PRE- AND POSTOP INSTRUCTIONS ANTERIOR CERVICAL DISCECTOMY FUSION SURGERY

This handout will review the care you need to follow in the days prior to your ANTERIOR CERVICAL DISCECTOMY FUSION (ACDF) surgery and once you are home after your surgery. This SURGERY typically TAKES PLACE AT A HOSPITAL BUT MAY ALSO BE SCHEDULED AT A SURGERY CENTER and involves INCISIONS IN THE FRONT OF YOUR NECK. If you have any questions or concerns, please ask your nurse or doctor. Our staff is here to help you. If you have questions after you are at home, please call the numbers listed at the end of this handout.
This information is part of your medical Informed Consent. Please read it and follow the advice carefully. You should retain the guide for future reference and bring it with you to office appointments and to the hospital for reference.

PREPARATION FOR SURGERY

Preoperative Laboratory Studies, and Medical Clearance

In preparation for surgery, you will have blood drawn for analysis. You may also require an electrocardiogram (ECG), a chest X-ray, and possibly additional preoperative studies. These are scheduled prior to surgery. Your ANTERIOR CERVICAL DISCECTOMY FUSION (ACDF) surgery is a reconstructive surgery that involves removal of a degenerative disc, decompression of the spinal cord and cervical nerve roots. It can be done either at a HOSPITAL, or at an OUTPATIENT SURGERY CENTER. Preoperative blood work is usually done just prior to your surgery.
Should you have medical problems, such as cardiac or pulmonary, renal disease, thyroid dysfunction, or diabetes to name a few, additional preoperative clearance examinations from your primary care doctor or treating specialist may be required. These tests performed before your scheduled surgery may allow your physician to identify particular health problems that could require further evaluation before anesthesia and surgery. REGARDLESS OF THE EXTENT OF YOUR PREOPERATIVE WORKUP, IT IS NOT A GUARANTEE THAT YOUR SURGERY MAY NOT BE CANCELLED if the anesthesiologist deems your medical problems at the time of the scheduled procedure as not appropriately managed, or deems your surgery TOO RISKY.
Diagnostic imaging studies of the lumbar spine, such as CT or MRI scans, a bone scan, and possibly a myelogram, may already have been performed and provide your surgeon with anatomic detail for surgery. Other electrodiagnostic tests (EMG/NCV or SSEPs) may give additional, important information.

Nothing to Eat or Drink After Midnight

Eat a light dinner before 7 P.M. on the evening before your surgery. DO NOT EAT, DRINK, SMOKE, CHEW, OR SWALLOW ANYTHING AFTER MIDNIGHT THE NIGHT BEFORE SURGERY except as directed by the surgery center.

Preoperative Screening

The hospital or surgery center may call you preoperatively to review your medications, and to determine whether there are any new medical problems unknown at the time of scheduling of your surgery that could potentially be problematic. They may also give you directions as to where and when to report. You should report no later than 2 hours prior to the scheduled surgery time.

Medications to Stop Prior to Surgery

It is imperative for you to stop all NSAIDS (non-steroidal anti-inflammatory drugs) and all other medications affecting the clotting ability of your blood during surgery a minimum of 10 DAYS PRIOR TO your scheduled SURGERY. You not stopping these drugs may affect platelet aggregation and therefore have an anticoagulative side effect. Therefore, significant intraoperative bleeding, increased complication rate with epidural hematoma with potential neurological deficits, infection, and wound problems may occur. There may also be a need for blood transfusions, and potential follow up surgeries to deal with these complications. There are other blood thinners (For example, COUMADIN, XARELTO, PRADAXA, LOVENOX, HEPARIN) that maybe prescribed by your doctor for heart and vascular disease. COUMADIN should be STOPPED 7 DAYS PRIOR TO SURGERY. XARELTO, PRADAXA AND OTHERS may have to be stopped only only a few days prior to surgery. Please check with your prescribing physician. Ideally, you are also OFF XARALTO, or PRADAX ONE WEEK PRIOR TO SURGERY. In addition, you should stop FISH OIL, homeopathic drugs, and any other non-essential drugs that you think may increase your risk of bleeding.
At times, it may not be possible for you to stop these drugs. Please consult with your primary care physician, cardiologist, pulmonologist, vascular surgeon or other subspecialty provider, that may have started you on this type of blood thinner, prior to signing up for surgery. It may be safe for you to come off a prescription blood thinner prior to surgery. However, it may not be. Please check with your doctor who prescribed it prior to surgery.

Report to Admitting in the Preop Area

The surgery center will notify you of the time and location where you should go before your surgery. Do not accept or follow any other directions unless you discuss it with our office, 520-204-1495.

AFTER YOUR OPERATION

Pain & Pain Control

After surgery you may experience pain in the region of the incision. Some pain in the front of the neck from the surgical exposure and retraction, and pain radiating into the arms as well as tingling or numbness may be present postoperatively. The latter could last weeks or months. In some cases, there may even be some weakness and new pain in the back of the neck stemming from irritated joints.
Initially, you may notice complete pain relief following the ACDF procedure. This is due to anesthesia and medication you received during surgery or in the recovery room. This effect will subside over time as the effect of anesthesia and other systemically administered anesthetic drugs wear off. However, new pain may develop several days postoperatively after an initial “HONEYMOON” period of several days. There may be new pain due to inflammation and swelling of the previously compressed nerves. This postoperative inflammatory response of the spinal nerves may produce throbbing or burning pain radiating into the arms. Don’t be alarmed about this type of new pain. It will diminish within a few weeks. Please tell your surgeon if you are experiencing any new symptoms or pain during your postoperative visit(s). Your physician may prescribe NEURONTIN (Gabapentin) or LYRICA (Pregabalin) or prescribe steroids to calm symptoms down quicker.
This major surgery and is done under general anesthesia with a secure airway. Therefore, some patients experience a sore throat and swallowing difficulty after general anesthesia and surgery. This is from manipulation of tissue and the presence of the breathing tube for anesthesia. Swallowing may be also be affected by the multilevel exposure in the front of your neck to gain access to your cervical spine. This may also contribute to hoarseness of the voice postoperatively. This hoarseness of the voice typically resolves in time but persists in rare cases, and a referral to an Ear Nose and Throat (ENT) surgeon may be necessary for further evaluation and treatment. The sore throat usually will subside within a week. The swallowing difficulty may take several weeks or months to calm down. Using throat lozenges or lemon drops, sipping cool liquids, or sucking ice chips may soothe this pain.
If you are SHORT OF BREATH, or have EXCESSIVE CHEST, OR CHEST WALL PAIN, please GO TO THE NEAREST EMERGENGY ROOM as you may be having a postoperative heart attack, or a symptomatic blood clot in the lungs. Postoperative MYOCARDAL INFARCTION, and PULMONARY EMBOLISM are rare but do occur occasionally and you should take these symptoms seriously.
If you are having pain with voiding, you may have a urinary tract infection. Sometimes, this symptom is accompanied by fevers and generalized malaise. If you are experiencing progressive neurological deficits with progressive weakness and consequently are having trouble moving arms and legs, please call 911 to be transferred to the NEAREST EMERGENCY ROOM to be evaluated.

Activity

ACDF is major surgery and you need to give your body time to heal. Below is a list of instructions that you should follow until your first follow-up visit after surgery. You no longer need to wear the anti-thrombosis (TED) stocking (heavy white stockings) once you are home.
You will be given a soft cervical collar after surgery and you should wear this collar intermittently as needed for comfort only. There is no need to wear this collar all the time, and you do not need to sleep in it. In fact, wearing the soft foam collar around your neck all the time may contribute to neck stiffness and more neck pain.
You may sleep any way you please; either on your back, stomach or side. You may also use pillows for support under your neck.
For your comfort, we suggest that you change your position at least every hour when awake. If you become uncomfortable change your position and activity. You should begin a walking program two to three days after surgery. You may shower 5 days after surgery. If you must shower sooner, you must keep the incision covered and dry while showering. No baths for 4 weeks. No hot tubs or swimming for 6 weeks. NO EXCESSIVE LIFTING please. This could aggravate any postoperative pain syndromes. "LISTEN TO YOUR BODY".
After getting home, you will be allowed in the car TWICE, ONCE TO GO HOME, THE SECOND TO COME BACK TO THE OFFICE. You will get your next set of instructions upon your return. For patients from out of state or country, there will be specific instructions.

Mobilization Program

It is important to mobilize after surgery to diminish the risk of deep vein thrombosis. In addition, it improves recovery, and patient satisfaction. Begin walking in the house and progress to outdoors. Take someone with you the first few times. Slowly increase the distance each day so that you will be walking 1 mile/day by your 2nd post-operative week, 2 miles/day at 2 weeks’ post-operative. Hopefully, by 4 weeks’ post-operative you will be walking 4 miles/day. If you feel soreness, reduce the distance and REST. These are GUIDELINES, NOT RULES.

• Day 1 Walk the length of the hallway at home 3-4 times, or walk to the end of the driveway and back once in the morning and again in the afternoon or evening.
• Day 2 Walk 1/2 block or the equivalent of a 1/2 block indoors once in the morning and again in the afternoon or evening.
• Day 3 Walk 1 block in the morning and again in the afternoon or evening.
• Day 4 Walk 2 blocks in the morning and again in the afternoon or evening.
• Day 5 Walk 3 blocks in the morning and again in the afternoon or evening. Continue increasing the distance you walk, as you are able. Let your comfort be your guide to how much you can do.

Limitations

• No driving for 2 weeks, or while taking narcotic pain medication. However, you may be a passenger.
• No lifting greater than 10 lbs. (about 1 gallon of milk) for the first 5-6 weeks after surgery.
• No sports activity until your first follow-up visit other than the walking program.
• No sexual activity for 2 weeks.

Showering / Personal Hygiene

You may shower the morning after surgery. However, it is important to keep the dressing and incisions dry. You may cover cover the dressing with an adhesive and occlusive dressing. DO NOT soak the incision. Do not disturb steri-strips, or sutures.

If You Are Not Sure

If you question whether or not you can do something beyond the instructions given, it is safe to assume that the answer will be NO.

Follow Up Visit in Our Office

Return to the office for your first visit approximately 7 - 10 days after surgery. Typically, you will be given a follow up appointment to our office during your preoperative visit. If you are not sure about your first postoperative visit, please call our office for an appointment (520-204-1495) or if you have questions or concerns. For GENERAL MEDICAL PROBLEMS CONTACT your personal physician.

Return to Driving

No driving for a minimum of 1 week, or for the time while taking extra narcotic pain medication as a result of the surgery. However, you may be a passenger.

Return to Work

Your return to work will depend on your recovery and the type of work you do. You must discuss this with your doctor before you return to work.

Pain Management

For pain management, you will usually be given a prescription for a drug like VICODIN (hydrocodone) or OXYCODONE. For additional pain medication, try Extra strength Tylenol or similar agent. In addition, you may receive a prescription for VALIUM which can help with postoperative muscle spasms.
You should take the pain medication you were given by our office with careful consideration and be knowledgeable about their potential compounding interaction with other narcotics or other medications. Check with your local pharmacist as well should you have any questions as to potential drug interactions.

MEDICATIONS

You may have an occasional increase in pain and/or numbness after surgery during the healing phase. This is normal and is caused by inflammation (or swelling) of muscle tissue and your spinal nerves. To reduce pain there are several approaches to decrease the pain you may be experiencing:
• Take the pain medicine as directed by your doctor for incisional pain. You can also take one extra strength acetaminophen (Tylenol) every 4 hours between the prescription medicines, only as directed. Do not take more than 4000 mg of Tylenol in a 24-hour period. NOTE: Some narcotic pain medicines also have Tylenol in them.
• Do not take narcotic pain medicine for burning pain radiating down the arm. This pain is most likely from inflammation of the cervical nerve roots. Narcotic pain medication does not help for this type of pain. Take Neurontin (Gabapentin) or Lyrica (Pregabalin) as instructed by your doctor/surgeon. Call the office for a follow up appointment. This neurognic pain typically improves within several weeks.
• Eventually you should no longer need to use narcotic pain medicine. Most patients find it unnecessary to take narcotic pain medication within a few days from surgery as the small incisions do not hurt that much.

Removal of Stitches

Surgical sutures are typically bioabsorbable and do not need to be removed. However, be sure to talk to you doctor during your first postoperative visit should you think you are experiencing problems with the wound or wound closure.

Incision Care

Caring for your Incision at home is important to prevent infection. Please follow these steps:
• Your incisions have been closed with absorbable suture material. In most cases, the incision is covered by a small dressing. You may remove the dressing 3-5 days after surgery.
• Take your temperature twice a day, once in the morning and once in the evening for the first 7 days.
The wound will be checked and the dressing will be changed prior to discharge home. You may take a shower when you get home. If the dressing gets wet, simply replace it with a new one. DO NOT TAKE BATH AND DO NOT SOAK THE WOUND. Once the dressing is removed you may leave the wound open to air.
Do not be alarmed when you have bloody or serosangineous drainage from the wound(s). This is normal and part of your postoperative recovery. There may also be some bruising around the incision. However, call our office if you have persistent drainage for more than 3 days or a new onset of drainage sometime after 7 - 10 days from your surgery. You should also let us know if you are having any fevers (temperature over 101 F) or chills. This may suggest a wound infection. Although uncommon wound infection occur in under 0.1 % of patients who underwent outpatient percutaneous decompression surgery.
Be advised though that elevated temperatures after surgery can be normal and often is a result of poor lung ventilation. Taking deep breath, and ambulating as much as you can tolerate may help with this problem.

When to Call Your Doctor or Nurse

PAIN IS A RED FLAG TELLING YOU TO REST. Avoid taking pain relieving medication in anticipation that something you will do is going to cause pain.

• If you have a temperature above 101 degrees F (38.8 degrees C) for two readings four hours apart. If you develop a low grade fever, keep a chart of your temperature pattern at 8 AM, 12 noon, 4 & 8 PM. Bring the chart to the office at your next visit.
• Clear drainage from your incision, excessive, wound redness, swelling, purulent drainage or infection.
• An increase in pain, redness and/or swelling by your incision.
• Difficulty urinating or controlling your bowel movements.

When to Call 911

• If you have difficulty breathing, or have an irregular heartbeat, or chest pain, or progressive neurological deficit (progressive weakness in the extremities).

Future Follow-Up Visits

Your first post-op visit is usually scheduled along with your surgery. If you are unsure of your first postoperative appointment, please call (520) 204-1495 to make your first post-operative appointment at the Center for Advanced Spine Care of Southern Arizona. This usually occurs 7 – 10 days after your surgical procedure. All other follow-up visits will be directed by your physician.

Medications

If you need a prescription filled.

Because your health condition may change over time, your doctor or another physician provider, who have access to your confidential medical records, will need to address your refill requests. By following these simple guidelines, you will avoid any delay in getting your prescription refilled:
• Contact your pharmacy at least 5 days before your prescription requires refilling, to protect your health, pharmacies will accept refill orders only from your doctor. So, when you call The Center for Advanced Spinal Care of Southern Arizona with your request an additional step is added. Your prescription will be filled faster if you call your pharmacy directly, they will then contact The Center for Advanced Spine Care of Southern Arizona.
• Use the same pharmacy. That way, your pharmacist will have your complete prescription records and you avoid the danger of mixing medications. To make it convenient for you, the Center for Advanced Spinal Care of Southern Arizona will work with the pharmacy of your choice. Please choose one pharmacy, and use only that pharmacy. It is an easy way to help protect your health, as well as your health records.
• Call your pharmacy early in the day. This gives your doctor time to review your records. To ensure you get the right medications, we do not rush refills without making sure the order and your records are reviewed. Often, physicians are in surgery or finishing with patients late in the day, and we do not want to interrupt those patients’ visits just like you would not like to have your visit interrupted when in the office with the physician. Therefore, refill requests received after 3 pm Monday through Thursday or after 10 am Friday will be reviewed and filled the next business day for The Center for Advanced Spine Care of Southern Arizona.

If You Run Out of Medication Before You Request a Refill

Always call your pharmacy at least 5 days before you run out of medication. This will give the pharmacy plenty of time to contact your doctor, for the doctor to review your record, and for the pharmacist to prepare your medication. All you have to do is watch your medication levels and there should be no reason for you to run out of medication or run out of medication early prior to the scheduled date. It is dangerous to “rush” an order. For your protection, refills are not done at night, over the weekend, on holidays or as an emergency if you have forgotten to call your pharmacy.

If You Run Out of Your Medication Early

Your doctor ordered your prescription according to a precise dosage for a prescribed amount of days. If you run out early, it may mean you are experiencing some difficulty with your dosage or medication. Call The Center for Advanced Spine Care of Southern Arizona immediately and explain your difficulty.

If Your Prescription Is Lost, Misplaced or Stolen:

To protect your health, lost or stolen prescriptions are replaced only with a physician visit. Stolen medication will require a police report to be completed and a copy of the report brought with to your visit. To avoid possible duplication of prescriptions when an order is lost or stolen, you will want to talk with your doctor. Call The Center for Advanced Spine Care to schedule an appointment. Please call our office at (520) 204-1495 with any additional questions that may come during your postoperative recovery.

Please acknowledge that you have read and understood these postop instructions.

PRE- AND POSTOP INSTRUCTIONS ANTERIOR CERVICAL DISCECTOMY FUSION SURGERY

This handout will review the care you need to follow in the days prior to your ANTERIOR CERVICAL HARDWARE REMOVAL WITH EXPLORATION SPINAL FUSION surgery and once you are home after your surgery. This SURGERY typically TAKES PLACE AT A HOSPITAL BUT MAY ALSO BE SCHEDULED AT A SURGERY CENTER and involves INCISIONS IN THE FRONT OF YOUR NECK. If you have any questions or concerns, please ask your nurse or doctor. Our staff is here to help you. If you have questions after you are at home, please call the numbers listed at the end of this handout.
This information is part of your medical Informed Consent. Please read it and follow the advice carefully. You should retain the guide for future reference and bring it with you to office appointments and to the hospital for reference.

PREPARATION FOR SURGERY

Preoperative Laboratory Studies, and Medical Clearance

In preparation for surgery, you will have blood drawn for analysis. You may also require an electrocardiogram (ECG), a chest X-ray, and possibly additional preoperative studies. These are scheduled prior to surgery. Your ANTERIOR CERVICAL HARDWARE REMOVAL WITH EXPLORATION SPINAL FUSION surgery is a reconstructive surgery that involves removal of a degenerative disc, decompression of the spinal cord and cervical nerve roots. It can be done either at a HOSPITAL, or at an OUTPATIENT SURGERY CENTER. Preoperative blood work is usually done just prior to your surgery.
Should you have medical problems, such as cardiac or pulmonary, renal disease, thyroid dysfunction, or diabetes to name a few, additional preoperative clearance examinations from your primary care doctor or treating specialist may be required. These tests performed before your scheduled surgery may allow your physician to identify particular health problems that could require further evaluation before anesthesia and surgery. REGARDLESS OF THE EXTENT OF YOUR PREOPERATIVE WORKUP, IT IS NOT A GUARANTEE THAT YOUR SURGERY MAY NOT BE CANCELLED if the anesthesiologist deems your medical problems at the time of the scheduled procedure as not appropriately managed, or deems your surgery TOO RISKY.
Diagnostic imaging studies of the lumbar spine, such as CT or MRI scans, a bone scan, and possibly a myelogram, may already have been performed and provide your surgeon with anatomic detail for surgery. Other electrodiagnostic tests (EMG/NCV or SSEPs) may give additional, important information.

Nothing to Eat or Drink After Midnight

Eat a light dinner before 7 P.M. on the evening before your surgery. DO NOT EAT, DRINK, SMOKE, CHEW, OR SWALLOW ANYTHING AFTER MIDNIGHT THE NIGHT BEFORE SURGERY except as directed by the surgery center.

Preoperative Screening

The hospital or surgery center may call you preoperatively to review your medications, and to determine whether there are any new medical problems unknown at the time of scheduling of your surgery that could potentially be problematic. They may also give you directions as to where and when to report. You should report no later than 2 hours prior to the scheduled surgery time.

Medications to Stop Prior to Surgery

It is imperative for you to stop all NSAIDS (non-steroidal anti-inflammatory drugs) and all other medications affecting the clotting ability of your blood during surgery a minimum of 10 DAYS PRIOR TO your scheduled SURGERY. You not stopping these drugs may affect platelet aggregation and therefore have an anticoagulative side effect. Therefore, significant intraoperative bleeding, increased complication rate with epidural hematoma with potential neurological deficits, infection, and wound problems may occur. There may also be a need for blood transfusions, and potential follow up surgeries to deal with these complications. There are other blood thinners (For example, COUMADIN, XARELTO, PRADAXA, LOVENOX, HEPARIN) that maybe prescribed by your doctor for heart and vascular disease. COUMADIN should be STOPPED 7 DAYS PRIOR TO SURGERY. XARELTO, PRADAXA AND OTHERS may have to be stopped only only a few days prior to surgery. Please check with your prescribing physician. Ideally, you are also OFF XARALTO, or PRADAX ONE WEEK PRIOR TO SURGERY. In addition, you should stop FISH OIL, homeopathic drugs, and any other non-essential drugs that you think may increase your risk of bleeding.
At times, it may not be possible for you to stop these drugs. Please consult with your primary care physician, cardiologist, pulmonologist, vascular surgeon or other subspecialty provider, that may have started you on this type of blood thinner, prior to signing up for surgery. It may be safe for you to come off a prescription blood thinner prior to surgery. However, it may not be. Please check with your doctor who prescribed it prior to surgery.

Report to Admitting in the Preop Area

The surgery center will notify you of the time and location where you should go before your surgery. Do not accept or follow any other directions unless you discuss it with our office, 520-204-1495.

AFTER YOUR OPERATION

Pain & Pain Control

After surgery you may experience pain in the region of the incision. Some pain in the front of the neck from the surgical exposure and retraction, and pain radiating into the arms as well as tingling or numbness may be present postoperatively. The latter could last weeks or months. In some cases, there may even be some weakness and new pain in the back of the neck stemming from irritated joints.
Initially, you may notice complete pain relief following the ACDF procedure. This is due to anesthesia and medication you received during surgery or in the recovery room. This effect will subside over time as the effect of anesthesia and other systemically administered anesthetic drugs wear off. However, new pain may develop several days postoperatively after an initial “HONEYMOON” period of several days. There may be new pain due to inflammation and swelling of the previously compressed nerves. This postoperative inflammatory response of the spinal nerves may produce throbbing or burning pain radiating into the arms. Don’t be alarmed about this type of new pain. It will diminish within a few weeks. Please tell your surgeon if you are experiencing any new symptoms or pain during your postoperative visit(s). Your physician may prescribe NEURONTIN (Gabapentin) or LYRICA (Pregabalin) or prescribe steroids to calm symptoms down quicker.
This major surgery and is done under general anesthesia with a secure airway. Therefore, some patients experience a sore throat and swallowing difficulty after general anesthesia and surgery. This is from manipulation of tissue and the presence of the breathing tube for anesthesia. Swallowing may be also be affected by the multilevel exposure in the front of your neck to gain access to your cervical spine. This may also contribute to hoarseness of the voice postoperatively. This hoarseness of the voice typically resolves in time but persists in rare cases, and a referral to an Ear Nose and Throat (ENT) surgeon may be necessary for further evaluation and treatment. The sore throat usually will subside within a week. The swallowing difficulty may take several weeks or months to calm down. Using throat lozenges or lemon drops, sipping cool liquids, or sucking ice chips may soothe this pain.
If you are SHORT OF BREATH, or have EXCESSIVE CHEST, OR CHEST WALL PAIN, please GO TO THE NEAREST EMERGENGY ROOM as you may be having a postoperative heart attack, or a symptomatic blood clot in the lungs. Postoperative MYOCARDAL INFARCTION, and PULMONARY EMBOLISM are rare but do occur occasionally and you should take these symptoms seriously.
If you are having pain with voiding, you may have a urinary tract infection. Sometimes, this symptom is accompanied by fevers and generalized malaise. If you are experiencing progressive neurological deficits with progressive weakness and consequently are having trouble moving arms and legs, please call 911 to be transferred to the NEAREST EMERGENCY ROOM to be evaluated.

Activity

ANTERIOR CERVICAL HARDWARE REMOVAL WITH EXPLORATION SPINAL FUSION is major surgery and you need to give your body time to heal. Below is a list of instructions that you should follow until your first follow-up visit after surgery. You no longer need to wear the anti-thrombosis (TED) stocking (heavy white stockings) once you are home.
You will be given a soft cervical collar after surgery and you should wear this collar intermittently as needed for comfort only. There is no need to wear this collar all the time, and you do not need to sleep in it. In fact, wearing the soft foam collar around your neck all the time may contribute to neck stiffness and more neck pain.
You may sleep any way you please; either on your back, stomach or side. You may also use pillows for support under your neck.
For your comfort, we suggest that you change your position at least every hour when awake. If you become uncomfortable change your position and activity. You should begin a walking program two to three days after surgery. You may shower 5 days after surgery. If you must shower sooner, you must keep the incision covered and dry while showering. No baths for 4 weeks. No hot tubs or swimming for 6 weeks. NO EXCESSIVE LIFTING please. This could aggravate any postoperative pain syndromes. "LISTEN TO YOUR BODY".
After getting home, you will be allowed in the car TWICE, ONCE TO GO HOME, THE SECOND TO COME BACK TO THE OFFICE. You will get your next set of instructions upon your return. For patients from out of state or country, there will be specific instructions.

Mobilization Program

It is important to mobilize after surgery to diminish the risk of deep vein thrombosis. In addition, it improves recovery, and patient satisfaction. Begin walking in the house and progress to outdoors. Take someone with you the first few times. Slowly increase the distance each day so that you will be walking 1 mile/day by your 2nd post-operative week, 2 miles/day at 2 weeks’ post-operative. Hopefully, by 4 weeks’ post-operative you will be walking 4 miles/day. If you feel soreness, reduce the distance and REST. These are GUIDELINES, NOT RULES.

• Day 1 Walk the length of the hallway at home 3-4 times, or walk to the end of the driveway and back once in the morning and again in the afternoon or evening.
• Day 2 Walk 1/2 block or the equivalent of a 1/2 block indoors once in the morning and again in the afternoon or evening.
• Day 3 Walk 1 block in the morning and again in the afternoon or evening.
• Day 4 Walk 2 blocks in the morning and again in the afternoon or evening.
• Day 5 Walk 3 blocks in the morning and again in the afternoon or evening. Continue increasing the distance you walk, as you are able. Let your comfort be your guide to how much you can do.

Limitations

• No driving for 2 weeks, or while taking narcotic pain medication. However, you may be a passenger.
• No lifting greater than 10 lbs. (about 1 gallon of milk) for the first 5-6 weeks after surgery.
• No sports activity until your first follow-up visit other than the walking program.
• No sexual activity for 2 weeks.

Showering / Personal Hygiene

You may shower the morning after surgery. However, it is important to keep the dressing and incisions dry. You may cover cover the dressing with an adhesive and occlusive dressing. DO NOT soak the incision. Do not disturb steri-strips, or sutures.

If You Are Not Sure

If you question whether or not you can do something beyond the instructions given, it is safe to assume that the answer will be NO.

Follow Up Visit in Our Office

Return to the office for your first visit approximately 7 - 10 days after surgery. Typically, you will be given a follow up appointment to our office during your preoperative visit. If you are not sure about your first postoperative visit, please call our office for an appointment (520-204-1495) or if you have questions or concerns. For GENERAL MEDICAL PROBLEMS CONTACT your personal physician.

Return to Driving

No driving for a minimum of 1 week, or for the time while taking extra narcotic pain medication as a result of the surgery. However, you may be a passenger.

Return to Work

Your return to work will depend on your recovery and the type of work you do. You must discuss this with your doctor before you return to work.

Pain Management

For pain management, you will usually be given a prescription for a drug like VICODIN (hydrocodone) or OXYCODONE. For additional pain medication, try Extra strength Tylenol or similar agent. In addition, you may receive a prescription for VALIUM which can help with postoperative muscle spasms.
You should take the pain medication you were given by our office with careful consideration and be knowledgeable about their potential compounding interaction with other narcotics or other medications. Check with your local pharmacist as well should you have any questions as to potential drug interactions.

MEDICATIONS

You may have an occasional increase in pain and/or numbness after surgery during the healing phase. This is normal and is caused by inflammation (or swelling) of muscle tissue and your spinal nerves. To reduce pain there are several approaches to decrease the pain you may be experiencing:
• Take the pain medicine as directed by your doctor for incisional pain. You can also take one extra strength acetaminophen (Tylenol) every 4 hours between the prescription medicines, only as directed. Do not take more than 4000 mg of Tylenol in a 24-hour period. NOTE: Some narcotic pain medicines also have Tylenol in them.
• Do not take narcotic pain medicine for burning pain radiating down the arm. This pain is most likely from inflammation of the cervical nerve roots. Narcotic pain medication does not help for this type of pain. Take Neurontin (Gabapentin) or Lyrica (Pregabalin) as instructed by your doctor/surgeon. Call the office for a follow up appointment. This neurognic pain typically improves within several weeks.
• Eventually you should no longer need to use narcotic pain medicine. Most patients find it unnecessary to take narcotic pain medication within a few days from surgery as the small incisions do not hurt that much.

Removal of Stitches

Surgical sutures are typically bioabsorbable and do not need to be removed. However, be sure to talk to you doctor during your first postoperative visit should you think you are experiencing problems with the wound or wound closure.

Incision Care

Caring for your Incision at home is important to prevent infection. Please follow these steps:
• Your incisions have been closed with absorbable suture material. In most cases, the incision is covered by a small dressing. You may remove the dressing 3-5 days after surgery.
• Take your temperature twice a day, once in the morning and once in the evening for the first 7 days.
The wound will be checked and the dressing will be changed prior to discharge home. You may take a shower when you get home. If the dressing gets wet, simply replace it with a new one. DO NOT TAKE BATH AND DO NOT SOAK THE WOUND. Once the dressing is removed you may leave the wound open to air.
Do not be alarmed when you have bloody or serosangineous drainage from the wound(s). This is normal and part of your postoperative recovery. There may also be some bruising around the incision. However, call our office if you have persistent drainage for more than 3 days or a new onset of drainage sometime after 7 - 10 days from your surgery. You should also let us know if you are having any fevers (temperature over 101 F) or chills. This may suggest a wound infection. Although uncommon wound infection occur in under 0.1 % of patients who underwent outpatient percutaneous decompression surgery.
Be advised though that elevated temperatures after surgery can be normal and often is a result of poor lung ventilation. Taking deep breath, and ambulating as much as you can tolerate may help with this problem.

When to Call Your Doctor or Nurse

PAIN IS A RED FLAG TELLING YOU TO REST. Avoid taking pain relieving medication in anticipation that something you will do is going to cause pain.

