosis
Spondylosis is the result of disc degeneration, which
leads to bulging of the annulus fbrosus. The degener-
ated, bulging annulus fbrosus creates an elevation of the
periosteum. Bony reactions occur, resulting in osteophyte
formation (Figures 17, 18). The osteophytes commonly oc-
cur in the lordotic spinal canal of the lumbar and cervical
spine (Benzel, 2001). In addition, there may be hypertrophy
and buckling of the ligamentum favum, leading to further
lumbar spine canal narrowing. With disc collapse, the neu-
ral foramina will decrease in height, which may result in
nerve root compression. Alterations in axial loads may lead
to posterior facet osteophyte formation, which can also
result in nerve root compression (Singh & Phillips, 2005).
Motion segment degeneration can lead to stiffened
levels, exhibiting disc degeneration, ligament calcifcation,
and osteophyte formation. Conversely, the motion segment
can be hypermobile, as in degenerative spondylolisthesis
(Jeong & Bendo, 2004). The degenerative cascade, a part
of the aging process, is caused by many factors and affects
the discs, facet joints, surrounding soft tissue, ligaments,
vertebrae, and articular processes. Benzel (2001) noted
that the spondylotic process is lessened by fusion or
immobilization.
II. Supporting Data
A. Refer to Lumbar Spinal Stenosis section.
B. If the patient has a mobile segment, refer to
Spondylolisthesis section.
C. Symptomatic age is 5070; spondylosis occurs
more often in men.
D. Everyone in the geriatric population has
degenerative changes. Clinical correlation is
key.
Spondylolisthesis and Spondylolysis
Spondylolisthesis comes from the Greek words spondylo,
meaning vertebrae, and listhesis, meaning slipping or slid-
ing. It most often occurs at L5S1, followed by L4L5. The
most frequent cause of spondylolisthesis is degenerative
changes related to chronic motion between two vertebrae
that results in anterior subluxation. Spondylolysis is a defect
in the pars interarticularis (bony region between the su-
perior and inferior articulating processes of an individual
vertebra). The defect may be an elongated, but intact, pars;
an acute fracture; or a lytic lesion representing a fatigue
fracture. Spondylolysis is also known as isthmic spondy-
lolysis or type-II spondylolisthesis. Spondylolisthesis is
classifed as follows:
A. Type I: Dysplastic
1. Type I is due to a developmental disorder
and characterized by presence of dysplastic
sacral facet joints that allow forward trans-
lation (movement) of one vertebra over
another. Undue stress on the pars may result
in fracture.
2. It is often associated with spina bifida and
congenital defects of the pars interarticularis.
B. Type II: Isthmic
1. Repeated fatigue fractures followed by
remodeling causes the development of a
stress fracture of the pars interarticularis.
2. Type II can also be a developmental injury
for some adolescents during growth spurts.
3. This is the most common cause of low back
pain in children.
C. Type III: Degenerative
Type III is an adult condition caused by chronic
intersegmental instability that produces facet
arthropathy (Figure 20).
D. Type IV: Traumatic
1. Type IV results from fracture of the pedicles,
the pars, or the superior/inferior articular
processes caused by a traumatic injury.
2. Type IV is very rare.
3. Type IV can occur acutely after an injury,
although most often it will develop during
the weeks to months after the injury.
E. Type V: Pathological
Type V is due to an internal alteration caus-
ing destabilization of the facet mechanism
producing a pathologic spondylolisthesis. Some
examples are tumors, infection, Pagets disease,
osteoporosis, and hyperthyroidism.
II. Grading and Incidence
A. Grading
The degree of subluxation is generally
measured using the Meyerding method. The
superior surface of the sacrum is divided into
fourths along its anteroposterior (AP) diameter.
Then the degree of subluxation is noted as a
grade:
Grade 1: 1%25% slippage
Grade 5: Greater than 100% slippage
B. Type I
Of all populations, Inuit are most at risk. As
many as 50% of Inuit acquire this condition,
related to both genetic and environmental fac-
tors. There is a 2:1 ratio of females to males. In
children, this condition has been diagnosed as
early as 3.5 months; 4% are found by age 6, and
6% by age 14 (Ahn et al., 2003; Hresko, 2003;
Rainville, Hartigan, & Liu, 2003).
C. Type II
Although type II spondylolisthesis is not a
congenital condition, there is a positive cor-
relation between congenital defects, including
spina bifda occulta and scoliosis, and the
development of type II spondylolisthesis.
As many as 50% of spondylolysis cases will
become type II spondylolisthesis. Males out-
number females 2:1, although females have
a higher likelihood of having a more severe
grade. There is a higher incidence among Cau-
casians than among African Americans, by a 6:1
ratio.
D. Type III
This condition commonly occurs after the
age of 40. Females are affected more often than
males, by a 5:1 ratio. African American females
are more often affected than Caucasian females.
Most commonly, type III spondylolisthesis
occurs at L4L5. Incidence increases mostly
with advancing age; other risk factors include
diabetes, arthritis, smoking, and obesity (Lin &
Jenis, 2003).
Figure 20. L4L5 degenerative spondylolisthesis (Note the disc degenera-
tion and compression on the existing L5 nerve root.)
E. Type IV
Traumatic spondylolisthesis is rare. Falls and
parachuting injuries have been most frequently
associated with this type. More often, spondy-
lolisthesis occurs after trauma and is related to
the sequels of recovery process.
F. Type V
Type V spondylolisthesis occurs with other
disease processes, and determining its inci-
dence has been diffcult. Incidence is increased
with diseases affecting the bone structure and
generation of osteoblast as well as conditions
that increase the osteoclasts.
