What is a Lower Back Fusion and why do we do it?
A spinal fusion is an operation to stabilise an area of the spine. It can be done by a variety of techniques depending upon the condition of the spine that is being treated, and the underlying pathology. The commonest 2 types of spinal fusion are called a Transforaminal Lumbar Interbody Fusion (TLIF) or a Posterior Lumbar Interbody Fusion (PLIF). Other options include an anterior operation (ALIF) or surgery with a surgical approach from the side (XLIF).
The aim of a spinal fusion is to ‘weld’ two vertebrae together to prevent painful movement. Spinal fusion is achieved by the use of bone graft between two bony surfaces of the spine. The idea is to make the body behave as if there has been a fracture, so that the two bony surfaces are joined together with new bone. This fusion is enhanced by the use of instrumentation.
There are 3 main indications for fusion surgery:
- To treat a spondylolisthesis. In this condition the arch of one of the vertebrae weakens or fractures. This allows a deformity to occur in which the nerves become increasingly compressed.
- When symptoms persist after previous surgical decompression or discectomy.
- To treat chronic mechanical spinal pain arising from one or more of the lower three spinal segments.
Although the success of surgery with regards to achieving fusion is excellent, this operation remains uncertain with regard to clinical outcome. The clinical outcome varies according to the underlying pathology.
Before you come into Hospital
Smoking has been shown to have an adverse affect on the outcome of fusion surgery. We, therefore, strongly advise you to stop smoking before you have your operation. If you are overweight, then please try to reduce it as this will lower your anaesthetic risk and optimise your recovery.
If you are on any medication that has the potential to thin your blood such as aspirin, clopidogrel, warfarin or any other blood thinning medication then we do need to know about this prior to the date of your injection as this will usually need to be stopped prior to your operation.
If you take anti-inflammatory tablets then you must stop taking them 7 days before your surgery.
How do we do a TLIF/PLIF?
The surgery is done under a general anaesthetic. You will meet the anaesthetist on the ward prior to your surgery who will explain the anaesthetic to you. The operation takes about 3 hours. Once asleep the patient is placed on their front on the operating table. X-ray is used to identify the correct area of the lower back. Either one or two incisions will be made, depending on the underlying pathology. A TLIF / PLIF involves the following steps:
- The spinal nerves are decompressed
- The disc is removed. The disc space is filled with a spacer, called a ‘cage’. Bone graft is packed in front of the cage. The bone graft used is bone that is removed as a part of the surgical approach.
- The adjacent vertebral bodies are rigidly fixed with rods and screws.
When appropriate minimally invasive techniques will be used for your surgery. These techniques cause less muscle damage, result in less post-operative pain, and lead to a quicker recovery.
At the end of the operation the wound(s) will be closed with dissolvable stitches and covered with a dressing.
What are the Risks?
The risk of infection is less than 1%. All patients receive a dose of intravenous antibiotics when they are going off to sleep. If you develop an infection it is most likely to be a superficial wound infection that will resolve with a short course of oral antibiotics. Occasionally patients develop a deep infection. This is much more serious and may require a prolonged course of intravenous antibiotics or additional surgery.
You will lose some blood during the operation. We would normally expect your body to be able to deal with this blood loss without needing a blood transfusion. There are large blood vessels in front of the disc and there are reported cases of these blood vessels being damaged during surgery resulting in a very serious and potentially life-threatening blood loss. This type of bleeding is extremely rare and is reported to occur in approximately 1 in 25 000 cases.
Developing blood clots in the legs (deep vein thrombosis – DVT) is a risk of any surgery. We worry about DVTs as bits can break off a travel around your body. This is called an embolus. An embolus can affect your breathing, cause you to have a stroke, and could potentially be fatal. DVTs occur in approximately 1 in 200 patients having back surgery. An embolus is a much less common occurrence. We minimize the risk of DVT by asking patients to wear hospital stockings following their surgery (TEDS), and mechanical pumps during and immediately after surgery. These pumps squeeze your lower legs, helping the blood to circulate. They are put on when you go to sleep and stay on until you start to mobilize. We encourage early mobilization as this also helps to prevent DVTs. If a patient is considered to be high risk for a DVT then we will prescribe blood thinning medication for a couple of weeks after your surgery.