• If you have a temperature above 101 degrees F (38.8 degrees C) for two readings four hours apart. If you develop a low grade fever, keep a chart of your temperature pattern at 8 AM, 12 noon, 4 & 8 PM. Bring the chart to the office at your next visit.
• Clear drainage from your incision, excessive, wound redness, swelling, purulent drainage or infection.
• An increase in pain, redness and/or swelling by your incision.
• Difficulty urinating or controlling your bowel movements.

When to Call 911

• If you have difficulty breathing, or have an irregular heartbeat, or chest pain, or progressive neurological deficit (progressive weakness in the extremities).

Future Follow-Up Visits

Your first post-op visit is usually scheduled along with your surgery. If you are unsure of your first postoperative appointment, please call (520) 204-1495 to make your first post-operative appointment at the Center for Advanced Spine Care of Southern Arizona. This usually occurs 7 – 10 days after your surgical procedure. All other follow-up visits will be directed by your physician.

Medications

If you need a prescription filled.

Because your health condition may change over time, your doctor or another physician provider, who have access to your confidential medical records, will need to address your refill requests. By following these simple guidelines, you will avoid any delay in getting your prescription refilled:
• Contact your pharmacy at least 5 days before your prescription requires refilling, to protect your health, pharmacies will accept refill orders only from your doctor. So, when you call The Center for Advanced Spinal Care of Southern Arizona with your request an additional step is added. Your prescription will be filled faster if you call your pharmacy directly, they will then contact The Center for Advanced Spine Care of Southern Arizona.
• Use the same pharmacy. That way, your pharmacist will have your complete prescription records and you avoid the danger of mixing medications. To make it convenient for you, the Center for Advanced Spinal Care of Southern Arizona will work with the pharmacy of your choice. Please choose one pharmacy, and use only that pharmacy. It is an easy way to help protect your health, as well as your health records.
• Call your pharmacy early in the day. This gives your doctor time to review your records. To ensure you get the right medications, we do not rush refills without making sure the order and your records are reviewed. Often, physicians are in surgery or finishing with patients late in the day, and we do not want to interrupt those patients’ visits just like you would not like to have your visit interrupted when in the office with the physician. Therefore, refill requests received after 3 pm Monday through Thursday or after 10 am Friday will be reviewed and filled the next business day for The Center for Advanced Spine Care of Southern Arizona.

If You Run Out of Medication Before You Request a Refill

Always call your pharmacy at least 5 days before you run out of medication. This will give the pharmacy plenty of time to contact your doctor, for the doctor to review your record, and for the pharmacist to prepare your medication. All you have to do is watch your medication levels and there should be no reason for you to run out of medication or run out of medication early prior to the scheduled date. It is dangerous to “rush” an order. For your protection, refills are not done at night, over the weekend, on holidays or as an emergency if you have forgotten to call your pharmacy.

If You Run Out of Your Medication Early

Your doctor ordered your prescription according to a precise dosage for a prescribed amount of days. If you run out early, it may mean you are experiencing some difficulty with your dosage or medication. Call The Center for Advanced Spine Care of Southern Arizona immediately and explain your difficulty.

If Your Prescription Is Lost, Misplaced or Stolen:

To protect your health, lost or stolen prescriptions are replaced only with a physician visit. Stolen medication will require a police report to be completed and a copy of the report brought with to your visit. To avoid possible duplication of prescriptions when an order is lost or stolen, you will want to talk with your doctor. Call The Center for Advanced Spine Care to schedule an appointment. Please call our office at (520) 204-1495 with any additional questions that may come during your postoperative recovery.

Please acknowledge that you have read and understood these postop instructions.

PRE- AND POSTOP INSTRUCTIONS ANTERIOR CERVICAL DISCECTOMY FUSION WITH CERVICAL CORPECTOMY SURGERY

This handout will review the care you need to follow in the days prior to your ANTERIOR CERVICAL DISCECTOMY FUSION (ACDF) WITH CERVICAL CORPECTOMY surgery and once you are home after your surgery. This SURGERY typically TAKES PLACE AT A HOSPITAL and involves INCISIONS IN THE FRONT OF YOUR NECK. This is a LARGE OPERATION with a HIGH CHANCE FOR PERI- AND POSTOPERATIVE COMPLICATIONS and the potential need for admission to the INTENSIVE CARE UNIT and/or a REHABILITATION UNIT. If you have any questions or concerns, please ask your nurse or doctor. Our staff is here to help you. If you have questions after you are at home, please call the numbers listed at the end of this handout.

This information is part of your medical Informed Consent. Please read it and follow the advice carefully. You should retain the guide for future reference and bring it with you to office appointments and to the hospital for reference.

PREPARATION FOR SURGERY

Preoperative Laboratory Studies, and Medical Clearance

In preparation for surgery, you will have blood drawn for analysis. You may also require an electrocardiogram (ECG), a chest X-ray, and possibly additional preoperative studies. These are scheduled prior to surgery. Your ANTERIOR CERVICAL DISCECTOMY FUSION (ACDF) WITH CERVICAL CORPECTOMY surgery is a reconstructive surgery that involves removal of a degenerative disc and cervical vertebral bodies, decompression of the spinal cord and cervical nerve roots. This is major surgery and is done at a HOSPITAL. Preoperative blood work is usually done at the hospital.

Should you have medical problems, such as cardiac or pulmonary, renal disease, thyroid dysfunction, or diabetes to name a few, additional preoperative clearance examinations from your primary care doctor or treating specialist may be required. These tests performed before your scheduled surgery may allow your physician to identify particular health problems that could require further evaluation before anesthesia and surgery. REGARDLESS OF THE EXTENT OF YOUR PREOPERATIVE WORKUP, IT IS NOT A GUARANTEE THAT YOUR SURGERY MAY NOT BE CANCELLED if the anesthesiologist deems your medical problems at the time of the scheduled procedure as not appropriately managed, or deems your surgery TOO RISKY.

Diagnostic imaging studies of the lumbar spine, such as CT or MRI scans, a bone scan, and possibly a myelogram, may already have been performed and provide your surgeon with anatomic detail for surgery. Other electrodiagnostic tests (EMG/NCV or SSEPs) may give additional, important information.

Nothing to Eat or Drink After Midnight

Eat a light dinner before 7 P.M. on the evening before your surgery. DO NOT EAT, DRINK, SMOKE, CHEW, OR SWALLOW ANYTHING AFTER MIDNIGHT THE NIGHT BEFORE SURGERY except as directed by the surgery center.

Preoperative Screening

The hospital may call you preoperatively to review your medications, and to determine whether there are any new medical problems unknown at the time of scheduling of your surgery that could potentially be problematic. They may also give you directions as to where and when to report. You should report no later than 2 hours prior to the scheduled surgery time.

Medications to Stop Prior to Surgery

It is imperative for you to stop all NSAIDS (non-steroidal anti-inflammatory drugs) and all other medications affecting the clotting ability of your blood during surgery a minimum of 10 DAYS PRIOR TO your scheduled SURGERY. You not stopping these drugs may affect platelet aggregation and therefore have an anticoagulative side effect. Therefore, significant intraoperative bleeding, increased complication rate with epidural hematoma with potential neurological deficits, infection, and wound problems may occur. There may also be a need for blood transfusions, and potential follow up surgeries to deal with these complications. There are other blood thinners (For example, COUMADIN, XARELTO, PRADAXA, LOVENOX, HEPARIN) that maybe prescribed by your doctor for heart and vascular disease. COUMADIN should be STOPPED 7 DAYS PRIOR TO SURGERY. XARELTO, PRADAXA AND OTHERS may have to be stopped only only a few days prior to surgery. Please check with your prescribing physician. Ideally, you are also OFF XARALTO, or PRADAX ONE WEEK PRIOR TO SURGERY. In addition, you should stop FISH OIL, homeopathic drugs, and any other non-essential drugs that you think may increase your risk of bleeding.
At times, it may not be possible for you to stop these drugs. Please consult with your primary care physician, cardiologist, pulmonologist, vascular surgeon or other subspecialty provider, that may have started you on this type of blood thinner, prior to signing up for surgery. It may be safe for you to come off a prescription blood thinner prior to surgery. However, it may not be. Please check with your doctor who prescribed it prior to surgery.

Report to Admitting in the Preop Area

The surgery center will notify you of the time and location where you should go before your surgery. Do not accept or follow any other directions unless you discuss it with our office, 520-204-1495.

AFTER YOUR OPERATION

Pain & Pain Control

After surgery you may experience pain in the region of the incision. Some pain in the front of the neck from the surgical exposure and retraction, and pain radiating into the arms as well as tingling or numbness may be present postoperatively. The latter could last weeks or months. In some cases, there may even be some weakness and new pain in the back of the neck stemming from irritated joints.

Initially, you may notice complete pain relief following the ACDF and corpectomy procedure. This is due to anesthesia and medication you received during surgery or in the recovery room. This effect will subside over time as the effect of anesthesia and other systemically administered anesthetic drugs wear off. However, new pain may develop several days postoperatively after an initial “HONEYMOON” period of several days. There may be new pain due to inflammation and swelling of the previously compressed nerves or spinal cord. Sometimes, rapid spinal cord expansion after this aggressive decompression procedure may lead to worsening of your preoperative spinal cord dysfunction symptoms, such as worsened balance and fine motor control. This postoperative inflammatory response of the spinal nerves and spinal cord may also produce throbbing or burning pain radiating into the arms. Don’t be alarmed about this type of new pain. It will diminish within a few weeks or months. Please tell your surgeon if you are experiencing any new symptoms or pain during your postoperative visit(s). Your physician may prescribe NEURONTIN (Gabapentin) or LYRICA (Pregabalin) or prescribe steroids to calm symptoms down quicker.

This major surgery and is done under general anesthesia with a secure airway. Therefore, some patients experience a sore throat and swallowing difficulty after general anesthesia and surgery. This is from manipulation of tissue and the presence of the breathing tube for anesthesia. Swallowing may be also be affected by the multilevel exposure in the front of your neck to gain access to your cervical spine. This may also contribute to hoarseness of the voice postoperatively. This hoarseness of the voice typically resolves in time but persists in rare cases, and a referral to an Ear Nose and Throat (ENT) surgeon may be necessary for further evaluation and treatment. The sore throat usually will subside within a week. The swallowing difficulty may take several weeks or months to calm down. Using throat lozenges or lemon drops, sipping cool liquids, or sucking ice chips may soothe this pain.

If you are SHORT OF BREATH, or have EXCESSIVE CHEST, OR CHEST WALL PAIN, please GO TO THE NEAREST EMERGENGY ROOM as you may be having a postoperative heart attack, or a symptomatic blood clot in the lungs. Postoperative MYOCARDAL INFARCTION, and PULMONARY EMBOLISM are rare but do occur occasionally and you should take these symptoms seriously.

If you are having pain with voiding, you may have a urinary tract infection. Sometimes, this symptom is accompanied by fevers and generalized malaise. If you are experiencing progressive neurological deficits with progressive weakness and consequently are having trouble moving arms and legs, please call 911 to be transferred to the NEAREST EMERGENCY ROOM to be evaluated.

Activity

ACDF is major surgery and you need to give your body time to heal. Below is a list of instructions that you should follow until your first follow-up visit after surgery. You no longer need to wear the anti-thrombosis (TED) stocking (heavy white stockings) once you are home.
You will be given a soft cervical collar after surgery and you should wear this collar intermittently as needed for comfort only. There is no need to wear this collar all the time, and you do not need to sleep in it. In fact, wearing the soft foam collar around your neck all the time may contribute to neck stiffness and more neck pain.

You may sleep any way you please; either on your back, stomach or side. You may also use pillows for support under your neck.
For your comfort, we suggest that you change your position at least every hour when awake. If you become uncomfortable change your position and activity. You should begin a walking program two to three days after surgery. You may shower 5 days after surgery. If you must shower sooner, you must keep the incision covered and dry while showering. No baths for 4 weeks. No hot tubs or swimming for 6 weeks. NO EXCESSIVE LIFTING please. This could aggravate any postoperative pain syndromes. "LISTEN TO YOUR BODY".

After getting home, you will be allowed in the car TWICE, ONCE TO GO HOME, THE SECOND TO COME BACK TO THE OFFICE. You will get your next set of instructions upon your return. For patients from out of state or country, there will be specific instructions.

Mobilization Program

It is important to mobilize after surgery to diminish the risk of deep vein thrombosis. In addition, it improves recovery, and patient satisfaction. Begin walking in the house and progress to outdoors. Take someone with you the first few times. Slowly increase the distance each day so that you will be walking 1 mile/day by your 2nd post-operative week, 2 miles/day at 2 weeks’ post-operative. Hopefully, by 4 weeks’ post-operative you will be walking 4 miles/day. If you feel soreness, reduce the distance and REST. These are GUIDELINES, NOT RULES.

• Day 1 Walk the length of the hallway at home 3-4 times, or walk to the end of the driveway and back once in the morning and again in the afternoon or evening.
• Day 2 Walk 1/2 block or the equivalent of a 1/2 block indoors once in the morning and again in the afternoon or evening.
• Day 3 Walk 1 block in the morning and again in the afternoon or evening.
• Day 4 Walk 2 blocks in the morning and again in the afternoon or evening.
• Day 5 Walk 3 blocks in the morning and again in the afternoon or evening. Continue increasing the distance you walk, as you are able. Let your comfort be your guide to how much you can do.

Limitations

• No driving for 2 weeks, or while taking narcotic pain medication. However, you may be a passenger.
• No lifting greater than 10 lbs. (about 1 gallon of milk) for the first 5-6 weeks after surgery.
• No sports activity until your first follow-up visit other than the walking program.
• No sexual activity for 2 weeks.

Showering / Personal Hygiene

You may shower the morning after surgery. However, it is important to keep the dressing and incisions dry. You may cover cover the dressing with an adhesive and occlusive dressing. DO NOT soak the incision. Do not disturb steri-strips, or sutures.

If You Are Not Sure

If you question whether or not you can do something beyond the instructions given, it is safe to assume that the answer will be NO.

Follow Up Visit in Our Office

Return to the office for your first visit approximately 7 - 10 days after surgery. Typically, you will be given a follow up appointment to our office during your preoperative visit. If you are not sure about your first postoperative visit, please call our office for an appointment (520-204-1495) or if you have questions or concerns. For GENERAL MEDICAL PROBLEMS CONTACT your personal physician.

Return to Driving

No driving for a minimum of 1 week, or for the time while taking extra narcotic pain medication as a result of the surgery. However, you may be a passenger.

Return to Work

Your return to work will depend on your recovery and the type of work you do. You must discuss this with your doctor before you return to work.

Pain Management

For pain management, you will usually be given a prescription for a drug like VICODIN (hydrocodone) or OXYCODONE. For additional pain medication, try Extra strength Tylenol or similar agent. In addition, you may receive a prescription for VALIUM which can help with postoperative muscle spasms.

You should take the pain medication you were given by our office with careful consideration and be knowledgeable about their potential compounding interaction with other narcotics or other medications. Check with your local pharmacist as well should you have any questions as to potential drug interactions.

MEDICATIONS

You may have an occasional increase in pain and/or numbness after surgery during the healing phase. This is normal and is caused by inflammation (or swelling) of muscle tissue and your spinal nerves. To reduce pain there are several approaches to decrease the pain you may be experiencing:

• Take the pain medicine as directed by your doctor for incisional pain. You can also take one extra strength acetaminophen (Tylenol) every 4 hours between the prescription medicines, only as directed. Do not take more than 4000 mg of Tylenol in a 24-hour period. NOTE: Some narcotic pain medicines also have Tylenol in them.
• Do not take narcotic pain medicine for burning pain radiating down the arm. This pain is most likely from inflammation of the cervical nerve roots. Narcotic pain medication does not help for this type of pain. Take Neurontin (Gabapentin) or Lyrica (Pregabalin) as instructed by your doctor/surgeon. Call the office for a follow up appointment. This neurognic pain typically improves within several weeks.
• Eventually you should no longer need to use narcotic pain medicine. Most patients find it unnecessary to take narcotic pain medication within a few days from surgery as the small incisions do not hurt that much.

Removal of Stitches

Surgical sutures are typically bioabsorbable and do not need to be removed. However, be sure to talk to you doctor during your first postoperative visit should you think you are experiencing problems with the wound or wound closure.

Incision Care

Caring for your Incision at home is important to prevent infection. Please follow these steps:

• Your incisions have been closed with absorbable suture material. In most cases, the incision is covered by a small dressing. You may remove the dressing 3-5 days after surgery.
• Take your temperature twice a day, once in the morning and once in the evening for the first 7 days.

The wound will be checked and the dressing will be changed prior to discharge home. You may take a shower when you get home. If the dressing gets wet, simply replace it with a new one. DO NOT TAKE BATH AND DO NOT SOAK THE WOUND. Once the dressing is removed you may leave the wound open to air.

Do not be alarmed when you have bloody or serosangineous drainage from the wound(s). This is normal and part of your postoperative recovery. There may also be some bruising around the incision. However, call our office if you have persistent drainage for more than 3 days or a new onset of drainage sometime after 7 - 10 days from your surgery. You should also let us know if you are having any fevers (temperature over 101 F) or chills. This may suggest a wound infection. Although uncommon wound infection occur in under 0.1 % of patients who underwent outpatient percutaneous decompression surgery.

Be advised though that elevated temperatures after surgery can be normal and often is a result of poor lung ventilation. Taking deep breath, and ambulating as much as you can tolerate may help with this problem.

When to Call Your Doctor or Nurse

PAIN IS A RED FLAG TELLING YOU TO REST. Avoid taking pain relieving medication in anticipation that something you will do is going to cause pain.

• If you have a temperature above 101 degrees F (38.8 degrees C) for two readings four hours apart. If you develop a low grade fever, keep a chart of your temperature pattern at 8 AM, 12 noon, 4 & 8 PM. Bring the chart to the office at your next visit.
• Clear drainage from your incision, excessive, wound redness, swelling, purulent drainage or infection.
• An increase in pain, redness and/or swelling by your incision.
• Difficulty urinating or controlling your bowel movements.

When to Call 911

• If you have difficulty breathing, or have an irregular heartbeat, or chest pain, or progressive neurological deficit (progressive weakness in the extremities).

Future Follow-Up Visits

Your first post-op visit is usually scheduled along with your surgery. If you are unsure of your first postoperative appointment, please call (520) 204-1495 to make your first post-operative appointment at the Center for Advanced Spine Care of Southern Arizona. This usually occurs 7 – 10 days after your surgical procedure. All other follow-up visits will be directed by your physician.

Medications

If you need a prescription filled.

Because your health condition may change over time, your doctor or another physician provider, who have access to your confidential medical records, will need to address your refill requests. By following these simple guidelines, you will avoid any delay in getting your prescription refilled:
• Contact your pharmacy at least 5 days before your prescription requires refilling, to protect your health, pharmacies will accept refill orders only from your doctor. So, when you call The Center for Advanced Spinal Care of Southern Arizona with your request an additional step is added. Your prescription will be filled faster if you call your pharmacy directly, they will then contact The Center for Advanced Spine Care of Southern Arizona.
• Use the same pharmacy. That way, your pharmacist will have your complete prescription records and you avoid the danger of mixing medications. To make it convenient for you, the Center for Advanced Spinal Care of Southern Arizona will work with the pharmacy of your choice. Please choose one pharmacy, and use only that pharmacy. It is an easy way to help protect your health, as well as your health records.
• Call your pharmacy early in the day. This gives your doctor time to review your records. To ensure you get the right medications, we do not rush refills without making sure the order and your records are reviewed. Often, physicians are in surgery or finishing with patients late in the day, and we do not want to interrupt those patients’ visits just like you would not like to have your visit interrupted when in the office with the physician. Therefore, refill requests received after 3 pm Monday through Thursday or after 10 am Friday will be reviewed and filled the next business day for The Center for Advanced Spine Care of Southern Arizona.

If You Run Out of Medication Before You Request a Refill

Always call your pharmacy at least 5 days before you run out of medication. This will give the pharmacy plenty of time to contact your doctor, for the doctor to review your record, and for the pharmacist to prepare your medication. All you have to do is watch your medication levels and there should be no reason for you to run out of medication or run out of medication early prior to the scheduled date. It is dangerous to “rush” an order. For your protection, refills are not done at night, over the weekend, on holidays or as an emergency if you have forgotten to call your pharmacy.

If You Run Out of Your Medication Early

Your doctor ordered your prescription according to a precise dosage for a prescribed amount of days. If you run out early, it may mean you are experiencing some difficulty with your dosage or medication. Call The Center for Advanced Spine Care of Southern Arizona immediately and explain your difficulty.

If Your Prescription Is Lost, Misplaced or Stolen:

To protect your health, lost or stolen prescriptions are replaced only with a physician visit. Stolen medication will require a police report to be completed and a copy of the report brought with to your visit. To avoid possible duplication of prescriptions when an order is lost or stolen, you will want to talk with your doctor. Call The Center for Advanced Spine Care to schedule an appointment. Please call our office at (520) 204-1495 with any additional questions that may come during your postoperative recovery.

Please acknowledge that you have read and understood these postop instructions.

PRE- AND POSTOP INSTRUCTIONS CERVICAL LAMINOTOMY RHIZOTOMY SURGERY

This handout will review the care you need to follow in the days prior to your CERVICAL LAMINOTOMY & RHIZOTOMY surgery and once you are home after your surgery. This SURGERY typically TAKES PLACE AT A SURGERY CENTER and involves INCISIONS IN THE BACK OF YOUR NECK near the midline on one or both sides. If you have any questions or concerns, please ask your nurse or doctor. Our staff is here to help you. If you have questions after you are at home, please call the numbers listed at the end of this handout.

This information is part of your medical Informed Consent. Please read it and follow the advice carefully. You should retain the guide for future reference and bring it with you to office appointments and to the hospital for reference.

PREPARATION FOR SURGERY

Preoperative Laboratory Studies, and Medical Clearance

In preparation for surgery, you will have blood drawn for analysis. You may also require an electrocardiogram (ECG), a chest X-ray, and possibly additional preoperative studies. These are scheduled prior to surgery. Your CERVICAL LAMINOTOMY & RHIZOTOMY surgery is a decompression and de-innervation surgery of painful areas in your neck that is typically done at an OUTPATIENT SURGERY CENTER. Preoperative blood work is usually done at the surgery center just prior to your surgery.

Should you have medical problems, such as cardiac or pulmonary, renal disease, thyroid dysfunction, or diabetes to name a few, additional preoperative clearance examinations from your primary care doctor or treating specialist may be required. These tests performed before your scheduled surgery may allow your physician to identify particular health problems that could require further evaluation before anesthesia and surgery. REGARDLESS OF THE EXTENT OF YOUR PREOPERATIVE WORKUP, IT IS NOT A GUARANTEE THAT YOUR SURGERY MAY BE DONE AT AN OUTPATIENT SURGERY CENTER. In some cases, the surgery may be cancelled if the anesthesiologist deems your medical problems at the time of the scheduled procedure as not appropriately managed, or deems your surgery at an outpatient surgery center as too risky and recommends that the procedure be done at a hospital instead.

Diagnostic imaging studies of the lumbar spine, such as CT or MRI scans, a bone scan, and possibly a myelogram, may already have been performed and provide your surgeon with anatomic detail for surgery. Other electrodiagnostic tests (EMG/NCV or SSEPs) may give additional, important information.

Nothing to Eat or Drink After Midnight

Eat a light dinner before 7 P.M. on the evening before your surgery. DO NOT EAT, DRINK, SMOKE, CHEW, OR SWALLOW ANYTHING AFTER MIDNIGHT THE NIGHT BEFORE SURGERY except as directed by the surgery center.

Preoperative Screening by the Surgery Center

The surgery center may call you preoperatively to review your medications, and to determine whether there are any new medical problems unknown at the time of scheduling of your surgery that could potentially be problematic. They may also give you directions as to where and when to report. You should report no later than 2 hours prior to the scheduled surgery time to the surgery center.

Medications to Stop Prior to Surgery

It is imperative for you to stop all NSAIDS (non-steroidal anti-inflammatory drugs) and all other medications affecting the clotting ability of your blood during surgery a minimum of 10 DAYS PRIOR TO your scheduled SURGERY. You not stopping these drugs may affect platelet aggregation and therefore have an anticoagulative side effect. Therefore, significant intraoperative bleeding, increased complication rate with epidural hematoma with potential neurological deficits, infection, and wound problems may occur. There may also be a need for blood transfusions, and potential follow up surgeries to deal with these complications. There are other blood thinners (For example, COUMADIN, XARELTO, PRADAXA, LOVENOX, HEPARIN) that maybe prescribed by your doctor for heart and vascular disease. COUMADIN should be STOPPED 7 DAYS PRIOR TO SURGERY. XARELTO, PRADAXA AND OTHERS may have to be stopped only only a few days prior to surgery. Please check with your prescribing physician. Ideally, you are also OFF XARALTO, or PRADAX ONE WEEK PRIOR TO SURGERY. In addition, you should stop FISH OIL, homeopathic drugs, and any other non-essential drugs that you think may increase your risk of bleeding.

At times, it may not be possible for you to stop these drugs. Please consult with your primary care physician, cardiologist, pulmonologist, vascular surgeon or other subspecialty provider, that may have started you on this type of blood thinner, prior to signing up for surgery. It may be safe for you to come off a prescription blood thinner prior to surgery. However, it may not be. Please check with your doctor who prescribed it prior to surgery.

Report to Admitting in the Preop Area

The surgery center will notify you of the time and location where you should go before your surgery. Do not accept or follow any other directions unless you discuss it with our office, 520-204-1495.

AFTER YOUR OPERATION

Pain & Pain Control

After surgery you may experience pain in the region of the incision. Some pain in the back of the neck from the surgical exposure and irritation of cervical nerve roots with pain radiating into the arms as well as tingling or numbness may be present postoperatively. The latter could last weeks or months. In some cases, there may even be some weakness and new pain in the back of the neck stemming from irritated joints.

Initially, you may notice complete pain relief following this outpatient procedure. This is due to local anesthesia and medication you received during surgery or in the recovery room. This effect will subside over time as the effect of local anesthesia and other systemically administered anesthetic drugs wear off. However, new pain may develop several days postoperatively after an initial “HONEYMOON” period of several days. There may be new pain on the surgical side due to inflammation and swelling of the previously compressed nerves. This postoperative inflammatory response of the spinal nerves may produce constant burning pain radiating into the arms. Don’t be alarmed about this type of new pain. It will diminish within a few weeks and may respond well to epidural steroid injections. Please tell your surgeon if you are experiencing this new type of pain during your postoperative visit(s). Your physician may prescribe NEURONTIN (Gabapentin) or LYRICA (Pregabalin), or schedule you for epidural steroid injections to calm symptoms down quicker.

Although this outpatient surgery can be done under sedation and local anesthesia, most patients find it more comfortable and less stressful to undergo a short general anesthesia with a secure airway. Therefore, some patients experience a sore throat and swallowing difficulty after general anesthesia and surgery. This is from manipulation of tissue and the presence of the breathing tube for anesthesia. The sore throat usually will subside within a week. The swallowing difficulty may take longer. Using throat lozenges or lemon drops, sipping cool liquids, or sucking ice chips may soothe this pain.

If you are SHORT OF BREATH, or have EXCESSIVE CHEST, OR CHEST WALL PAIN, please GO TO THE NEAREST EMERGENGY ROOM as you may be having a postoperative heart attack, or a symptomatic blood clot in the lungs. Postoperative MYOCARDAL INFARCTION, and PULMONARY EMBOLISM are rare but do occur occasionally and you should take these symptoms seriously.

If you are having pain with voiding, you may have a urinary tract infection. Sometimes, this symptom is accompanied by fevers and generalized malaise. If you are unable to void and these symptoms are coupled with excruciating leg or back pain, please report to the NEAREST EMERGENCY ROOM to be evaluated for a symptomatic EPIDURAL HEMATOMA.

Activity

Although this is a small outpatient surgery, you need to give your body time to heal. Below is a list of instructions that you should follow until your first follow-up visit after surgery. You no longer need to wear the anti-thrombosis (TED) stocking (heavy white stockings) once you are home.

You may be given a soft cervical collar after surgery and you should wear this collar only intermittently as needed for comfort only. There is no need to wear this collar all the time, and you do not need to sleep in it. In fact, wearing the soft foam collar around your neck all the time may contribute to neck stiffness and more neck pain.

You may sleep any way you please; either on your back, stomach or side. You may also use pillows for support under your neck.
For your comfort, we suggest that you change your position at least every hour when awake. If you become uncomfortable change your position and activity. You should begin a walking program two to three days after surgery. You may shower 5 days after surgery. If you must shower sooner, you must keep the incision covered and dry while showering. No baths for 4 weeks. No hot tubs or swimming for 6 weeks. NO EXCESSIVE LIFTING please. This could aggravate any postoperative pain syndromes. "LISTEN TO YOUR BODY".

After getting home you will be allowed in the car TWICE, ONCE TO GO HOME, THE SECOND TO COME BACK TO THE OFFICE. You will get your next set of instructions upon your return. For patients from out of state or country, there will be specific instructions.

Mobilization Program

It is important to mobilize after surgery to diminish the risk of deep vein thrombosis. In addition, it improves recovery, and patient satisfaction. Begin walking in the house and progress to outdoors. Take someone with you the first few times. Slowly increase the distance each day so that you will be walking 1 mile/day by your 2nd post-operative week, 2 miles/day at 2 weeks’ post-operative. Hopefully, by 4 weeks’ post-operative you will be walking 4 miles/day. If you feel soreness, reduce the distance and REST. These are GUIDELINES, NOT RULES.

• Day 1 Walk the length of the hallway at home 3-4 times, or walk to the end of the driveway and back once in the morning and again in the afternoon or evening.
• Day 2 Walk 1/2 block or the equivalent of a 1/2 block indoors once in the morning and again in the afternoon or evening.
• Day 3 Walk 1 block in the morning and again in the afternoon or evening.
• Day 4 Walk 2 blocks in the morning and again in the afternoon or evening.
• Day 5 Walk 3 blocks in the morning and again in the afternoon or evening. Continue increasing the distance you walk, as you are able. Let your comfort be your guide to how much you can do.

Limitations

• No driving for 2 weeks, or while taking narcotic pain medication. However, you may be a passenger.
• No lifting greater than 10 lbs. (about 1 gallon of milk) for the first 5-6 weeks after surgery.
• No sports activity until your first follow-up visit other than the walking program.
• No sexual activity for 2 weeks.

Showering / Personal Hygiene

You may shower the morning after surgery. However, it is important to keep the dressing and incisions dry. You may cover cover the dressing with an adhesive and occlusive dressing. DO NOT soak the incision. Do not disturb steri-strips, or sutures.

If You Are Not Sure

If you question whether or not you can do something beyond the instructions given, it is safe to assume that the answer will be NO.

Follow Up Visit in Our Office

Return to the office for your first visit approximately 7 - 10 days after surgery. Typically, you will be given a follow up appointment to our office during your preoperative visit. If you are not sure about your first postoperative visit, please call our office for an appointment (520-204-1495) or if you have questions or concerns. For GENERAL MEDICAL PROBLEMS CONTACT your personal physician.