A. Symptoms are dependent on the type and
grade of spondylolisthesis.
B. Pain can begin insidiously and is aggravated
by activity, especially back-extension types of
movements.
C. Pain is in the low back with or without
radiation.
D. Pain is usually worse with prolonged walking
or standing and improved with sitting.
E. Symptoms often are similar to those of lumbar
stenosis, but the patient may experience more
back pain. (Please see the Lumbar Stenosis
section.)
F. Patient may complain of a slipping sensation in
the lower back.
G. Patients may have difficulty walking.
H. On examination, one maybe able to palpate the
step-off of the vertebrae.
I. In most cases, the patient doesnt present with
radicular pain, because it occurs more often in
high grades.
IV. Definitions
A. Spondylo: Vertebra (denotes relationship to
vertebra or spinal column)
B. -listhesis: To slip
C. -lysis: Loosening, releasing, destruction
Degenerative Disc Disease
Degenerative disc disease (DDD) is described as a
change in the composition and function of the disc. A discs
water content and vascularity decreases with age. By the
age of 30, there is no longer a direct vascular supply to the
discs, and they become desiccated, providing less support
and resistance to movement. During the aging process, the
nucleus pulposus becomes less elastic, and tears develop
in the annulus fbrosis. It is commonly accepted that the
disc may become painful if the outer third is exposed to a
noxious stimulus. Many patients are asymptomatic despite
radiographic degenerative changes (Figure 21). Symptoms
include pain, dysfunction, and disability (Burkus & Zde-
blick, 2004).
II. Supporting Data
A. Patients are generally relatively young; they
present with a history of gradually worsening
back pain.
B. The pain is described as deep, midline, and
aching.
C. Pain may radiate into the buttocks or upper
thighs; it is worse when patient stands in one
position.
D. A radiographic-based grading scale has been
devised to indicate the degree of DDD on MRI
testing. Modic endplate changes are graded as
follows:
1. Type I. Study shows disruption and fissur-
ing of the vertebral endplates; decreased
signal on T1-weighted images and increased
signal intensity on T2-weighted images.
Figure 21. L4L5 and L5S1 degenerative disc disease: Lumbar
spine MRI, T2-weighted image
2. Type II. Yellow marrow replacement results
in increased signal intensity on T1-weighted
images and increased signal intensity on T2-
weighted images.
3. Type III. Bony sclerosis indicated; decreased
signal intensity on both T1- and T2-weight-
ed images.
E. Resnick et al. (2005a) have proposed the fol-
lowing evidence-based guidelines regarding
the use of MRI in degenerative disease of the
lumbar spine:
1. MRI scanning should be used as a diagnos-
tic test instead of discography for the initial
evaluation of patients with chronic low back
pain.
2. MRI-documented disc spaces that appear
to be normal should not be considered for
treatment as a source of low back pain.
3. Lumbar discography should not be used as
a stand-alone test on which treatment deci-
sions are based for patients with low back
pain.
4. If discography is performed as a diagnostic
tool to identify the course of a patients low
back pain, both a concordant pain response
and abnormalities should be present at the
same level.
Degenerative Scoliosis
Degenerative scoliosis occurs in previously nonscoliotic
spines in which the degenerative cascade, including disc
degeneration, facet and ligamentum favum hypertrophy, and
motion segment hypermobility can lead to deformity in all
planes (i.e., axial, sagittal, coronal). Deformity causes the patient
to be out of spinal balance. This imbalance leads to postural
deformities, pain, and disability (Rosner & Ondra, 2005).
II. Supporting Data
A. Observe patients posture and gait.
1. Will often observe a kyphotic deformity.
2. If manual correction of posture is attempted,
patient is unable to balance because the cen-
ter of gravity has been shifted.
B. Refer to Spinal Stenosis and Spondylolisthesis
sections.
C. Standing scoliosis films with AP and lateral
views; lateral bending scoliosis films to assess
flexibility of the curve; lumbar flexion/exten-
sion films to evaluate for instability; for
preoperative planning, dual energy X-ray
absorptiometry (DEXA) scan to assess whether
osteoporosis is present.
D. Patient should undergo same nonsurgical man-
agement as other spine patients.
E. If surgical, deformity correction can be very
extensive with long operative period.
F. Patient may require long hospitalization and
rehabilitation.
G. Preoperative planning includes nutritional
assessment.
Medical Treatment of Lumbar Spondylosis,
Spondylolisthesis, Spondylolysis, and
Degenerative Disc Disease
I. Patient Education
General physical well-being is of the utmost importance
in the treatment of low back disorders. It includes patient
education in the following areas:
A. Appropriate weight/body mass index
B. Smoking cessation
C. Positive mental outlook
D. Progressive aerobic exercise
E. Daily stretching and strengthening exercise
program.
II. Specific to Degenerative Disc Disease
A. A minimum of 34 months of aggressive medi-
cal management is usually attempted prior to
surgical intervention.
B. Promote general well-being, such as smoking
cessation, weight management, and maximiz-
ing physical function.
C. Minimize chronic narcotic use.
D. Optimize nutritional status.
E. Encourage regular exercise, outpatient back-
rehabilitation school, and manipulation.
F. Refer to HNP and Stenosis sections.
Surgical Treatment
Two-thirds of adults in the United States will experi-
ence low back pain at some time. Approximately 151,000
undergo a lumbar fusion each year (Lipson, 2004). Deyo,
Nachemson, and Mirza (2004) noted that the number of
spinal fusions increased by 77% between 1996 and 2001
and that although spinal fusion is undoubtedly effective
for some conditions in some patients, its efficacy for some
indications remains unclear (p. 724).