The spinal instrumentation is inserted very close to the emerging spinal nerves. In doing this there is a risk of physical damage to the nerve. This can lead to loss of nerve function with persisting pain, weakness, and numbness in the territory of that nerve. This complication can occur in up to 5% of patients. Although further surgery may be undertaken to remove or adjust an implant, the loss of function and pain from a damaged nerve may be permanent.
With any lower back surgery there is a risk of nerve injury which could cause leg pain and weakness. It is possible that a nerve injury could also affect your bladder and bowel function, as well as erectile function in men.
Occasionally the lining to the nerve (the dura) can be damaged causing the leakage of the fluid that surrounds the nerves (the cerebro-spinal fluid). Some tears are managed conservatively, whilst others require surgical repair. Patients who have had a dural tear may be asked to stay in bed for a short period of time following their operation on flat bed rest. This would normally be for between 24 hours and 5-days. Occasionally a persistent leakage of spinal fluid occurs which may require further surgery.
Scar tissue can form around the nerve and can cause persisting neurological symptoms. This is not common. We will usually try and treat this with injections rather than further surgery.
Even is a successful fusion is achieved, it does not guarantee the relief of back pain. 5-10% of patients will report increased back pain following this type of surgery.
Failure of Fusion
A small number of patients do not develop a satisfactory fusion. In these cases there can be on-going pain, usually back pain. In this situation your fusion may need to be redone.
Risks Associated with having an Operation on your Front
When getting you ready for surgery, care is taken to ensure that everything is protected. The does however remain a small risk of pressure damage. This can cause some temporary skin damage to the tip of your nose and your chin. This would normally completely recover over 2-3 weeks. There is a very small risk of some damage to your vision. Visual damage is reported as occurring in 1 in 10 000 cases.
Following any operation there is a small risk of post-operative medical complications, such as chest infections or urine infections.
What Can I Expect Following my Fusion?
When you wake up following your operation you will feel bruised in your lower back. We try and minimize this by injecting local anaesthetic around the wound. You will also be given a patient controlled morphine pump (PCA) to help with your pain relief for the first 24-hours after your operation. Some patients require a urinary catheter.
Day 1 post-op – You will be seen by a physiotherapist with the aim of getting you up on to your feet. You should continue to practice getting up.
Days 2-5 post-op – Gradually increase your mobility about the ward with the aid of the physiotherapists and nursing staff. When resting, it is good to alternate between sitting and lying down. If you place a pillow between your knees then you can lie on your side. You will be discharged home when you are moving around comfortably and safely. Before you go home the nurses will explain how you need to look after your wound(s).
The post-operative discomfort will take a few weeks to settle down. The wound will be closed with a dissolvable suture, so there will be no stitches that need to be taken out. Your wound will require minimal attention after discharge.
Following your operation you should not take any anti-inflammatories. This is because they reduce the potential for fusion, and therefore reduce the likelihood of a successful outcome.
For the first 6-weeks you will need to take things relatively easy. During this time you should gradually increase your walking distance. You should aim to walk twice a day. During the first 6-weeks you should limit activity to gentle walking and stretches. You must avoid any lifting.
You should continue to wear your hospital stockings for the first 6-weeks.
After 6-weeks you can increase your activity level and start to do some gentle non-impact exercise as comfort allows (gentle swimming, light cycling, cross-trainer). You can start to do some light lifting, but should not lift more than 10kg until 3-months following your operation. Do not return to impact or increased torsion exercise (eg. jogging, golf) for 6-months.
Returning to Work
People with non-manual jobs will normally be able to return to work after 4-weeks, pending a satisfactory review. It will be 3-months before you can return to manual work.
There is no restriction with the DVLA, though there will be with your insurance company. You will need to be able to undertake an emergency stop, and be in complete control of your car at all times without being distracted by pain. If this is not the case then your insurance will NOT be valid. Most patients are back to driving within 4 weeks of their surgery.
