Pre-op instructions / surgery the process
A Few Weeks Before Surgery
Once a decision has been made to proceed with surgery and consent obtained, a date for surgery will be given to you. One week prior to surgery you will have blood tests and when required chest X-Rays, ECG or other investigations. Any complex medical issues may require extra consultations with a physician and issues relating to risks of anaesthesia may require a brief consultation with my anaesthetist.
Take advantage of this time to consider the amount of time you will need off work after the procedure and discuss this with your employer if indicated. Dr Scholsem can post or email you a medical certificate when required. It is also important to plan ahead for what help you may need at home after surgery and discuss this with family and friends. Arranging this prior to surgery will help you to be able to focus on your recovery post-operatively.
A Few Days Before Surgery:
Do I need to do anything special the day or night before surgery?
Try to relax and get as much sleep as possible. Don’t make any drastic changes in your routine and make sure to stop any anti inflammatory drugs seven days before the surgery (unless specified otherwise) and blood thinners such as Warfarin, Aspirin and herbal supplements etc Dr Scholsem will tell you the exact date to stop them.
Do not hesitate to call us if something has changed or you have any questions.
Eat a light dinner the evening before your surgery. We will tell you when you need to start fasting and when to come to hospital. Except in complex cases, patients are admitted to hospital on the day of surgery.
Keep taking the following medications the morning of surgery with a sip of water:
- Bring a current list of medications that you take regularly.
- Bring containers to store your contacts, eyeglasses, hearing aid, etc.
- Do not bring jewellery or other valuables, including wedding rings or body piercing.
- Do not wear makeup, hairpins, nail polish, body powder, or contact lenses if possible.
- If you are a smoker it is highly advisable to reduce or stop smoking before and after the procedure. Smoking has been shown to increase the risk of non-union as well as post-operative complications
- Don’t forget to bring all your imaging: X-rays, CT, MRI if you did not leave it at the office prior to surgery.
On the day of surgery
The hospital will direct you where to go for registration. After checking in you will be asked to change into a hospital gown and taken into the pre-op area where a nurse will go through your past medical history, medications and allergies.
Dr Scholsem and the anaesthetist will also meet with you in the pre operative area. Dr Scholsem will go through the major steps of the surgery again and make sure that nothing has changed since he last saw you. Your family member can stay with you until your are transferred to the operating room.
Once the surgery is complete you will spend approximately 30 minutes to one hour in recovery where Dr Scholsem will again come to see you. There will be a nurse by your side to attend to any need and Dr Scholsem will telephone your next of kin to reassure them and let them know when they can see you.
Most patients will have a PCA (patient controlled analgesia) pump with which to control the pain from the surgical site. You will usually receive some intravenous antibiotics for at least 24 hours following surgery and as much pain relief as you need. Solid foods can be ingested once the bowels have started to work (usually 24-hours). For surgery lasting more than 1 or 2 hours patients will have a catheter in their bladder draining their urine.
Hospital Post Operative Day1
In most of the patients the PCA will be stopped and you will be given oral slow release painkillers. They will be as strong as the IV painkillers you received overnight and will manage the pain more effectively due to their better pharmacodynamics.
You will be seen by the physiotherapist the morning after surgery and he /she will encourage and supervise your early mobilisation. You will be shown techniques to get in and out of bed and chairs, how to use a walker and mobilise in the hallway and stairs.
Drain and indwelling catheter
You may have a drain in your incision post-operatively to help prevent fluid from collecting at the surgical site. This is not used in every surgery, and typically removed on post-operative day 1 or 2. Removing a drain is not painful. Indwelling catheters are also typically removed on day 1 or 2.
Dr Scholsem will see you every day and will make sure that your recovery is progressing according to plan.
Expected Length of Hospital Stay and what to do at home
The amount of time you will be in hospital depends on your individual surgery and post-operative recovery.
In consultation with Dr Scholsem a joint decision will be made when it is safe for you to be discharged and if needed Dr Scholsem will be able to organise a transfer to rehabilitation.
Please refer to the Post-operative Instruction booklet for more post-op info
Post-operative instructions and expectations
- Home care instructions after lumbar fusion
- Post operative instructions after cervical foraminotomy, cervical laminectomy with or without fusion
- Home care instructions after lumbar laminectomy or discectomy surgery
- Post operative instructions after anterior cervical discectomy and fusion or total disc replacement
Instructions for patients having spinal surgery
More than 80% of Australians have or will experience the crippling aches characteristic of neck or back pain. Sometimes the pain is caused by an injury or traumatic accident. Other times, nature simply takes its course, and the spine slowly begins to deteriorate with age.
Dealing with spinal pathologies in the elderly comes with three specific considerations:
- Patient considerations (multiple comorbidities, nutrition, global deconditioning,…)
- Spine considerations (multilevel pathology, degenerative scoliosis, spondylolisthesis, …)
- Bone considerations
Lumbar spinal stenosis is a common condition in elderly patients and also one of the most common reasons to perform spinal surgery at an advanced age. Disc degeneration, facet degeneration and hypertrophy, and ligamentum flavum hypertrophy and calcification usually participate in the genesis of a stenotic condition in the elderly. These changes can lead to symptoms by themselves or decompensate a preexisting narrow canal.
This creates pressure on the spinal cord and spinal nerve roots, causing pain, numbness, or weakness in the legs. The lumbar region is the most common area in which spinal stenosis occurs.
Some sufferers are debilitated by the pain to the point that their quality of life diminishes to a fraction of what it used to be; they can become shells of their former selves. Back and lower limb pain takes a toll not only on the patient, but also on his or her family and friends. Many patients find that along with their back health, their relationships slowly deteriorate as well.