To address questions related to fusion surgery for
degenerative disease of the lumbar spine, the American
Association of Neurological Surgeons and the Congress
of Neurological Surgeons Joint Section on Disorders of
the Spine and Peripheral Nerves commissioned a group
of orthopedic and neurosurgical spine surgeons to per-
form an evidenced-based review of the literature. Resnick
et al. (2005a, b, c) completed this exhaustive review of
the literature, published as Guidelines for the Performance
of Fusion Procedures for Degenerative Disease of the Lumbar
Spine. These guidelines provide the current evidence avail-
able for degenerative lumbar spine fusion procedures. The
guidelines cover topics including the following:
assessment and functional outcomes
assessment and economic outcomes
correlation between radiographic and func-
tional outcome
intractable low back pain without stenosis or
spondylolisthesis
lumbar fusion
injection therapies, low back pain, and fusion
bracing
electrophysiologic monitoring
bone extenders and substitutes.
bone growth stimulators and lumbar fusion
The following section on lumbar fusion techniques is not
intended to advocate spinal fusion or one fusion technique
over another. The goal is to give the reader an appreciation
for the basic physiology of bone healing and the various
fusion techniques currently being performed.
I. Bone Healing
A solid bony fusion must be achieved to provide perma-
nent spinal stability. Spinal instrumentation provides only
temporary, internal fixation. If a solid bony fusion is not
achieved, fusion failure may result in fatigue and failure of
supporting instrumentation and persistence or worsening
of symptoms. Nurses caring for lumbar fusion patients are
in a pivotal position to explain and reinforce to the patient
the importance of providing an ideal environment to pro-
mote bony healing.
A. Three primary bone types
1. Woven bone: Occurs in embryonic develop-
ment; fracture healing; and disease states
such as hyperparathyroidism and Pagets
disease
2. Cortical bone
a. Composed of osteons
(1) Compact, cylindrical
(2) Haversian canals are vascular chan-
nels at the center, connected to one
another by horizontal Volkmanns
canals (Figure 22)
b. Forms internal and external tables of flat
bones and external surfaces of long bones
c. Mechanical strength depends on the tight
packing of the osteons
3. Cancellous bone
a. Also referred to as trabecular bone
b. Lies between the cortical bone
c. Honeycomb interstices containing hema-
topoietic stem cells and bony trabeculae
d. Arrayed in a perpendicular orientation
to provide support
e. Continually undergoing remodeling
Treatment of Lumbar Spine Disorders
B. Cellular components
1. Osteoblasts: Mature, metabolically active
bone forming cells
2. Osteocytes: Mature osteoblasts trapped in
the bone matrix
3. Osteoclasts: Multinucleated bone-resorbing
cells controlled by hormonal and cellular
mechanisms
4. Bone metabolism: Under constant regulation
by a host of hormonal and local factors.
C. Basic physiology of bone repair
1. Osteogenesis
a. Ability of the graft to produce new bone
b. Dependent on the presence of live bone
cells in the graft; unites the graft with
the host bone
2. Osteoconduction
a. The physical property of the graft to
serve as a scaffold for bone healing.
b. Allows for the ingrowth of neovascula-
ture and infiltration of osteogenic pre-
cursor cells into the graft in cancellous
autograft and allograft
3. Osteoinduction
a. Ability of the graft material to induce
stem cells to differentiate into mature
bone cells
b. Typically associated with the presence of
bone growth factors within the graft mate-
rial or as a supplement to the bone graft.
(1) Bone morphogenic proteins (BMPs)
and demineralized bone matrix are the
principal osteoinductive materials.
(2) Autograft and allograft have some
osteoinductive properties, but to a
much lesser degree.
4. Autograft is the only material demonstrat-
ing all three properties (osteogenesis, osteo-
conduction, and osteoinduction).
D. Basic principles of bone remodeling
1. The process of a bone graft becoming a solid
fusion that is incorporated into the native
bone in the spine is very similar to the pro-
cess of bone healing after fracture.
2. The process has three stages.
a. Early inflammatory stage (weeks 12)
(1) A micro-hematoma forms in the bone.
(2) Inflammatory changes occur at the
area of the graft.
(3) Inflammation promotes granulation.
(4) The use of antiinflammatory medi-
cations or cytotoxic drugs during
this period may inhibit bone healing
and fusion formation.
(5) With vascular ingrowth progres-
sion, a collagen matrix is laid down
and a soft callus forms (Pilitsis,
Lucas, & Rengachary, 2002).
b. Repair stage (weeks 26)
(1) Development of vascular and capil-
lary supply to the new bone.
(2) Collagen and callus bone forms.
(3) The bone formed during this period
is very weak for 46 weeks, requir-
ing either internal fixation (instru-
mentation) or bracing.
(4) Use of nicotine during this period
can inhibit capillary growth and
result in failure of the bone to heal.
c. Late remodeling stage (slow process,
requiring months to years)
(1) Restoration of the original bone
shape, structure, and mechanical
strength occurs.
(2) As the patient places axial forces
on the new bone, additional
bone forms in the areas of stress.
Conversely, the areas that do not
receive stress will resorb.
E. Wolffs law
Wolffs law states that bone placed under
compressive stress is remodeled. Bone is formed
where stresses require its presence and resorbed
where stresses do not require it (Kalfas, 2001).
Thus, when a bone graft is placed, it needs
mechanical compressive stress so that new bone
will be formed, thereby healing the bone.