You should not fly for 6-weeks following your surgery. You should not undertake any long haul flights for 3-months. If traveling on a long haul flight within 6-months of your operation then you should wear your hospital stockings when flying.
You will be seen back in the clinic a few weeks after your operation. An appointment will be made for you before you are discharged.
What Patients Say
Mr Langdon has a calm and reassuringly expert professional manner that inspires confidence. He understood my fear of surgery and provided me with clear information in response to my many questions. He allowed me to take my time and reach a decision that I was happy with.
Mr Langdon took time to explain the procedure to me, also the possible side effects. He gave me every confidence regarding what would happen on the day
Mr Langdon’s manner was professional and friendly – he gave me confidence in the operation and hospital care. December 2020
Very professional and explained in detail all that could and would happen. December 2020
Cannot fault Mr Langdon in any way. February 2021
I felt that every one of my procedures was explained extremely well and prior to my operation. Mr Langdon outlined all of the issues that could occur, I felt very cared for and looked after, especially after my operation. February 2021
From my very first appointment I felt confident that I had chosen the right consultant, he made a plan and he stuck to it & made everything understandable. February 2021
James Langdon was pleasant, listened, explained my problem and possible solutions. Also has a great approach when mentioning I look at and manage my problem to evaluate it as tolerable and carry on or as needed intervention. July 2021
Mr Langdon is a very caring, nice guy who obviously knows his business. July 2021
Mr Langdon was excellent. He came recommended to me through a friend who knows him so I was always confident with his ability. He explained everything perfectly during the 1st assessment. The operation he performed on me was very successful and I am recovering well, and he also checked in on me after the operation a few times and talked me through the recovery. All in all, I’m very happy and satisfied. October 2020
Mr Langdon was brilliant from the start. I saw him at a different clinic first – but then the procedure was at Spire Harpenden. I feel he’s the best consultant I’ve seen in regards to my back – and I’ll certainly recommend him to friends and family for his outstanding knowledge and quick responses. October 2020
Displayed his knowledge perfectly with understanding my issue and needs. October 2020
I read about my consultant prior to booking my appointment with him as I felt he specialised in the treatment that I needed. He was very thorough and gave me lots of information about my procedure. He arranged for me to have my MRI scan ASAP and was booked in for my procedure very quickly. I have a follow up appointment with him in 2 weeks and hope to greet him with some positive results to my treatment. October 2020
First class. October 2020
Mr Langdon is kind, approachable and professional. November 2020
Explained clearly what would happen, good communication skills (eye contact, listened to me). November 2020
Excellent relaxed manner. November 2020
Mr Langdon is very attentive, understanding and patient I didn’t feel rushed at any stage. My decision was based on the straightforward and detailed information I received both verbally and written. Mr Langdon knows his stuff and I would without any hesitation recommend him 100%. I’m early recovery but I’m hopeful and confident that I will get my life back. Thank you James! November 2020
Very professional, willing to explain my questions and concerns. August 2020
Mr James Langdon was extremely helpful and informative. Fantastic bedside manner. July 2020
Mr Langdon has been fantastic. Not only, importantly, inspiring confidence, but practical and down to earth. He always ensured I had the opportunity to ask questions. Feb 2020
Extremely lucky to have Mr Langdon and his team, in every way so professional and so easy to talk with. September 2020
I had every faith in my consultant, that he was advising me and working in my best interest. September 2020
Mr Langdon is a caring person, listened to me and fully explained and discussed everything with me. I had complete confidence in him. September 2020
Once again a massive thank you to Mr Langdon and his team for their outstanding work and making the whole experience bearable. September 2020
I would like to express my sincere thanks and gratitude for curing my pain. For months I have suffered in agony day and night. I was in despair and you were my last hope. Now I am not in pain! I am continually smiling and enjoying life again! March 2020
Mr Langdon was great from start to finish. I know that he saw me at the end of an already full clinic and on top of that arranged an immediate MRI…making him much later than he needed to be in getting home! I was in a great deal of pain and I very much appreciated his help in getting me sorted as fast as possible. He made sure I was early on in the running order of procedures on the day of my treatment and everything was explained well to me both before and afterwards. Cannot fault in any way. Thank you very much.
