Spine surgery

Patient handbook

Table of contents

Section A: Preparing for surgery 1

Section B: Blood Management Program 7

Section C: Spine anatomy, spine conditions and surgical definitions 17

Section D: Your hospital stay 23

Section E: Lumbar surgery (Back) 31

Section F: Cervical spine (Neck) 35

Section G: Guidelines for your recovery 39

Preparing for surgery

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My surgery packetMeet the team!Spine surgeon:The attending physician is responsible for your care from admission through outpatient follow-up All members of the surgery team report to your surgeon While in the hospital, the surgeon will see you at varied times throughout the day as he/she is in between his clinic patients or between surgeries Throughout the day, you will be cared for by the rest of the surgery team There is regular communication between the team and your surgeon All decisions about your care are approved by your surgeon

Resident physicians:Physicians in training to be surgeons are an active part of the surgery team and will provide a large portion of your care including performing procedures, writing orders, and prescribing medications

Physician assistant/Nurse practitioners:Surgery team members that assess your progress, address questions/concerns, and provide care such as procedures and prescribing medications

Nurses:The nursing team will assist you with your medical and activity needs, administer medication and treatments, provide education, and communicate with the surgery team about your care

Before your surgeryGetting preparedYour preoperative evaluation appointment is very important! Be sure to bring a complete list of your medications, dosages, frequency, as well as any vitamins or supplements that you take on a regular basis

At your preoperative appointment, your care team will discuss the medications that you will need to discontinue before surgery

Do not eat or drink after midnight the night before your surgery. This includes coffee and tea, gum, candy, mints and tobacco products You may take your medications that the

preoperative evaluation appointment instructed you to take with a sip of water

You are encouraged to choose one contact person for the surgical team to communicate with about your condition to your family and friends

Notify your surgeon prior to coming to the hospital if there is a change in your physical condition such as cold, fever or a wound near your surgery site

Pre-anesthesia testing (PAT): Please come prepared with accurate medical history, a list of allergies and reactions, and medications including dosing and frequency

If you had blood work and were given a green striped band, please bring it with you the morning of surgery

If you are planning to be discharged the same day of surgery, you will need a driver and responsible person to stay with you at home for 24 hours following surgery

Medications:If you take Plavix, (clopidogrel bisulfate) aspirin or any prescription or over-the-counter NSAIDs such as ibuprofen (Motrin, Advil), Aleve, Naprosyn (naproxen), Mobic (meloxicam, Voltaren (diclofenac sodium) or Celebrex (celecoxib), you will need to stop taking this medication 7 to 10 days before your surgery, unless otherwise specified by your doctor.

If you take any over-the-counter herbal or supplements (fish oil, herbals, Glucosamine chondroitin), you will need to stop taking these 7 to 10 days before your surgery

If you take Coumadin or any other blood thinners, you will need to stop 3 to 10 days before your surgery The doctor prescribing this medication will instruct you for certain

Please notify your surgical team and follow up with your prescribing doctor if you are taking any antiplatelet or anticoagulant medications If these medications are not stopped as instructed, this could potentially result in having your surgery cancelled

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Morning of surgery Arriving to the hospital • Your arrival time is typically 2 hours prior to

your scheduled procedure You will be called after 3 p m the day prior to your surgery or Friday after 3 p m if your surgery is Monday Time to arrive: ______:______ a.m. / p.m.

• Take an antibacterial shower the night prior to and the morning of surgery

• Do not wear any jewelry or bring any valuables No jewelry is allowed in the operating room Do not wear make-up, contact lenses, nail polish, or tampons

• Remember to bring the green striped band if you were given one at the laboratory (blood work)

• If you take morning medicine for your heart, blood pressure, breathing, seizures, anxiety or acid reflux we would like you to take that medicine with a sip of water the morning of surgery Do not take any other kind of medicine unless the anesthesiologist tells you to Do not take any diabetic medicine or insulin Do not take water pills If you use inhalers, use them as you normally do and bring them with you If you take aspirin, anti-inflammatory medication (ibuprofen/motrin/aleve), or blood thinners (such as Coumadin or Plavix), green tea, or any over the counter herbs, vitamins or supplements, speak with your doctors as to whether to stop them before your surgery