F. Limitations to proper bone healing
A number of factors may negatively affect
proper bone healing: anti-infammatory, cyto-
toxic, and steroid medications during the early
infammatory stage; nicotine use; radiation; and
systemic illnesses (e.g., diabetes mellitus, rheu-
matoid arthritis, osteoporosis) (Pilitsis, Lucas,
Figure 22. Cortical and cancellous bone in the lumbar vertebrae
& Rengachary, 2002). If the graft site is shielded
from stress, according to Wolffs law, new bone
will not be formed.
G. Graft materials
1. Autograft (from the recipients own body)
2. Allograft (Cadaver bone)
3. Biologics
a. Demineralized bone matrices:
Demineralized bone is made from bone
that has been decalcified under acidic
conditions. The matrices are composed of
a mixture of type I collagen and noncol-
lagenous proteinsincluding a variety of
growth factors and cytokines. It is both
osteoinductive and osteoconductive.
(1) Variable carrier material dependent
on the specific product
(2) Many products and manufactures
on the market
b. Recombinant human bone morphoge-
netic protein
(1) Derived from bone matrix
(2) Highly osteoinductive
(3) Osteoconductive, osteogenic
(4) Only one product is approved
by the U.S. Food and Drug
Administration (FDA): INFUSE

Bone Graft (rhBMP-2)
(5) FDA approves INFUSE Bone
Graft for spinal surgery use with
LT-CAGE
, INTERFIX, or
INTERFIX RP devices
a) Indications are skeletal matu-
rity with degenerative disc dis-
ease at one level.
(b) May also have spondylolis-
thesis (up to grade I) at the
involved level.
(c) It is to be implanted via an
anterior open or an ante-
rior laparoscopic approach.
(Medtronic Sofamor Danek,
April 4, 2005)
(6) Also FDA-approved for open frac-
tures of the tibia.
4. Synthetic osteoconductive materials
Synthetic osteoconductive materials are
artifcial substrates that are only osteocon-
ductive (Figures 23, 24). They are scaffolds
for the ingrowth of new bone (Whang &
Wang, 2005).
Ceramics
Coralline matrices
Mineralized collagen
Bioactive glasses
Calcium sulfate
Acid polymers
Porous metals
H. Osteoporosis
Osteoporosis, defned as a decrease in bone
mineral density, is developed by everyone
with aging. Women reach peak bone mass
by age 2530. There is then a slow decline in
Figure 24. A synthetic osteoconductive material Figure 23. A synthetic osteoconductive material
bone mass until menopause; postmenopausal
women experience a rapid decline in bone
mass. Although men experience a slower
decline, by age 60 men and women have
roughly equal rates of bone loss. It is impor-
tant when considering spinal care in older
adults to understand that both men and
women are afficted with osteoporosis (Tis &
Kuklo, 2005).
The microarchitectural deterioration that
occurs as a consequence of osteoporosis may
compromise the effectiveness of internal
fixation, and, with severe osteoporosis, may
eliminate the option of internal fixation. Surgi-
cal options for the patient with poor bone
quality include utilizing multiple points of fixa-
tion, anterior and posterior instrumentation,
augmentation with wires, polymethylmeth-
acrylate, calcium phosphate paste, and, if
possible, a noninstrumented fusion (Dmitriev
& Kuklo, 2005; Rosner & Ondra, 2005).
II. Fusion Techniques
A. Posterolateral lumbar fusion with or without
instrumentation
1. This procedure is performed via an incision
over the lumbar spine with fusion of two
or more lumbar vertebrae. The procedure
involves decortication of the transverse pro-
cesses, facet joints, and pars interarticularis.
Autograft bone is harvested from either
the surgical decompression site or from an
iliac crest and is placed over all decorticated
surfaces. If instrumentation is used, it is laid
down after the instrumentation is in place.
Pedicle screw fixation is done utilizing the
largest screw the pedicle is able to hold
(Figures 25, 26). A 3-D image guidance sys-
tem may be used for visualization.
B. Posterior lumbar interbody fusion (PLIF)
Posterior elements are removed to gain
access to the disc space. Once the disc space
is cleared, an interbody spacer (e.g., cages,
allograft wedges, allograft bone dowel) is
placed into the disc space with disc distraction.
The distractors are then removed. The spacer
remains in the disc space and is left under com-
pression. The fusion is then strengthened by
adding pedicle screw fxation (Figure 27). In-
strumentation adds internal support to correct
spine alignment (by replacing lumbar lordosis)
and secures adequate stabilization while
the vertebral bones fuse (at approximately 6
months).
C. Transforaminal lumbar interbody fusion
(TLIF)
Utilizing a posterior approach, a unilateral
facetectomy and laminectomy are performed.
Spacers (e.g., cages, femoral rings, allograft)
packed with autograft bone are placed into the
disc space. The operative site is supplemented
with pedicle screw and rod instrumentation
(Figure 28; Starkweather, 2006).
D. Anterior lumbar interbody fusion
An anterior lumbar interbody fusion is
performed using an abdominal approach. The
Figure 26. Pedicle screw fixation: Posterior view
Figure 25. Pedicle screw fixation: Superior view
indications include degenerative disc disease
with associated back pain. There should be
no neural compression or degenerative spon-
dylolisthesis, because no direct nerve root
decompression is achieved intraoperatively.
During exposure, care is taken to avoid vascu-
lar injury and superior hypogastric stretching
or injury leading to retrograde ejaculation
(Burkus, 2004; Truumees & Brebach, 2004).
1. Generally the anterior longitudinal ligament
is divided and reflected to opposite sides to
allow spine and disc work.
2. The disc space is cleaned, and an interbody
device is placed in the disc space.
3. LT-CAGE
can be packed with recombi-

nant human bone morphogenetic protein
(Figures 29, 30).