Return to Driving

No driving for a minimum of 1 week, or for the time while taking extra narcotic pain medication as a result of the surgery. However, you may be a passenger.

Return to Work

Your return to work will depend on your recovery and the type of work you do. You must discuss this with your doctor before you return to work.

Pain Management

For pain management, you will usually be given a prescription for a drug like VICODIN (hydrocodone) or OXYCODONE. For additional pain medication, try Extra strength Tylenol or similar agent. In addition, you may receive a prescription for VALIUM which can help with postoperative muscle spasms.

You should take the pain medication you were given by our office with careful consideration and be knowledgeable about their potential compounding interaction with other narcotics or other medications. Check with your local pharmacist as well should you have any questions as to potential drug interactions.

MEDICATIONS

You may have an occasional increase in pain and/or numbness after surgery during the healing phase. This is normal and is caused by inflammation (or swelling) of muscle tissue and your spinal nerves. To reduce pain there are several approaches to decrease the pain you may be experiencing:

• Ice back of the neck area for 15-20 minutes every hour for 4 consecutive hours with a small ice pack. Do not put the ice directly on your skin. Use a ready-made ice pack or put ice in a plastic bag then wrap the ice pack or bag in a towel before you use it. If you have been given a cooling device, please use while in bed.
• Reduce your activity (i.e. walking) for the next 48 hours and simply rest.
• Take the pain medicine as directed by your doctor for incisional pain. You can also take one extra strength acetaminophen (Tylenol) every 4 hours between the prescription medicines, only as directed. Do not take more than 4000 mg of Tylenol in a 24-hour period. NOTE: Some narcotic pain medicines also have Tylenol in them.
• Do not take narcotic pain medicine for burning pain radiating down the leg. This pain is most likely from inflammation of the nerve. Narcotic pain medication does not help for this type of pain. Take Neurontin (Gabapentin) or Lyrica (Pregabalin) as instructed by your doctor/surgeon. Call the office for a follow up appointment. This neurognic pain typically improves dramatically with an epidural steroid injection into your lower back by placing steroids around the inflamed nerves.
• Eventually you should no longer need to use narcotic pain medicine. Most patients find it unnecessary to take narcotic pain medication within a few days from surgery as the small incisions do not hurt that much.

Removal of Staples or Stitches

Surgical skin staples or sutures are typically removed during your first postoperative visit. If you live far away out of town and an early postoperative visit in our office may pose a particularly hardship for you, you may contact your primary care physician to have her/him remove the staples or stitches. Skin stapes should be removed no later than 2 weeks from the day of surgery. We typically use biodegradable stitches for skin closure and they may simply dissolve and fall off. However, you may have them removed no later than 2 weeks from surgery as well if they bother you. You may develop redness around the staples which typically resolves quickly without additional treatment.

Incision Care

Caring for your Incision at home is important to prevent infection. Please follow these steps:

• Your incisions have been closed either with skin staples or with absorbable suture material. In most cases these areas are covered with a Band-Aid or a small dressing. You may remove the dressing 3-5 days after surgery.
• The stiches will gradually fall off with time and this is normal.
• Staples should be removed within 14 days of your surgery. It is therefore prudent for you to show for your first postoperative visit.
• Take your temperature twice a day, once in the morning and once in the evening for the first 7 days.
The wound will be checked and the dressing will be changed prior to discharge home from the surgery center. You may take a shower when you get home. If the Band-Aid gets wet, simply replace it with a new one. DO NOT TAKE BATH AND DO NOT SOAK THE WOUND. Once the dressing is removed you may leave the wound open to air.

Do not be alarmed when you have bloody or serosangineous drainage from the wound(s). This is normal and part of your postoperative recovery. There may also be some bruising around the lumbar incisional area(s). However, call our office if you have persistent drainage for more than 3 days or a new onset of drainage sometime after 7 - 10 days from your surgery. You should also let us know if you are having any fevers (temperature over 101 F) or chills. This may suggest a wound infection. Although uncommon wound infection occur in under 0.1 % of patients who underwent outpatient percutaneous decompression surgery.

Be advised though that elevated temperatures after surgery can be normal and often is a result of poor lung ventilation. Taking deep breath, and ambulating as much as you can tolerate may help with this problem.

When to Call Your Doctor or Nurse

PAIN IS A RED FLAG TELLING YOU TO REST. Avoid taking pain relieving medication in anticipation that something you will do is going to cause pain.

• If you have a temperature above 101 degrees F (38.8 degrees C) for two readings four hours apart. If you develop a low grade fever, keep a chart of your temperature pattern at 8 AM, 12 noon, 4 & 8 PM. Bring the chart to the office at your next visit.
• Clear drainage from your incision, excessive, wound redness, swelling, purulent drainage or infection.
• An increase in pain, redness and/or swelling by your incision.
• Difficulty urinating or controlling your bowel movements.

When to Call 911

• If you have difficulty breathing, or have an irregular heartbeat, or chest pain.

Future Follow-Up Visits

Your first post-op visit is usually scheduled along with your surgery. If you are unsure of your first postoperative appointment, please call (520) 204-1495 to make your first post-operative appointment at the Center for Advanced Spine Care of Southern Arizona. This usually occurs 7 – 10 days after your surgical procedure. All other follow-up visits will be directed by your physician.

Medications

If you need a prescription filled.

Because your health condition may change over time, your doctor or another physician provider, who have access to your confidential medical records, will need to address your refill requests. By following these simple guidelines, you will avoid any delay in getting your prescription refilled:

• Contact your pharmacy at least 5 days before your prescription requires refilling, to protect your health, pharmacies will accept refill orders only from your doctor. So, when you call The Center for Advanced Spinal Care of Southern Arizona with your request an additional step is added. Your prescription will be filled faster if you call your pharmacy directly, they will then contact The Center for Advanced Spine Care of Southern Arizona.
• Use the same pharmacy. That way, your pharmacist will have your complete prescription records and you avoid the danger of mixing medications. To make it convenient for you, the Center for Advanced Spinal Care of Southern Arizona will work with the pharmacy of your choice. Please choose one pharmacy, and use only that pharmacy. It is an easy way to help protect your health, as well as your health records.
• Call your pharmacy early in the day. This gives your doctor time to review your records. To ensure you get the right medications, we do not rush refills without making sure the order and your records are reviewed. Often, physicians are in surgery or finishing with patients late in the day, and we do not want to interrupt those patients’ visits just like you would not like to have your visit interrupted when in the office with the physician. Therefore, refill requests received after 3 pm Monday through Thursday or after 10 am Friday will be reviewed and filled the next business day for The Center for Advanced Spine Care of Southern Arizona.

If You Run Out of Medication Before You Request a Refill

Always call your pharmacy at least 5 days before you run out of medication. This will give the pharmacy plenty of time to contact your doctor, for the doctor to review your record, and for the pharmacist to prepare your medication. All you have to do is watch your medication levels and there should be no reason for you to run out of medication or run out of medication early prior to the scheduled date. It is dangerous to “rush” an order. For your protection, refills are not done at night, over the weekend, on holidays or as an emergency if you have forgotten to call your pharmacy.

If You Run Out of Your Medication Early

Your doctor ordered your prescription according to a precise dosage for a prescribed amount of days. If you run out early, it may mean you are experiencing some difficulty with your dosage or medication. Call The Center for Advanced Spine Care of Southern Arizona immediately and explain your difficulty.

If Your Prescription Is Lost, Misplaced or Stolen:

To protect your health, lost or stolen prescriptions are replaced only with a physician visit. Stolen medication will require a police report to be completed and a copy of the report brought with to your visit. To avoid possible duplication of prescriptions when an order is lost or stolen, you will want to talk with your doctor. Call The Center for Advanced Spine Care to schedule an appointment. Please call our office at (520) 204-1495 with any additional questions that may come during your postoperative recovery.

Please acknowledge that you have read and understood these postop instructions.

PRE- AND POSTOP INSTRUCTIONS POSTERIOR CERVICAL LAMINECTOMY & FUSION SURGERY

This handout will review the care you need to follow in the days prior to your POSTERIOR CERVICAL LAMINECTOMY & FUSION surgery and once you are home after your surgery. This SURGERY typically TAKES PLACE AT A HOSPITAL and involves a LONGER MIDLINE INCISION IN THE BACK OF YOUR NECK. If you have any questions or concerns, please ask your nurse or doctor. Our staff is here to help you. If you have questions after you are at home, please call the numbers listed at the end of this handout.

This information is part of your medical Informed Consent. Please read it and follow the advice carefully. You should retain the guide for future reference and bring it with you to office appointments and to the hospital for reference.

PREPARATION FOR SURGERY

Preoperative Laboratory Studies, and Medical Clearance

In preparation for surgery, you will have blood drawn for analysis. You may also require an electrocardiogram (ECG), a chest X-ray, and possibly additional preoperative studies. These are scheduled prior to surgery. Your POSTERIOR CERVICAL LAMINECTOMY & FUSION surgery is a decompression and stabilization surgery of painful areas in your neck that is typically done at a HOSPITAL. It is done by removing the bony covering of the spinal cord in the back of the neck (removal of lamina[e]) and placing titanium implants including screws and rods to stabilize the neck after the decompression. The goal of this surgery is to decompress the cervical spinal cord as well as cervical nerve roots, and to stabilize the cervical spine. Preoperative blood work is usually done at the surgery center just prior to your surgery.

Should you have medical problems, such as cardiac or pulmonary, renal disease, thyroid dysfunction, or diabetes to name a few, additional preoperative clearance examinations from your primary care doctor or treating specialist may be required. These tests performed before your scheduled surgery may allow your physician to identify particular health problems that could require further evaluation before anesthesia and surgery. REGARDLESS OF THE EXTENT OF YOUR PREOPERATIVE WORKUP, IT IS NOT A GUARANTEE THAT YOUR SURGERY MAY BE DONE AT AN OUTPATIENT SURGERY CENTER. In some cases, the surgery may be cancelled if the anesthesiologist deems your medical problems at the time of the scheduled procedure as not appropriately managed, or deems your surgery at an outpatient surgery center as too risky and recommends that the procedure be done at a hospital instead.

Diagnostic imaging studies of the lumbar spine, such as CT or MRI scans, a bone scan, and possibly a myelogram, may already have been performed and provide your surgeon with anatomic detail for surgery. Other electrodiagnostic tests (EMG/NCV or SSEPs) may give additional, important information.

Nothing to Eat or Drink After Midnight

Eat a light dinner before 7 P.M. on the evening before your surgery. DO NOT EAT, DRINK, SMOKE, CHEW, OR SWALLOW ANYTHING AFTER MIDNIGHT THE NIGHT BEFORE SURGERY except as directed by the surgery center.

Preoperative Screening by the Hospital

The surgery center may call you preoperatively to review your medications, and to determine whether there are any new medical problems unknown at the time of scheduling of your surgery that could potentially be problematic. They may also give you directions as to where and when to report. You should report no later than 2 hours prior to the scheduled surgery time to the surgery center.

Medications to Stop Prior to Surgery

It is imperative for you to stop all NSAIDS (non-steroidal anti-inflammatory drugs) and all other medications affecting the clotting ability of your blood during surgery a minimum of 10 DAYS PRIOR TO your scheduled SURGERY. You not stopping these drugs may affect platelet aggregation and therefore have an anticoagulative side effect. Therefore, significant intraoperative bleeding, increased complication rate with epidural hematoma with potential neurological deficits, infection, and wound problems may occur. There may also be a need for blood transfusions, and potential follow up surgeries to deal with these complications. There are other blood thinners (For example, COUMADIN, XARELTO, PRADAXA, LOVENOX, HEPARIN) that maybe prescribed by your doctor for heart and vascular disease. COUMADIN should be STOPPED 7 DAYS PRIOR TO SURGERY. XARELTO, PRADAXA AND OTHERS may have to be stopped only only a few days prior to surgery.
Please check with your prescribing physician. Ideally, you are also OFF XARALTO, or PRADAX ONE WEEK PRIOR TO SURGERY. In addition, you should stop FISH OIL, homeopathic drugs, and any other non-essential drugs that you think may increase your risk of bleeding.

At times, it may not be possible for you to stop these drugs. Please consult with your primary care physician, cardiologist, pulmonologist, vascular surgeon or other subspecialty provider, that may have started you on this type of blood thinner, prior to signing up for surgery. It may be safe for you to come off a prescription blood thinner prior to surgery. However, it may not be. Please check with your doctor who prescribed it prior to surgery.

Report to Admitting in the Preop Area

The hospital will notify you of the time and location where you should go before your surgery. Do not accept or follow any other directions unless you discuss it with our office, 520-204-1495.

AFTER YOUR OPERATION

Pain & Pain Control

After surgery you may experience pain in the region of the incision. Some pain in the back of the neck from the surgical exposure and irritation of cervical nerve roots with pain radiating into the arms as well as tingling or numbness may be present postoperatively. The latter could ldast weeks or months. In some cases, there may even be some weakness and new pain in the back of the neck stemming from irritated joints.

Initially, you may notice complete pain relief following this outpatient procedure. This is due to local anesthesia and medication you received during surgery or in the recovery room. This effect will subside over time as the effect of local anesthesia and other systemically administered anesthetic drugs wear off. However, new pain may develop several days postoperatively after an initial “HONEYMOON” period of several days. There may be new pain on the surgical side due to inflammation and swelling of the previously compressed nerves. This postoperative inflammatory response of the spinal nerves may produce constant burning pain radiating into the arms. Don’t be alarmed about this type of new pain. It will diminish within a few weeks and may respond well to epidural steroid injections. Please tell your surgeon if you are experiencing this new type of pain during your postoperative visit(s). Your physician may prescribe NEURONTIN (Gabapentin) or LYRICA (Pregabalin), or schedule you for epidural steroid injections to calm symptoms down quicker.

Although this outpatient surgery can be done under sedation and local anesthesia, most patients find it more comfortable and less stressful to undergo a short general anesthesia with a secure airway. Therefore, some patients experience a sore throat and swallowing difficulty after general anesthesia and surgery. This is from manipulation of tissue and the presence of the breathing tube for anesthesia. The sore throat usually will subside within a week. The swallowing difficulty may take longer. Using throat lozenges or lemon drops, sipping cool liquids, or sucking ice chips may soothe this pain.

If you are SHORT OF BREATH, or have EXCESSIVE CHEST, OR CHEST WALL PAIN, please GO TO THE NEAREST EMERGENGY ROOM as you may be having a postoperative heart attack, or a symptomatic blood clot in the lungs. Postoperative MYOCARDAL INFARCTION, and PULMONARY EMBOLISM are rare but do occur occasionally and you should take these symptoms seriously.

If you are having pain with voiding, you may have a urinary tract infection. Sometimes, this symptom is accompanied by fevers and generalized malaise. If you are unable to void and these symptoms are coupled with excruciating leg or back pain, please report to the NEAREST EMERGENCY ROOM to be evaluated for a symptomatic EPIDURAL HEMATOMA.

Activity

This is a major inpatient surgery, you need to give your body time to heal. Below is a list of instructions that you should follow until your first follow-up visit after surgery. You no longer need to wear the anti-thrombosis (TED) stocking (heavy white stockings) once you are home.
You may be given a soft cervical collar after surgery and you should wear this collar only intermittently as needed for comfort only. There is no need to wear this collar all the time, and you do not need to sleep in it. In fact, wearing the soft foam collar around your neck all the time may contribute to neck stiffness and more neck pain.

You may sleep any way you please; either on your back, stomach or side. You may also use pillows for support under your neck.
For your comfort, we suggest that you change your position at least every hour when awake. If you become uncomfortable change your position and activity. You should begin a walking program two to three days after surgery. You may shower 5 days after surgery. If you must shower sooner, you must keep the incision covered and dry while showering. No baths for 4 weeks. No hot tubs or swimming for 6 weeks. NO EXCESSIVE LIFTING please. This could aggravate any postoperative pain syndromes. "LISTEN TO YOUR BODY".

After getting home you will be allowed in the car TWICE, ONCE TO GO HOME, THE SECOND TO COME BACK TO THE OFFICE. You will get your next set of instructions upon your return. For patients from out of state or country, there will be specific instructions.

Mobilization Program

It is important to mobilize after surgery to diminish the risk of deep vein thrombosis. In addition, it improves recovery, and patient satisfaction. Begin walking in the house and progress to outdoors. Take someone with you the first few times. Slowly increase the distance each day so that you will be walking 1 mile/day by your 2nd post-operative week, 2 miles/day at 2 weeks’ post-operative. Hopefully, by 4 weeks’ post-operative you will be walking 4 miles/day. If you feel soreness, reduce the distance and REST. These are GUIDELINES, NOT RULES.

• Day 1 Walk the length of the hallway at home 3-4 times, or walk to the end of the driveway and back once in the morning and again in the afternoon or evening.
• Day 2 Walk 1/2 block or the equivalent of a 1/2 block indoors once in the morning and again in the afternoon or evening.
• Day 3 Walk 1 block in the morning and again in the afternoon or evening.
• Day 4 Walk 2 blocks in the morning and again in the afternoon or evening.
• Day 5 Walk 3 blocks in the morning and again in the afternoon or evening. Continue increasing the distance you walk, as you are able. Let your comfort be your guide to how much you can do.

Limitations

• No driving for 2 weeks, or while taking narcotic pain medication. However, you may be a passenger.
• No lifting greater than 10 lbs. (about 1 gallon of milk) for the first 5-6 weeks after surgery.
• No sports activity until your first follow-up visit other than the walking program.
• No sexual activity for 2 weeks.

Showering / Personal Hygiene

You may shower the morning after surgery. However, it is important to keep the dressing and incisions dry. You may cover cover the dressing with an adhesive and occlusive dressing. DO NOT soak the incision. Do not disturb steri-strips, or sutures.

If You Are Not Sure

If you question whether or not you can do something beyond the instructions given, it is safe to assume that the answer will be NO.

Follow Up Visit in Our Office

Return to the office for your first visit approximately 7 - 10 days after surgery. Typically, you will be given a follow up appointment to our office during your preoperative visit. If you are not sure about your first postoperative visit, please call our office for an appointment (520-204-1495) or if you have questions or concerns. For GENERAL MEDICAL PROBLEMS CONTACT your personal physician.

Return to Driving

No driving for a minimum of 1 week, or for the time while taking extra narcotic pain medication as a result of the surgery. However, you may be a passenger.

Return to Work

Your return to work will depend on your recovery and the type of work you do. You must discuss this with your doctor before you return to work.

Pain Management

For pain management, you will usually be given a prescription for a drug like VICODIN (hydrocodone) or OXYCODONE. For additional pain medication, try Extra strength Tylenol or similar agent. In addition, you may receive a prescription for VALIUM which can help with postoperative muscle spasms.

You should take the pain medication you were given by our office with careful consideration and be knowledgeable about their potential compounding interaction with other narcotics or other medications. Check with your local pharmacist as well should you have any questions as to potential drug interactions.

MEDICATIONS

You may have an occasional increase in pain and/or numbness after surgery during the healing phase. This is normal and is caused by inflammation (or swelling) of muscle tissue and your spinal nerves. To reduce pain there are several approaches to decrease the pain you may be experiencing:

• Ice back of the neck area for 15-20 minutes every hour for 4 consecutive hours with a small ice pack. Do not put the ice directly on your skin. Use a ready-made ice pack or put ice in a plastic bag then wrap the ice pack or bag in a towel before you use it. If you have been given a cooling device, please use while in bed.
• Reduce your activity (i.e. walking) for the next 48 hours and simply rest.
• Take the pain medicine as directed by your doctor for incisional pain. You can also take one extra strength acetaminophen (Tylenol) every 4 hours between the prescription medicines, only as directed. Do not take more than 4000 mg of Tylenol in a 24-hour period. NOTE: Some narcotic pain medicines also have Tylenol in them.
• Do not take narcotic pain medicine for burning pain radiating down the leg. This pain is most likely from inflammation of the nerve. Narcotic pain medication does not help for this type of pain. Take Neurontin (Gabapentin) or Lyrica (Pregabalin) as instructed by your doctor/surgeon. Call the office for a follow up appointment. This neurognic pain typically improves dramatically with an epidural steroid injection into your lower back by placing steroids around the inflamed nerves.
• Eventually you should no longer need to use narcotic pain medicine. Most patients find it unnecessary to take narcotic pain medication within a few days from surgery as the small incisions do not hurt that much.

Removal of Staples or Stitches

Surgical skin staples or sutures are typically removed during your first postoperative visit. If you live far away out of town and an early postoperative visit in our office may pose a particularly hardship for you, you may contact your primary care physician to have her/him remove the staples or stitches. Skin stapes should be removed no later than 2 weeks from the day of surgery. We typically use biodegradable stitches for skin closure and they may simply dissolve and fall off. However, you may have them removed no later than 2 weeks from surgery as well if they bother you. You may develop redness around the staples which typically resolves quickly without additional treatment.

Incision Care

Caring for your Incision at home is important to prevent infection. Please follow these steps:

• Your incisions have been closed either with skin staples or with absorbable suture material. In most cases these areas are covered with a Band-Aid or a small dressing. You may remove the dressing 3-5 days after surgery.
• The stiches will gradually fall off with time and this is normal.
• Staples should be removed within 14 days of your surgery. It is therefore prudent for you to show for your first postoperative visit.
• Take your temperature twice a day, once in the morning and once in the evening for the first 7 days.
The wound will be checked and the dressing will be changed prior to discharge home from the surgery center. You may take a shower when you get home. If the Band-Aid gets wet, simply replace it with a new one. DO NOT TAKE BATH AND DO NOT SOAK THE WOUND. Once the dressing is removed you may leave the wound open to air.

Do not be alarmed when you have bloody or serosangineous drainage from the wound(s). This is normal and part of your postoperative recovery. There may also be some bruising around the lumbar incisional area(s). However, call our office if you have persistent drainage for more than 3 days or a new onset of drainage sometime after 7 - 10 days from your surgery. You should also let us know if you are having any fevers (temperature over 101 F) or chills. This may suggest a wound infection. Although uncommon wound infection occur in under 0.1 % of patients who underwent outpatient percutaneous decompression surgery.
Be advised though that elevated temperatures after surgery can be normal and often is a result of poor lung ventilation. Taking deep breath, and ambulating as much as you can tolerate may help with this problem.

When to Call Your Doctor or Nurse

PAIN IS A RED FLAG TELLING YOU TO REST. Avoid taking pain relieving medication in anticipation that something you will do is going to cause pain.

• If you have a temperature above 101 degrees F (38.8 degrees C) for two readings four hours apart. If you develop a low grade fever, keep a chart of your temperature pattern at 8 AM, 12 noon, 4 & 8 PM. Bring the chart to the office at your next visit.
• Clear drainage from your incision, excessive, wound redness, swelling, purulent drainage or infection.
• An increase in pain, redness and/or swelling by your incision.
• Difficulty urinating or controlling your bowel movements.

When to Call 911

• If you have difficulty breathing, or have an irregular heartbeat, or chest pain.

Future Follow-Up Visits

Your first post-op visit is usually scheduled along with your surgery. If you are unsure of your first postoperative appointment, please call (520) 204-1495 to make your first post-operative appointment at the Center for Advanced Spine Care of Southern Arizona. This usually occurs 7 – 10 days after your surgical procedure. All other follow-up visits will be directed by your physician.

Medications

If you need a prescription filled.

Because your health condition may change over time, your doctor or another physician provider, who have access to your confidential medical records, will need to address your refill requests. By following these simple guidelines, you will avoid any delay in getting your prescription refilled:

• Contact your pharmacy at least 5 days before your prescription requires refilling, to protect your health, pharmacies will accept refill orders only from your doctor. So, when you call The Center for Advanced Spinal Care of Southern Arizona with your request an additional step is added. Your prescription will be filled faster if you call your pharmacy directly, they will then contact The Center for Advanced Spine Care of Southern Arizona.
• Use the same pharmacy. That way, your pharmacist will have your complete prescription records and you avoid the danger of mixing medications. To make it convenient for you, the Center for Advanced Spinal Care of Southern Arizona will work with the pharmacy of your choice. Please choose one pharmacy, and use only that pharmacy. It is an easy way to help protect your health, as well as your health records.
• Call your pharmacy early in the day. This gives your doctor time to review your records. To ensure you get the right medications, we do not rush refills without making sure the order and your records are reviewed. Often, physicians are in surgery or finishing with patients late in the day, and we do not want to interrupt those patients’ visits just like you would not like to have your visit interrupted when in the office with the physician. Therefore, refill requests received after 3 pm Monday through Thursday or after 10 am Friday will be reviewed and filled the next business day for The Center for Advanced Spine Care of Southern Arizona.

If You Run Out of Medication Before You Request a Refill

Always call your pharmacy at least 5 days before you run out of medication. This will give the pharmacy plenty of time to contact your doctor, for the doctor to review your record, and for the pharmacist to prepare your medication. All you have to do is watch your medication levels and there should be no reason for you to run out of medication or run out of medication early prior to the scheduled date. It is dangerous to “rush” an order. For your protection, refills are not done at night, over the weekend, on holidays or as an emergency if you have forgotten to call your pharmacy.

If You Run Out of Your Medication Early

Your doctor ordered your prescription according to a precise dosage for a prescribed amount of days. If you run out early, it may mean you are experiencing some difficulty with your dosage or medication. Call The Center for Advanced Spine Care of Southern Arizona immediately and explain your difficulty.

If Your Prescription Is Lost, Misplaced or Stolen:

To protect your health, lost or stolen prescriptions are replaced only with a physician visit. Stolen medication will require a police report to be completed and a copy of the report brought with to your visit. To avoid possible duplication of prescriptions when an order is lost or stolen, you will want to talk with your doctor. Call The Center for Advanced Spine Care to schedule an appointment. Please call our office at (520) 204-1495 with any additional questions that may come during your postoperative recovery.

Please acknowledge that you have read and understood these postop instructions.

PRE- AND POSTOP INSTRUCTIONS THORACIC LAMINOTOMY RHIZOTOMY SURGERY

This handout will review the care you need to follow in the days prior to your THORACIC LAMINOTOMY & RHIZOTOMY surgery and once you are home after your surgery. This SURGERY typically TAKES PLACE AT A SURGERY CENTER and involves INCISIONS IN YOUR MID TO UPPER BACK on the back of your chest near the midline on one or both sides. If you have any questions or concerns, please ask your nurse or doctor. Our staff is here to help you. If you have questions after you are at home, please call the numbers listed at the end of this handout.

This information is part of your medical Informed Consent. Please read it and follow the advice carefully. You should retain the guide for future reference and bring it with you to office appointments and to the hospital for reference.

PREPARATION FOR SURGERY

Preoperative Laboratory Studies, and Medical Clearance

In preparation for surgery, you will have blood drawn for analysis. You may also require an electrocardiogram (ECG), a chest X-ray, and possibly additional preoperative studies. These are scheduled prior to surgery. Your THORACIC LAMINOTOMY & RHIZOTOMY surgery is a decompression and de-innervation surgery of painful areas in our mid to upper back that is typically done at an OUTPATIENT SURGERY CENTER. Preoperative blood work is usually done at the surgery center just prior to your surgery.

Should you have medical problems, such as cardiac or pulmonary, renal disease, thyroid dysfunction, or diabetes to name a few, additional preoperative clearance examinations from your primary care doctor or treating specialist may be required. These tests performed before your scheduled surgery may allow your physician to identify particular health problems that could require further evaluation before anesthesia and surgery. REGARDLESS OF THE EXTENT OF YOUR PREOPERATIVE WORKUP, IT IS NOT A GUARANTEE THAT YOUR SURGERY MAY BE DONE AT AN OUTPATIENT SURGERY CENTER. In some cases, the surgery may be cancelled if the anesthesiologist deems your medical problems at the time of the scheduled procedure as not appropriately managed, or deems your surgery at an outpatient surgery center as too risky and recommends that the procedure be done at a hospital instead.

Diagnostic imaging studies of the lumbar spine, such as CT or MRI scans, a bone scan, and possibly a myelogram, may already have been performed and provide your surgeon with anatomic detail for surgery. Other electrodiagnostic tests (EMG/NCV or SSEPs) may give additional, important information.

Nothing to Eat or Drink After Midnight

Eat a light dinner before 7 P.M. on the evening before your surgery. DO NOT EAT, DRINK, SMOKE, CHEW, OR SWALLOW ANYTHING AFTER MIDNIGHT THE NIGHT BEFORE SURGERY except as directed by the surgery center.

Preoperative Screening by the Surgery Center

The surgery center may call you preoperatively to review your medications, and to determine whether there are any new medical problems unknown at the time of scheduling of your surgery that could potentially be problematic. They may also give you directions as to where and when to report. You should report no later than 2 hours prior to the scheduled surgery time to the surgery center.

Medications to Stop Prior to Surgery

It is imperative for you to stop all NSAIDS (non-steroidal anti-inflammatory drugs) and all other medications affecting the clotting ability of your blood during surgery a minimum of 10 DAYS PRIOR TO your scheduled SURGERY. You not stopping these drugs may affect platelet aggregation and therefore have an anticoagulative side effect. Therefore, significant intraoperative bleeding, increased complication rate with epidural hematoma with potential neurological deficits, infection, and wound problems may occur. There may also be a need for blood transfusions, and potential follow up surgeries to deal with these complications. There are other blood thinners (For example, COUMADIN, XARELTO, PRADAXA, LOVENOX, HEPARIN) that maybe prescribed by your doctor for heart and vascular disease. COUMADIN should be STOPPED 7 DAYS PRIOR TO SURGERY. XARELTO, PRADAXA AND OTHERS may have to be stopped only only a few days prior to surgery. Please check with your prescribing physician. Ideally, you are also OFF XARALTO, or PRADAX ONE WEEK PRIOR TO SURGERY. In addition, you should stop FISH OIL, homeopathic drugs, and any other non-essential drugs that you think may increase your risk of bleeding.

At times, it may not be possible for you to stop these drugs. Please consult with your primary care physician, cardiologist, pulmonologist, vascular surgeon or other subspecialty provider, that may have started you on this type of blood thinner, prior to signing up for surgery. It may be safe for you to come off a prescription blood thinner prior to surgery. However, it may not be. Please check with your doctor who prescribed it prior to surgery.

Report to Admitting in the Preop Area

The surgery center will notify you of the time and location where you should go before your surgery. Do not accept or follow any other directions unless you discuss it with our office, 520-204-1495.

AFTER YOUR OPERATION

Pain & Pain Control

After surgery you may experience pain in the region of the incision. Some mid and upper back pain and pain radiating along the ribs to the front of the chest wall as well as tingling or numbness may develop postoperatively.

