The goal of Minimally Invasive Posterior Fusion surgery is to relieve pressure on painful nerves, stabilize any unwanted motion between bones, and correct unwanted deformity.
Dr. Paul performs the procedure through two smaller incisions several inches to the side of the center of the spine on the back. Minimally invasive instruments and retractors are used to dilate through the muscles to access the spine. Using this versatile approach, Dr. Paul can then access arthritic joints, spinal stenosis, disc herniations, cysts, and other pathologies.
After alleviating compression on the nerves, he begins removing the disc remaining between the vertebral bodies. When complete, he fills the space with donated bone and cage devices that help support the boney fusion and improve the bones’ position. Pedicle screws and short rods are applied to help hold the construct together while the fusion heals.
Dr. Paul takes great care to meet short-term pain relief and neurologic improvement goals along with long-term goals of spinal balance and realignment, so additional surgeries are less likely later in life. He uses specialized intraoperative imaging and software to minimize adjacent level disease.
The unique nature of the retractors allows powerful realignment of any deformities through a less invasive approach. This can lead to better outcomes and a lower rate of degeneration at other levels. Your implants are MRI compatible and are not known to set off metal detectors.
Approximate surgical time is an hour and a half for one level or two to three hours for two levels. Additional time can be required in cases of prior surgery. Remember, substantially more time is involved in putting you to sleep, prepping, and draping prior to surgery, and then the additional time required to wake you up. As a result, many hours are required in total.
Dr. Paul usually calls the waiting room to update a family member or friend about you briefly. Kevin will also typically check on you in the recovery room and speak to the nurse and Dr. Paul about your recovery. Nursing will let your family know when they can see you. The wake-up and recovery time varies quite a bit but is often more than two hours.
Making arrangements before surgery helps ensure all necessary steps are taken and allows you to focus on recovery.
Information to help you arrive on time for your procedure and to better understand the process on procedure day.
After surgery, you can expect some pain. Your surgeon and the staff will use every reasonable measure to help.
Explore Dr. Paul’s approach to long-term recovery, focusing on tailored treatment plans and ongoing support.
We have attempted to define the more common risks of surgery under each of the procedures outlined. It is impossible to outline all potential poor outcomes, but we have attempted to do so in good faith. It has not been formed as legal protection for us, only to better inform you. Please read them thoroughly.
Infections are a known complication of lumbar surgery. Infection rates are more associated with smoking, poorly controlled diabetes, obesity, and other health factors. Less invasive and shorter procedures also have lower complication rates. Infections requiring additional surgery are extremely rare in Dr. Paul’s practice.
Bleeding can be a serious complication since blood accumulation can compress the spinal cord or nerve roots. For that reason, we require discontinuing blood thinners, some anti-inflammatories and all herbal medications.
Spinal Leaks are a known complication in spine surgery but typically can be managed. They occur approximately 3 to 5% of the time They can be the result of adherent bone, disc, ligament or scar tissue to the dura and the membrane surrounding your nerves or spinal cord. They are far more associated with revision surgery, severe nerve compression and advanced age. If this occurs, we typically repair the leak during your operation. You may be required to lay flat for a short period of time afterwards. Late presenting or persisting spinal leaks can require additional surgery. Spinal leaks typically do not affect long term outcomes.
Neuropraxia & Nerve Injury - Nerves under pressure can react with pain or increased weakness after being decompressed. These issues are expected and usually resolve with treatment or time. The goal of fusion is to realign and improve the position of the spine which can cause some nerves to be stretched and also induce typically temporary changes. Rarely, these changes are permanent As a precaution, Dr. Paul utilizes a state-of-the-art nerve and spinal cord monitoring system to avoid neurologic problems.
Non-Union - Not all fusions heal. Some heal as early as three months, but many take longer. Some fusions require a year to heal. Dr. Paul’s team gets x-rays regularly during the first year and meets with you to make sure the fusion is successful. Some fusions will require revision surgery to fix the problem.
Medical Complications related to the heart, lung and kidneys and other organs are also a possibility. Although shorter less invasive procedures are associated with lower complication rates, they can still occur. We work closely with your primary care doctor and other specialists to make sure your medical conditions are optimized prior to surgery.
Naturally, once anesthetics have worn off, pain will become increasingly evident in the areas involved in a surgical procedure. You may not have much incisional pain after surgery because local anesthesia is injected at the time of surgery. This will wear off in the evening. We recommend you use the pain medicine prescribed or muscle relaxant to avoid the potential for getting behind your pain.
Dr. Paul will prescribe pain-killers, also known as analgesics, to reduce the discomfort of this post-surgical recovery period. Medications prescribed can range from over-the-counter NSAIDs (after the first five days) to potent prescription opioids depending on the projected severity of pain. If you are or have undergone a fusion procedure, you should avoid NSAIDs for the first 6 weeks.
Patients should take care to manage their dosing relative to the pain experienced. Opioids can usually be tapered off within the first two weeks of surgery. NSAIDs may be taken with protective measures for the gastrointestinal system such as proton-pump inhibitors (PPIs) such as omeprazole, antacids such as TUMS, and bismuth salts such as Pepto Bismol to reduce the risk of ulcer formation.
Taking proper care of your incision is essential for healing. Follow these guidelines to ensure a smooth recovery:
It is very common to have increased pain at night and when you first get up out of bed. Any time you remain in one position for an extended period of time, the muscles may tighten and swell, and you can experience pain. As a result, transitioning can bring on pain. Transitioning includes lying to sitting, sitting to standing. Anticipate this and use medication appropriately and or take time to do these activities. Do not try to move quickly. You won’t do anything to harm your surgery but you may have an increase in pain. This will improve with time.