4. The femoral ring is packed with autograft.
E. Combined anterior/posterior fusion
Anterior/posterior lumbar fusions are
indicated for patients in whom instability from
spondylolisthesis or other degenerative prob-
lems leads to the need for both anterior and
posterior column fxation.
F. Minimal-access/minimally invasive fusion
techniques
1. The minimally invasive percutaneous PLIF
procedure utilizes a hybrid of microsurgical
and endoscopic techniques through four 2-
cm incisions (Figure 31).
2. An interbody distractor device is placed
into the disc space to restore intervertebral
height, and an appropriate-size graft is
placed. The pedicle-screw rod instrumenta-
tion is placed through the same incisions.
3. The guiding K-wire is advanced to the
planned segmental fusion site. A multiaxial
pedicle screw is passed over the K-wire, and
the pedicle screw is then inserted into the
Figure 28. L4L5, L5S1 transforaminal lumbar
interbody fusion: Lateral X ray
Figure 27. L5S1 Posterior lumbar interbody fusion:
Lateral X ray
pedicle. For each ipsilateral pair of pedicles
within the motion segment that is fused, the
rod inserter is passed through both screw
heads.
G. Intraoperative image guidance
1. Preoperatively, a CT or MRI scan through
the appropriate spinal levels is obtained,
and image data are transferred to the com-
puter workstation in the operating suite.
2. Three to five reference points for each spinal
segment to be instrumented are selected and
stored in the image data set and then identi-
fied in the operative field and registered.
3. This information allows the surgeon to
have real-time, 3-D information about the
patients bony anatomy during the opera-
tive procedure.
III. Disc Arthroplasty (Artificial Disc Replacement)
To date, the only FDA-approved lumbar artifcial disc
replacements are the Charit (Zigler & Bennett, 2005) and
the ProDisc-L. Under FDA investigation is the Maverick and
Flexicore lumbar disc prostheses. Proponents of artifcial
disc replacement cite its stabilization and preservation of the
motion segment. As results of preservation of the motion
segment, proponents report decreased adjacent level-disease
and a reduction in other complications of lumbar fusion (i.e.,
hardware failure, graft problems, graft site pain, symptomatic
pseudoarthrosis, loss of motion across fused segments, loss of
normal sagittal balance (Guyer & Elders, 2005).
Correct patient selection as well as accurate and correct
placement are important for optimal surgical results. Clinical
indications for the Charit include single-level degenerative
Figure 29. LT-CAGE
Figure 30. Anterior lumbar interbody fusion: Lateral view

Figure 31. Minimal-access (minimally invasive) fusion
disc disease at L4L5 or L5S1, confrmed by provoca-
tive discography; back and or leg pain without nerve root
compression; and failure of nonsurgical treatment (Guyer
& Elders, 2005). Clinical indications for the ProDisc-L are
disabling low back pain caused by one or two adjacent levels
between L3S1. The pain must primarily originate from the
disc and be refractory to aggressive nonoperative treatment
for at least 6 months (Zigler & Bennett, 2005). Both devices are
placed through an anterior approach.
IV. Intradiscal electrothermal annuloplasty (IDET)
The clinical indication is degenerative disc disease with
maintained disc height and failed nonsurgical treatment. MRI
fndings and discography must correlate with each other.
A specialized catheter is threaded through an introducer
to the affected area. The catheter is heated to 90 C for 17
minutes. The purpose is to cauterize the annular tear and pain
fbers, thereby decreasing or alleviating the low back pain.
This minimally invasive procedure is done in an
interventional radiology suite or operating room under
fuoroscopy. It is performed as an outpatient procedure us-
ing conscious sedation.
V. Nursing Assessment, Intervention, and Monitoring
A. Preoperative
1. Surgical procedure
2. Informed consent (obtained by surgeon)
3. Expected outcomes (postoperative and long
term)
4. Required preoperative testing
5. Discontinuation of medications (e.g., herbal
products, NSAIDs, anticoagulants, aspirin,
warfarin, clopidogrel bisulfate)
B. Perioperative
1. Explain to patient where and when to arrive
as well as surgery time.
2. Instruct patient on eating and drinking
restrictions.
3. Instruct patient on medications to be taken
the morning of the surgery with a sip of
water.
4. Remind patient to wear comfortable cloth-
ing and to leave jewelry and valuables at
home.
5. Remind patient to remove dentures, partial
plates, eyeglasses, contact lenses, nail polish,
and sculptured nails.
C. Intraoperative
1. Plan for equipment needs
2. Potential 3-D stereotactic guidance system
3. Specialty table
4. May need fluoroscope in room
D. Postoperative
a. Strength and sensation assessment as
compared with preoperative status
b. Special attention to the neurological
assessment and correlation to the opera-
tive intervention
2. Mobility
(e.g., CSF leak).
b. Instruct and help patient to roll to side and
bring legs down while simultaneously
rising from the bed with the torso. This
minimizes twisting at the waist.
chair using the legs rather than the back.
3. Bracing
a. The decision whether to brace and the
type of brace used to use varies widely.
b. The decision is dependent on the sur-
gery performed, bone quality, and phy-
sician preference.
c. If braces are ordered, patient should be
given specific guidelines regarding use.
4. Pain control
Methods to reduce postoperative pain
vary according to clinical practice prefer-
ences. The difference between patient-
controlled analgesia (PCA) and epidural
infusion was investigated by Cohen and
colleagues (1997) in a prospective, random-
ized, double-blind clinical trial. The study
involved 54 patients randomized between
two groups who received either an epidu-
ral or PCA delivery system. Postoperative
time to liquids and solid food, ambulation,
length of stay, side effects, and perception
of pain were not statistically significant.