Initially, you may notice complete pain relief following this outpatient procedure. This is due to local anesthesia and medication you received during surgery or in the recovery room. This effect will subside over time as the effect of local anesthesia and other systemically administered anesthetic drugs wear off. However, new pain may develop several days postoperatively after an initial “HONEYMOON” period of several days. There may be new pain on the surgical side due to inflammation and swelling of the previously compressed nerves. This postoperative inflammatory response of the spinal nerves may produce constant burning pain along the ribs as the intercostal nerve originates from the spinal cord and is in the surgical field. Typically, it occurs 4 – 10 days postoperatively after a short period of no pain. Don’t be alarmed about this type of new pain. It will diminish within a few weeks and may respond well to epidural steroid injections. Please tell your surgeon if you are experiencing this new type of pain during your postoperative visit(s). Your physician may prescribe NEURONTIN (Gabapentin) or LYRICA (Pregabalin) or schedule you for epidural steroid injections to calm symptoms down quicker.

Although this outpatient surgery can be done under sedation and local anesthesia, most patients find it more comfortable and less stressful to undergo a short general anesthesia with a secure airway. Therefore, some patients experience a sore throat and swallowing difficulty after general anesthesia and surgery. This is from manipulation of tissue and the presence of the breathing tube for anesthesia. The sore throat usually will subside within a week. The swallowing difficulty may take longer. Using throat lozenges or lemon drops, sipping cool liquids, or sucking ice chips may soothe this pain.

If you are SHORT OF BREATH, or have EXCESSIVE CHEST, OR CHEST WALL PAIN, please GO TO THE NEAREST EMERGENGY ROOM as you may be having a postoperative heart attack, or a symptomatic blood clot in the lungs. Postoperative MYOCARDAL INFARCTION, and PULMONARY EMBOLISM are rare but do occur occasionally and you should take these symptoms seriously.

If you are having pain with voiding, you may have a urinary tract infection. Sometimes, this symptom is accompanied by fevers and generalized malaise. If you are unable to void and these symptoms are coupled with excruciating leg or back pain, please report to the NEAREST EMERGENCY ROOM to be evaluated for a symptomatic EPIDURAL HEMATOMA.

Activity

Although this is a small outpatient surgery, you need to give your body time to heal. Below is a list of instructions that you should follow until your first follow-up visit after surgery. You no longer need to wear the anti-thrombosis (TED) stocking (heavy white stockings) once you are home. You may sleep either on your back, stomach or side. You may also use pillows for support, when lying on your side. Place pillows behind your back and between your legs. When on your back place pillows underneath your legs. You may climb stairs, just try not to over-do.

For your comfort, we suggest that you change your position at least every hour when awake. If you become uncomfortable change your position and activity. You should begin a walking program two to three days after surgery. You may shower 5 days after surgery. If you must shower sooner, you must keep the incision covered and dry while showering. No baths for 4 weeks. No hot tubs or swimming for 6 weeks. NO BENDING, TWISTING OR LIFTING.

Once you are permitted to sit, use ONLY a straight back chair such as a dining room chair of kitchen chair. A sturdy "wing back" chair is an option. Each day increase the time & frequency that you sit. (Example: 1st day, sit 3 times for 15 minutes each/2nd day 4 times for 20 minutes each/3rd day 5 times for 25 minutes, etc.) If there is pain after a few minutes GET UP. "LISTEN TO YOUR BODY"

After leaving the hospital you will be allowed in the car TWICE, ONCE TO GO HOME, THE SECOND TO COME BACK TO THE OFFICE. You will get your next set of instructions upon your return. For patients from out of state or country, there will be specific instructions.

Walking Program

Begin walking in the house and progress to outdoors. Take someone with you the first few times. Slowly increase the distance each day so that you will be walking 1 mile/day by your 2nd post-operative week, 2 miles/day at 2 weeks’ post-operative. Hopefully, by 4 weeks’ post-operative you will be walking 4 miles/day. If you feel soreness, reduce the distance and REST. These are GUIDELINES, NOT RULES.

• Day 1 Walk the length of the hallway at home 3-4 times, or walk to the end of the driveway and back once in the morning and again in the afternoon or evening.
• Day 2 Walk 1/2 block or the equivalent of a 1/2 block indoors once in the morning and again in the afternoon or evening.
• Day 3 Walk 1 block in the morning and again in the afternoon or evening.
• Day 4 Walk 2 blocks in the morning and again in the afternoon or evening.
• Day 5 Walk 3 blocks in the morning and again in the afternoon or evening. Continue increasing the distance you walk, as you are able. Let your comfort be your guide to how much you can do.

Limitations

• No driving for 2 weeks, or while taking narcotic pain medication. However, you may be a passenger.
• No lifting greater than 10 lbs. (about 1 gallon of milk) for the first 5-6 weeks after surgery.
• No bending at the waist, however, you may squat with your knees.
• No sports activity until your first follow-up visit other than the walking program.
• No sexual activity for 2 weeks.

Showering / Personal Hygiene

You may shower the morning after surgery. However, it is important to keep the dressing and incisions dry. You may cover cover the dressing with an adhesive and occlusive dressing. DO NOT soak the incision. Do not disturb steri-strips, staples, or sutures.

If You Are Not Sure

If you question whether or not you can do something beyond the instructions given, it is safe to assume that the answer will be NO.

Follow Up Visit in Our Office

Return to the office for your first visit approximately 7 - 10 days after surgery. Typically, you will be given a follow up appointment to our office during your preoperative visit. If you are not sure about your first postoperative visit, please call our office for an appointment (520-204-1495) or if you have questions or concerns. For GENERAL MEDICAL PROBLEMS CONTACT your personal physician.

Return to Driving

No driving for a minimum of 1 week, or for the time while taking extra narcotic pain medication as a result of the surgery. However, you may be a passenger.

Return to Work

Your return to work will depend on your recovery and the type of work you do. You must discuss this with your doctor before you return to work.

Pain Management

For pain management, you will usually be given a prescription for a drug like VICODIN (hydrocodone) or OXYCODONE. For additional pain medication, try Extra strength Tylenol or similar agent. In addition, you may receive a prescription for VALIUM which can help with postoperative muscle spasms.

You should take the pain medication you were given by our office with careful consideration and be knowledgeable about their potential compounding interaction with other narcotics or other medications. Check with your local pharmacist as well should you have any questions as to potential drug interactions.

MEDICATIONS

You may have an occasional increase in back, leg pain and/or numbness after surgery during the healing phase. This is normal and is caused by inflammation (or swelling) of muscle tissue and your spinal nerves in your lower back. To reduce pain there are several approaches to decrease the pain you may be experiencing:

• Ice the low back area for 15-20 minutes every hour for 4 consecutive hours. Do not put the ice directly on your skin. Use a ready-made ice pack or put ice in a plastic bag then wrap the ice pack or bag in a towel before you use it. If you have been given a cooling device, please use while in bed.
• Avoid sitting for more than 30-60 minutes at a time for the next 48 hours.
• Reduce your activity (i.e. walking) for the next 48 hours.
• Take the pain medicine as directed by your doctor for incisional pain. You can also take one extra strength acetaminophen (Tylenol) every 4 hours between the prescription medicines, only as directed. Do not take more than 4000 mg of Tylenol in a 24-hour period. NOTE: Some narcotic pain medicines also have Tylenol in them.
• Do not take narcotic pain medicine for burning pain radiating down the leg. This pain is most likely from inflammation of the nerve. Narcotic pain medication does not help for this type of pain. Take Neurontin (Gabapentin) or Lyrica (Pregabalin) as instructed by your doctor/surgeon. Call the office for a follow up appointment. This neurognic pain typically improves dramatically with an epidural steroid injection into your lower back by placing steroids around the inflamed nerves.
• Eventually you should no longer need to use narcotic pain medicine. Most patients find it unnecessary to take narcotic pain medication within a few days from surgery as the small incisions do not hurt that much.

Removal of Staples or Stitches

Surgical skin staples or sutures are typically removed during your first postoperative visit. If you live far away out of town and an early postoperative visit in our office may pose a particularly hardship for you, you may contact your primary care physician to have her/him remove the staples or stitches. Skin stapes should be removed no later than 2 weeks from the day of surgery. We typically use biodegradable stitches for skin closure and they may simply dissolve and fall off. However, you may have them removed no later than 2 weeks from surgery as well if they bother you. You may develop redness around the staples which typically resolves quickly without additional treatment.

Incision Care

Caring for your Incision at home is important to prevent infection. Please follow these steps:

• Your incisions have been closed either with skin staples or with absorbable suture material. In most cases these areas are covered with a Band-Aid or a small dressing. You may remove the dressing 3-5 days after surgery.
• The stiches will gradually fall off with time and this is normal.
• Staples should be removed within 14 days of your surgery. It is therefore prudent for you to show for your first postoperative visit.
• Take your temperature twice a day, once in the morning and once in the evening for the first 7 days.

The wound will be checked and the dressing will be changed prior to discharge home from the surgery center. You may take a shower when you get home. If the Band-Aid gets wet, simply replace it with a new one. DO NOT TAKE BATH AND DO NOT SOAK THE WOUND. Once the dressing is removed you may leave the wound open to air.

Do not be alarmed when you have bloody or serosangineous drainage from the wound(s). This is normal and part of your postoperative recovery. There may also be some bruising around the incisional area(s). However, call our office if you have persistent drainage for more than 3 days or a new onset of drainage sometime after 7 - 10 days from your surgery. You should also let us know if you are having any fevers (temperature over 101 F) or chills. This may suggest a wound infection. Although uncommon wound infection occur in under 0.1 % of patients who underwent outpatient percutaneous decompression surgery.
Be advised though that elevated temperatures after surgery can be normal and often is a result of poor lung ventilation. Taking deep breath, and ambulating as much as you can tolerate may help with this problem.

When to Call Your Doctor or Nurse

PAIN IS A RED FLAG TELLING YOU TO REST. Avoid taking pain relieving medication in anticipation that something you will do is going to cause pain.

• If you have a temperature above 101 degrees F (38.8 degrees C) for two readings four hours apart. If you develop a low grade fever, keep a chart of your temperature pattern at 8 AM, 12 noon, 4 & 8 PM. Bring the chart to the office at your next visit.
• Clear drainage from your incision, excessive, wound redness, swelling, purulent drainage or infection.
• An increase in pain, redness and/or swelling by your incision.
• Difficulty urinating or controlling your bowel movements.

When to Call 911

• If you have difficulty breathing, or have an irregular heartbeat, or chest pain, or progressive neurological deficit (progressive weakness in the extremities).

Future Follow-Up Visits

Your first post-op visit is usually scheduled along with your surgery. If you are unsure of your first postoperative appointment, please call (520) 204-1495 to make your first post-operative appointment at the Center for Advanced Spine Care of Southern Arizona. This usually occurs 7 – 10 days after your surgical procedure. All other follow-up visits will be directed by your physician.

Medications

If you need a prescription filled.

Because your health condition may change over time, your doctor or another physician provider, who have access to your confidential medical records, will need to address your refill requests. By following these simple guidelines, you will avoid any delay in getting your prescription refilled:

• Contact your pharmacy at least 5 days before your prescription requires refilling, to protect your health, pharmacies will accept refill orders only from your doctor. So, when you call The Center for Advanced Spinal Care of Southern Arizona with your request an additional step is added. Your prescription will be filled faster if you call your pharmacy directly, they will then contact The Center for Advanced Spine Care of Southern Arizona.
• Use the same pharmacy. That way, your pharmacist will have your complete prescription records and you avoid the danger of mixing medications. To make it convenient for you, the Center for Advanced Spinal Care of Southern Arizona will work with the pharmacy of your choice. Please choose one pharmacy, and use only that pharmacy. It is an easy way to help protect your health, as well as your health records.
• Call your pharmacy early in the day. This gives your doctor time to review your records. To ensure you get the right medications, we do not rush refills without making sure the order and your records are reviewed. Often, physicians are in surgery or finishing with patients late in the day, and we do not want to interrupt those patients’ visits just like you would not like to have your visit interrupted when in the office with the physician. Therefore, refill requests received after 3 pm Monday through Thursday or after 10 am Friday will be reviewed and filled the next business day for The Center for Advanced Spine Care of Southern Arizona.

If You Run Out of Medication Before You Request a Refill

Always call your pharmacy at least 5 days before you run out of medication. This will give the pharmacy plenty of time to contact your doctor, for the doctor to review your record, and for the pharmacist to prepare your medication. All you have to do is watch your medication levels and there should be no reason for you to run out of medication or run out of medication early prior to the scheduled date. It is dangerous to “rush” an order. For your protection, refills are not done at night, over the weekend, on holidays or as an emergency if you have forgotten to call your pharmacy.

If You Run Out of Your Medication Early

Your doctor ordered your prescription according to a precise dosage for a prescribed amount of days. If you run out early, it may mean you are experiencing some difficulty with your dosage or medication. Call The Center for Advanced Spine Care of Southern Arizona immediately and explain your difficulty.

If Your Prescription Is Lost, Misplaced or Stolen:

To protect your health, lost or stolen prescriptions are replaced only with a physician visit. Stolen medication will require a police report to be completed and a copy of the report brought with to your visit. To avoid possible duplication of prescriptions when an order is lost or stolen, you will want to talk with your doctor. Call The Center for Advanced Spine Care to schedule an appointment. Please call our office at (520) 204-1495 with any additional questions that may come during your postoperative recovery.

Please acknowledge that you have read and understood these postop instructions.

PRE- AND POSTOP INSTRUCTIONS ANTERIOR LUMBAR SPINAL FUSION SURGERY

This handout will review the care you need to follow in the days prior to your ANTERIOR LUMBAR SPINAL FUSION (ALIF) surgery and once you are home after your surgery. This SURGERY typically TAKES PLACE AT A HOSPITAL and involves an INCISION THROUGH YOUR ABDOMEN. If you have any questions or concerns, please ask your nurse or doctor. Our staff is here to help you. If you have questions after you are at home, please call the numbers listed at the end of this handout.

This information is part of your medical Informed Consent. Please read it and follow the advice carefully. You should retain the guide for future reference and bring it with you to office appointments and to the hospital for reference.

PREPARATION FOR SURGERY

Preoperative Laboratory Studies, and Medical Clearance

In preparation for surgery, you will have blood drawn for analysis. You may also require an electrocardiogram (ECG), a chest X-ray, and possibly additional preoperative studies. These are scheduled prior to surgery. If your fusion surgery is done at a hospital, you may be asked to visit the PREOPERATIVE ADMISSION TESTING clinic.

Should you have medical problems, such as cardiac or pulmonary, renal disease, thyroid dysfunction, or diabetes to name a few, additional preoperative clearance examinations from your primary care doctor or treating specialist may be required. These tests performed before your scheduled surgery may allow your physician to identify particular health problems that could require further evaluation before anesthesia and surgery. Regardless of the extent of your preoperative workup, it is not a guarantee that your surgery may not be cancelled if your medical problems at the time of the scheduled procedure are not appropriately managed and therefore may put you at high risk for postoperative complications or even death.

Diagnostic imaging studies of the lumbar spine, such as CT or MRI scans, a bone scan, and possibly a myelogram, may already have been performed and provide your surgeon with anatomic detail for surgery. Other electrodiagnostic tests (EMG/NCV or SSEPs) may give additional, important information.

Preoperative General Surgery Consultation

The opening of your abdominal cavity is usually done by a general surgeon. A preoperative consultation with a general surgeon is essential in ensuring your safety. In some cases of prior abdominal surgery an ALIF may not be advisable. If you have not had your visit with the general surgeon on the day of your preoperative visit with us, please let our staff members know so that this referral can be facilitated prior to your ALIF surgery.

Nothing to Eat or Drink After Midnight

Eat a light dinner before 7 P.M. on the evening before your surgery. DO NOT EAT, DRINK, SMOKE, CHEW, OR SWALLOW ANYTHING AFTER MIDNIGHT THE NIGHT BEFORE SURGERY except as directed by the hospital.

Medications to Stop Prior to Surgery

It is imperative for you to stop all NSAIDS (non-steroidal anti-inflammatory drugs) and all other medications affecting the clotting ability of your blood during surgery a minimum of 10 DAYS PRIOR TO your scheduled SURGERY. You not stopping these drugs may affect platelet aggregation and therefore have an anticoagulative side effect. Therefore, significant intraoperative bleeding, increased complication rate with epidural hematoma with potential neurological deficits, infection, and wound problems may occur. There may also be a need for blood transfusions, and potential follow up surgeries to deal with these complications. There are other blood thinners (For example, COUMADIN, XARELTO, PRADAXA, LOVENOX, HEPARIN) that maybe prescribed by your doctor for heart and vascular disease. COUMADIN should be STOPPED 7 DAYS PRIOR TO SURGERY. XARELTO, PRADAXA AND OTHERS may have to be stopped only only a few days prior to surgery. Please check with your prescribing physician. Ideally, you are also OFF XARALTO, or PRADAX ONE WEEK PRIOR TO SURGERY. In addition, you should stop FISH OIL, homeopathic drugs, and any other non-essential drugs that you think may increase your risk of bleeding.

At times, it may not be possible for you to stop these drugs. Please consult with your primary care physician, cardiologist, pulmonologist, vascular surgeon or other subspecialty provider, that may have started you on this type of blood thinner, prior to signing up for surgery. It may be safe for you to come off a prescription blood thinner prior to surgery. However, it may not be. Please check with your doctor who prescribed it prior to surgery.

Preoperative Screening by the Hospital

The hospital may call you several days prior to your scheduled surgery to review your medications, and to determine whether there are any new medical problems unknown at the time of scheduling your surgery that could potentially be problematic. They may also give you directions as to where and when to report. You should report no later than 2 hours prior to the scheduled surgery time at the hospital.

Report to Admitting in the Preop Area

The hospital will notify you of the time and location where you should go before your surgery. Do not accept or follow any other directions unless you discuss it with our office, 520-204-1495.

AFTER YOUR OPERATION

Pain & Pain Control

After surgery you may experience pain in the region of the incision. Some back and leg pain as well as tingling or numbness may also be present.

Initially, it may be of greater intensity than pre-operatively, but will subside over time as the healing process occurs. This discomfort is caused from surgical retraction of tissue as well as inflammation and swelling of the abdominal content. Typically, the exposure and opening of your abdominal cavity is done on the left side. A postoperative inflammatory response of the spinal nerves traveling through the psoas muscle down into the left leg may produce constant burning in the left leg, or even in some cases weakness of the left hip flexor making it difficult for you to walk, sit, or get up from a sitting position. Retraction of the psoas muscle is sometimes required to expose your anterior lumbar spine to perform the surgery on it. This traction injury to the muscle and nerves traveling in that muscle will improve in time and typically goes away within a few weeks. This “new” pain may be present right away or start to develop around postoperative day 4 – 10 after a short “honeymoon” period of no leg pain. Don’t be alarmed about this type of new pain. It will diminish within a few weeks. Please tell your surgeon if you are experiencing this new type of pain during your postoperative visit. Your physician may prescribe additional medication or recommend additional supportive care measures.

Following an ALIF you may also find that the left leg is warmer than the right leg. Please don’t be alarmed. There is no problem with the circulation of the right leg since the exposure took place on the left side. The exposure to the anterior lumbar spine may produce a sympathectomy effect by the mere fact of having had a surgical exposure. This may decrease the vascular tone in the left leg and, hence, make it appear warmer than the right leg.

Also monitor both lower extremities for new onset of postoperative swelling. In rare cases, small tears in the large veins going down both legs may occur during the surgical exposure of your anterior lumbar spine. Obviously, these tears are repaired during your surgery but may produce small blood clots in the large veins and therefore contribute to swelling and tenderness in the legs. Bilateral leg swelling can occur in both legs and often occurs around the ankles following major surgery such as an ALIF and maybe from third spacing of fluids. However, unilateral swelling and excessive pain in one extremity (typically on the left, or exposure side) is of concern and should prompt evaluation by your surgeon within 24 hours. If for some reason you cannot be seen by your spinal surgeon within 24 hours of you noticing this problem, please go to the nearest emergency room as you may have blood clots in the venous outflow system of the lower extremities.

Some patients experience a sore throat and swallowing difficulty after general anesthesia and surgery. This is from manipulation of tissue and the presence of the breathing tube for anesthesia. The sore throat usually will subside within a week. The swallowing difficulty may take longer. Using throat lozenges or lemon drops, sipping cool liquids, or sucking ice chips may soothe this pain.

If you are SHORT OF BREATH, or have EXCESSIVE CHEST, OR CHEST WALL PAIN, please GO TO THE NEAREST EMERGENGY ROOM as you may be having a postoperative heart attack, or a symptomatic blood clot in the lungs. Postoperative MYOCARDAL INFARCTION, and PULMONARY EMBOLISM are rare but do occur occasionally and you should take these symptoms seriously.

If you are having pain with voiding, you may have a urinary tract infection. Sometimes, this symptom is accompanied by fevers and generalized malaise. If you are unable to void and these symtpoms are coupled with excruciating leg or back pain, please report to the NEAREST EMERGENCY ROOM to be evaluated for a symptomatic EPIDURAL HEMATOMA.

Activity

This is a major surgery and you need to give your body time to heal. Below is a list of instructions that you should follow until your first follow-up visit after surgery. You no longer need to wear the anti-thrombosis (TED) stocking (heavy white stockings) once you are home. You may sleep either on your back, stomach or side. You may also use pillows for support, when lying on your side. Place pillows behind your back and between your legs. When on your back place pillows underneath your legs. You may climb stairs, just try not to over-do.

For your comfort, we suggest that you change your position at least every hour when awake. If you become uncomfortable change your position and activity. You should begin a walking program two to three days after surgery. You may shower 5 days after surgery. If you must shower sooner, you must keep the incision covered and dry while showering. No baths for 4 weeks. No hot tubs or swimming for 6 weeks. NO BENDING, TWISTING OR LIFTING.

Once you are permitted to sit, use ONLY a straight back chair such as a dining room chair of kitchen chair. A sturdy "wing back" chair is an option. Each day increase the time & frequency that you sit. (Example: 1st day, sit 3 times for 15 minutes each/2nd day 4 times for 20 minutes each/3rd day 5 times for 25 minutes, etc.) If there is pain after a few minutes GET UP. "LISTEN TO YOUR BODY"

After leaving the hospital you will be allowed in the car TWICE, ONCE TO GO HOME, THE SECOND TO COME BACK TO THE OFFICE. You will get your next set of instructions upon your return. For patients from out of state or country, there will be specific instructions.

Walking Program

Begin walking in the house and progress to outdoors. Take someone with you the first few times. Slowly increase the distance each day so that you will be walking 1 mile/day by your 2nd post-operative week, 2 miles/day at 2 weeks’ post-operative. Hopefully, by 2 months’ post-operative you will be walking 4 miles/day. If you feel soreness, reduce the distance and REST. These are GUIDELINES, NOT RULES.

• Day 1 Walk the length of the hallway at home 3-4 times, or walk to the end of the driveway and back once in the morning and again in the afternoon or evening.
• Day 2 Walk 1/2 block or the equivalent of a 1/2 block indoors once in the morning and again in the afternoon or evening.
• Day 3 Walk 1 block in the morning and again in the afternoon or evening.
• Day 4 Walk 2 blocks in the morning and again in the afternoon or evening.
• Day 5 Walk 3 blocks in the morning and again in the afternoon or evening. Continue increasing the distance you walk, as you are able. Let your comfort be your guide to how much you can do.

Limitations

• No driving for 2 weeks, or while taking narcotic pain medication. However, you may be a passenger.
• No lifting greater than 10 lbs. (about 1 gallon of milk) for the first 5-6 weeks after surgery.
• No bending at the waist, however, you may squat with your knees.
• No sports activity until your first follow-up visit other than the walking program.
• No sexual activity for 2 weeks.

Showering / Personal Hygiene

You may shower the morning after surgery. However, it is important to keep the dressing and incisions dry. You may cover cover the dressing with an adhesive and occlusive dressing. DO NOT soak the incision. Do not disturb steri-strips, or sutures.

If You Are Not Sure

If you question whether or not you can do something beyond the instructions given, it is safe to assume that the answer will be NO.

Follow Up Visit in Our Office

Return to the office for your first visit approximately 7 - 10 days after surgery. Typically, you will be given a follow up appointment to our office during your preoperative visit. If you are not sure about your first postoperative visit, please call our office for an appointment (520-204-1495) or if you have questions or concerns. For GENERAL MEDICAL PROBLEMS CONTACT your personal physician.

Return to Driving

No driving for a minimum of 2 weeks, or for the time while taking extra narcotic pain medication as a result of the surgery. However, you may be a passenger.

Return to Work

Your return to work will depend on your recovery and the type of work you do. You must discuss this with your doctor before you return to work.

Pain Management

For pain management, you will usually be given a prescription for a drug like VICODIN (hydrocodone) or OXYCODONE. For additional pain medication, try Extra strength Tylenol or similar agent. In addition, you may receive a prescription for VALIUM which can help with postoperative muscle spasms.

You should take the pain medication you were given by our office with careful consideration and be knowledgeable about their potential compounding interaction with other narcotics or other medications. Check with your local pharmacist as well should you have any questions as to potential drug interactions.

MEDICATIONS

You may have an occasional increase in back, leg pain and/or numbness after surgery during the healing phase. This is normal and is caused by inflammation (or swelling) of muscle tissue in your low back. To reduce pain there are several approaches to decrease the pain you may be experiencing.

• Ice the low back area for 15-20 minutes every hour for 4 consecutive hours. Do not put the ice directly on your skin. Use a ready-made ice pack or put ice in a plastic bag then wrap the ice pack or bag in a towel before you use it. If you have been given a cooling device, please use while in bed.
• Avoid sitting for more than 30-60 minutes at a time for the next 48 hours.
• Reduce your activity (i.e. walking) for the next 48 hours.
• Take the pain medicine as directed by your doctor. You can also take one extra strength acetaminophen (Tylenol) every 4 hours between the prescription medicines, only as directed. Do not take more than 4000 mg of Tylenol in a 24-hour period. NOTE: Some narcotic pain medicines also have Tylenol in them.
• Do not take the anti-inflammatory drugs (i.e. lbuprofen, Motrin, Advil, Aleve, Celebrex, Aspirin) for 3 months following surgery.
• Eventually you should no longer need to use pain medicine.

Removal of Staples or Stitches

Surgical skin staples or sutures are typically removed during your first postoperative visit. If you live far away out of town and an early postoperative visit in our office may pose a particularly hardship for you, you may contact your primary care physician to have her/him remove the staples or stitches. Skin stapes should be removed no later than 2 weeks from the day of surgery. We typically use biodegradable stitches for skin closure and they may simply dissolve and fall off. However, you may have them removed no later than 2 weeks from surgery as well if they bother you. You may develop redness around the staples which typically resolves quickly without additional treatment.

Incision Care

Caring for your Incision at home is important to prevent infection. Please follow these steps:

• Your incisions have been closed with absorbable suture material underneath the skin, and in the skin, and small pieces of surgical tape (steri-strips) on the surface of the skin. In most cases, these areas are covered with a dressing. You may remove the dressing 3-5 days after surgery.
• The steri-strips will gradually peel away with time as they get wet and this is normal. You may peel off the steri-strips anytime after 10 days.
• The wound should be evaluated by your surgeon within 14 days of your surgery. It is therefore prudent for you to show for your first postoperative visit.
• Take your temperature twice a day, once in the morning and once in the evening for the first 7 days.

The wound will be checked and the dressing will be changed prior to discharge home from the hospital. Your dressing will be water occlusive and you may take a shower with it when you get home. However, do not take bath and do not soak the wound. Once the dressing is removed you may leave the wound open to air.

Do not be alarmed when you have bloody or serosangineous drainage from the wound. This is normal and part of your postoperative recovery. There may also be some bruising around the incisional area. However, call our office if you have persistent drainage for more than 3 days or a new onset of drainage sometime after 7 - 10 days from your surgery. You should also let us know if you are having any fevers (temperature over 101 F) or chills. This may suggest a wound infection. Although extremely uncommon after ALIF, wound infection can occur in under 0.5 % of lumbar ALIF patients.

Be advised though that elevated temperatures after surgery can be normal and often is a result of poor lung ventilation. Taking deep breath, and ambulating as much as you can tolerate may help with this problem.

When to Call Your Doctor or Nurse

PAIN IS A RED FLAG TELLING YOU TO REST. Avoid taking pain relieving medication in anticipation that something you will do is going to cause pain.

• If you have a temperature above 101 degrees F (38.8 degrees C) for two readings four hours apart. If you develop a low grade fever, keep a chart of your temperature pattern at 8 AM, 12 noon, 4 & 8 PM. Bring the chart to the office at your next visit.
• Clear drainage from your incision, excessive, wound redness, swelling, purulent drainage or infection.
• An increase in pain, redness and/or swelling by your incision.
• Difficulty urinating or controlling your bowel movements.

When to Call 911

• If you have difficulty breathing, or have an irregular heartbeat, or chest pain, or progressive neurological deficit (progressive weakness in the extremities).

Future Follow-Up Visits

Your first post-op visit is usually scheduled along with your surgery. If you are unsure of your first postoperative appointment, please call (520) 204-1495 to make your first post-operative appointment at the Center for Advanced Spine Care of Southern Arizona. This usually occurs 7 – 10 days after your surgical procedure. All other follow-up visits will be directed by your physician.

Medications

If you need a prescription filled.

Because your health condition may change over time, your doctor or another physician provider, who have access to your confidential medical records, will need to address your refill requests. By following these simple guidelines, you will avoid any delay in getting your prescription refilled:
• Contact your pharmacy at least 5 days before your prescription requires refilling, to protect your health, pharmacies will accept refill orders only from your doctor. So, when you call The Center for Advanced Spinal Care of Southern Arizona with your request an additional step is added. Your prescription will be filled faster if you call your pharmacy directly, they will then contact The Center for Advanced Spine Care of Southern Arizona.
• Use the same pharmacy. That way, your pharmacist will have your complete prescription records and you avoid the danger of mixing medications. To make it convenient for you, the Center for Advanced Spinal Care of Southern Arizona will work with the pharmacy of your choice. Please choose one pharmacy, and use only that pharmacy. It is an easy way to help protect your health, as well as your health records.
• Call your pharmacy early in the day. This gives your doctor time to review your records. To ensure you get the right medications, we do not rush refills without making sure the order and your records are reviewed. Often, physicians are in surgery or finishing with patients late in the day, and we do not want to interrupt those patients’ visits just like you would not like to have your visit interrupted when in the office with the physician. Therefore, refill requests received after 3 pm Monday through Thursday or after 10 am Friday will be reviewed and filled the next business day for The Center for Advanced Spine Care of Southern Arizona.

If You Run Out of Medication Before You Request a Refill

Always call your pharmacy at least 5 days before you run out of medication. This will give the pharmacy plenty of time to contact your doctor, for the doctor to review your record, and for the pharmacist to prepare your medication. All you have to do is watch your medication levels and there should be no reason for you to run out of medication or run out of medication early prior to the scheduled date. It is dangerous to “rush” an order. For your protection, refills are not done at night, over the weekend, on holidays or as an emergency if you have forgotten to call your pharmacy.

If You Run Out of Your Medication Early

Your doctor ordered your prescription according to a precise dosage for a prescribed amount of days. If you run out early, it may mean you are experiencing some difficulty with your dosage or medication. Call The Center for Advanced Spine Care of Southern Arizona immediately and explain your difficulty.