Very patient took his time explaining the surgery and aftercare. Very knowledge about my condition. Made me feel relaxed and in safe hands as I was very scared of the surgery itself and the possible risks.
Very caring, explained fully what was wrong and what he was going to do. December 2019
He was very professional and helpful before, during and after my minor treatment. December 2019
Mr Langdon was extremely helpful and reassuring. December 2019
Mr Langdon was clear and confident with his communication. This is reassuring for a patient. December 2019
Professional and treated to a high standard. Mr Langdon was excellent, he knew everything on my condition explaining all the options available. December 2019
Mr Langdon’s manner was very polite, professional and efficient, he answered all her questions and came to see her quickly after her epidural. June 2017
I have just completed a 102 mile walk over 7 days. Thank you so much for patching me up and making this experience possible. June 2017
Thank you for your specialist surgical and operational skills as well as your patient friendly approach. The two don’t always go together. We need people like you to maintain such high standards of surgery and care. October 2017
I wanted to take the opportunity to thank you and your team following my surgery. It has been so long since I felt so well and without pain. The surgery and my recuperation has far surpassed my expectations and has made a huge difference to my lifestyle. December 2017
Three months on from my back operation and I am feeling so much better. Thank you for all the kindness and support you showed when I was in such desperate pain. February 2018
Thank you so much for the work that you have done. What an incredible job you have and do. Life changing. March 2018
Thank you for all you have done for me during the last few weeks. I am most grateful not only for the main work but also the extras like telephoning to keep me informed. April 2018
I cannot thank you enough for the success of my back operation. Everyone was so pessimistic and you were so positive. May 2018
I was at all times given all necessary information, listened to, and I had confidence that Mr Langdon would complete the operation successfully. August 2018
Highly skilled and intuitive. October 2018
He was brilliant, I felt so comfortable that he would look after me even though I felt so anxious, and he made sure to give me all the information I needed. Also, every nurse and employee of Spire had nothing but brilliant things to say about Mr Langdon – I didn’t even need to ask. They would look on my notes and see I had Mr Langdon and say I was in excellent hands, and so I felt extremely happy. My partner also has disc problems so I will very much be pointing him to Mr Langdon October 2018
Very understanding and caring chap from start to finish, and a great bedside manner, unusual for some consultants. He is trying hard to understand my problems and working with me on a treatment plan for the present, and the future. November 2018
My consultant is obviously a very competent person and comes across as such. My procedure was fully explained both before and after my surgery. He also has a professional sense of humour, which helped as I was very nervous November 2018
Mr Langdon was always prepared to fully explain what was wrong and what he could do about it, he gave me a lot of confidence to make the decision to operate, and so far so good. Albeit early days. November 2018
Mr Langdon was very professional and helpful, he came in on his day off because my treatment had to be moved. November 2018
Excellent, extremely knowledgeable on his speciality. I managed to get an appointment to see him at very short notice for which I was very grateful. December 2018
Excellent surgeon, great manner, explained procedure well. December 2018
A good sense of humour, understanding and non-judgmental. They explained everything very clearly. January 2019
Mr Langdon, very professional and calm, did not push the treatment on me which I really liked, but advised and let me make up my own mind. January 2019
James Langdon is a really good person to have on your side. He’s smart, attentive and very dedicated. January 2019
I felt very safe with Mr Langdon, he fully explained the procedure, the risks and the recovery. January 2019
A very professional consultant. Showed great care and understood me as a person and patient. Saw me pre procedure and after in recovery room and own room. Visited again before going home in late evening and yet again first thing the next morning. It felt like I was Mr Langdon’s only patient which I know is far from the truth. Unfortunately, I am a nervous patient but could not have been in better hands. Many thanks January 2019
Explained everything in detail, understood my concerns, excellent bedside manner, very professional. January 2019
James Langdon is very patient – he answers questions and really listens to you and explains again if you haven’t quite got something. March 2019