Epidural catheter dislodgement occurred
in 11% of patients, and the total cost for
epidural analgesia was approximately $550
more for a 3-day postoperative course.
Limitations included the low dosage of
bupivacaine used and the placement of the
catheter tip. The high incidence of epidural
catheter dislodgment and cost factors favor
use of PCA.
A similar study by Fisher and colleagues
(2003) demonstrated that both PCA and
patient-controlled epidural analgesia (PCEA)
provide good overall patient satisfaction.
The only clinical advantage of PCEA over
PCA for spine fusion patients was the lower
quantity of opioids consumed, although
the PCEA group experienced significantly
more side effects than the PCA group did.
There were no other significant differences.
Therefore, the patient or physician can select
either postoperative pain management
delivery system.
Continuous epidural infusion of 0.1%
ropivacaine resulted in lower pain scores,
lower opioid consumption, and higher
patient satisfaction when compared with
placebo (saline) in a study by Gottschalk
and colleagues (2004). Application of ropiva-
caine using an epidural catheter seems to be
highly effective for postoperative pain after
major lumbar spinal surgery.
If postoperative pain is out of proportion
and impairs activities, an X ray or CT scan,
or both, of the lumbar spine should be con-
sidered to evaluate the screw location and to
demonstrate integrity of the spinal canal.
Other pain management options include
the following: intravenous hydromorphone
or morphine sulfate, as needed, until the
patient is able to take oral medications;
codeine, hydrocodone, or oxycodone, with
or without acetaminophen, as needed, when
the patient is able to take oral medications;
antispasmodics, if muscle spasms are pres-
ent; neuropathic pain medications (e.g.,
Gabapentin).
E. Nutrition
1. Patients are at high risk of developing a
postoperative ileus.
2. The timing of initial oral intake varies widely.
In the fasting patient, the presence of bowel
sounds may not reflect gastrointestinal motil-
ity when the patient eats (Holte & Kehlet,
2002). Regarding early postoperative eating
and its effect on postoperative ileus, Holte
and Kehlets (2002) literature review found
that early enteral feeding had minimal effect
and was not of clinical significance. They
noted, however, that the effect of feeding
may be masked by the use of opioids, coun-
teracting the potential benefit of early eating.
F. Constipation prevention
1. Consider initiating preoperatively.
2. Ensure adequate water intake.
3. Diet should include adequate fresh fruits,
vegetables, and fiber.
4. Stool softener (e.g., docusate) may be used
two to three times per day.
5. Motility agents (e.g., senna) should be used
only as needed.
G. Urination
1. A Foley catheter should be kept in place until
the patient is able to stand to void or to reli-
ably use a urinal or bedpan. The goal should
be to remove the Foley catheter within 24
hours of surgery.
2. Urinary hesitancy, especially during the
immediate postoperative period, is usually
transient.
3. Assess urinary output, frequency, and vol-
ume.
4. Assess to ensure there is adequate emp-
bladder catheterization may be necessary
to assess the patient for retention or incom-
plete emptying.
H. Discharge planning
1. Discharge planning should be initiated
preoperatively.
2. Reinforce to patient the need to avoid lift-
ing, bending, twisting, and sitting for long
periods of time.
3. Remind patient to change positions frequently.
4. Remind patient not to drive while using
5. Sexual activity may be resumed as advised
by the physician and when comfortable.
6. Ensure the patient is aware of return-to-
work and activity recommendations.
7. Reinforce alternative planning and problem
solving for everyday activities (e.g., vacu-
uming, doing laundry, and performing child
care).
8. Incision care varies with the type of closure.
9. Ensure the patient is aware of postoperative
follow-up recommendations.
I. Postoperative
1. Talk to patient about gradually returning to
ADLs and lifestyle.
2. Patient should begin ambulation within the
first 24 hours. Activity will improve pain
tolerance and decrease muscle spasms.
3. Patient should avoid heavy lifting (anything
heavier than a gallon of milk) for the first
46 weeks.
4. Patient should avoid prolonged sitting or
standing for the first 46 weeks, including
long car trips.
5. Patient should begin a walking program
that includes progressively longer distances
two to three times per day.
6. Patients return to work will vary, depend-
ing on type of work (sedentary work earlier
than heavy labor). Return to work may be a
gradual progression to full time.
7. Outpatient therapy will be decided on an
individual basis and discussed at follow-up
surgical visit.
8. Patient should be instructed on incision
care, dressing removal, bathing, and obser-
vation of incision for redness, swelling, or
drainage.
9. Call surgeons office for temperature higher
than 100.6 F.
10. Patient will gradually be weaned from pain
medication.
J. Common postoperative complications (Green-
berg, 2001, pp.187-189)
Common postoperative complications are as
follows:
1. Superficial wound infections
a. 0.9%5% incidence
b. Increased risk with age, long-term ste-
roid use, obesity, or diabetes mellitus
c. Most superficial infections are caused by
S. aureus.
d. Mild infections are usually treated with
714 days of oral antibiotics.
2. Increased motor deficit
a. 1%8% incidence
b. Can be transient with nerve root stretch-
ing or manipulation.
3. Unintended durotomy
a. 0.3%13% incidence
b. Generally revealed intraoperatively
c. May be repaired with a 4.0 silk or
Neuralon, fibrin glue, or muscle plug
(may be necessary for poor-quality dura
or difficult locations).
d. Possible sequelae include a CSF fistula
(external CSF leak) or pseudomeningo-
cele.
e. A CSF leak generally presents as a
wound leak, a collection, or postural
headaches.
f. In most circumstances, activity is
restricted to flat lying position for
2448 hours. Head of bed is gradually
increased.
g. In some situations, the physician may
elect to have a blood patch placed to
plug the tunnel.