After your surgery, it’s important to follow these guidelines to ensure a smooth and successful recovery. Daily walking is highly encouraged as part of your healing process. Start with short distances and gradually increase both the distance and duration each day. If you need to climb stairs, you may do so as necessary, but take your time and avoid overexertion.
Please adhere to a 10-pound lifting limit until your follow-up appointment. Additionally, avoid bending or twisting at the waist, as these movements can strain your healing body. Driving is not permitted while you are taking pain medications or muscle relaxants, so plan accordingly.
Refrain from sexual activity for the first two weeks after surgery to allow your body adequate time to recover. If physical therapy is deemed necessary, it will be arranged during your first follow-up appointment to support your rehabilitation journey.
There are no post-operative restrictions in climbing or descending stairs.
You may have some mild to moderate discomfort going up and down stairs immediately after surgery. However, you are allowed to do so since you will not hurt your surgery. Similarly, getting on and off the toilet may give you some discomfort but you will not do any damage to your surgery. If you have a lower toilet, a raised toilet seat may be helpful.
We often talk to patients about the first two weeks being the most difficult after a lumbar fusion. The first 2 days are the hardest in that 2-weeks. The more generally active you are the more the muscle soreness improves. Please do not just lay in bed.
In the early weeks, gradually increase activities. Remain on your feet for more extended periods and improve your walking distances. You may return to a sedentary job in as little as 2-3 weeks but with no bending, twisting, or lifting more than 10 pounds. Sit only in chairs with good lumbar support.
You may start a regular aerobic activity such as vigorous walking, Stairmaster, or low impact aerobic exercise classes if allowed after the first follow up appointment. This is typically in 2-3 weeks. Once you are off of any narcotic pain killers, you are free to drive from our standpoint.
From a mechanical perspective, you lose some motion with any fusion. The question becomes how your remaining levels and joints compensate to retain your function and everyday lifestyle. Dr. Paul’s team rarely relies on braces and extensive immobilization. The instrumentation and current spinal techniques generally create enough stability to allow the bones to fuse. As a result, we allow people to move sooner after surgery. This also helps to maintain strength and flexibility in the remaining portions of your core and spine. If necessary, we typically order physical therapy after your 2-week visit with Kevin. Exceptions would include fusions involving four or more levels and people with osteopenia.
After the first six weeks, we typically decrease restrictions. If you were given a brace, it is typically no longer required, and we allow for more bending or twisting as required for normal everyday activities. After the first 6 weeks, we typically decrease restrictions. This time period varies greatly based on how many levels have been fused.
We will often raise the lifting restriction to 20 to 30 pounds. You may return to light duty or physical labor if pain-free and allowed by your surgeon—with minimal bending or twisting. We do not recommend returning to work if you commute more than one hour each way. You may swim after six weeks. Continue your physical therapy exercise program. You may be shown specific therapeutic exercises at your six-week visit.
The most dramatic changes will take place in the first 8 weeks post-op. Even if you experience some of your pre-op pain during this time you should not be too concerned. We follow our patients for a year post-op knowing the nerves may take a long time to heal. Most feel significantly better after the first week or two.
You may travel by car for more than 3 hours in 2-3 weeks, but with frequent breaks. You may travel by plane in 4 weeks for trips less than 4 hours. After 6 weeks, you can resume all travel. Discuss international travel with Dr. Paul’s team. You may drive as soon as you are off narcotic painkillers.
With proper post-operative activity, therapy and positive mindset, people lose minimal function with a short lumbar fusion. The goal is for improved overall function with surgery. The degree to which people notice a loss of motion is very subjective and individual. From a mechanical perspective, you lose some motion with any fusion. The question becomes how your remaining levels and joints compensate to retain your function and everyday lifestyle. Dr. Paul’s team rarely relies on braces and extensive immobilization. The instrumentation and current spinal techniques generally create enough stability to allow the bones to fuse. As a result, we allow people to move sooner after surgery. This also helps to maintain strength and flexibility in the remaining portions of your core and spine. If necessary, we typically order physical therapy after your two-week visit with Kevin. Exceptions would include fusions involving four or more levels and people with osteopenia.
It’s especially essential to maintain or improve motion through your hips, knees, and upper back after a lumbar fusion. Flexibility, core strengthening, and an emphasis on function during the postoperative course helps to optimize your motion.
Dr. Paul typically does not have long-term restrictions for his patients once they have successfully healed.
This is a complex discussion. A fusion can place some stress on other levels of your spine. However, how and why it does this can be controversial and depends on your individual situation and predispositions. Your surgery was done for a degenerative condition that may affect other parts of your spine in the future. If you have had surgery at one level in your spine, it is possible that the degenerative process could take place at another level. Since the spine has 36 levels, this is not unusual over a lifetime. Most people handle degenerative difficulties with self-care and non-operative care. That being said, Dr. Paul and his team go to great lengths to minimize the chances of needing additional care for your spine. That includes careful surgical planning, intraoperative decision making, and post-operative care.
The use of a lumbar brace is often used with an instrumented fusion (use of spacer implant, screws, and rods). This bracing is typically for 6 weeks only, which usually aligns with the second post-op visit. The brace is to be worn anytime you are standing, sitting, or walking for more than a few minutes. If you need to get up briefly to use the washroom, you may do so without the brace on. You do not need to use the brace while bathing or sleeping.
We look at the brace as serving three purposes:
If Dr. Paul believes you are at higher risk for not healing your fusion, he may order a bone stimulator. These are painless devices that you wear for approximately half an hour each day. You can wear them over your brace.
Watch the video to learn more about the science behind, how to control, and apply bone stimulators.
We strongly recommend implementing the use of myChart to contact the office. Our staff monitors the messages during business hours.