Mr James Langdon was in every way, courteous, clearly good at his particular area of expertise, took time out every day to see me and check that all was ok. Was happy to answer any questions I had. April 2019
Mr Langdon was very understanding about my condition and talked me through every procedure that could help me get more mobile again. I was always at ease with him with his caring attitude. A true professional thanks. April 2019
Mr Langdon gave a full explanation of the procedure and what would happen and what to do afterwards. Perfect. May 2019
Fully informed by Consultant Surgeon and Consultant Anaethetist who put me at ease with procedure. May 2019
I saw Mr Langdon before I had the operation and he explained everything that would happen on the day of the operation. June 2019
Very attentive, understood exactly what I was saying and made me feel confident that what I was doing was the right thing. June 2019
Mr. Langdon gave you complete confidence that all would be well and that he was available if needed at any time. He showed kindness and consideration. June 2019
Calm, professional, helpful. July 2019
Everything went off so smoothly. So pleased that the operation was so successful & the next day I was able to walk around without pain. July 2019
In overall terms he was absolutely brilliant. Clearly he is a brilliant surgeon but also a wonderful and understanding human being who, whilst pointing out the risks involved in the operation, filled me with absolute confidence that if success was possible, it would definitely be achieved – and I am delighted to say that it was. He is certainly a hero to me! It was also abundantly clear that all the staff at the hospital have absolute confidence in him and hold him in the highest regard. August 2019
Excellent, he fitted me in with an early appointment and treated me extremely well. September 2019
Extremely helpful explained everything very clearly. September 2019
Mr Langdon has been very clear and concise about the treatment he would be providing and the possible outcome. He has a very professional manner and I felt very at ease with him. He provided me with lots of information and visited me numerous times after my operation to see how I was and to explain what was done and what I should expect. I would be very happy to see Mr Langdon again in the future should I have a need to. September 2019
Caring conscientious and totally professional in all respects. September 2019
Mr Langdon gave me the confidence to go ahead with surgery that I was very worried about. He is very professional and thoroughly explained all the pros, cons and side effects that could possibly happen. All of the above helped me to make a more informed decision. October 2019
James Langdon was the consummate professional. He explained his diagnosis in plain language that was easy to understand and interpret from a layman’s point of view. He was careful to manage expectations and clear about potential risks keeping them in perspective and proportionate to the circumstances. His manner was direct whilst always retaining a caring attitude listening to the patient and answering questions clearly; even taking time out to follow up with my wife whilst I was still in post Op recovery. Very thorough and I would highly recommend James. October 2019
Fully explained the treatment I required and the reasons why. I felt very confident I was in good hands. October 2019
Professional, inspires confidence. October 2019
He was very understanding explaining everything very carefully and advising me on altering medication for the procedure and when to restart normal regime. November 2019
He was courteous, listened, understood the issue very quickly. Explained everything well and was sure to confirm I understood and asked if I had questions. I didn’t feel hurried. He provided an effective and efficient service. I’d definitely recommend him. November 2019
Professional and approachable. November 2019
Extremely happy. Care was first class throughout the stay and looked after all my needs November 2019
Very approachable, caring, friendly, put me at ease. December 2019
Very approachable and knowledgeable. Felt I was in very safe hands. December 2019
Very professional throughout. December 2019
Mr Langdon diagnosed my problem, explained fully the options I had regarding treatment also all the risks involved if I chose to have an operation. Mr Langdon organised a scan to confirm his diagnosis, and explained to me prior to my operation all that was involved in the procedure. Post operation Mr Langdon visited me in my room to check on my recovery and gave me the opportunity to ask any questions on the operation. I am very satisfied with Mr Langdon and his team on my treatment. December 2019
My marks of 10 across all questions reflect my opinion of James Langdon. Brilliant in all respects, in particular his explanation to a non medical man of my problem and his solution. December 2019
The consultant was fantastic. He explained everything I needed to know at each stage and I felt very confident that I was in good hands. December 2019
Spire Harpenden Hospital
(01582) 714 304