4. Pseudomeningocele
a. 0.7%2% incidence
b. Appears similar radiographically to a
spinal epidural abscess.
c. If a dural tear is suspected or visualized,
the patient is maintained in a flat posi-
tion for 2448 hours to minimize dural
pressure. Raise the head of the bed slow-
ly (10 degrees every hour) until upright.
If the patient complains of positional
headache (i.e., headache when upright),
then resume flat lying position.
d. Some surgeons may place a lumbar
drain to decrease dural pressure and
allow for dural repair.
e. Surgical exploration may be necessary if
symptoms do not resolve.
K. Uncommon complications
1. Instability
a. Instability is usually found in predis-
posed patients undergoing decompres-
sion without fusion, especially if a sig-
nificant amount of facet is removed.
b. Obtain flexion/extension films to deter-
mine amount of movement and need for
fusion.
2. Direct injury to neural structures
3. Deep infections: <1% incidence; this
includes discitis at 0.5%, spinal epidural
abscess at 0.67%, and osteomyelitis.
4. Thrombophlebitis and deep-vein thrombosis
with risk of pulmonary embolism: 0.1% inci-
dence.
5. Complications of positioning: compression
neuropathies, anterior tibial compartment
syndrome, pressure on the eye, cervical
spine injuries.
L. Outcomes
1. Standard: Lumbar fusion is recommended
as a treatment for carefully selected patients
with disabling low back pain due to one- or
two-level degenerative disease without ste-
nosis or spondylolisthesis.
2. Optional: An intensive course of physical
therapy and cognitive therapy is recom-
mended as a treatment option for patient
with low back pain in whom conventional
medical management has failed (Resnick et
al., 2005b).
I. L5S1 Herniated Disc
D. K., a 30-year-old female, had intermittent right-but-
tock and lower extremity pain, approximately 3 months
in duration. Upon presentation to clinic, she had been
experiencing acute pain exacerbation for the past 2 weeks.
She described the pain as radiating from her right but-
tock into her posterior lower extremity to her lateral foot.
She denied weakness in her right leg, bowel or bladder
problems, or any symptomatology in her left leg. Her pain
was aggravated by sitting and alleviated by changing posi-
tions frequently. She participated in physical therapy for
2 weeks, which exacerbated her symptoms. She also had
tried NSAIDs and ice.
A. History and review of systems
1. Social history: Married with two small
children. Works as a transcriptionist but
had been unable to work for 1 week
2. Medical history: Depression, which she
noted is under fair control
3. Surgical history: Hysterectomy, tonsillectomy
4. Medications: Wellbutrin, ibuprofen, cyclo-
benzaprine, hydrocodone/APAP
5. Allergies: No known drug allergies
6. Review of systems: Unremarkable
B. Focused neurologic examination and
diagnostics
The neurological examination indicated an
absent right Achilles refex and a markedly
positive straight leg raise on the right with a
positive crossed straight leg test. Her gait was
antalgic. Strength and sensation were normal in
the bilateral lower extremities. Her MRI dem-
onstrated a large L5S1 herniated disc to the
right (Figures 32, 33).
C. Further conservative treatment
D. K. wished to pursue all nonoperative
options. She underwent an ESI for pain relief
the day of the initial clinic visit. Two weeks
later, she had experienced a decrease in her
pain. However, her ADLs continued to be
significantly impaired. She wished to proceed
with surgery.
D. Operative intervention
D. K. underwent an L5S1 microdiscectomy
for a right S1 radiculopathy. She has done well
postoperatively, and at 1 year after surgery had
no pain and was participating in all of her usual
activities.
II. L45L Herniated Disc; L5S1 Foraminal Stenosis
D. B., a 39-year-old male, had a 4-month history of low
back pain, previous right leg pain, and, currently, left leg
pain. Approximately 4 months ago he had intermittent
Case Studies
Figure 32. L5S1 herniated nucleus pulposus (HNP): MRI, sagittal
view
Figure 33. L5S1 herniated disc, eccentric to the right: Axial T2-weighted
MRI image
right leg pain, which had resolved. He now described pain
that radiated from his low back to his left buttock down
the posterior thigh to the knee. Distally from the knee he
had numbness down his posterior lower leg to the lateral
aspect of his foot. His pain was aggravated by being in any
one position for too long. His pain was alleviated by lying
in a fetal position. He denied any weakness or any bowel
or bladder diffculty. He had tried chiropractic manipula-
tion and NSAIDs, without any pain relief.
1. Social history: Married, previously active
businessman. Occasional tobacco, rare alco-
hol use
2. Medical history: No past medical problems
3. Surgical history: Remote history of facial frac-
tures after a motor vehicle collision
4. Medications: Naprosyn, hydrocodone/
APAP, cyclobenzaprine
B. Focused neurological examination and
diagnostics
The neurological examination indicated a
decreased sensation to light touch and pinprick
in the posterior thigh, calf, and lateral foot on
the left lower extremity. Right lower extremity
sensation was intact. Bilateral lower extremity
strength was intact. Bilateral patellar refexes
were normal, as was the right Achilles refex.
The left Achilles refex was absent. Motor
strengths were full in bilateral lower extremi-
ties. Straight leg test was positive on the left at
30 degrees. His gait was markedly antalgic.
MRI revealed a large extruded fragment at
L4L5, eccentric to the right, but essentially
flling the spinal canal with a concomitant disc
bulge at L5S1, causing some encroachment on
the left S1 nerve root (Figure 34).