If Your Prescription Is Lost, Misplaced or Stolen:

To protect your health, lost or stolen prescriptions are replaced only with a physician visit. Stolen medication will require a police report to be completed and a copy of the report brought with to your visit. To avoid possible duplication of prescriptions when an order is lost or stolen, you will want to talk with your doctor. Call The Center for Advanced Spine Care to schedule an appointment. Please call our office at (520) 204-1495 with any additional questions that may come during your postoperative recovery.

Please acknowledge that you have read and understood these postop instructions.

PRE- AND POSTOP INSTRUCTIONS COMPLEX SPINAL FUSION SURGERY

This handout will review the care you need to follow in the days prior to your COMPLEX SPINAL FUSION surgery and once you are home after your surgery. This SURGERY typically TAKES PLACE AT A HOSPITAL and involves an INCISION OR INCISIONS TO EXPOSE A LARGE AREA OF YOUR SPINE from above your buttock area possibly into the thoracic or cervical area. This is a LARGE OPERATION with a HIGH CHANCE FOR PERI- AND POSTOPERATIVE COMPLICATIONS and the potential need for admission to the INTENSIVE CARE UNIT and/or a REHABILITATION UNIT. If you have any questions or concerns, please ask your nurse or doctor. Our staff is here to help you. If you have questions after you are at home, please call the numbers listed at the end of this handout.

This information is part of your medical Informed Consent. Please read it and follow the advice carefully. You should retain the guide for future reference and bring it with you to office appointments and to the hospital for reference.

PREPARATION FOR SURGERY

Preoperative Laboratory Studies, and Medical Clearance

In preparation for surgery, you will have blood drawn for analysis. You may also require an electrocardiogram (ECG), a chest X-ray, and possibly additional preoperative studies. These are scheduled prior to surgery. If your fusion surgery is done at a hospital, you may be asked to visit the PREOPERATIVE ADMISSION TESTING clinic.

Should you have medical problems, such as cardiac or pulmonary, renal disease, thyroid dysfunction, or diabetes to name a few, additional preoperative clearance examinations from your primary care doctor or treating specialist may be required. These tests performed before your scheduled surgery may allow your physician to identify particular health problems that could require further evaluation before anesthesia and surgery. Regardless of the extent of your preoperative workup, it is not a guarantee that your surgery may not be cancelled if your medical problems at the time of the scheduled procedure are not appropriately managed and therefore may put you at high risk for postoperative complications or even death.

Diagnostic imaging studies of the lumbar spine, such as CT or MRI scans, a bone scan, and possibly a myelogram, may already have been performed and provide your surgeon with anatomic detail for surgery. Other electrodiagnostic tests (EMG/NCV or SSEPs) may give additional, important information.

Nothing to Eat or Drink After Midnight

Eat a light dinner before 7 P.M. on the evening before your surgery. DO NOT EAT, DRINK, SMOKE, CHEW, OR SWALLOW ANYTHING AFTER MIDNIGHT THE NIGHT BEFORE SURGERY except as directed by the hospital.

Medications to Stop Prior to Surgery

It is imperative for you to stop all NSAIDS (non-steroidal anti-inflammatory drugs) and all other medications affecting the clotting ability of your blood during surgery a minimum of 10 DAYS PRIOR TO your scheduled SURGERY. You not stopping these drugs may affect platelet aggregation and therefore have an anticoagulative side effect. Therefore, significant intraoperative bleeding, increased complication rate with epidural hematoma with potential neurological deficits, infection, and wound problems may occur. There may also be a need for blood transfusions, and potential follow up surgeries to deal with these complications. There are other blood thinners (For example, COUMADIN, XARELTO, PRADAXA, LOVENOX, HEPARIN) that maybe prescribed by your doctor for heart and vascular disease. COUMADIN should be STOPPED 7 DAYS PRIOR TO SURGERY. XARELTO, PRADAXA AND OTHERS may have to be stopped only only a few days prior to surgery. Please check with your prescribing physician. Ideally, you are also OFF XARALTO, or PRADAX ONE WEEK PRIOR TO SURGERY. In addition, you should stop FISH OIL, homeopathic drugs, and any other non-essential drugs that you think may increase your risk of bleeding.

At times, it may not be possible for you to stop these drugs. Please consult with your primary care physician, cardiologist, pulmonologist, vascular surgeon or other subspecialty provider, that may have started you on this type of blood thinner, prior to signing up for surgery. It may be safe for you to come off a prescription blood thinner prior to surgery. However, it may not be. Please check with your doctor who prescribed it prior to surgery.

Preoperative Screening by the Hospital

The hospital may call you several days prior to your scheduled surgery to review your medications, and to determine whether there are any new medical problems unknown at the time of scheduling your surgery that could potentially be problematic. They may also give you directions as to where and when to report. You should report no later than 2 hours prior to the scheduled surgery time at the hospital.

Report to Admitting in the Preop Area

The hospital will notify you of the time and location where you should go before your surgery. Do not accept or follow any other directions unless you discuss it with our office, 520-204-1495.

AFTER YOUR OPERATION

Pain & Pain Control

After surgery you may experience pain in the region of the incision. Some back and leg pain as well as tingling or numbness may also be present. Because of the complexity of your surgery, you may be given a pain pump. This “Patient Controlled Anesthesia” (PCA) allows you to push a button on a hand control, which in turn operates the pain pump by injecting a strong pain medication intravenously.

Initially, the postoperative pain may be of greater intensity than pre-operatively, but will subside over time as the healing process occurs. This discomfort is caused from surgical retraction of tissue as well as inflammation and swelling of the previously compressed nerves. A postoperative inflammatory response of the spinal nerves may produce constant burning in the legs. Typically, it occurs 4 – 10 days postoperatively after a short “honeymoon” period of no leg pain. Don’t be alarmed about this type of new pain. It will diminish within a few weeks and may respond well to epidural steroid injections. Please tell your surgeon if you are experiencing this new type of pain during your postoperative visit. Your physician may prescribe NEURONTIN (Gabapentin) or LYRICA (Pregabalin).

Some patients experience a sore throat and swallowing difficulty after general anesthesia and surgery. This is from manipulation of tissue and the presence of the breathing tube for anesthesia. The sore throat usually will subside within a week. The swallowing difficulty may take longer. Using throat lozenges or lemon drops, sipping cool liquids, or sucking ice chips may soothe this pain.

If you are SHORT OF BREATH, or have EXCESSIVE CHEST, OR CHEST WALL PAIN, please NOTIFY YOUR NURSE OR DOCTOR RIGHT AWAY if you are still institutionalized. If you are at home, GO TO THE NEAREST EMERGENGY ROOM as you may be having a postoperative heart attack, or a symptomatic blood clot in the lungs. Postoperative MYOCARDAL INFARCTION, and PULMONARY EMBOLISM are rare but do occur occasionally and you should take these symptoms seriously.

If you are having pain with voiding, you may have a urinary tract infection. Sometimes, this symptom is accompanied by fevers and generalized malaise. If you at any point are unable to void and these symptoms are coupled with excruciating leg or back pain, please report to the NEAREST EMERGENCY ROOM to be evaluated for a symptomatic EPIDURAL HEMATOMA.

Activity

This is a major surgery and you need to give your body time to heal. Below is a list of instructions that you should follow until your first follow-up visit after surgery. You no longer need to wear the anti-thrombosis (TED) stocking (heavy white stockings) once you are home. You may sleep either on your back, stomach or side. You may also use pillows for support, when lying on your side. Place pillows behind your back and between your legs. When on your back place pillows underneath your legs. You may climb stairs, just try not to over-do.
For your comfort, we suggest that you change your position at least every hour when awake. If you become uncomfortable change your position and activity. You should begin a walking program two to three days after surgery. You may shower 5 days after surgery. If you must shower sooner, you must keep the incision covered and dry while showering. No baths for 4 weeks. No hot tubs or swimming for 6 weeks. NO BENDING, TWISTING OR LIFTING.

Once you are permitted to sit, use ONLY a straight back chair such as a dining room chair of kitchen chair. A sturdy "wing back" chair is an option. Each day increase the time & frequency that you sit. (Example: 1st day, sit 3 times for 15 minutes each/2nd day 4 times for 20 minutes each/3rd day 5 times for 25 minutes, etc.) If there is pain after a few minutes GET UP. "LISTEN TO YOUR BODY"

After leaving the hospital or rehabilitation unit, you will be allowed in the car TWICE, ONCE TO GO HOME, THE SECOND TO COME BACK TO THE OFFICE. You will get your next set of instructions upon your return. For patients from out of state or country, there will be specific instructions.

Walking Program

Once you get home, begin walking in the house and progress to outdoors. Take someone with you the first few times. Slowly increase the distance each day so that you will be walking 1 mile/day by your 2nd post-operative week, 2 miles/day at 2 weeks’ post-operative. Hopefully, by 2 months’ post-operative you will be walking 4 miles/day. If you feel soreness, reduce the distance and REST. These are GUIDELINES, NOT RULES.

• Day 1 Walk the length of the hallway at home 3-4 times, or walk to the end of the driveway and back once in the morning and again in the afternoon or evening.
• Day 2 Walk 1/2 block or the equivalent of a 1/2 block indoors once in the morning and again in the afternoon or evening.
• Day 3 Walk 1 block in the morning and again in the afternoon or evening.
• Day 4 Walk 2 blocks in the morning and again in the afternoon or evening.
• Day 5 Walk 3 blocks in the morning and again in the afternoon or evening. Continue increasing the distance you walk, as you are able. Let your comfort be your guide to how much you can do.

Limitations

• No driving for 2 weeks, or while taking narcotic pain medication. However, you may be a passenger.
• No lifting greater than 10 lbs. (about 1 gallon of milk) for the first 5-6 weeks after surgery.
• No bending at the waist, however, you may squat with your knees.
• No sports activity until your first follow-up visit other than the walking program.
• No sexual activity for 2 weeks.

Showering / Personal Hygiene

You may shower the morning after surgery. However, it is important to keep the dressing and incisions dry. You may cover cover the dressing with an adhesive and occlusive dressing. DO NOT soak the incision. Do not disturb steri-strips, staples, or sutures.

If You Are Not Sure

If you question whether or not you can do something beyond the instructions given, it is safe to assume that the answer will be NO.

Follow Up Visit in Our Office

Return to the office for your first visit approximately 7 - 10 days after surgery. Typically, you will be given a follow up appointment to our office during your preoperative visit. If you are not sure about your first postoperative visit, please call our office for an appointment (520-204-1495) or if you have questions or concerns. For GENERAL MEDICAL PROBLEMS CONTACT your personal physician.

Return to Driving

No driving for a minimum of 2 weeks, or for the time while taking extra narcotic pain medication as a result of the surgery. However, you may be a passenger.

Return to Work

Your return to work will depend on your recovery and the type of work you do. You must discuss this with your doctor before you return to work.

Pain Management

For pain management, you will usually be given a prescription for a drug like VICODIN (hydrocodone) or OXYCODONE. For additional pain medication, try Extra strength Tylenol or similar agent. In addition, you may receive a prescription for VALIUM which can help with postoperative muscle spasms.

You should take the pain medication you were given by our office with careful consideration and be knowledgeable about their potential compounding interaction with other narcotics or other medications. Check with your local pharmacist as well should you have any questions as to potential drug interactions.

DO NOT USE ANY ASPIRIN or ASPIRIN containing medication. DO NOT use ADVIL, IBUPROFEN, NAPROXEN, TORADOL or similar medication that contain these drugs. These drugs may interfere with the healing of your spinal fusion.

MEDICATIONS

You may have an occasional increase in back, leg pain and/or numbness after surgery during the healing phase. This is normal and is caused by inflammation (or swelling) of muscle tissue in your low back. To reduce pain there are several approaches to decrease the pain you may be experiencing.

• Ice the low back area for 15-20 minutes every hour for 4 consecutive hours. Do not put the ice directly on your skin. Use a ready-made ice pack or put ice in a plastic bag then wrap the ice pack or bag in a towel before you use it. If you have been given a cooling device, please use while in bed.
• Avoid sitting for more than 30-60 minutes at a time for the next 48 hours.
• Reduce your activity (i.e. walking) for the next 48 hours.
• Take the pain medicine as directed by your doctor. You can also take one extra strength acetaminophen (Tylenol) every 4 hours between the prescription medicines, only as directed. Do not take more than 4000 mg of Tylenol in a 24-hour period. NOTE: Some narcotic pain medicines also have Tylenol in them.
• Do not take the anti-inflammatory drugs (i.e. lbuprofen, Motrin, Advil, Aleve, Celebrex, Aspirin) for 3 months following surgery.
• Eventually you should no longer need to use pain medicine.

Removal of Staples or Stitches

Surgical skin staples or sutures are typically removed during your first postoperative visit. If you live far away out of town and an early postoperative visit in our office may pose a particularly hardship for you, you may contact your primary care physician to have her/him remove the staples or stitches. Skin stapes should be removed no later than 2 weeks from the day of surgery. We typically use biodegradable stitches for skin closure and they may simply dissolve and fall off. However, you may have them removed no later than 2 weeks from surgery as well if they bother you. You may develop redness around the staples which typically resolves quickly without additional treatment.

Incision Care

Caring for your Incision at home is important to prevent infection. Please follow these steps:

• Your incisions have been closed either with skin staples or with absorbable suture material underneath the skin and small pieces of surgical tape (steri-strips) on the surface of the skin. In most cases these areas are covered with a dressing. You may remove the dressing 3-5 days after surgery.
• The steri-strips will gradually peel away with time as they get wet and this is normal. You may peel off the steri-strips anytime after 10 days.
• Staples should be removed within 14 days of your surgery. It is therefore prudent for you to show for your first postoperative visit.
• Take your temperature twice a day, once in the morning and once in the evening for the first 7 days.

The wound will be checked and the dressing will be changed prior to discharge home from the hospital. Your dressing will be water occlusive and you may take a shower with it when you get home. However, do not take bath and do not soak the wound. Once the dressing is removed you may leave the wound open to air.

Do not be alarmed when you have bloody or serosangineous drainage from the wound. This is normal and part of your postoperative recovery. There may also be some bruising around the lumbar incisional area. However, call our office if you have persistent drainage for more than 3 days or a new onset of drainage sometime after 7 - 10 days from your surgery. You should also let us know if you are having any fevers (temperature over 101 F) or chills. This may suggest a wound infection. Although uncommon wound infection occur in under 2 - 4 % of lumbar spinal fusion patients.

Be advised though that elevated temperatures after surgery can be normal and often is a result of poor lung ventilation. Taking deep breath, and ambulating as much as you can tolerate may help with this problem.

When to Call Your Doctor or Nurse

PAIN IS A RED FLAG TELLING YOU TO REST. Avoid taking pain relieving medication in anticipation that something you will do is going to cause pain.

• If you have a temperature above 101 degrees F (38.8 degrees C) for two readings four hours apart. If you develop a low grade fever, keep a chart of your temperature pattern at 8 AM, 12 noon, 4 & 8 PM. Bring the chart to the office at your next visit.
• Clear drainage from your incision, excessive, wound redness, swelling, purulent drainage or infection.
• An increase in pain, redness and/or swelling by your incision.
• Difficulty urinating or controlling your bowel movements.

When to Call 911

• If you have difficulty breathing, or have an irregular heartbeat, or chest pain, or progressive neurological deficit (progressive weakness in the extremities).

Future Follow-Up Visits

Your first post-op visit is usually scheduled along with your surgery. If you are unsure of your first postoperative appointment, please call (520) 204-1495 to make your first post-operative appointment at the Center for Advanced Spine Care of Southern Arizona. This usually occurs 7 – 10 days after your surgical procedure. All other follow-up visits will be directed by your physician.

Medications

If you need a prescription filled.

Because your health condition may change over time, your doctor or another physician provider, who have access to your confidential medical records, will need to address your refill requests. By following these simple guidelines, you will avoid any delay in getting your prescription refilled:

• Contact your pharmacy at least 5 days before your prescription requires refilling, to protect your health, pharmacies will accept refill orders only from your doctor. So, when you call The Center for Advanced Spinal Care of Southern Arizona with your request an additional step is added. Your prescription will be filled faster if you call your pharmacy directly, they will then contact The Center for Advanced Spine Care of Southern Arizona.
• Use the same pharmacy. That way, your pharmacist will have your complete prescription records and you avoid the danger of mixing medications. To make it convenient for you, the Center for Advanced Spinal Care of Southern Arizona will work with the pharmacy of your choice. Please choose one pharmacy, and use only that pharmacy. It is an easy way to help protect your health, as well as your health records.
• Call your pharmacy early in the day. This gives your doctor time to review your records. To ensure you get the right medications, we do not rush refills without making sure the order and your records are reviewed. Often, physicians are in surgery or finishing with patients late in the day, and we do not want to interrupt those patients’ visits just like you would not like to have your visit interrupted when in the office with the physician. Therefore, refill requests received after 3 pm Monday through Thursday or after 10 am Friday will be reviewed and filled the next business day for The Center for Advanced Spine Care of Southern Arizona.

If You Run Out of Medication Before You Request a Refill

Always call your pharmacy at least 5 days before you run out of medication. This will give the pharmacy plenty of time to contact your doctor, for the doctor to review your record, and for the pharmacist to prepare your medication. All you have to do is watch your medication levels and there should be no reason for you to run out of medication or run out of medication early prior to the scheduled date. It is dangerous to “rush” an order. For your protection, refills are not done at night, over the weekend, on holidays or as an emergency if you have forgotten to call your pharmacy.

If You Run Out of Your Medication Early

Your doctor ordered your prescription according to a precise dosage for a prescribed amount of days. If you run out early, it may mean you are experiencing some difficulty with your dosage or medication. Call The Center for Advanced Spine Care of Southern Arizona immediately and explain your difficulty.

If Your Prescription Is Lost, Misplaced or Stolen:

To protect your health, lost or stolen prescriptions are replaced only with a physician visit. Stolen medication will require a police report to be completed and a copy of the report brought with to your visit. To avoid possible duplication of prescriptions when an order is lost or stolen, you will want to talk with your doctor. Call The Center for Advanced Spine Care to schedule an appointment. Please call our office at (520) 204-1495 with any additional questions that may come during your postoperative recovery.

Please acknowledge that you have read and understood these postop instructions.

PRE- AND POSTOP INSTRUCTIONS LUMBAR LAMINECTOMY SURGERY

This handout will review the care you need to follow in the days prior to your LUMBAR LAMINECTOMY surgery and once you are home after your surgery. This SURGERY typically TAKES PLACE AT A HOSPITAL and involves an INCISION IN YOUR LOWER BACK just above your buttock area. If you have any questions or concerns, please ask your nurse or doctor. Our staff is here to help you. If you have questions after you are at home, please call the numbers listed at the end of this handout.

This information is part of your medical Informed Consent. Please read it and follow the advice carefully. You should retain the guide for future reference and bring it with you to office appointments and to the hospital for reference.

PREPARATION FOR SURGERY

Preoperative Laboratory Studies, and Medical Clearance

In preparation for surgery, you will have blood drawn for analysis. You may also require an electrocardiogram (ECG), a chest X-ray, and possibly additional preoperative studies. These are scheduled prior to surgery. If your surgery is done at a hospital, you may be asked to visit the PREOPERATIVE ADMISSION TESTING clinic.

Should you have medical problems, such as cardiac or pulmonary, renal disease, thyroid dysfunction, or diabetes to name a few, additional preoperative clearance examinations from your primary care doctor or treating specialist may be required. These tests performed before your scheduled surgery may allow your physician to identify particular health problems that could require further evaluation before anesthesia and surgery. Regardless of the extent of your preoperative workup, it is not a guarantee that your surgery may not be cancelled if your medical problems at the time of the scheduled procedure are not appropriately managed and therefore may put you at high risk for postoperative complications or even death.

Diagnostic imaging studies of the lumbar spine, such as CT or MRI scans, a bone scan, and possibly a myelogram, may already have been performed and provide your surgeon with anatomic detail for surgery. Other electrodiagnostic tests (EMG/NCV or SSEPs) may give additional, important information.

Nothing to Eat or Drink After Midnight

Eat a light dinner before 7 P.M. on the evening before your surgery. DO NOT EAT, DRINK, SMOKE, CHEW, OR SWALLOW ANYTHING AFTER MIDNIGHT THE NIGHT BEFORE SURGERY except as directed by the hospital.

Medications to Stop Prior to Surgery

It is imperative for you to stop all NSAIDS (non-steroidal anti-inflammatory drugs) and all other medications affecting the clotting ability of your blood during surgery a minimum of 10 DAYS PRIOR TO your scheduled SURGERY. You not stopping these drugs may affect platelet aggregation and therefore have an anticoagulative side effect. Therefore, significant intraoperative bleeding, increased complication rate with epidural hematoma with potential neurological deficits, infection, and wound problems may occur. There may also be a need for blood transfusions, and potential follow up surgeries to deal with these complications. There are other blood thinners (For example, COUMADIN, XARELTO, PRADAXA, LOVENOX, HEPARIN) that maybe prescribed by your doctor for heart and vascular disease. COUMADIN should be STOPPED 7 DAYS PRIOR TO SURGERY. XARELTO, PRADAXA AND OTHERS may have to be stopped only only a few days prior to surgery. Please check with your prescribing physician. Ideally, you are also OFF XARALTO, or PRADAX ONE WEEK PRIOR TO SURGERY. In addition, you should stop FISH OIL, homeopathic drugs, and any other non-essential drugs that you think may increase your risk of bleeding.

At times, it may not be possible for you to stop these drugs. Please consult with your primary care physician, cardiologist, pulmonologist, vascular surgeon or other subspecialty provider, that may have started you on this type of blood thinner, prior to signing up for surgery. It may be safe for you to come off a prescription blood thinner prior to surgery. However, it may not be. Please check with your doctor who prescribed it prior to surgery.

Preoperative Screening by the Hospital

The hospital may call you several days prior to your scheduled surgery to review your medications, and to determine whether there are any new medical problems unknown at the time of scheduling your surgery that could potentially be problematic. They may also give you directions as to where and when to report. You should report no later than 2 hours prior to the scheduled surgery time at the hospital.

Report to Admitting in the Preop Area

The hospital will notify you of the time and location where you should go before your surgery. Do not accept or follow any other directions unless you discuss it with our office, 520-204-1495.

AFTER YOUR OPERATION

Pain & Pain Control

After surgery you may experience pain in the region of the incision. Some back and leg pain as well as tingling or numbness may also be present.

Initially, it may be of greater intensity than pre-operatively, but will subside over time as the healing process occurs. This discomfort is caused from surgical retraction of tissue as well as inflammation and swelling of the previously compressed nerves. A postoperative inflammatory response of the spinal nerves may produce constant burning in the legs. Typically, it occurs 4 – 10 days postoperatively after a short “honeymoon” period of no leg pain. Don’t be alarmed about this type of new pain. It will diminish within a few weeks and may respond well to epidural steroid injections. Please tell your surgeon if you are experiencing this new type of pain during your postoperative visit. Your physician may prescribe NEURONTIN (Gabapentin) or LYRICA (Pregabalin).

Some patients experience a sore throat and swallowing difficulty after general anesthesia and surgery. This is from manipulation of tissue and the presence of the breathing tube for anesthesia. The sore throat usually will subside within a week. The swallowing difficulty may take longer. Using throat lozenges or lemon drops, sipping cool liquids, or sucking ice chips may soothe this pain.

If you are SHORT OF BREATH, or have EXCESSIVE CHEST, OR CHEST WALL PAIN, please GO TO THE NEAREST EMERGENGY ROOM as you may be having a postoperative heart attack, or a symptomatic blood clot in the lungs. Postoperative MYOCARDAL INFARCTION, and PULMONARY EMBOLISM are rare but do occur occasionally and you should take these symptoms seriously.

If you are having pain with voiding, you may have a urinary tract infection. Sometimes, this symptom is accompanied by fevers and generalized malaise. If you are unable to void and these symtpoms are coupled with excruciating leg or back pain, please report to the NEAREST EMERGENCY ROOM to be evaluated for a symptomatic EPIDURAL HEMATOMA.

Activity

This is a major surgery and you need to give your body time to heal. Below is a list of instructions that you should follow until your first follow-up visit after surgery. You no longer need to wear the anti-thrombosis (TED) stocking (heavy white stockings) once you are home. You may sleep either on your back, stomach or side. You may also use pillows for support, when lying on your side. Place pillows behind your back and between your legs. When on your back place pillows underneath your legs. You may climb stairs, just try not to over-do.

For your comfort, we suggest that you change your position at least every hour when awake. If you become uncomfortable change your position and activity. You should begin a walking program two to three days after surgery. You may shower 5 days after surgery. If you must shower sooner, you must keep the incision covered and dry while showering. No baths for 4 weeks. No hot tubs or swimming for 6 weeks. NO BENDING, TWISTING OR LIFTING.

Once you are permitted to sit, use ONLY a straight back chair such as a dining room chair of kitchen chair. A sturdy "wing back" chair is an option. Each day increase the time & frequency that you sit. (Example: 1st day, sit 3 times for 15 minutes each/2nd day 4 times for 20 minutes each/3rd day 5 times for 25 minutes, etc.) If there is pain after a few minutes GET UP. "LISTEN TO YOUR BODY"

After leaving the hospital you will be allowed in the car TWICE, ONCE TO GO HOME, THE SECOND TO COME BACK TO THE OFFICE. You will get your next set of instructions upon your return. For patients from out of state or country, there will be specific instructions.

Walking Program

Begin walking in the house and progress to outdoors. Take someone with you the first few times. Slowly increase the distance each day so that you will be walking 1 mile/day by your 2nd post-operative week, 2 miles/day at 2 weeks’ post-operative. Hopefully, by 2 months’ post-operative you will be walking 4 miles/day. If you feel soreness, reduce the distance and REST. These are GUIDELINES, NOT RULES.

• Day 1 Walk the length of the hallway at home 3-4 times, or walk to the end of the driveway and back once in the morning and again in the afternoon or evening.
• Day 2 Walk 1/2 block or the equivalent of a 1/2 block indoors once in the morning and again in the afternoon or evening.
• Day 3 Walk 1 block in the morning and again in the afternoon or evening.
• Day 4 Walk 2 blocks in the morning and again in the afternoon or evening.
• Day 5 Walk 3 blocks in the morning and again in the afternoon or evening. Continue increasing the distance you walk, as you are able. Let your comfort be your guide to how much you can do.

Limitations

• No driving for 2 weeks, or while taking narcotic pain medication. However, you may be a passenger.
• No lifting greater than 10 lbs. (about 1 gallon of milk) for the first 5-6 weeks after surgery.
• No bending at the waist, however, you may squat with your knees.
• No sports activity until your first follow-up visit other than the walking program.
• No sexual activity for 2 weeks.

Showering / Personal Hygiene

You may shower the morning after surgery. However, it is important to keep the dressing and incisions dry. You may cover cover the dressing with an adhesive and occlusive dressing. DO NOT soak the incision. Do not disturb steri-strips, staples, or sutures.

If You Are Not Sure

If you question whether or not you can do something beyond the instructions given, it is safe to assume that the answer will be NO.

Follow Up Visit in Our Office

Return to the office for your first visit approximately 7 - 10 days after surgery. Typically, you will be given a follow up appointment to our office during your preoperative visit. If you are not sure about your first postoperative visit, please call our office for an appointment (520-204-1495) or if you have questions or concerns. For GENERAL MEDICAL PROBLEMS CONTACT your personal physician.

Return to Driving

No driving for a minimum of 2 weeks, or for the time while taking extra narcotic pain medication as a result of the surgery. However, you may be a passenger.

Return to Work

Your return to work will depend on your recovery and the type of work you do. You must discuss this with your doctor before you return to work.

Pain Management

For pain management, you will usually be given a prescription for a drug like VICODIN (hydrocodone) or OXYCODONE. For additional pain medication, try Extra strength Tylenol or similar agent. In addition, you may receive a prescription for VALIUM which can help with postoperative muscle spasms.

You should take the pain medication you were given by our office with careful consideration and be knowledgeable about their potential compounding interaction with other narcotics or other medications. Check with your local pharmacist as well should you have any questions as to potential drug interactions.

MEDICATIONS

You may have an occasional increase in back, leg pain and/or numbness after surgery during the healing phase. This is normal and is caused by inflammation (or swelling) of muscle tissue in your low back. To reduce pain there are several approaches to decrease the pain you may be experiencing.

• Ice the low back area for 15-20 minutes every hour for 4 consecutive hours. Do not put the ice directly on your skin. Use a ready-made ice pack or put ice in a plastic bag then wrap the ice pack or bag in a towel before you use it. If you have been given a cooling device, please use while in bed.
• Avoid sitting for more than 30-60 minutes at a time for the next 48 hours.
• Reduce your activity (i.e. walking) for the next 48 hours.
• Take the pain medicine as directed by your doctor. You can also take one extra strength acetaminophen (Tylenol) every 4 hours between the prescription medicines, only as directed. Do not take more than 4000 mg of Tylenol in a 24-hour period. NOTE: Some narcotic pain medicines also have Tylenol in them.
• Do not take the anti-inflammatory drugs (i.e. lbuprofen, Motrin, Advil, Aleve, Celebrex, Aspirin) for 3 months following surgery.
• Eventually you should no longer need to use pain medicine.

Removal of Staples or Stitches

Surgical skin staples or sutures are typically removed during your first postoperative visit. If you live far away out of town and an early postoperative visit in our office may pose a particularly hardship for you, you may contact your primary care physician to have her/him remove the staples or stitches. Skin stapes should be removed no later than 2 weeks from the day of surgery. We typically use biodegradable stitches for skin closure and they may simply dissolve and fall off. However, you may have them removed no later than 2 weeks from surgery as well if they bother you. You may develop redness around the staples which typically resolves quickly without additional treatment.

Incision Care

Caring for your Incision at home is important to prevent infection. Please follow these steps:

• Your incisions have been closed either with skin staples or with absorbable suture material underneath the skin and small pieces of surgical tape (steri-strips) on the surface of the skin. In most cases these areas are covered with a dressing. You may remove the dressing 3-5 days after surgery.
• The steri-strips will gradually peel away with time as they get wet and this is normal. You may peel off the steri-strips anytime after 10 days.
• Staples should be removed within 14 days of your surgery. It is therefore prudent for you to show for your first postoperative visit.
• Take your temperature twice a day, once in the morning and once in the evening for the first 7 days.

The wound will be checked and the dressing will be changed prior to discharge home from the hospital. Your dressing will be water occlusive and you may take a shower with it when you get home. However, do not take bath and do not soak the wound. Once the dressing is removed you may leave the wound open to air.

Do not be alarmed when you have bloody or serosangineous drainage from the wound. This is normal and part of your postoperative recovery. There may also be some bruising around the lumbar incisional area. However, call our office if you have persistent drainage for more than 3 days or a new onset of drainage sometime after 7 - 10 days from your surgery. You should also let us know if you are having any fevers (temperature over 101 F) or chills. This may suggest a wound infection. Although uncommon wound infection occur in under 1% of lumbar laminectomy patients.