There’s good news for older patients who suffer from back and leg pain. Evidence from four prospective uncontrolled trials that measured pre- and post-surgery walking ability suggests that these patients significantly improved after surgery.
The treatment of lumbar spinal stenosis often depends of course on the severity of a patient’s symptoms and the severity of neurologic compression. Patients with mild or moderate stenosis may respond very well to conservative treatments. Conservative treatments may consist of oral anti-inflammatory medications and pain medications. Muscle relaxant medications should be used for severe pain and muscle spasms, and only for short duration in elderly patients. Complications secondary to medications are more common in the elderly, and all medications should be closely monitored by the prescribing physician. Physical therapy, manipulation, and modalities may also be utilised, primarily to improve a patient’s strength, endurance, and level of function. Epidural steroid injections may provide dramatic improvement of pain, but only 25% have long-term relief according to a study authored by Surin.
When a patient has severe spinal stenosis and symptomatology, or a patient with mild or moderate stenosis has failed conservative modalities, surgical intervention is considered. Patients noted to have multiple spinal levels involved are indicated for a laminectomy. If a patient only has one or two levels of involvement, then minimally invasive procedures such as a microscopic laminectomy or intra-laminar decompression may be considered. The goals of surgery are to improve a patient’s pain and level of function, as well as prevent further deterioration of function and worsening pain. Patients who demonstrate instability or mal-alignment of the spine may also require spinal fusion (mending the spine bones together) in addition to a decompression procedure. There is a high rate of success for patients treated surgically, yet there is a notable increase in morbidity and mortality in elderly patients over 80 years-old, especially those with significant medical problems. A careful pre-operative evaluation and delicate peri-operative and post operative management is particularly important in this setting.
Going home straight away after spinal surgery can be daunting and Dr Scholsem has organised partnership with the Rehabilitation Department at St George Public Hospital for public and private patients as well as Kareena Private Hospital, Waratah Private Hospital, Calvary and President Private Hospital.
If Dr Scholsem feels that you could benefit from rehabilitation or you do not feel confident going back home after your surgery you could be transferred directly to one of the many centres around Sydney. Dr Scholsem will discuss all this with you before and after your surgery and transfer can be easily organised if required.
Some Link medical reviews
CONCLUSION Symptomatic spinal stenosis, spondylolisthesis, degenerative scoliosis, and vertebral fractures are conditions that can cause disabling pain or neuropathy in elderly patients. In a non emergency setting, non operative therapies, including physical therapy, corticosteroid injections, opioid analgesia, epidural corticosteroid injections, image-guided minimally invasive procedures, and bracing, should be used before surgical treatment is considered. The surgical treatment of symptomatic spinal disorders is challenging in any patient population. Medical comorbidities, osteoporosis, and age associated changes in cognition can increase the risk for peri-operative complications in the elderly population after spinal surgery. Pre-operative risk assessment, an appropriate surgical approach, and post operative physical therapy are crucial to successful outcomes after any spinal surgery, even non fusion procedures. Although clinical case series and state-wide or national registry studies 27,28,31 indicate a slightly higher risk of peri-operative complications in older patients, cohort studies that have included younger control groups have failed to show significant differences 42,44 Clinical outcomes, in terms of satisfaction after surgery, as well as pain and functional improvement, appear to be similar in elderly patients and younger ones. However, the quality of the evidence as it stands is poor, and randomised, controlled trials or well controlled prospective cohort studies are needed to more accurately determine the complication risk and efficacy of lumbar spine surgery in elderly patients. As of now, age should not be an independent exclusion factor, and the decision to proceed with spinal decompression or fusion in any patient should be made on a case-by-case basis.
Medications are the most frequently prescribed therapy for low back pain. A challenge in choosing pharmacologic therapy is that each class of medication is associated with a unique balance of risks and benefits.
Opioids, when to prescribe
The primary medical use of opioids is in the treatment of severe pain.
Opioids should be initiated and continued with extreme caution to avoid the unnecessary development of dependence and the potential diversion of opioids to the ‘black market’. There is increasing abuse of pharmaceutical opioids, rather than heroin, and increasingly opioids involved in fatal overdose cases have been pharmaceutical opioids obtained from the ‘black market’.
Before opioids are prescribed, give consideration to the use of non-opioid analgesics and non-pharmacological approaches to pain management (eg physical therapies as well as non-opioid medications) as alternatives or adjuncts to medication.
When opioids are required, long-acting opioids are preferred over short-acting and injectable forms.
Appropriate times to prescribe
It is appropriate to prescribe opioids for:
short-term acute pain in known patients with clear pathology
chronic malignant pain
chronic non-malignant opioid-responsive pain where relevant specialist assistance has been sought and there is ongoing authority and review (use long-acting forms)
How to Avoid Addiction
The best way is not to take these drugs in the first place. Try non-medication pain relief methods — like physical therapy, heat, or ice — and non-opioid pain killers such as NSAIDs (Iboprofen, meloxicam, voltaren)
If you’re still in pain, it’s fine to consider adding opioids to your other pain treatments, but only if you and your doctor agree that the relief you will gain from them outweighs the risks. You might go to a doctor who specialises in pain management. They can help you get the best relief and avoid complications.
You will take the lowest possible dose to ease your pain for a short period. Before you start, your doctor will work with you to set treatment goals. You will see them every few months for follow-up visits to check your progress.
Your doctor can slowly increase the dose if you need more relief. And if your pain does not improve within 1 to 4 weeks, make a plan to get off these drugs and try something else.