C. Operative intervention
D. B. underwent L4 laminectomy, partial
right-sided L4 laminectomy removal of L4L5
extruded disc herniation, and left L5S1
foraminotomyall with the use of the operat-
ing microscope. At 6 weeks after surgery, he
had complete relief of his symptoms.
III. L4L5 Stenosis
A. M., a 53-year-old male, had a 2-year history of pro-
gressive bilateral foot pain and burning sensations that
radiated down his lower extremities. His symptoms were
aggravated by standing and walking and alleviated by
sitting down. He denied any leg weakness or any bowel
or bladder diffculty. He had undergone chiropractic
treatment, NSAID use, and physical therapy without any
symptom relief.
1. Social history: Single, works at a seden-
tary computer job. Occasional tobacco use,
denies alcohol use
2. Medical history: Depression, obesity, high
triglycerides
3. Surgical history: Tonsillectomy, remote
4. Medications: Ibuprofen, gemfibrozil
B. Focus neurological examination and
diagnostics
The neurological examination indicated
full-strength and intact sensation in his bilateral
lower extremities. Patella refexes were intact,
the right Achilles refex was absent, and the left
Achilles was diminished. A review of his MRI
scan revealed L4L5 stenosis (Figure 35).
A. M. underwent a L4L5 decompressive
laminectomy for stenosis. He has done well af-
ter surgery, with a gradual increase in walking
distance and resumption of normal activities.
Figure 34. L4L5 HNP, L5S1 bulge: MRI, sagittal view
The top arrow points to a mild disc bulge with annular tear at L3L4.
The bottom arrow points to a disc bulge with annular tear at L5S1.
At L4L5, a massive extruded disc is causing severe canal stenosis.
IV. L5S1 Grade-II Spondylolisthesis
J. K., a 52-year-old male, had a long history of low
back pain and a 3-month history of right posterior lower
extremity pain. His pain was aggravated by any activity
and improved with rest. He denied any paresthesias, weak-
ness, or bowel/bladder diffculty. He had participated in
physical therapy, chiropractic manipulation, bed rest, and
NSAID use without pain relief.
1. Social history: Married, has worked 25 years
as a shipper. Quit smoking 5 years ago,
denies alcohol intake
2. Medical history: Hypertension, asthma
3. Surgical history: Cardiac catheterization
and ablation this year; carpal tunnel release;
shoulder surgery
4. Medications: Aspirin, lisinopril, lovastatin,
metoprolol, omeprazole, amitriptyline,
hydrocodone, glucosamine/chondroitin,
multiple herbs and supplements
5. Allergies: Sulfa-caused hives
diagnostics
The neurological examination revealed
decreased sensation to pinprick on the right
lateral lower extremity and top of the right foot.
A 4/5 weakness was noted in the right extensor
hallicus longus (EHL) and right dorsifexion.
He had diffculty walking on his heel on the
right side. Knee and Achilles refexes were nor-
mal bilaterally. Review of his MRI demonstrates
a grade-2 spondylolisthesis at L5-S1 with bilat-
eral L5 nerve root compression (Figure 36).
J. K. underwent an L5S1 anterior-posterior
decompression and fusion (Figure 37). He has
done remarkably well with return to all goal
activities.
V. Multilevel Lumbar Stenosis with L4L5 Grade-I
Spondylolisthesis for Decompression and Fusion
D. S., a 74-year-old male, had a 15-month history of low
back and right hip pain. He described pain radiating from
his back into his right hip and down to the right lateral calf.
He noted some numbness in his right foot with ambulation,
which was better with rest. His legs fatigued easily, and
the distance he was able to walk had decreased. He had
received chiropractic manipulation, worn a back brace, and
had an ESI with pain relief. He rated his pain at its worst as
8 on a scale of 10.
1. Social history: A widowed retired professor
who lives alone. His children are in the area.
He denied tobacco use; occasional alcohol use
Figure 35. L4L5 stenosis, central and neuroforaminal:
MRI, axial view
Figure 36. L5S1 DDD and grade-II spondylolisthesis:
Lateral radiograph
2. Medical history: Recently diagnosed pros-
tate cancer, treatment almost finished;
hypertension; diverticulitis
3. Surgical history: Laparotomy, remote
4. Medications: Allopurinol, lovastatin, hydro-
chlorothiazide, atenolol, lisinopril
6. Review of systems: Diverticulitis and hyper-
tension well controlled
diagnostics
On neurological examination, D. S. had full
bilateral lower extremity strength. Bilateral
knee refexes were intact; Achilles refexes were
absent. Sensation was intact. He was slow to
rise from a chair and walked with a fexed
posture.
His MRI of the lumbar spine revealed
disc degeneration at L4L5 with a grade-1
spondylolisthesis. There was also severe disc
degeneration at L5S1, severe canal stenosis at
L4L5, and moderate canal stenosis at L3L4.
(Figures 38, 39).
D. S. underwent a L3L4 laminectomy and
L4L5 instrumented fusion. (Figures 40, 41). He
has returned to normal activities with complete
resolution of his pain.
Figure 39. Lumbar stenosis: MRI, axial view Figure 37. Anterior-posterior fusion: Instrumentation has been
placed both anteriorly and posteriorly
Figure 38. L4L5 stenosis with grade-I spondylolisthesis: MRI, sag-
ittal view
Figure 40. Postoperative lateral radiograph with instrumentation in
place
Figure 41. Postoperative anteroposterior radiograph with instrumen-
tation in place
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Lumbar Spine Surgery

A Guide to Preoperative and Postoperative Patient Care

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Figure 30. Anterior lumbar interbody fusion: Lateral view

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