Be advised though that elevated temperatures after surgery can be normal and often is a result of poor lung ventilation. Taking deep breath, and ambulating as much as you can tolerate may help with this problem.

When to Call Your Doctor or Nurse

PAIN IS A RED FLAG TELLING YOU TO REST. Avoid taking pain relieving medication in anticipation that something you will do is going to cause pain.

• If you have a temperature above 101 degrees F (38.8 degrees C) for two readings four hours apart. If you develop a low grade fever, keep a chart of your temperature pattern at 8 AM, 12 noon, 4 & 8 PM. Bring the chart to the office at your next visit.
• Clear drainage from your incision, excessive, wound redness, swelling, purulent drainage or infection.
• An increase in pain, redness and/or swelling by your incision.
• Difficulty urinating or controlling your bowel movements.

When to Call 911

• If you have difficulty breathing, or have an irregular heartbeat, or chest pain, or progressive neurological deficit (progressive weakness in the extremities).

Future Follow-Up Visits

Your first post-op visit is usually scheduled along with your surgery. If you are unsure of your first postoperative appointment, please call (520) 204-1495 to make your first post-operative appointment at the Center for Advanced Spine Care of Southern Arizona. This usually occurs 7 – 10 days after your surgical procedure. All other follow-up visits will be directed by your physician.

Medications

If you need a prescription filled.

Because your health condition may change over time, your doctor or another physician provider, who have access to your confidential medical records, will need to address your refill requests. By following these simple guidelines, you will avoid any delay in getting your prescription refilled:

• Contact your pharmacy at least 5 days before your prescription requires refilling, to protect your health, pharmacies will accept refill orders only from your doctor. So, when you call The Center for Advanced Spinal Care of Southern Arizona with your request an additional step is added. Your prescription will be filled faster if you call your pharmacy directly, they will then contact The Center for Advanced Spine Care of Southern Arizona.
• Use the same pharmacy. That way, your pharmacist will have your complete prescription records and you avoid the danger of mixing medications. To make it convenient for you, the Center for Advanced Spinal Care of Southern Arizona will work with the pharmacy of your choice. Please choose one pharmacy, and use only that pharmacy. It is an easy way to help protect your health, as well as your health records.
• Call your pharmacy early in the day. This gives your doctor time to review your records. To ensure you get the right medications, we do not rush refills without making sure the order and your records are reviewed. Often, physicians are in surgery or finishing with patients late in the day, and we do not want to interrupt those patients’ visits just like you would not like to have your visit interrupted when in the office with the physician. Therefore, refill requests received after 3 pm Monday through Thursday or after 10 am Friday will be reviewed and filled the next business day for The Center for Advanced Spine Care of Southern Arizona.

If You Run Out of Medication Before You Request a Refill

Always call your pharmacy at least 5 days before you run out of medication. This will give the pharmacy plenty of time to contact your doctor, for the doctor to review your record, and for the pharmacist to prepare your medication. All you have to do is watch your medication levels and there should be no reason for you to run out of medication or run out of medication early prior to the scheduled date. It is dangerous to “rush” an order. For your protection, refills are not done at night, over the weekend, on holidays or as an emergency if you have forgotten to call your pharmacy.

If You Run Out of Your Medication Early

Your doctor ordered your prescription according to a precise dosage for a prescribed amount of days. If you run out early, it may mean you are experiencing some difficulty with your dosage or medication. Call The Center for Advanced Spine Care of Southern Arizona immediately and explain your difficulty.

If Your Prescription Is Lost, Misplaced or Stolen:

To protect your health, lost or stolen prescriptions are replaced only with a physician visit. Stolen medication will require a police report to be completed and a copy of the report brought with to your visit. To avoid possible duplication of prescriptions when an order is lost or stolen, you will want to talk with your doctor. Call The Center for Advanced Spine Care to schedule an appointment. Please call our office at (520) 204-1495 with any additional questions that may come during your postoperative recovery.

Please acknowledge that you have read and understood these postop instructions.

PRE- AND POSTOP INSTRUCTIONS LAMINOTOMY MICRODISCECTOMY SURGERY

This handout will review the care you need to follow in the days prior to your LUMBAR LAMINOTOMY MICRODISCECTOMY surgery and once you are home after your surgery. This SURGERY typically TAKES PLACE AT A SURGERY CENTER and involves INCISIONS IN YOUR LOWER BACK just above your buttock area near the midline or on the sides. If you have any questions or concerns, please ask your nurse or doctor. Our staff is here to help you. If you have questions after you are at home, please call the numbers listed at the end of this handout.
This information is part of your medical Informed Consent. Please read it and follow the advice carefully. You should retain the guide for future reference and bring it with you to office appointments and to the hospital for reference.

PREPARATION FOR SURGERY

Preoperative Laboratory Studies, and Medical Clearance

In preparation for surgery, you will have blood drawn for analysis. You may also require an electrocardiogram (ECG), a chest X-ray, and possibly additional preoperative studies. These are scheduled prior to surgery. Your LAMINOTOMY MICRDODISCECTOMY surgery is a decompression surgery that is typically done at an OUTPATIENT SURGERY CENTER. Preoperative blood work is usually done at the surgery center just prior to your surgery.

Should you have medical problems, such as cardiac or pulmonary, renal disease, thyroid dysfunction, or diabetes to name a few, additional preoperative clearance examinations from your primary care doctor or treating specialist may be required. These tests performed before your scheduled surgery may allow your physician to identify particular health problems that could require further evaluation before anesthesia and surgery. REGARDLESS OF THE EXTENT OF YOUR PREOPERATIVE WORKUP, IT IS NOT A GUARANTEE THAT YOUR SURGERY MAY BE DONE AT AN OUTPATIENT SURGERY CENTER. In some cases, the surgery may be cancelled if the anesthesiologist deems your medical problems at the time of the scheduled procedure as not appropriately managed, or deems your surgery at an outpatient surgery center as too risky and recommends that the procedure be done at a hospital instead.

Diagnostic imaging studies of the lumbar spine, such as CT or MRI scans, a bone scan, and possibly a myelogram, may already have been performed and provide your surgeon with anatomic detail for surgery. Other electrodiagnostic tests (EMG/NCV or SSEPs) may give additional, important information.

Nothing to Eat or Drink After Midnight

Eat a light dinner before 7 P.M. on the evening before your surgery. DO NOT EAT, DRINK, SMOKE, CHEW, OR SWALLOW ANYTHING AFTER MIDNIGHT THE NIGHT BEFORE SURGERY except as directed by the surgery center.

Preoperative Screening by the Surgery Center

The surgery center may call you preoperatively to review your medications, and to determine whether there are any new medical problems unknown at the time of scheduling of your surgery that could potentially be problematic. They may also give you directions as to where and when to report. You should report no later than 2 hours prior to the scheduled surgery time to the surgery center.

Medications to Stop Prior to Surgery

It is imperative for you to stop all NSAIDS (non-steroidal anti-inflammatory drugs) and all other medications affecting the clotting ability of your blood during surgery a minimum of 10 DAYS PRIOR TO your scheduled SURGERY. You not stopping these drugs may affect platelet aggregation and therefore have an anticoagulative side effect. Therefore, significant intraoperative bleeding, increased complication rate with epidural hematoma with potential neurological deficits, infection, and wound problems may occur. There may also be a need for blood transfusions, and potential follow up surgeries to deal with these complications. There are other blood thinners (For example, COUMADIN, XARELTO, PRADAXA, LOVENOX, HEPARIN) that maybe prescribed by your doctor for heart and vascular disease. COUMADIN should be STOPPED 7 DAYS PRIOR TO SURGERY. XARELTO, PRADAXA AND OTHERS may have to be stopped only only a few days prior to surgery. Please check with your prescribing physician. Ideally, you are also OFF XARALTO, or PRADAX ONE WEEK PRIOR TO SURGERY. In addition, you should stop FISH OIL, homeopathic drugs, and any other non-essential drugs that you think may increase your risk of bleeding.

At times, it may not be possible for you to stop these drugs. Please consult with your primary care physician, cardiologist, pulmonologist, vascular surgeon or other subspecialty provider, that may have started you on this type of blood thinner, prior to signing up for surgery. It may be safe for you to come off a prescription blood thinner prior to surgery. However, it may not be. Please check with your doctor who prescribed it prior to surgery.

Report to Admitting in the Preop Area

The surgery center will notify you of the time and location where you should go before your surgery. Do not accept or follow any other directions unless you discuss it with our office, 520-204-1495.

AFTER YOUR OPERATION

Pain & Pain Control

After surgery you may experience pain in the region of the incision. Some back and leg pain as well as tingling or numbness may also be present.

Initially, you may notice complete pain relief following this outpatient procedure. This is due to local anesthesia and medication you received during surgery or in the recovery room. This effect will subside over time as the effect of local anesthesia and other systemically administered anesthestic drugs wear off. However, new pain may develop several days postoperatively after an initial “HONEYMOON” period of several days. There may be new pain on the side of the operated extremity or extremities due to inflammation and swelling of the previously compressed nerves. This postoperative inflammatory response of the spinal nerves may produce constant burning in the legs. Typically, it occurs 4 – 10 days postoperatively after a short period of no leg pain. Don’t be alarmed about this type of new pain. It will diminish within a few weeks and may respond well to epidural steroid injections. Please tell your surgeon if you are experiencing this new type of pain during your postoperative visit(s). Your physician may prescribe NEURONTIN (Gabapentin) or LYRICA (Pregabalin) or schedule you for epidural steroid injections to calm symptoms down quicker.

Although this outpatient surgery can be done under sedation and local anesthesia, most patients find it more comfortable and less stressful to undergo a short general anesthesia with a secure airway. Therefore, some patients experience a sore throat and swallowing difficulty after general anesthesia and surgery. This is from manipulation of tissue and the presence of the breathing tube for anesthesia. The sore throat usually will subside within a week. The swallowing difficulty may take longer. Using throat lozenges or lemon drops, sipping cool liquids, or sucking ice chips may soothe this pain.

If you are SHORT OF BREATH, or have EXCESSIVE CHEST, OR CHEST WALL PAIN, please GO TO THE NEAREST EMERGENGY ROOM as you may be having a postoperative heart attack, or a symptomatic blood clot in the lungs. Postoperative MYOCARDAL INFARCTION, and PULMONARY EMBOLISM are rare but do occur occasionally and you should take these symptoms seriously.

If you are having pain with voiding, you may have a urinary tract infection. Sometimes, this symptom is accompanied by fevers and generalized malaise. If you are unable to void and these symtpoms are coupled with excruciating leg or back pain, please report to the NEAREST EMERGENCY ROOM to be evaluated for a symptomatic EPIDURAL HEMATOMA.

Activity

Although this is a small outpatient surgery, you need to give your body time to heal. Below is a list of instructions that you should follow until your first follow-up visit after surgery. You no longer need to wear the anti-thrombosis (TED) stocking (heavy white stockings) once you are home. You may sleep either on your back, stomach or side. You may also use pillows for support, when lying on your side. Place pillows behind your back and between your legs. When on your back place pillows underneath your legs. You may climb stairs, just try not to over-do.

For your comfort, we suggest that you change your position at least every hour when awake. If you become uncomfortable change your position and activity. You should begin a walking program two to three days after surgery. You may shower 5 days after surgery. If you must shower sooner, you must keep the incision covered and dry while showering. No baths for 4 weeks. No hot tubs or swimming for 6 weeks. NO BENDING, TWISTING OR LIFTING.

Once you are permitted to sit, use ONLY a straight back chair such as a dining room chair of kitchen chair. A sturdy "wing back" chair is an option. Each day increase the time & frequency that you sit. (Example: 1st day, sit 3 times for 15 minutes each/2nd day 4 times for 20 minutes each/3rd day 5 times for 25 minutes, etc.) If there is pain after a few minutes GET UP. "LISTEN TO YOUR BODY"

After leaving the hospital you will be allowed in the car TWICE, ONCE TO GO HOME, THE SECOND TO COME BACK TO THE OFFICE. You will get your next set of instructions upon your return. For patients from out of state or country, there will be specific instructions.

Walking Program

Begin walking in the house and progress to outdoors. Take someone with you the first few times. Slowly increase the distance each day so that you will be walking 1 mile/day by your 2nd post-operative week, 2 miles/day at 2 weeks’ post-operative. Hopefully, by 4 weeks’ post-operative you will be walking 4 miles/day. If you feel soreness, reduce the distance and REST. These are GUIDELINES, NOT RULES.

• Day 1 Walk the length of the hallway at home 3-4 times, or walk to the end of the driveway and back once in the morning and again in the afternoon or evening.
• Day 2 Walk 1/2 block or the equivalent of a 1/2 block indoors once in the morning and again in the afternoon or evening.
• Day 3 Walk 1 block in the morning and again in the afternoon or evening.
• Day 4 Walk 2 blocks in the morning and again in the afternoon or evening.
• Day 5 Walk 3 blocks in the morning and again in the afternoon or evening. Continue increasing the distance you walk, as you are able. Let your comfort be your guide to how much you can do.

Limitations

• No driving for 2 weeks, or while taking narcotic pain medication. However, you may be a passenger.
• No lifting greater than 10 lbs. (about 1 gallon of milk) for the first 5-6 weeks after surgery.
• No bending at the waist, however, you may squat with your knees.
• No sports activity until your first follow-up visit other than the walking program.
• No sexual activity for 2 weeks.

Showering / Personal Hygiene

You may shower the morning after surgery. However, it is important to keep the dressing and incisions dry. You may cover cover the dressing with an adhesive and occlusive dressing. DO NOT soak the incision. Do not disturb steri-strips, staples, or sutures.

If You Are Not Sure

If you question whether or not you can do something beyond the instructions given, it is safe to assume that the answer will be NO.

Follow Up Visit in Our Office

Return to the office for your first visit approximately 7 - 10 days after surgery. Typically, you will be given a follow up appointment to our office during your preoperative visit. If you are not sure about your first postoperative visit, please call our office for an appointment (520-204-1495) or if you have questions or concerns. For GENERAL MEDICAL PROBLEMS CONTACT your personal physician.

Return to Driving

No driving for a minimum of 1 week, or for the time while taking extra narcotic pain medication as a result of the surgery. However, you may be a passenger.

Return to Work

Your return to work will depend on your recovery and the type of work you do. You must discuss this with your doctor before you return to work.

Pain Management

For pain management, you will usually be given a prescription for a drug like VICODIN (hydrocodone) or OXYCODONE. For additional pain medication, try Extra strength Tylenol or similar agent. In addition, you may receive a prescription for VALIUM which can help with postoperative muscle spasms.

You should take the pain medication you were given by our office with careful consideration and be knowledgeable about their potential compounding interaction with other narcotics or other medications. Check with your local pharmacist as well should you have any questions as to potential drug interactions.

MEDICATIONS

You may have an occasional increase in back, leg pain and/or numbness after surgery during the healing phase. This is normal and is caused by inflammation (or swelling) of muscle tissue and your spinal nerves in your lower back. To reduce pain there are several approaches to decrease the pain you may be experiencing:

• Ice the low back area for 15-20 minutes every hour for 4 consecutive hours. Do not put the ice directly on your skin. Use a ready-made ice pack or put ice in a plastic bag then wrap the ice pack or bag in a towel before you use it. If you have been given a cooling device, please use while in bed.
• Avoid sitting for more than 30-60 minutes at a time for the next 48 hours.
• Reduce your activity (i.e. walking) for the next 48 hours.
• Take the pain medicine as directed by your doctor for incisional pain. You can also take one extra strength acetaminophen (Tylenol) every 4 hours between the prescription medicines, only as directed. Do not take more than 4000 mg of Tylenol in a 24-hour period. NOTE: Some narcotic pain medicines also have Tylenol in them.
• Do not take narcotic pain medicine for burning pain radiating down the leg. This pain is most likely from inflammation of the nerve. Narcotic pain medication does not help for this type of pain. Take Neurontin (Gabapentin) or Lyrica (Pregabalin) as instructed by your doctor/surgeon. Call the office for a follow up appointment. This neurognic pain typically improves dramatically with an epidural steroid injection into your lower back by placing steroids around the inflamed nerves.
• Eventually you should no longer need to use narcotic pain medicine. Most patients find it unnecessary to take narcotic pain medication within a few days from surgery as the small incisions do not hurt that much.

Removal of Staples or Stitches

Surgical skin staples or sutures are typically removed during your first postoperative visit. If you live far away out of town and an early postoperative visit in our office may pose a particularly hardship for you, you may contact your primary care physician to have her/him remove the staples or stitches. Skin stapes should be removed no later than 2 weeks from the day of surgery. We typically use biodegradable stitches for skin closure and they may simply dissolve and fall off. However, you may have them removed no later than 2 weeks from surgery as well if they bother you. You may develop redness around the staples which typically resolves quickly without additional treatment.

Incision Care

Caring for your Incision at home is important to prevent infection. Please follow these steps:

• Your incisions have been closed either with skin staples or with absorbable suture material. In most cases these areas are covered with a Band-Aid or a small dressing. You may remove the dressing 3-5 days after surgery.
• The stiches will gradually fall off with time and this is normal.
• Staples should be removed within 14 days of your surgery. It is therefore prudent for you to show for your first postoperative visit.
• Take your temperature twice a day, once in the morning and once in the evening for the first 7 days.

The wound will be checked and the dressing will be changed prior to discharge home from the surgery center. You may take a shower when you get home. If the Band-Aid gets wet, simply replace it with a new one. DO NOT TAKE BATH AND DO NOT SOAK THE WOUND. Once the dressing is removed you may leave the wound open to air.

Do not be alarmed when you have bloody or serosangineous drainage from the wound(s). This is normal and part of your postoperative recovery. There may also be some bruising around the lumbar incisional area(s). However, call our office if you have persistent drainage for more than 3 days or a new onset of drainage sometime after 7 - 10 days from your surgery. You should also let us know if you are having any fevers (temperature over 101 F) or chills. This may suggest a wound infection. Although uncommon wound infection occur in under 0.1 % of patients who underwent outpatient percutaneous decompression surgery.

Be advised though that elevated temperatures after surgery can be normal and often is a result of poor lung ventilation. Taking deep breath, and ambulating as much as you can tolerate may help with this problem.

When to Call Your Doctor or Nurse

PAIN IS A RED FLAG TELLING YOU TO REST. Avoid taking pain relieving medication in anticipation that something you will do is going to cause pain.

• If you have a temperature above 101 degrees F (38.8 degrees C) for two readings four hours apart. If you develop a low grade fever, keep a chart of your temperature pattern at 8 AM, 12 noon, 4 & 8 PM. Bring the chart to the office at your next visit.
• Clear drainage from your incision, excessive, wound redness, swelling, purulent drainage or infection.
• An increase in pain, redness and/or swelling by your incision.
• Difficulty urinating or controlling your bowel movements.

When to Call 911

• If you have difficulty breathing, or have an irregular heartbeat, or chest pain, or progressive neurological deficit (progressive weakness in the extremities).

Future Follow-Up Visits

Your first post-op visit is usually scheduled along with your surgery. If you are unsure of your first postoperative appointment, please call (520) 204-1495 to make your first post-operative appointment at the Center for Advanced Spine Care of Southern Arizona. This usually occurs 7 – 10 days after your surgical procedure. All other follow-up visits will be directed by your physician.

Medications

If you need a prescription filled.

Because your health condition may change over time, your doctor or another physician provider, who have access to your confidential medical records, will need to address your refill requests. By following these simple guidelines, you will avoid any delay in getting your prescription refilled:

• Contact your pharmacy at least 5 days before your prescription requires refilling, to protect your health, pharmacies will accept refill orders only from your doctor. So, when you call The Center for Advanced Spinal Care of Southern Arizona with your request an additional step is added. Your prescription will be filled faster if you call your pharmacy directly, they will then contact The Center for Advanced Spine Care of Southern Arizona.
• Use the same pharmacy. That way, your pharmacist will have your complete prescription records and you avoid the danger of mixing medications. To make it convenient for you, the Center for Advanced Spinal Care of Southern Arizona will work with the pharmacy of your choice. Please choose one pharmacy, and use only that pharmacy. It is an easy way to help protect your health, as well as your health records.
• Call your pharmacy early in the day. This gives your doctor time to review your records. To ensure you get the right medications, we do not rush refills without making sure the order and your records are reviewed. Often, physicians are in surgery or finishing with patients late in the day, and we do not want to interrupt those patients’ visits just like you would not like to have your visit interrupted when in the office with the physician. Therefore, refill requests received after 3 pm Monday through Thursday or after 10 am Friday will be reviewed and filled the next business day for The Center for Advanced Spine Care of Southern Arizona.

If You Run Out of Medication Before You Request a Refill

Always call your pharmacy at least 5 days before you run out of medication. This will give the pharmacy plenty of time to contact your doctor, for the doctor to review your record, and for the pharmacist to prepare your medication. All you have to do is watch your medication levels and there should be no reason for you to run out of medication or run out of medication early prior to the scheduled date. It is dangerous to “rush” an order. For your protection, refills are not done at night, over the weekend, on holidays or as an emergency if you have forgotten to call your pharmacy.

If You Run Out of Your Medication Early

Your doctor ordered your prescription according to a precise dosage for a prescribed amount of days. If you run out early, it may mean you are experiencing some difficulty with your dosage or medication. Call The Center for Advanced Spine Care of Southern Arizona immediately and explain your difficulty.

If Your Prescription Is Lost, Misplaced or Stolen:

To protect your health, lost or stolen prescriptions are replaced only with a physician visit. Stolen medication will require a police report to be completed and a copy of the report brought with to your visit. To avoid possible duplication of prescriptions when an order is lost or stolen, you will want to talk with your doctor. Call The Center for Advanced Spine Care to schedule an appointment. Please call our office at (520) 204-1495 with any additional questions that may come during your postoperative recovery.

Please acknowledge that you have read and understood these postop instructions.

PRE- AND POSTOP INSTRUCTIONS LAMINOTOMY RHIZOTOMY SURGERY

This handout will review the care you need to follow in the days prior to your LUMBAR LAMINOTOMY RHIZOTOMY surgery and once you are home after your surgery. This SURGERY typically TAKES PLACE AT A SURGERY CENTER and involves INCISIONS IN YOUR LOWER BACK just above your buttock area near the midline or on the sides. If you have any questions or concerns, please ask your nurse or doctor. Our staff is here to help you. If you have questions after you are at home, please call the numbers listed at the end of this handout.

This information is part of your medical Informed Consent. Please read it and follow the advice carefully. You should retain the guide for future reference and bring it with you to office appointments and to the hospital for reference.

PREPARATION FOR SURGERY

Preoperative Laboratory Studies, and Medical Clearance

In preparation for surgery, you will have blood drawn for analysis. You may also require an electrocardiogram (ECG), a chest X-ray, and possibly additional preoperative studies. These are scheduled prior to surgery. Your LAMINOTOMY RHIZOTOMY surgery is a decompression surgery and a de-innervation procedure of painful areas in your lumbar spine that is typically done at an OUTPATIENT SURGERY CENTER. Preoperative blood work is usually done at the surgery center just prior to your surgery.

Should you have medical problems, such as cardiac or pulmonary, renal disease, thyroid dysfunction, or diabetes to name a few, additional preoperative clearance examinations from your primary care doctor or treating specialist may be required. These tests performed before your scheduled surgery may allow your physician to identify particular health problems that could require further evaluation before anesthesia and surgery. REGARDLESS OF THE EXTENT OF YOUR PREOPERATIVE WORKUP, IT IS NOT A GUARANTEE THAT YOUR SURGERY MAY BE DONE AT AN OUTPATIENT SURGERY CENTER. In some cases, the surgery may be cancelled if the anesthesiologist deems your medical problems at the time of the scheduled procedure as not appropriately managed, or deems your surgery at an outpatient surgery center as too risky and recommends that the procedure be done at a hospital instead.

Diagnostic imaging studies of the lumbar spine, such as CT or MRI scans, a bone scan, and possibly a myelogram, may already have been performed and provide your surgeon with anatomic detail for surgery. Other electrodiagnostic tests (EMG/NCV or SSEPs) may give additional, important information.

Nothing to Eat or Drink After Midnight

Eat a light dinner before 7 P.M. on the evening before your surgery. DO NOT EAT, DRINK, SMOKE, CHEW, OR SWALLOW ANYTHING AFTER MIDNIGHT THE NIGHT BEFORE SURGERY except as directed by the surgery center.

Preoperative Screening by the Surgery Center

The surgery center may call you preoperatively to review your medications, and to determine whether there are any new medical problems unknown at the time of scheduling of your surgery that could potentially be problematic. They may also give you directions as to where and when to report. You should report no later than 2 hours prior to the scheduled surgery time to the surgery center.

Medications to Stop Prior to Surgery

It is imperative for you to stop all NSAIDS (non-steroidal anti-inflammatory drugs) and all other medications affecting the clotting ability of your blood during surgery a minimum of 10 DAYS PRIOR TO your scheduled SURGERY. You not stopping these drugs may affect platelet aggregation and therefore have an anticoagulative side effect. Therefore, significant intraoperative bleeding, increased complication rate with epidural hematoma with potential neurological deficits, infection, and wound problems may occur. There may also be a need for blood transfusions, and potential follow up surgeries to deal with these complications. There are other blood thinners (For example, COUMADIN, XARELTO, PRADAXA, LOVENOX, HEPARIN) that maybe prescribed by your doctor for heart and vascular disease. COUMADIN should be STOPPED 7 DAYS PRIOR TO SURGERY. XARELTO, PRADAXA AND OTHERS may have to be stopped only only a few days prior to surgery. Please check with your prescribing physician. Ideally, you are also OFF XARALTO, or PRADAX ONE WEEK PRIOR TO SURGERY. In addition, you should stop FISH OIL, homeopathic drugs, and any other non-essential drugs that you think may increase your risk of bleeding.

At times, it may not be possible for you to stop these drugs. Please consult with your primary care physician, cardiologist, pulmonologist, vascular surgeon or other subspecialty provider, that may have started you on this type of blood thinner, prior to signing up for surgery. It may be safe for you to come off a prescription blood thinner prior to surgery. However, it may not be. Please check with your doctor who prescribed it prior to surgery.

Report to Admitting in the Preop Area

The surgery center will notify you of the time and location where you should go before your surgery. Do not accept or follow any other directions unless you discuss it with our office, 520-204-1495.

AFTER YOUR OPERATION

Pain & Pain Control

After surgery you may experience pain in the region of the incision. Some back and leg pain as well as tingling or numbness may also be present.

Initially, you may notice complete pain relief following this outpatient procedure. This is due to local anesthesia and medication you received during surgery or in the recovery room. This effect will subside over time as the effect of local anesthesia and other systemically administered anesthestic drugs wear off. However, new pain may develop several days postoperatively after an initial “HONEYMOON” period of several days. There may be new pain on the side of the operated extremity or extremities due to inflammation and swelling of the previously compressed nerves. This postoperative inflammatory response of the spinal nerves may produce constant burning in the legs. Typically, it occurs 4 – 10 days postoperatively after a short period of no leg pain. Don’t be alarmed about this type of new pain. It will diminish within a few weeks and may respond well to epidural steroid injections. Please tell your surgeon if you are experiencing this new type of pain during your postoperative visit(s). Your physician may prescribe NEURONTIN (Gabapentin) or LYRICA (Pregabalin) or schedule you for epidural steroid injections to calm symptoms down quicker.

Although this outpatient surgery can be done under sedation and local anesthesia, most patients find it more comfortable and less stressful to undergo a short general anesthesia with a secure airway. Therefore, some patients experience a sore throat and swallowing difficulty after general anesthesia and surgery. This is from manipulation of tissue and the presence of the breathing tube for anesthesia. The sore throat usually will subside within a week. The swallowing difficulty may take longer. Using throat lozenges or lemon drops, sipping cool liquids, or sucking ice chips may soothe this pain.

If you are SHORT OF BREATH, or have EXCESSIVE CHEST, OR CHEST WALL PAIN, please GO TO THE NEAREST EMERGENGY ROOM as you may be having a postoperative heart attack, or a symptomatic blood clot in the lungs. Postoperative MYOCARDAL INFARCTION, and PULMONARY EMBOLISM are rare but do occur occasionally and you should take these symptoms seriously.

If you are having pain with voiding, you may have a urinary tract infection. Sometimes, this symptom is accompanied by fevers and generalized malaise. If you are unable to void and these symtpoms are coupled with excruciating leg or back pain, please report to the NEAREST EMERGENCY ROOM to be evaluated for a symptomatic EPIDURAL HEMATOMA.

Activity

Although this is a small outpatient surgery, you need to give your body time to heal. Below is a list of instructions that you should follow until your first follow-up visit after surgery. You no longer need to wear the anti-thrombosis (TED) stocking (heavy white stockings) once you are home. You may sleep either on your back, stomach or side. You may also use pillows for support, when lying on your side. Place pillows behind your back and between your legs. When on your back place pillows underneath your legs. You may climb stairs, just try not to over-do.

For your comfort, we suggest that you change your position at least every hour when awake. If you become uncomfortable change your position and activity. You should begin a walking program two to three days after surgery. You may shower 5 days after surgery. If you must shower sooner, you must keep the incision covered and dry while showering. No baths for 4 weeks. No hot tubs or swimming for 6 weeks. NO BENDING, TWISTING OR LIFTING.

Once you are permitted to sit, use ONLY a straight back chair such as a dining room chair of kitchen chair. A sturdy "wing back" chair is an option. Each day increase the time & frequency that you sit. (Example: 1st day, sit 3 times for 15 minutes each/2nd day 4 times for 20 minutes each/3rd day 5 times for 25 minutes, etc.) If there is pain after a few minutes GET UP. "LISTEN TO YOUR BODY"

After leaving the hospital you will be allowed in the car TWICE, ONCE TO GO HOME, THE SECOND TO COME BACK TO THE OFFICE. You will get your next set of instructions upon your return. For patients from out of state or country, there will be specific instructions.

Walking Program

Begin walking in the house and progress to outdoors. Take someone with you the first few times. Slowly increase the distance each day so that you will be walking 1 mile/day by your 2nd post-operative week, 2 miles/day at 2 weeks’ post-operative. Hopefully, by 4 weeks’ post-operative you will be walking 4 miles/day. If you feel soreness, reduce the distance and REST. These are GUIDELINES, NOT RULES.

• Day 1 Walk the length of the hallway at home 3-4 times, or walk to the end of the driveway and back once in the morning and again in the afternoon or evening.
• Day 2 Walk 1/2 block or the equivalent of a 1/2 block indoors once in the morning and again in the afternoon or evening.
• Day 3 Walk 1 block in the morning and again in the afternoon or evening.
• Day 4 Walk 2 blocks in the morning and again in the afternoon or evening.
• Day 5 Walk 3 blocks in the morning and again in the afternoon or evening. Continue increasing the distance you walk, as you are able. Let your comfort be your guide to how much you can do.