What to expect Where to go the day of surgeryThe Surgery Check-In suite and the waiting room are located at the main entrance of the hospital

The pre-op department is open Monday-Friday 5:30 a m – 10:30 p m The number is 570-271-6571 The scheduling/control desk number is 570-271-7850

Check in: Please come through the main entrance Enter the door with the sign:

“SURGICAL CHECK-IN AND WAITING AREA”

Please be at the Surgical Unit on time Two people may stay with you until you go to the pre-op area Do not bring small children with you. The nursing staff will tell your family where they may wait The doctor will speak to your family after the surgery

You will check-in and be taken to the pre-operative holding area You may experience some waiting while you are being prepared for surgery The nurses will prepare you for surgery and make final documentation of your allergies, medications, and medical history

Your family may wait in the surgical waiting area They will be updated from the operating room and updated by the surgeon after surgery You will be rejoined with your family after you are awake and stable in the recovery room

Finalizing: You will meet with your surgeon and anesthesiologist prior to going back for any final questions and final consent of the procedure The surgeon will ask you what surgery you are having, any changes in your health and confirm your symptoms related to the procedure

Surgery:You will be taken back to the operating room by the anesthesiologist and will be put asleep for your procedure in the operating room After the surgery is completed, you will be woken up and taken to the recovery room

Recovery:You will be in the recovery for short while then taken to your room in the hospital when stable You will be discharged home when stable Remember to have a driver and regular clothing/ shoes

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Patient information for pre-admission screening of Staphylococcus aureus and methicillin-resistant Staphylococcus aureus (MRSA)As an important part of pre-admission screening, patients are required to have a nasal (nose) culture before surgery to check for the bacteria Staphylococcus aureus and methicillin-resistant Staphylococcus aureus (MRSA) This helps to reduce the risk of infection after surgery

During your pre-admission visit, we will take a nasal culture If your culture shows a positive result, a nurse will call you and we will call in a prescription for a nasal ointment, mupirocin (Bactroban®), to your pharmacy

Bactroban is an antibiotic ointment that you will apply into each side of your nose for five days during the week before your surgery. You must complete the five-day treatment one to two days before your surgery

Your pharmacy will give you 10 small tubes of ointment Each tube is one dose Use one tube every night and one tube every morning for five days as follows:

1 Remove the cap and squeeze one-half of one tube of the nasal ointment into one nostril, and then the other half into the other nostril

2 Gently press the sides of your nose together, let go and repeat for one minute

3 Throw away the tube after you use it 4 Wash your hands with soap and water

Also, we recommend that you shower on the night before and on the morning of surgery, as outlined in this booklet, with the surgical cleanser provided to you Pay close attention to cleaning your underarms, groin, buttocks and surgical site area

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Staph decolonization protocol pre-op

As an important part of your pre-admission screening, you may have a nasal (nose) culture to check for Staphylococcus aureus bacteria which may cause infection after surgery.

If this test returns positive for this bacteria, you will need to:

1. Apply an anti-septic ointment (Bactroban or mupirocin) to your nose as below.2. Bath daily with an antiseptic solution that contains chlorhexidene (Hibiclens) as below.

Remove cap. Apply one-half the contents of the tube in one nostril.Apply the other half of the tube contents in the other nostril.

Press nostrils together. Massage for approximately one minute. Discard tube. Do not reuse.

Avoid contact with eyes.Contact your healthcare professional if you have any questions.

ANTIBACTERIAL SHOWER

For the 5 days you are applying the nasal ointment, you must also take a chlorhexidene (Hibiclens) bath/shower as below.

1. Thoroughly rinse the area to cleanse with water. Turn off water.

2. Apply enough of the chlorhexidene (Hibiclens) to cover the skin. Pay special attention to the underarms and groin.

3. Leave product on skin for 2 minutes. 4. Rinse thoroughly with water.5. Do not use lotion or other bathing

products after showering.