Limitations

• No driving for 2 weeks, or while taking narcotic pain medication. However, you may be a passenger.
• No lifting greater than 10 lbs. (about 1 gallon of milk) for the first 5-6 weeks after surgery.
• No bending at the waist, however, you may squat with your knees.
• No sports activity until your first follow-up visit other than the walking program.
• No sexual activity for 2 weeks.

Showering / Personal Hygiene

You may shower the morning after surgery. However, it is important to keep the dressing and incisions dry. You may cover cover the dressing with an adhesive and occlusive dressing. DO NOT soak the incision. Do not disturb steri-strips, staples, or sutures.

If You Are Not Sure

If you question whether or not you can do something beyond the instructions given, it is safe to assume that the answer will be NO.

Follow Up Visit in Our Office

Return to the office for your first visit approximately 7 - 10 days after surgery. Typically, you will be given a follow up appointment to our office during your preoperative visit. If you are not sure about your first postoperative visit, please call our office for an appointment (520-204-1495) or if you have questions or concerns. For GENERAL MEDICAL PROBLEMS CONTACT your personal physician.

Return to Driving

No driving for a minimum of 1 week, or for the time while taking extra narcotic pain medication as a result of the surgery. However, you may be a passenger.

Return to Work

Your return to work will depend on your recovery and the type of work you do. You must discuss this with your doctor before you return to work.

Pain Management

For pain management, you will usually be given a prescription for a drug like VICODIN (hydrocodone) or OXYCODONE. For additional pain medication, try Extra strength Tylenol or similar agent. In addition, you may receive a prescription for VALIUM which can help with postoperative muscle spasms.

You should take the pain medication you were given by our office with careful consideration and be knowledgeable about their potential compounding interaction with other narcotics or other medications. Check with your local pharmacist as well should you have any questions as to potential drug interactions.

MEDICATIONS

You may have an occasional increase in back, leg pain and/or numbness after surgery during the healing phase. This is normal and is caused by inflammation (or swelling) of muscle tissue and your spinal nerves in your lower back. To reduce pain there are several approaches to decrease the pain you may be experiencing:

• Ice the low back area for 15-20 minutes every hour for 4 consecutive hours. Do not put the ice directly on your skin. Use a ready-made ice pack or put ice in a plastic bag then wrap the ice pack or bag in a towel before you use it. If you have been given a cooling device, please use while in bed.
• Avoid sitting for more than 30-60 minutes at a time for the next 48 hours.
• Reduce your activity (i.e. walking) for the next 48 hours.
• Take the pain medicine as directed by your doctor for incisional pain. You can also take one extra strength acetaminophen (Tylenol) every 4 hours between the prescription medicines, only as directed. Do not take more than 4000 mg of Tylenol in a 24-hour period. NOTE: Some narcotic pain medicines also have Tylenol in them.
• Do not take narcotic pain medicine for burning pain radiating down the leg. This pain is most likely from inflammation of the nerve. Narcotic pain medication does not help for this type of pain. Take Neurontin (Gabapentin) or Lyrica (Pregabalin) as instructed by your doctor/surgeon. Call the office for a follow up appointment. This neurognic pain typically improves dramatically with an epidural steroid injection into your lower back by placing steroids around the inflamed nerves.
• Eventually you should no longer need to use narcotic pain medicine. Most patients find it unnecessary to take narcotic pain medication within a few days from surgery as the small incisions do not hurt that much.

Removal of Staples or Stitches

Surgical skin staples or sutures are typically removed during your first postoperative visit. If you live far away out of town and an early postoperative visit in our office may pose a particularly hardship for you, you may contact your primary care physician to have her/him remove the staples or stitches. Skin stapes should be removed no later than 2 weeks from the day of surgery. We typically use biodegradable stitches for skin closure and they may simply dissolve and fall off. However, you may have them removed no later than 2 weeks from surgery as well if they bother you. You may develop redness around the staples which typically resolves quickly without additional treatment.

Incision Care

Caring for your Incision at home is important to prevent infection. Please follow these steps:

• Your incisions have been closed either with skin staples or with absorbable suture material. In most cases these areas are covered with a Band-Aid or a small dressing. You may remove the dressing 3-5 days after surgery.
• The stiches will gradually fall off with time and this is normal.
• Staples should be removed within 14 days of your surgery. It is therefore prudent for you to show for your first postoperative visit.
• Take your temperature twice a day, once in the morning and once in the evening for the first 7 days.

The wound will be checked and the dressing will be changed prior to discharge home from the surgery center. You may take a shower when you get home. If the Band-Aid gets wet, simply replace it with a new one. DO NOT TAKE BATH AND DO NOT SOAK THE WOUND. Once the dressing is removed you may leave the wound open to air.

Do not be alarmed when you have bloody or serosangineous drainage from the wound(s). This is normal and part of your postoperative recovery. There may also be some bruising around the lumbar incisional area(s). However, call our office if you have persistent drainage for more than 3 days or a new onset of drainage sometime after 7 - 10 days from your surgery. You should also let us know if you are having any fevers (temperature over 101 F) or chills. This may suggest a wound infection. Although uncommon wound infection occur in under 0.1 % of patients who underwent outpatient percutaneous decompression surgery.

Be advised though that elevated temperatures after surgery can be normal and often is a result of poor lung ventilation. Taking deep breath, and ambulating as much as you can tolerate may help with this problem.

When to Call Your Doctor or Nurse

PAIN IS A RED FLAG TELLING YOU TO REST. Avoid taking pain relieving medication in anticipation that something you will do is going to cause pain.

• If you have a temperature above 101 degrees F (38.8 degrees C) for two readings four hours apart. If you develop a low grade fever, keep a chart of your temperature pattern at 8 AM, 12 noon, 4 & 8 PM. Bring the chart to the office at your next visit.
• Clear drainage from your incision, excessive, wound redness, swelling, purulent drainage or infection.
• An increase in pain, redness and/or swelling by your incision.
• Difficulty urinating or controlling your bowel movements.

When to Call 911

• If you have difficulty breathing, or have an irregular heartbeat, or chest pain, or progressive neurological deficit (progressive weakness in the extremities).

Future Follow-Up Visits

Your first post-op visit is usually scheduled along with your surgery. If you are unsure of your first postoperative appointment, please call (520) 204-1495 to make your first post-operative appointment at the Center for Advanced Spine Care of Southern Arizona. This usually occurs 7 – 10 days after your surgical procedure. All other follow-up visits will be directed by your physician.

Medications

If you need a prescription filled.

Because your health condition may change over time, your doctor or another physician provider, who have access to your confidential medical records, will need to address your refill requests. By following these simple guidelines, you will avoid any delay in getting your prescription refilled:

• Contact your pharmacy at least 5 days before your prescription requires refilling, to protect your health, pharmacies will accept refill orders only from your doctor. So, when you call The Center for Advanced Spinal Care of Southern Arizona with your request an additional step is added. Your prescription will be filled faster if you call your pharmacy directly, they will then contact The Center for Advanced Spine Care of Southern Arizona.
• Use the same pharmacy. That way, your pharmacist will have your complete prescription records and you avoid the danger of mixing medications. To make it convenient for you, the Center for Advanced Spinal Care of Southern Arizona will work with the pharmacy of your choice. Please choose one pharmacy, and use only that pharmacy. It is an easy way to help protect your health, as well as your health records.
• Call your pharmacy early in the day. This gives your doctor time to review your records. To ensure you get the right medications, we do not rush refills without making sure the order and your records are reviewed. Often, physicians are in surgery or finishing with patients late in the day, and we do not want to interrupt those patients’ visits just like you would not like to have your visit interrupted when in the office with the physician. Therefore, refill requests received after 3 pm Monday through Thursday or after 10 am Friday will be reviewed and filled the next business day for The Center for Advanced Spine Care of Southern Arizona.

If You Run Out of Medication Before You Request a Refill

Always call your pharmacy at least 5 days before you run out of medication. This will give the pharmacy plenty of time to contact your doctor, for the doctor to review your record, and for the pharmacist to prepare your medication. All you have to do is watch your medication levels and there should be no reason for you to run out of medication or run out of medication early prior to the scheduled date. It is dangerous to “rush” an order. For your protection, refills are not done at night, over the weekend, on holidays or as an emergency if you have forgotten to call your pharmacy.

If You Run Out of Your Medication Early

Your doctor ordered your prescription according to a precise dosage for a prescribed amount of days. If you run out early, it may mean you are experiencing some difficulty with your dosage or medication. Call The Center for Advanced Spine Care of Southern Arizona immediately and explain your difficulty.

If Your Prescription Is Lost, Misplaced or Stolen:

To protect your health, lost or stolen prescriptions are replaced only with a physician visit. Stolen medication will require a police report to be completed and a copy of the report brought with to your visit. To avoid possible duplication of prescriptions when an order is lost or stolen, you will want to talk with your doctor. Call The Center for Advanced Spine Care to schedule an appointment. Please call our office at (520) 204-1495 with any additional questions that may come during your postoperative recovery.

Please acknowledge that you have read and understood these postop instructions.

PRE- AND POSTOP INSTRUCTIONS LAMINOTOMY RHIZOTOMY WITH HARDWARE REMOVAL SURGERY

This handout will review the care you need to follow in the days prior to your LUMBAR LAMINOTOMY RHIZOTOMY WITH HARDWARE REMOVAL surgery and once you are home after your surgery. This SURGERY typically TAKES PLACE AT A SURGERY CENTER and involves INCISIONS IN YOUR LOWER BACK just above your buttock area near the midline or on the sides. If you have any questions or concerns, please ask your nurse or doctor. Our staff is here to help you. If you have questions after you are at home, please call the numbers listed at the end of this handout.

This information is part of your medical Informed Consent. Please read it and follow the advice carefully. You should retain the guide for future reference and bring it with you to office appointments and to the hospital for reference.

PREPARATION FOR SURGERY

Preoperative Laboratory Studies, and Medical Clearance

In preparation for surgery, you will have blood drawn for analysis. You may also require an electrocardiogram (ECG), a chest X-ray, and possibly additional preoperative studies. These are scheduled prior to surgery. Your LAMINOTOMY RHIZOTOMY WITH HARDWARE REMOVAL surgery is a decompression surgery and a de-innervation procedure of painful areas in your lumbar spine that is typically done at an OUTPATIENT SURGERY CENTER. Preoperative blood work is usually done at the surgery center just prior to your surgery.

Should you have medical problems, such as cardiac or pulmonary, renal disease, thyroid dysfunction, or diabetes to name a few, additional preoperative clearance examinations from your primary care doctor or treating specialist may be required. These tests performed before your scheduled surgery may allow your physician to identify particular health problems that could require further evaluation before anesthesia and surgery. REGARDLESS OF THE EXTENT OF YOUR PREOPERATIVE WORKUP, IT IS NOT A GUARANTEE THAT YOUR SURGERY MAY BE DONE AT AN OUTPATIENT SURGERY CENTER. In some cases, the surgery may be cancelled if the anesthesiologist deems your medical problems at the time of the scheduled procedure as not appropriately managed, or deems your surgery at an outpatient surgery center as too risky and recommends that the procedure be done at a hospital instead.

Diagnostic imaging studies of the lumbar spine, such as CT or MRI scans, a bone scan, and possibly a myelogram, may already have been performed and provide your surgeon with anatomic detail for surgery. Other electrodiagnostic tests (EMG/NCV or SSEPs) may give additional, important information.

Nothing to Eat or Drink After Midnight

Eat a light dinner before 7 P.M. on the evening before your surgery. DO NOT EAT, DRINK, SMOKE, CHEW, OR SWALLOW ANYTHING AFTER MIDNIGHT THE NIGHT BEFORE SURGERY except as directed by the surgery center.

Preoperative Screening by the Surgery Center

The surgery center may call you preoperatively to review your medications, and to determine whether there are any new medical problems unknown at the time of scheduling of your surgery that could potentially be problematic. They may also give you directions as to where and when to report. You should report no later than 2 hours prior to the scheduled surgery time to the surgery center.

Medications to Stop Prior to Surgery

It is imperative for you to stop all NSAIDS (non-steroidal anti-inflammatory drugs) and all other medications affecting the clotting ability of your blood during surgery a minimum of 10 DAYS PRIOR TO your scheduled SURGERY. You not stopping these drugs may affect platelet aggregation and therefore have an anticoagulative side effect. Therefore, significant intraoperative bleeding, increased complication rate with epidural hematoma with potential neurological deficits, infection, and wound problems may occur. There may also be a need for blood transfusions, and potential follow up surgeries to deal with these complications. There are other blood thinners (For example, COUMADIN, XARELTO, PRADAXA, LOVENOX, HEPARIN) that maybe prescribed by your doctor for heart and vascular disease. COUMADIN should be STOPPED 7 DAYS PRIOR TO SURGERY. XARELTO, PRADAXA AND OTHERS may have to be stopped only only a few days prior to surgery. Please check with your prescribing physician. Ideally, you are also OFF XARALTO, or PRADAX ONE WEEK PRIOR TO SURGERY. In addition, you should stop FISH OIL, homeopathic drugs, and any other non-essential drugs that you think may increase your risk of bleeding.

At times, it may not be possible for you to stop these drugs. Please consult with your primary care physician, cardiologist, pulmonologist, vascular surgeon or other subspecialty provider, that may have started you on this type of blood thinner, prior to signing up for surgery. It may be safe for you to come off a prescription blood thinner prior to surgery. However, it may not be. Please check with your doctor who prescribed it prior to surgery.

Report to Admitting in the Preop Area

The surgery center will notify you of the time and location where you should go before your surgery. Do not accept or follow any other directions unless you discuss it with our office, 520-204-1495.

AFTER YOUR OPERATION

Pain & Pain Control

After surgery you may experience pain in the region of the incision. Some back and leg pain as well as tingling or numbness may also be present.

Initially, you may notice complete pain relief following this outpatient procedure. This is due to local anesthesia and medication you received during surgery or in the recovery room. This effect will subside over time as the effect of local anesthesia and other systemically administered anesthestic drugs wear off. However, new pain may develop several days postoperatively after an initial “HONEYMOON” period of several days. There may be new pain on the side of the operated extremity or extremities due to inflammation and swelling of the previously compressed nerves. This postoperative inflammatory response of the spinal nerves may produce constant burning in the legs. Typically, it occurs 4 – 10 days postoperatively after a short period of no leg pain. Don’t be alarmed about this type of new pain. It will diminish within a few weeks and may respond well to epidural steroid injections. Please tell your surgeon if you are experiencing this new type of pain during your postoperative visit(s). Your physician may prescribe NEURONTIN (Gabapentin) or LYRICA (Pregabalin) or schedule you for epidural steroid injections to calm symptoms down quicker.

Although this outpatient surgery can be done under sedation and local anesthesia, most patients find it more comfortable and less stressful to undergo a short general anesthesia with a secure airway. Therefore, some patients experience a sore throat and swallowing difficulty after general anesthesia and surgery. This is from manipulation of tissue and the presence of the breathing tube for anesthesia. The sore throat usually will subside within a week. The swallowing difficulty may take longer. Using throat lozenges or lemon drops, sipping cool liquids, or sucking ice chips may soothe this pain.

If you are SHORT OF BREATH, or have EXCESSIVE CHEST, OR CHEST WALL PAIN, please GO TO THE NEAREST EMERGENGY ROOM as you may be having a postoperative heart attack, or a symptomatic blood clot in the lungs. Postoperative MYOCARDAL INFARCTION, and PULMONARY EMBOLISM are rare but do occur occasionally and you should take these symptoms seriously.

If you are having pain with voiding, you may have a urinary tract infection. Sometimes, this symptom is accompanied by fevers and generalized malaise. If you are unable to void and these symtpoms are coupled with excruciating leg or back pain, please report to the NEAREST EMERGENCY ROOM to be evaluated for a symptomatic EPIDURAL HEMATOMA.

Activity

Although this is a small outpatient surgery, you need to give your body time to heal. Below is a list of instructions that you should follow until your first follow-up visit after surgery. You no longer need to wear the anti-thrombosis (TED) stocking (heavy white stockings) once you are home. You may sleep either on your back, stomach or side. You may also use pillows for support, when lying on your side. Place pillows behind your back and between your legs. When on your back place pillows underneath your legs. You may climb stairs, just try not to over-do.

For your comfort, we suggest that you change your position at least every hour when awake. If you become uncomfortable change your position and activity. You should begin a walking program two to three days after surgery. You may shower 5 days after surgery. If you must shower sooner, you must keep the incision covered and dry while showering. No baths for 4 weeks. No hot tubs or swimming for 6 weeks. NO BENDING, TWISTING OR LIFTING.

Once you are permitted to sit, use ONLY a straight back chair such as a dining room chair of kitchen chair. A sturdy "wing back" chair is an option. Each day increase the time & frequency that you sit. (Example: 1st day, sit 3 times for 15 minutes each/2nd day 4 times for 20 minutes each/3rd day 5 times for 25 minutes, etc.) If there is pain after a few minutes GET UP. "LISTEN TO YOUR BODY"

After leaving the hospital you will be allowed in the car TWICE, ONCE TO GO HOME, THE SECOND TO COME BACK TO THE OFFICE. You will get your next set of instructions upon your return. For patients from out of state or country, there will be specific instructions.

Walking Program

Begin walking in the house and progress to outdoors. Take someone with you the first few times. Slowly increase the distance each day so that you will be walking 1 mile/day by your 2nd post-operative week, 2 miles/day at 2 weeks’ post-operative. Hopefully, by 4 weeks’ post-operative you will be walking 4 miles/day. If you feel soreness, reduce the distance and REST. These are GUIDELINES, NOT RULES.

• Day 1 Walk the length of the hallway at home 3-4 times, or walk to the end of the driveway and back once in the morning and again in the afternoon or evening.
• Day 2 Walk 1/2 block or the equivalent of a 1/2 block indoors once in the morning and again in the afternoon or evening.
• Day 3 Walk 1 block in the morning and again in the afternoon or evening.
• Day 4 Walk 2 blocks in the morning and again in the afternoon or evening.
• Day 5 Walk 3 blocks in the morning and again in the afternoon or evening. Continue increasing the distance you walk, as you are able. Let your comfort be your guide to how much you can do.

Limitations

• No driving for 2 weeks, or while taking narcotic pain medication. However, you may be a passenger.
• No lifting greater than 10 lbs. (about 1 gallon of milk) for the first 5-6 weeks after surgery.
• No bending at the waist, however, you may squat with your knees.
• No sports activity until your first follow-up visit other than the walking program.
• No sexual activity for 2 weeks.

Showering / Personal Hygiene

You may shower the morning after surgery. However, it is important to keep the dressing and incisions dry. You may cover cover the dressing with an adhesive and occlusive dressing. DO NOT soak the incision. Do not disturb steri-strips, staples, or sutures.

If You Are Not Sure

If you question whether or not you can do something beyond the instructions given, it is safe to assume that the answer will be NO.

Follow Up Visit in Our Office

Return to the office for your first visit approximately 7 - 10 days after surgery. Typically, you will be given a follow up appointment to our office during your preoperative visit. If you are not sure about your first postoperative visit, please call our office for an appointment (520-204-1495) or if you have questions or concerns. For GENERAL MEDICAL PROBLEMS CONTACT your personal physician.

Return to Driving

No driving for a minimum of 1 week, or for the time while taking extra narcotic pain medication as a result of the surgery. However, you may be a passenger.

Return to Work

Your return to work will depend on your recovery and the type of work you do. You must discuss this with your doctor before you return to work.

Pain Management

For pain management, you will usually be given a prescription for a drug like VICODIN (hydrocodone) or OXYCODONE. For additional pain medication, try Extra strength Tylenol or similar agent. In addition, you may receive a prescription for VALIUM which can help with postoperative muscle spasms.

You should take the pain medication you were given by our office with careful consideration and be knowledgeable about their potential compounding interaction with other narcotics or other medications. Check with your local pharmacist as well should you have any questions as to potential drug interactions.

MEDICATIONS

You may have an occasional increase in back, leg pain and/or numbness after surgery during the healing phase. This is normal and is caused by inflammation (or swelling) of muscle tissue and your spinal nerves in your lower back. To reduce pain there are several approaches to decrease the pain you may be experiencing:

• Ice the low back area for 15-20 minutes every hour for 4 consecutive hours. Do not put the ice directly on your skin. Use a ready-made ice pack or put ice in a plastic bag then wrap the ice pack or bag in a towel before you use it. If you have been given a cooling device, please use while in bed.
• Avoid sitting for more than 30-60 minutes at a time for the next 48 hours.
• Reduce your activity (i.e. walking) for the next 48 hours.
• Take the pain medicine as directed by your doctor for incisional pain. You can also take one extra strength acetaminophen (Tylenol) every 4 hours between the prescription medicines, only as directed. Do not take more than 4000 mg of Tylenol in a 24-hour period. NOTE: Some narcotic pain medicines also have Tylenol in them.
• Do not take narcotic pain medicine for burning pain radiating down the leg. This pain is most likely from inflammation of the nerve. Narcotic pain medication does not help for this type of pain. Take Neurontin (Gabapentin) or Lyrica (Pregabalin) as instructed by your doctor/surgeon. Call the office for a follow up appointment. This neurognic pain typically improves dramatically with an epidural steroid injection into your lower back by placing steroids around the inflamed nerves.
• Eventually you should no longer need to use narcotic pain medicine. Most patients find it unnecessary to take narcotic pain medication within a few days from surgery as the small incisions do not hurt that much.

Removal of Staples or Stitches

Surgical skin staples or sutures are typically removed during your first postoperative visit. If you live far away out of town and an early postoperative visit in our office may pose a particularly hardship for you, you may contact your primary care physician to have her/him remove the staples or stitches. Skin stapes should be removed no later than 2 weeks from the day of surgery. We typically use biodegradable stitches for skin closure and they may simply dissolve and fall off. However, you may have them removed no later than 2 weeks from surgery as well if they bother you. You may develop redness around the staples which typically resolves quickly without additional treatment.

Incision Care

Caring for your Incision at home is important to prevent infection. Please follow these steps:

• Your incisions have been closed either with skin staples or with absorbable suture material. In most cases these areas are covered with a Band-Aid or a small dressing. You may remove the dressing 3-5 days after surgery.
• The stiches will gradually fall off with time and this is normal.
• Staples should be removed within 14 days of your surgery. It is therefore prudent for you to show for your first postoperative visit.
• Take your temperature twice a day, once in the morning and once in the evening for the first 7 days.

The wound will be checked and the dressing will be changed prior to discharge home from the surgery center. You may take a shower when you get home. If the Band-Aid gets wet, simply replace it with a new one. DO NOT TAKE BATH AND DO NOT SOAK THE WOUND. Once the dressing is removed you may leave the wound open to air.

Do not be alarmed when you have bloody or serosangineous drainage from the wound(s). This is normal and part of your postoperative recovery. There may also be some bruising around the lumbar incisional area(s). However, call our office if you have persistent drainage for more than 3 days or a new onset of drainage sometime after 7 - 10 days from your surgery. You should also let us know if you are having any fevers (temperature over 101 F) or chills. This may suggest a wound infection. Although uncommon wound infection occur in under 0.1 % of patients who underwent outpatient percutaneous decompression surgery.

Be advised though that elevated temperatures after surgery can be normal and often is a result of poor lung ventilation. Taking deep breath, and ambulating as much as you can tolerate may help with this problem.

When to Call Your Doctor or Nurse

PAIN IS A RED FLAG TELLING YOU TO REST. Avoid taking pain relieving medication in anticipation that something you will do is going to cause pain.

• If you have a temperature above 101 degrees F (38.8 degrees C) for two readings four hours apart. If you develop a low grade fever, keep a chart of your temperature pattern at 8 AM, 12 noon, 4 & 8 PM. Bring the chart to the office at your next visit.
• Clear drainage from your incision, excessive, wound redness, swelling, purulent drainage or infection.
• An increase in pain, redness and/or swelling by your incision.
• Difficulty urinating or controlling your bowel movements.

When to Call 911

• If you have difficulty breathing, or have an irregular heartbeat, or chest pain, or progressive neurological deficit (progressive weakness in the extremities).

Future Follow-Up Visits

Your first post-op visit is usually scheduled along with your surgery. If you are unsure of your first postoperative appointment, please call (520) 204-1495 to make your first post-operative appointment at the Center for Advanced Spine Care of Southern Arizona. This usually occurs 7 – 10 days after your surgical procedure. All other follow-up visits will be directed by your physician.

Medications

If you need a prescription filled.

Because your health condition may change over time, your doctor or another physician provider, who have access to your confidential medical records, will need to address your refill requests. By following these simple guidelines, you will avoid any delay in getting your prescription refilled:

• Contact your pharmacy at least 5 days before your prescription requires refilling, to protect your health, pharmacies will accept refill orders only from your doctor. So, when you call The Center for Advanced Spinal Care of Southern Arizona with your request an additional step is added. Your prescription will be filled faster if you call your pharmacy directly, they will then contact The Center for Advanced Spine Care of Southern Arizona.
• Use the same pharmacy. That way, your pharmacist will have your complete prescription records and you avoid the danger of mixing medications. To make it convenient for you, the Center for Advanced Spinal Care of Southern Arizona will work with the pharmacy of your choice. Please choose one pharmacy, and use only that pharmacy. It is an easy way to help protect your health, as well as your health records.
• Call your pharmacy early in the day. This gives your doctor time to review your records. To ensure you get the right medications, we do not rush refills without making sure the order and your records are reviewed. Often, physicians are in surgery or finishing with patients late in the day, and we do not want to interrupt those patients’ visits just like you would not like to have your visit interrupted when in the office with the physician. Therefore, refill requests received after 3 pm Monday through Thursday or after 10 am Friday will be reviewed and filled the next business day for The Center for Advanced Spine Care of Southern Arizona.

If You Run Out of Medication Before You Request a Refill

Always call your pharmacy at least 5 days before you run out of medication. This will give the pharmacy plenty of time to contact your doctor, for the doctor to review your record, and for the pharmacist to prepare your medication. All you have to do is watch your medication levels and there should be no reason for you to run out of medication or run out of medication early prior to the scheduled date. It is dangerous to “rush” an order. For your protection, refills are not done at night, over the weekend, on holidays or as an emergency if you have forgotten to call your pharmacy.

If You Run Out of Your Medication Early

Your doctor ordered your prescription according to a precise dosage for a prescribed amount of days. If you run out early, it may mean you are experiencing some difficulty with your dosage or medication. Call The Center for Advanced Spine Care of Southern Arizona immediately and explain your difficulty.

If Your Prescription Is Lost, Misplaced or Stolen:

To protect your health, lost or stolen prescriptions are replaced only with a physician visit. Stolen medication will require a police report to be completed and a copy of the report brought with to your visit. To avoid possible duplication of prescriptions when an order is lost or stolen, you will want to talk with your doctor. Call The Center for Advanced Spine Care to schedule an appointment. Please call our office at (520) 204-1495 with any additional questions that may come during your postoperative recovery.

Please acknowledge that you have read and understood these postop instructions.

PRE- AND POSTOP INSTRUCTIONS LUMBAR SPINAL FUSION SURGERY

This handout will review the care you need to follow in the days prior to your LUMBAR SPINAL FUSION surgery and once you are home after your surgery. This SURGERY typically TAKES PLACE AT A HOSPITAL and involves an INCISION IN YOUR LOWER BACK just above your buttock area. In addition, this lumbar fusion surgery entails placement of metallic screws and rods, which are typically made of medical grade titanium. If you have any questions or concerns, please ask your nurse or doctor. Our staff is here to help you. If you have questions after you are at home, please call the numbers listed at the end of this handout.

This information is part of your medical Informed Consent. Please read it and follow the advice carefully. You should retain the guide for future reference and bring it with you to office appointments and to the hospital for reference.

PREPARATION FOR SURGERY

Preoperative Laboratory Studies, and Medical Clearance

In preparation for surgery, you will have blood drawn for analysis. You may also require an electrocardiogram (ECG), a chest X-ray, and possibly additional preoperative studies. These are scheduled prior to surgery. If your fusion surgery is done at a hospital, you may be asked to visit the PREOPERATIVE ADMISSION TESTING clinic.

Should you have medical problems, such as cardiac or pulmonary, renal disease, thyroid dysfunction, or diabetes to name a few, additional preoperative clearance examinations from your primary care doctor or treating specialist may be required. These tests performed before your scheduled surgery may allow your physician to identify particular health problems that could require further evaluation before anesthesia and surgery. Regardless of the extent of your preoperative workup, it is not a guarantee that your surgery may not be cancelled if your medical problems at the time of the scheduled procedure are not appropriately managed and therefore may put you at high risk for postoperative complications or even death.

Diagnostic imaging studies of the lumbar spine, such as CT or MRI scans, a bone scan, and possibly a myelogram, may already have been performed and provide your surgeon with anatomic detail for surgery. Other electrodiagnostic tests (EMG/NCV or SSEPs) may give additional, important information.

Nothing to Eat or Drink After Midnight

Eat a light dinner before 7 P.M. on the evening before your surgery. DO NOT EAT, DRINK, SMOKE, CHEW, OR SWALLOW ANYTHING AFTER MIDNIGHT THE NIGHT BEFORE SURGERY except as directed by the hospital.

Medications to Stop Prior to Surgery

It is imperative for you to stop all NSAIDS (non-steroidal anti-inflammatory drugs) and all other medications affecting the clotting ability of your blood during surgery a minimum of 10 DAYS PRIOR TO your scheduled SURGERY. You not stopping these drugs may affect platelet aggregation and therefore have an anticoagulative side effect. Therefore, significant intraoperative bleeding, increased complication rate with epidural hematoma with potential neurological deficits, infection, and wound problems may occur. There may also be a need for blood transfusions, and potential follow up surgeries to deal with these complications. There are other blood thinners (For example, COUMADIN, XARELTO, PRADAXA, LOVENOX, HEPARIN) that maybe prescribed by your doctor for heart and vascular disease. COUMADIN should be STOPPED 7 DAYS PRIOR TO SURGERY. XARELTO, PRADAXA AND OTHERS may have to be stopped only only a few days prior to surgery. Please check with your prescribing physician. Ideally, you are also OFF XARALTO, or PRADAX ONE WEEK PRIOR TO SURGERY. In addition, you should stop FISH OIL, homeopathic drugs, and any other non-essential drugs that you think may increase your risk of bleeding.

At times, it may not be possible for you to stop these drugs. Please consult with your primary care physician, cardiologist, pulmonologist, vascular surgeon or other subspecialty provider, that may have started you on this type of blood thinner, prior to signing up for surgery. It may be safe for you to come off a prescription blood thinner prior to surgery. However, it may not be. Please check with your doctor who prescribed it prior to surgery.

Preoperative Screening by the Hospital

The hospital may call you several days prior to your scheduled surgery to review your medications, and to determine whether there are any new medical problems unknown at the time of scheduling your surgery that could potentially be problematic. They may also give you directions as to where and when to report. You should report no later than 2 hours prior to the scheduled surgery time at the hospital.

Report to Admitting in the Preop Area

The hospital will notify you of the time and location where you should go before your surgery. Do not accept or follow any other directions unless you discuss it with our office, 520-204-1495.