Even if you finish this treatment, on the night before and the morning of surgery, take another chlorhexidene (Hibiclens) bath/shower, as outlined on the “Help Prevent Skin Infections After Surgery” information sheet.

PRECAUTIONS:• Do not use in contact with genital area• Do not use on wounds on more than

the superficial layers of the skin• Do not use in the eyes or mouth• If contact occurs in any of the areas

listed above, rinse with cold water right away.

NASAL BACTROBAN TREATMENT

Your surgery date is: __________________________________________________________

If your test is positive, start the treatment on: ________________________________________

If you have any questions, please call: _____________________________________________

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83049-1-1/16-KG/DS

You will be given one of the following:

Soap instructions:Use half of the bottle the night before surgery. Use the remaining half on the morning of surgery.

1. Pour soap on a damp washcloth and start by washing your chest, and then each arm. Pay special attention to the armpits.

2. Continue to pour soap on the washcloth, keeping it wet.

3. Wash your back, and then each leg. Pay special attention to the groin, but do not use directly on the genitals. Wash your buttocks last.

4. Leave the soap on for 2 minutes before rinsing.

Wipe instructions:Use three packets (six wipes total) the night before surgery. Use the other three packets (six wipes total) on the morning of surgery.

1. Use one wipe for your left arm and one wipe for your right arm. Use one wipe for your chest and upper back. Pay special attention to the armpits.

2. Use one wipe for your left leg and one wipe for your right leg. Pay special attention to the groin, but do not use directly on the genitals. Use one wipe for the lower back and buttocks.

3. Do not rinse.

Wash entire body:The night before and the morning of surgery

Do not shave face or body the night before or the morning of surgery.

Pay special attention to the circled areas below.

Do not use the soap/wipes:

• above the neck

• in eyes or mouth

• on open wounds

• directly on genitals

Do not use lotion or other skin-care products after using soap or wipes.

Surgical wipes (6 packs)

Surgical liquid soap (1 bottle)

Help prevent skin infections after surgeryGeneral skin-washing checklist

front back

A-450-045-F Rev 2-16

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Blood Management Program

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Blood Management ProgramPreoperative instructionsFour weeks before your surgery (or as soon as you receive these instructions):Begin the following supplements and continue until the day before your surgery:

• Folic acid – 800 mcg, one tablet once a day

• Ferrous sulfate (oral iron supplement) – 325 mg, one tablet once a day (The bottle may say 65 mg instead of 325 mg )

• Vitamin C – 250 mg, one tablet once a day

Important information:• Take your vitamin C and iron supplement

(ferrous sulfate) together • Do not take vitamin C and iron with

coffee, tea, calcium or dairy products. Wait at least one hour after your last cup of coffee, tea, or dairy product to take the pills

If you take aspirin, Plavix or any other blood thinners, make your surgeon aware at least 10 days before your surgery.

Seven days before your surgery, stop using the following:

• Multivitamins and/or vitamin E supplements

• Herbal teas and all herbal supplements, including (but not limited to) glucosamine, CoQ10, saw palmetto, ginger, Ginkgo biloba, St John’s wort, rose hips, valerian, ginseng, feverfew, willow bark, Echinacea, ephedra, kava-kava and cranberry

• Olive oil and/or garlic• Omega-3s, including fish oil, flaxseed oil

and krill oil, as well as salmon• Green tea• Naproxen (e g , Aleve®, Naprosyn®) and

ibuprofen (e g , Advil®, Motrin®)

The exceptions:• If you have macular degeneration,

continue taking your prescribed eye vitamins

• Acetaminophen (e g , Tylenol®) and tramadol (e g , Ultram®) are acceptable You do not have to stop taking these unless otherwise instructed by your surgeon

Your physician will review your medications with you, and may make other changes in your medications prior to surgery.

Good nutrition is very important Review the food source guide in your guidebook

Our goal is to optimize your blood count to decrease blood transfusions and improve your recovery time and overall healing If you have any questions about the Blood Management Program, call 800-329-3021 or the main hospital number, 570-271-6211, and ask them to page Blood Management

Blood Management ProgramThe following information will help answer some of the most commonly asked questions about Geisinger’s Blood Management Program The techniques described can be used before any surgery We will discuss the Blood Management Program with you in person, either in a preoperative class or at your clinic appointment If you need further details before meeting with your blood manager, call 800-329-3021

What is the Blood Management Program?Geisinger established its Blood Management Program in 2004 in response to growing concerns about the safety of the nation’s blood supply, as well as the national blood shortage Geisinger is the first healthcare provider in central and northeast Pennsylvania to offer this advanced program The Blood Management Program, also known as bloodless medicine and surgery, is an advanced method of providing medical care that minimizes your blood loss before, during and after treatment, and allows appropriate transfusions to occur for those who accept blood transfusions

The Blood Management Program reduces the need for blood transfusions It optimizes your blood levels before surgery and decreases any blood you may lose with surgery, ensuring that you do as well as possible after surgery This approach permits doctors to care for you by reducing or eliminating the use of transfused blood or blood components, because you are able to retain your own blood during treatment This speeds up your healing and recovery processes

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While some technologies to perform these procedures were developed years ago, Geisinger is the first healthcare system in the region to use these techniques in an organized approach to medical care

Geisinger’s approach to blood conservation goes beyond one physician’s method, a particular surgical technique or a special piece of equipment Through the Blood Management Program, our doctors, nurses, therapists and technicians combine their expertise in a healthcare setting that supports this approach We have developed specific policies and procedures that include evidence-based best practices in caring for you When you enroll in Geisinger’s Blood Management Program, everyone you come in contact with — admissions staff, nurses and medical laboratory specialists and physicians — are aware of your choice to use blood conservation techniques This integrated approach assures you of our commitment to your safe care

Why should I choose Geisinger’s Blood Management Program?The advanced techniques and technology used in the Blood Management Program allow you to recover more quickly and to go home sooner than patients receiving higher numbers of transfusions or blood components Blood conservation techniques minimize the potential for post-op infection, mis-testing or mislabeling of blood, and delays in treatment, and they help you achieve a state of post-op optimization more quickly, so you can get back to your life sooner

You actively participate in your healthcare decisions along with your physician You may also have religious reasons for seeking bloodless medical care At Geisinger, we honor your religious beliefs, and we will work with you to ensure that you receive the highest level of care without violating your beliefs

How does the Blood Management Program work?Geisinger’s Blood Management Program uses proven, state-of-the-art technology and the latest scientific research to care for you while reducing or eliminating the use of blood transfusions In the past, patients were asked to donate their own blood before surgery in case of blood loss during the procedure Risks involved with this

technique include an increase in the severity of preoperative anemia, possible mislabeling of blood, and deterioration of the blood during storage Other options are available in lieu of donating your own blood before surgery to allow you to have a better surgical outcome Some of the specialized techniques and equipment include:

Potential medications (pre- or post-operatively)• IV iron therapy, synthetic erythropoietin

injections, intramuscular 812, IV folic acid and oral (by mouth) supplements, such as ferrous sulfate (iron), vitamin C, folic acid, 812, Vitron-C®, multivitamins or prenatal vitamins may be administered

• Acute normovolemic hemodilution (ANH) – This is a technique in which one to three units of your blood are taken and replaced with volume expanders (see definition below) This is done in the operating room just before your surgery Your blood is held at your bedside and then given back to you during or after surgery to replace any blood lost during the operation Your blood never goes to the blood bank for storage

• Advanced cell saver system – The Geisinger Blood Management Program includes the use of this extremely sophisticated system that carefully conserves and recirculates blood that might otherwise be lost during surgery

• Synthetic erythropoietin – This hormone stimulates bone marrow to produce more red blood cells and may be used to boost your hemoglobin level