AFTER YOUR OPERATION

Pain & Pain Control

After surgery you may experience pain in the region of the incision. Some back and leg pain as well as tingling or numbness may also be present.

Initially, it may be of greater intensity than pre-operatively, but will subside over time as the healing process occurs. This discomfort is caused from surgical retraction of tissue as well as inflammation and swelling of the previously compressed nerves. A postoperative inflammatory response of the spinal nerves may produce constant burning in the legs. Typically, it occurs 4 – 10 days postoperatively after a short “honeymoon” period of no leg pain. Don’t be alarmed about this type of new pain. It will diminish within a few weeks and may respond well to epidural steroid injections. Please tell your surgeon if you are experiencing this new type of pain during your postoperative visit. Your physician may prescribe NEURONTIN (Gabapentin) or LYRICA (Pregabalin).

Some patients experience a sore throat and swallowing difficulty after general anesthesia and surgery. This is from manipulation of tissue and the presence of the breathing tube for anesthesia. The sore throat usually will subside within a week. The swallowing difficulty may take longer. Using throat lozenges or lemon drops, sipping cool liquids, or sucking ice chips may soothe this pain.

If you are SHORT OF BREATH, or have EXCESSIVE CHEST, OR CHEST WALL PAIN, please GO TO THE NEAREST EMERGENGY ROOM as you may be having a postoperative heart attack, or a symptomatic blood clot in the lungs. Postoperative MYOCARDAL INFARCTION, and PULMONARY EMBOLISM are rare but do occur occasionally and you should take these symptoms seriously.

If you are having pain with voiding, you may have a urinary tract infection. Sometimes, this symptom is accompanied by fevers and generalized malaise. If you are unable to void and these symtpoms are coupled with excruciating leg or back pain, please report to the NEAREST EMERGENCY ROOM to be evaluated for a symptomatic EPIDURAL HEMATOMA.

Activity

This is a major surgery and you need to give your body time to heal. Below is a list of instructions that you should follow until your first follow-up visit after surgery. You no longer need to wear the anti-thrombosis (TED) stocking (heavy white stockings) once you are home. You may sleep either on your back, stomach or side. You may also use pillows for support, when lying on your side. Place pillows behind your back and between your legs. When on your back place pillows underneath your legs. You may climb stairs, just try not to over-do.
For your comfort, we suggest that you change your position at least every hour when awake. If you become uncomfortable change your position and activity. You should begin a walking program two to three days after surgery. You may shower 5 days after surgery. If you must shower sooner, you must keep the incision covered and dry while showering. No baths for 4 weeks. No hot tubs or swimming for 6 weeks. NO BENDING, TWISTING OR LIFTING.

Once you are permitted to sit, use ONLY a straight back chair such as a dining room chair of kitchen chair. A sturdy "wing back" chair is an option. Each day increase the time & frequency that you sit. (Example: 1st day, sit 3 times for 15 minutes each/2nd day 4 times for 20 minutes each/3rd day 5 times for 25 minutes, etc.) If there is pain after a few minutes GET UP. "LISTEN TO YOUR BODY"

After leaving the hospital you will be allowed in the car TWICE, ONCE TO GO HOME, THE SECOND TO COME BACK TO THE OFFICE. You will get your next set of instructions upon your return. For patients from out of state or country, there will be specific instructions.

Walking Program

Begin walking in the house and progress to outdoors. Take someone with you the first few times. Slowly increase the distance each day so that you will be walking 1 mile/day by your 2nd post-operative week, 2 miles/day at 2 weeks’ post-operative. Hopefully, by 2 months’ post-operative you will be walking 4 miles/day. If you feel soreness, reduce the distance and REST. These are GUIDELINES, NOT RULES.

• Day 1 Walk the length of the hallway at home 3-4 times, or walk to the end of the driveway and back once in the morning and again in the afternoon or evening.
• Day 2 Walk 1/2 block or the equivalent of a 1/2 block indoors once in the morning and again in the afternoon or evening.
• Day 3 Walk 1 block in the morning and again in the afternoon or evening.
• Day 4 Walk 2 blocks in the morning and again in the afternoon or evening.
• Day 5 Walk 3 blocks in the morning and again in the afternoon or evening. Continue increasing the distance you walk, as you are able. Let your comfort be your guide to how much you can do.

Limitations

• No driving for 2 weeks, or while taking narcotic pain medication. However, you may be a passenger.
• No lifting greater than 10 lbs. (about 1 gallon of milk) for the first 5-6 weeks after surgery.
• No bending at the waist, however, you may squat with your knees.
• No sports activity until your first follow-up visit other than the walking program.
• No sexual activity for 2 weeks.

Showering / Personal Hygiene

You may shower the morning after surgery. However, it is important to keep the dressing and incisions dry. You may cover cover the dressing with an adhesive and occlusive dressing. DO NOT soak the incision. Do not disturb steri-strips, staples, or sutures.

If You Are Not Sure

If you question whether or not you can do something beyond the instructions given, it is safe to assume that the answer will be NO.

Follow Up Visit in Our Office

Return to the office for your first visit approximately 7 - 10 days after surgery. Typically, you will be given a follow up appointment to our office during your preoperative visit. If you are not sure about your first postoperative visit, please call our office for an appointment (520-204-1495) or if you have questions or concerns. For GENERAL MEDICAL PROBLEMS CONTACT your personal physician.

Return to Driving

No driving for a minimum of 2 weeks, or for the time while taking extra narcotic pain medication as a result of the surgery. However, you may be a passenger.

Return to Work

Your return to work will depend on your recovery and the type of work you do. You must discuss this with your doctor before you return to work.

Pain Management

For pain management, you will usually be given a prescription for a drug like VICODIN (hydrocodone) or OXYCODONE. For additional pain medication, try Extra strength Tylenol or similar agent. In addition, you may receive a prescription for VALIUM which can help with postoperative muscle spasms.

You should take the pain medication you were given by our office with careful consideration and be knowledgeable about their potential compounding interaction with other narcotics or other medications. Check with your local pharmacist as well should you have any questions as to potential drug interactions.

DO NOT USE ANY ASPIRIN or ASPIRIN containing medication. DO NOT use ADVIL, IBUPROFEN, NAPROXEN, TORADOL or similar medication that contain these drugs. These drugs may interfere with the healing of your spinal fusion.

MEDICATIONS

You may have an occasional increase in back, leg pain and/or numbness after surgery during the healing phase. This is normal and is caused by inflammation (or swelling) of muscle tissue in your low back. To reduce pain there are several approaches to decrease the pain you may be experiencing.

• Ice the low back area for 15-20 minutes every hour for 4 consecutive hours. Do not put the ice directly on your skin. Use a ready-made ice pack or put ice in a plastic bag then wrap the ice pack or bag in a towel before you use it. If you have been given a cooling device, please use while in bed.
• Avoid sitting for more than 30-60 minutes at a time for the next 48 hours.
• Reduce your activity (i.e. walking) for the next 48 hours.
• Take the pain medicine as directed by your doctor. You can also take one extra strength acetaminophen (Tylenol) every 4 hours between the prescription medicines, only as directed. Do not take more than 4000 mg of Tylenol in a 24-hour period. NOTE: Some narcotic pain medicines also have Tylenol in them.
• Do not take the anti-inflammatory drugs (i.e. lbuprofen, Motrin, Advil, Aleve, Celebrex, Aspirin) for 3 months following surgery.
• Eventually you should no longer need to use pain medicine.

Removal of Staples or Stitches

Surgical skin staples or sutures are typically removed during your first postoperative visit. If you live far away out of town and an early postoperative visit in our office may pose a particularly hardship for you, you may contact your primary care physician to have her/him remove the staples or stitches. Skin stapes should be removed no later than 2 weeks from the day of surgery. We typically use biodegradable stitches for skin closure and they may simply dissolve and fall off. However, you may have them removed no later than 2 weeks from surgery as well if they bother you. You may develop redness around the staples which typically resolves quickly without additional treatment.

Incision Care

Caring for your Incision at home is important to prevent infection. Please follow these steps:

• Your incisions have been closed either with skin staples or with absorbable suture material underneath the skin and small pieces of surgical tape (steri-strips) on the surface of the skin. In most cases these areas are covered with a dressing. You may remove the dressing 3-5 days after surgery.
• The steri-strips will gradually peel away with time as they get wet and this is normal. You may peel off the steri-strips anytime after 10 days.
• Staples should be removed within 14 days of your surgery. It is therefore prudent for you to show for your first postoperative visit.
• Take your temperature twice a day, once in the morning and once in the evening for the first 7 days.

The wound will be checked and the dressing will be changed prior to discharge home from the hospital. Your dressing will be water occlusive and you may take a shower with it when you get home. However, do not take bath and do not soak the wound. Once the dressing is removed you may leave the wound open to air.

Do not be alarmed when you have bloody or serosangineous drainage from the wound. This is normal and part of your postoperative recovery. There may also be some bruising around the lumbar incisional area. However, call our office if you have persistent drainage for more than 3 days or a new onset of drainage sometime after 7 - 10 days from your surgery. You should also let us know if you are having any fevers (temperature over 101 F) or chills. This may suggest a wound infection. Although uncommon wound infection occur in under 2 - 4 % of lumbar spinal fusion patients.

Be advised though that elevated temperatures after surgery can be normal and often is a result of poor lung ventilation. Taking deep breath, and ambulating as much as you can tolerate may help with this problem.

When to Call Your Doctor or Nurse

PAIN IS A RED FLAG TELLING YOU TO REST. Avoid taking pain relieving medication in anticipation that something you will do is going to cause pain.

• If you have a temperature above 101 degrees F (38.8 degrees C) for two readings four hours apart. If you develop a low grade fever, keep a chart of your temperature pattern at 8 AM, 12 noon, 4 & 8 PM. Bring the chart to the office at your next visit.
• Clear drainage from your incision, excessive, wound redness, swelling, purulent drainage or infection.
• An increase in pain, redness and/or swelling by your incision.
• Difficulty urinating or controlling your bowel movements.

When to Call 911

• If you have difficulty breathing, or have an irregular heartbeat, or chest pain, or progressive neurological deficit (progressive weakness in the extremities).

Future Follow-Up Visits

Your first post-op visit is usually scheduled along with your surgery. If you are unsure of your first postoperative appointment, please call (520) 204-1495 to make your first post-operative appointment at the Center for Advanced Spine Care of Southern Arizona. This usually occurs 7 – 10 days after your surgical procedure. All other follow-up visits will be directed by your physician.

Medications

If you need a prescription filled.

Because your health condition may change over time, your doctor or another physician provider, who have access to your confidential medical records, will need to address your refill requests. By following these simple guidelines, you will avoid any delay in getting your prescription refilled:
• Contact your pharmacy at least 5 days before your prescription requires refilling, to protect your health, pharmacies will accept refill orders only from your doctor. So, when you call The Center for Advanced Spinal Care of Southern Arizona with your request an additional step is added. Your prescription will be filled faster if you call your pharmacy directly, they will then contact The Center for Advanced Spine Care of Southern Arizona.
• Use the same pharmacy. That way, your pharmacist will have your complete prescription records and you avoid the danger of mixing medications. To make it convenient for you, the Center for Advanced Spinal Care of Southern Arizona will work with the pharmacy of your choice. Please choose one pharmacy, and use only that pharmacy. It is an easy way to help protect your health, as well as your health records.
• Call your pharmacy early in the day. This gives your doctor time to review your records. To ensure you get the right medications, we do not rush refills without making sure the order and your records are reviewed. Often, physicians are in surgery or finishing with patients late in the day, and we do not want to interrupt those patients’ visits just like you would not like to have your visit interrupted when in the office with the physician. Therefore, refill requests received after 3 pm Monday through Thursday or after 10 am Friday will be reviewed and filled the next business day for The Center for Advanced Spine Care of Southern Arizona.

If You Run Out of Medication Before You Request a Refill

Always call your pharmacy at least 5 days before you run out of medication. This will give the pharmacy plenty of time to contact your doctor, for the doctor to review your record, and for the pharmacist to prepare your medication. All you have to do is watch your medication levels and there should be no reason for you to run out of medication or run out of medication early prior to the scheduled date. It is dangerous to “rush” an order. For your protection, refills are not done at night, over the weekend, on holidays or as an emergency if you have forgotten to call your pharmacy.

If You Run Out of Your Medication Early

Your doctor ordered your prescription according to a precise dosage for a prescribed amount of days. If you run out early, it may mean you are experiencing some difficulty with your dosage or medication. Call The Center for Advanced Spine Care of Southern Arizona immediately and explain your difficulty.

If Your Prescription Is Lost, Misplaced or Stolen:

To protect your health, lost or stolen prescriptions are replaced only with a physician visit. Stolen medication will require a police report to be completed and a copy of the report brought with to your visit. To avoid possible duplication of prescriptions when an order is lost or stolen, you will want to talk with your doctor. Call The Center for Advanced Spine Care to schedule an appointment. Please call our office at (520) 204-1495 with any additional questions that may come during your postoperative recovery.

Please acknowledge that you have read and understood these postop instructions.

PRE- AND POSTOP INSTRUCTIONS SI ABLATION & LAMINOTOMY SURGERY

This handout will review the care you need to follow in the days prior to your SI ABLATION AND LUMBAR LAMINOTOMY surgery and once you are home after your surgery. This SURGERY typically TAKES PLACE AT A SURGERY CENTER and involves INCISIONS IN YOUR LOWER BACK just above your buttock area near the midline or on the sides. If you have any questions or concerns, please ask your nurse or doctor. Our staff is here to help you. If you have questions after you are at home, please call the numbers listed at the end of this handout.

This information is part of your medical Informed Consent. Please read it and follow the advice carefully. You should retain the guide for future reference and bring it with you to office appointments and to the hospital for reference.

PREPARATION FOR SURGERY

Preoperative Laboratory Studies, and Medical Clearance

In preparation for surgery, you will have blood drawn for analysis. You may also require an electrocardiogram (ECG), a chest X-ray, and possibly additional preoperative studies. These are scheduled prior to surgery. Your SI ABLATION AND LUMBAR LAMINOTOMY surgery is a decompression surgery and de-innervation surgery of painful areas in your sacroiliac joints and at the lumbosacral junction that is typically done at an OUTPATIENT SURGERY CENTER. Preoperative blood work is usually done at the surgery center just prior to your surgery.

Should you have medical problems, such as cardiac or pulmonary, renal disease, thyroid dysfunction, or diabetes to name a few, additional preoperative clearance examinations from your primary care doctor or treating specialist may be required. These tests performed before your scheduled surgery may allow your physician to identify particular health problems that could require further evaluation before anesthesia and surgery. REGARDLESS OF THE EXTENT OF YOUR PREOPERATIVE WORKUP, IT IS NOT A GUARANTEE THAT YOUR SURGERY MAY BE DONE AT AN OUTPATIENT SURGERY CENTER. In some cases, the surgery may be cancelled if the anesthesiologist deems your medical problems at the time of the scheduled procedure as not appropriately managed, or deems your surgery at an outpatient surgery center as too risky and recommends that the procedure be done at a hospital instead.

Diagnostic imaging studies of the lumbar spine, such as CT or MRI scans, a bone scan, and possibly a myelogram, may already have been performed and provide your surgeon with anatomic detail for surgery. Other electrodiagnostic tests (EMG/NCV or SSEPs) may give additional, important information.

Nothing to Eat or Drink After Midnight

Eat a light dinner before 7 P.M. on the evening before your surgery. DO NOT EAT, DRINK, SMOKE, CHEW, OR SWALLOW ANYTHING AFTER MIDNIGHT THE NIGHT BEFORE SURGERY except as directed by the surgery center.

Preoperative Screening by the Surgery Center

The surgery center may call you preoperatively to review your medications, and to determine whether there are any new medical problems unknown at the time of scheduling of your surgery that could potentially be problematic. They may also give you directions as to where and when to report. You should report no later than 2 hours prior to the scheduled surgery time to the surgery center.

Medications to Stop Prior to Surgery

It is imperative for you to stop all NSAIDS (non-steroidal anti-inflammatory drugs) and all other medications affecting the clotting ability of your blood during surgery a minimum of 10 DAYS PRIOR TO your scheduled SURGERY. You not stopping these drugs may affect platelet aggregation and therefore have an anticoagulative side effect. Therefore, significant intraoperative bleeding, increased complication rate with epidural hematoma with potential neurological deficits, infection, and wound problems may occur. There may also be a need for blood transfusions, and potential follow up surgeries to deal with these complications. There are other blood thinners (For example, COUMADIN, XARELTO, PRADAXA, LOVENOX, HEPARIN) that maybe prescribed by your doctor for heart and vascular disease. COUMADIN should be STOPPED 7 DAYS PRIOR TO SURGERY. XARELTO, PRADAXA AND OTHERS may have to be stopped only only a few days prior to surgery. Please check with your prescribing physician. Ideally, you are also OFF XARALTO, or PRADAX ONE WEEK PRIOR TO SURGERY. In addition, you should stop FISH OIL, homeopathic drugs, and any other non-essential drugs that you think may increase your risk of bleeding.

At times, it may not be possible for you to stop these drugs. Please consult with your primary care physician, cardiologist, pulmonologist, vascular surgeon or other subspecialty provider, that may have started you on this type of blood thinner, prior to signing up for surgery. It may be safe for you to come off a prescription blood thinner prior to surgery. However, it may not be. Please check with your doctor who prescribed it prior to surgery.

Report to Admitting in the Preop Area

The surgery center will notify you of the time and location where you should go before your surgery. Do not accept or follow any other directions unless you discuss it with our office, 520-204-1495.

AFTER YOUR OPERATION

Pain & Pain Control

After surgery you may experience pain in the region of the incision. Some back and leg pain as well as tingling or numbness may also be present.

Initially, you may notice complete pain relief following this outpatient procedure. This is due to local anesthesia and medication you received during surgery or in the recovery room. This effect will subside over time as the effect of local anesthesia and other systemically administered anesthestic drugs wear off. However, new pain may develop several days postoperatively after an initial “HONEYMOON” period of several days. There may be new pain on the side of the operated extremity or extremities due to inflammation and swelling of the previously compressed nerves. This postoperative inflammatory response of the spinal nerves may produce constant burning in the legs. Typically, it occurs 4 – 10 days postoperatively after a short period of no leg pain. Don’t be alarmed about this type of new pain. It will diminish within a few weeks and may respond well to epidural steroid injections. Please tell your surgeon if you are experiencing this new type of pain during your postoperative visit(s). Your physician may prescribe NEURONTIN (Gabapentin) or LYRICA (Pregabalin) or schedule you for epidural steroid injections to calm symptoms down quicker.

Although this outpatient surgery can be done under sedation and local anesthesia, most patients find it more comfortable and less stressful to undergo a short general anesthesia with a secure airway. Therefore, some patients experience a sore throat and swallowing difficulty after general anesthesia and surgery. This is from manipulation of tissue and the presence of the breathing tube for anesthesia. The sore throat usually will subside within a week. The swallowing difficulty may take longer. Using throat lozenges or lemon drops, sipping cool liquids, or sucking ice chips may soothe this pain.

If you are SHORT OF BREATH, or have EXCESSIVE CHEST, OR CHEST WALL PAIN, please GO TO THE NEAREST EMERGENGY ROOM as you may be having a postoperative heart attack, or a symptomatic blood clot in the lungs. Postoperative MYOCARDAL INFARCTION, and PULMONARY EMBOLISM are rare but do occur occasionally and you should take these symptoms seriously.

If you are having pain with voiding, you may have a urinary tract infection. Sometimes, this symptom is accompanied by fevers and generalized malaise. If you are unable to void and these symtpoms are coupled with excruciating leg or back pain, please report to the NEAREST EMERGENCY ROOM to be evaluated for a symptomatic EPIDURAL HEMATOMA.

Activity

Although this is a small outpatient surgery, you need to give your body time to heal. Below is a list of instructions that you should follow until your first follow-up visit after surgery. You no longer need to wear the anti-thrombosis (TED) stocking (heavy white stockings) once you are home. You may sleep either on your back, stomach or side. You may also use pillows for support, when lying on your side. Place pillows behind your back and between your legs. When on your back place pillows underneath your legs. You may climb stairs, just try not to over-do.

For your comfort, we suggest that you change your position at least every hour when awake. If you become uncomfortable change your position and activity. You should begin a walking program two to three days after surgery. You may shower 5 days after surgery. If you must shower sooner, you must keep the incision covered and dry while showering. No baths for 4 weeks. No hot tubs or swimming for 6 weeks. NO BENDING, TWISTING OR LIFTING.

Once you are permitted to sit, use ONLY a straight back chair such as a dining room chair of kitchen chair. A sturdy "wing back" chair is an option. Each day increase the time & frequency that you sit. (Example: 1st day, sit 3 times for 15 minutes each/2nd day 4 times for 20 minutes each/3rd day 5 times for 25 minutes, etc.) If there is pain after a few minutes GET UP. "LISTEN TO YOUR BODY"

After leaving the hospital you will be allowed in the car TWICE, ONCE TO GO HOME, THE SECOND TO COME BACK TO THE OFFICE. You will get your next set of instructions upon your return. For patients from out of state or country, there will be specific instructions.

Walking Program

Begin walking in the house and progress to outdoors. Take someone with you the first few times. Slowly increase the distance each day so that you will be walking 1 mile/day by your 2nd post-operative week, 2 miles/day at 2 weeks’ post-operative. Hopefully, by 4 weeks’ post-operative you will be walking 4 miles/day. If you feel soreness, reduce the distance and REST. These are GUIDELINES, NOT RULES.

• Day 1 Walk the length of the hallway at home 3-4 times, or walk to the end of the driveway and back once in the morning and again in the afternoon or evening.
• Day 2 Walk 1/2 block or the equivalent of a 1/2 block indoors once in the morning and again in the afternoon or evening.
• Day 3 Walk 1 block in the morning and again in the afternoon or evening.
• Day 4 Walk 2 blocks in the morning and again in the afternoon or evening.
• Day 5 Walk 3 blocks in the morning and again in the afternoon or evening. Continue increasing the distance you walk, as you are able. Let your comfort be your guide to how much you can do.

Limitations

• No driving for 2 weeks, or while taking narcotic pain medication. However, you may be a passenger.
• No lifting greater than 10 lbs. (about 1 gallon of milk) for the first 5-6 weeks after surgery.
• No bending at the waist, however, you may squat with your knees.
• No sports activity until your first follow-up visit other than the walking program.
• No sexual activity for 2 weeks.

Showering / Personal Hygiene

You may shower the morning after surgery. However, it is important to keep the dressing and incisions dry. You may cover cover the dressing with an adhesive and occlusive dressing. DO NOT soak the incision. Do not disturb steri-strips, staples, or sutures.

If You Are Not Sure

If you question whether or not you can do something beyond the instructions given, it is safe to assume that the answer will be NO.

Follow Up Visit in Our Office

Return to the office for your first visit approximately 7 - 10 days after surgery. Typically, you will be given a follow up appointment to our office during your preoperative visit. If you are not sure about your first postoperative visit, please call our office for an appointment (520-204-1495) or if you have questions or concerns. For GENERAL MEDICAL PROBLEMS CONTACT your personal physician.

Return to Driving

No driving for a minimum of 1 week, or for the time while taking extra narcotic pain medication as a result of the surgery. However, you may be a passenger.

Return to Work

Your return to work will depend on your recovery and the type of work you do. You must discuss this with your doctor before you return to work.

Pain Management

For pain management, you will usually be given a prescription for a drug like VICODIN (hydrocodone) or OXYCODONE. For additional pain medication, try Extra strength Tylenol or similar agent. In addition, you may receive a prescription for VALIUM which can help with postoperative muscle spasms.

You should take the pain medication you were given by our office with careful consideration and be knowledgeable about their potential compounding interaction with other narcotics or other medications. Check with your local pharmacist as well should you have any questions as to potential drug interactions.

MEDICATIONS

You may have an occasional increase in back, leg pain and/or numbness after surgery during the healing phase. This is normal and is caused by inflammation (or swelling) of muscle tissue and your spinal nerves in your lower back. To reduce pain there are several approaches to decrease the pain you may be experiencing:

• Ice the low back area for 15-20 minutes every hour for 4 consecutive hours. Do not put the ice directly on your skin. Use a ready-made ice pack or put ice in a plastic bag then wrap the ice pack or bag in a towel before you use it. If you have been given a cooling device, please use while in bed.
• Avoid sitting for more than 30-60 minutes at a time for the next 48 hours.
• Reduce your activity (i.e. walking) for the next 48 hours.
• Take the pain medicine as directed by your doctor for incisional pain. You can also take one extra strength acetaminophen (Tylenol) every 4 hours between the prescription medicines, only as directed. Do not take more than 4000 mg of Tylenol in a 24-hour period. NOTE: Some narcotic pain medicines also have Tylenol in them.
• Do not take narcotic pain medicine for burning pain radiating down the leg. This pain is most likely from inflammation of the nerve. Narcotic pain medication does not help for this type of pain. Take Neurontin (Gabapentin) or Lyrica (Pregabalin) as instructed by your doctor/surgeon. Call the office for a follow up appointment. This neurognic pain typically improves dramatically with an epidural steroid injection into your lower back by placing steroids around the inflamed nerves.
• Eventually you should no longer need to use narcotic pain medicine. Most patients find it unnecessary to take narcotic pain medication within a few days from surgery as the small incisions do not hurt that much.

Removal of Staples or Stitches

Surgical skin staples or sutures are typically removed during your first postoperative visit. If you live far away out of town and an early postoperative visit in our office may pose a particularly hardship for you, you may contact your primary care physician to have her/him remove the staples or stitches. Skin stapes should be removed no later than 2 weeks from the day of surgery. We typically use biodegradable stitches for skin closure and they may simply dissolve and fall off. However, you may have them removed no later than 2 weeks from surgery as well if they bother you. You may develop redness around the staples which typically resolves quickly without additional treatment.

Incision Care

Caring for your Incision at home is important to prevent infection. Please follow these steps:

• Your incisions have been closed either with skin staples or with absorbable suture material. In most cases these areas are covered with a Band-Aid or a small dressing. You may remove the dressing 3-5 days after surgery.
• The stiches will gradually fall off with time and this is normal.
• Staples should be removed within 14 days of your surgery. It is therefore prudent for you to show for your first postoperative visit.
• Take your temperature twice a day, once in the morning and once in the evening for the first 7 days.

The wound will be checked and the dressing will be changed prior to discharge home from the surgery center. You may take a shower when you get home. If the Band-Aid gets wet, simply replace it with a new one. DO NOT TAKE BATH AND DO NOT SOAK THE WOUND. Once the dressing is removed you may leave the wound open to air.

Do not be alarmed when you have bloody or serosangineous drainage from the wound(s). This is normal and part of your postoperative recovery. There may also be some bruising around the lumbar incisional area(s). However, call our office if you have persistent drainage for more than 3 days or a new onset of drainage sometime after 7 - 10 days from your surgery. You should also let us know if you are having any fevers (temperature over 101 F) or chills. This may suggest a wound infection. Although uncommon wound infection occur in under 0.1 % of patients who underwent outpatient percutaneous decompression surgery.

Be advised though that elevated temperatures after surgery can be normal and often is a result of poor lung ventilation. Taking deep breath, and ambulating as much as you can tolerate may help with this problem.

When to Call Your Doctor or Nurse

PAIN IS A RED FLAG TELLING YOU TO REST. Avoid taking pain relieving medication in anticipation that something you will do is going to cause pain.

• If you have a temperature above 101 degrees F (38.8 degrees C) for two readings four hours apart. If you develop a low grade fever, keep a chart of your temperature pattern at 8 AM, 12 noon, 4 & 8 PM. Bring the chart to the office at your next visit.
• Clear drainage from your incision, excessive, wound redness, swelling, purulent drainage or infection.
• An increase in pain, redness and/or swelling by your incision.
• Difficulty urinating or controlling your bowel movements.

When to Call 911

• If you have difficulty breathing, or have an irregular heartbeat, or chest pain, or progressive neurological deficit (progressive weakness in the extremities).

Future Follow-Up Visits

Your first post-op visit is usually scheduled along with your surgery. If you are unsure of your first postoperative appointment, please call (520) 204-1495 to make your first post-operative appointment at the Center for Advanced Spine Care of Southern Arizona. This usually occurs 7 – 10 days after your surgical procedure. All other follow-up visits will be directed by your physician.

Medications

If you need a prescription filled.

Because your health condition may change over time, your doctor or another physician provider, who have access to your confidential medical records, will need to address your refill requests. By following these simple guidelines, you will avoid any delay in getting your prescription refilled:

• Contact your pharmacy at least 5 days before your prescription requires refilling, to protect your health, pharmacies will accept refill orders only from your doctor. So, when you call The Center for Advanced Spinal Care of Southern Arizona with your request an additional step is added. Your prescription will be filled faster if you call your pharmacy directly, they will then contact The Center for Advanced Spine Care of Southern Arizona.
• Use the same pharmacy. That way, your pharmacist will have your complete prescription records and you avoid the danger of mixing medications. To make it convenient for you, the Center for Advanced Spinal Care of Southern Arizona will work with the pharmacy of your choice. Please choose one pharmacy, and use only that pharmacy. It is an easy way to help protect your health, as well as your health records.
• Call your pharmacy early in the day. This gives your doctor time to review your records. To ensure you get the right medications, we do not rush refills without making sure the order and your records are reviewed. Often, physicians are in surgery or finishing with patients late in the day, and we do not want to interrupt those patients’ visits just like you would not like to have your visit interrupted when in the office with the physician. Therefore, refill requests received after 3 pm Monday through Thursday or after 10 am Friday will be reviewed and filled the next business day for The Center for Advanced Spine Care of Southern Arizona.

If You Run Out of Medication Before You Request a Refill

Always call your pharmacy at least 5 days before you run out of medication. This will give the pharmacy plenty of time to contact your doctor, for the doctor to review your record, and for the pharmacist to prepare your medication. All you have to do is watch your medication levels and there should be no reason for you to run out of medication or run out of medication early prior to the scheduled date. It is dangerous to “rush” an order. For your protection, refills are not done at night, over the weekend, on holidays or as an emergency if you have forgotten to call your pharmacy.

If You Run Out of Your Medication Early

Your doctor ordered your prescription according to a precise dosage for a prescribed amount of days. If you run out early, it may mean you are experiencing some difficulty with your dosage or medication. Call The Center for Advanced Spine Care of Southern Arizona immediately and explain your difficulty.

If Your Prescription Is Lost, Misplaced or Stolen:

To protect your health, lost or stolen prescriptions are replaced only with a physician visit. Stolen medication will require a police report to be completed and a copy of the report brought with to your visit. To avoid possible duplication of prescriptions when an order is lost or stolen, you will want to talk with your doctor. Call The Center for Advanced Spine Care to schedule an appointment. Please call our office at (520) 204-1495 with any additional questions that may come during your postoperative recovery.

Please acknowledge that you have read and understood these postop instructions.