• Platelet gel – Platelets spun from your own blood are mixed with a thrombin calcium substance to make a gel that is applied to the surgical site The platelet gel reduces micro-bleeding, reduces swelling, decreases pain, stimulates tissue growth and enhances the healing process

• Microsampling and soft-draw tubes – These devices take very small amounts of blood for testing, rather than the larger quantities routinely drawn

• Volume expanders – These intravenous fluids dilute the blood. Each ounce of blood contains a lower concentration of red blood cells, so the amount of red blood cells lost during surgery is reduced

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How can I receive more information?We will discuss the Blood Management Program with you at your history and physical appointment at Geisinger before your surgery If your history and physical appointment is not scheduled until just before your surgery, we will contact you by telephone If you need more information, call 800-329-3021

Food sources for treatment or prevention of anemiaRed blood cells need iron so they can carry oxygen to all the cells of the body A low blood iron level, called anemia, is a developed condition Including foods rich in iron with daily meals can prevent anemia Eating foods containing vitamin C (ascorbic acid) will improve your iron absorption Red blood cells also need vitamin B12 and folic acid in their formation and maturation

Excellent food sources of iron

Beef Chicken Clams Lamb Liver (calf/beef, chicken) Mackerel Oysters Pork SalmonSardines Scallops Shrimp Tuna Turkey Veal

Good food sources of iron• Beans (e g , lima beans, lentils, peas,

soybeans, baked beans) • Blackstrap molasses • Chard• Dried fruit (e g , apricots, prunes, peaches,

dates, raisins)• Eggs• Greens (e g , dandelion, mustard, turnip,

beet, collard) • Iron-fortified cereals • Spinach • Whole and enriched grains

Keep your medical conditions in mind when adding these foods to your daily eating plans:• If you are diabetic, blackstrap molasses

should not be your first choice for iron-rich foods, as it is a sugar and should be avoided by the diabetic patient (unless you have been informed about appropriate carbohydrate exchanges)

• If you are on Coumadin, follow all of your Coumadin (anticoagulation) restrictions Dark green leafy vegetables and liver are not recommended to add to your daily intake

Food sources of vitamin C (ascorbic acid) • Fruit • Fruit juices (100 percent) containing lemon,

orange, tangerine, lime, mango, papaya, honeydew, cantaloupe, strawberry, kiwi

• Vegetables (e g , tomatoes, spinach, greens, broccoli, green bell peppers, chili peppers, sweet peppers, Brussels sprouts)

Vitamin B12Vitamin B12 helps maintain healthy nerve cells and red blood cells, and is bound to protein in food Hydrochloric acid in your stomach releases the vitamin B12 from the proteins in food during digestion and combines it with a substance called gastric intrinsic factor It is then absorbed in your intestinal tract

Food sources of vitamin B12• Dairy products• Eggs• Fish • Meats (including liver and poultry)

Folate (folic acid)Folate is a water-soluble vitamin that occurs naturally in food and helps produce and maintain new cells It is needed to make normal blood cells

Food sources of folate• Asparagus • Broccoli • Cabbage• Citrus fruits and juices• Dried beans and peas • Leafy green vegetables (e g , spinach,

turnip greens)• Liver • Whole wheat, wheat bran, wheat germ,

yeast

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Helpful hints for people with anemiaIron is better absorbed if meals do not include coffee, tea or foods containing EDTA (a food preservative in processed foods) Read the ingredient list on food labels to find EDTA. Stopping herbal medications and certain foods seven days before surgery will lessen the amount of bleeding you have with your surgery Some of them have anti-platelet and anticoagulant properties, and include vitamin E, omega-3s, garlic, olive oil, glucosamine, green tea, ginseng, ginkgo, ginger, CoQ10 enzyme and cranberry juice

Omega-3s (4.5 oz. salmon, fish oil, krill oil and flaxseed oil) – Decrease platelet aggregation (clot formation); prolong bleeding times; increase fibrinolysis (breaking down of blood clots); decrease Von Willebrand factor, fibrinogen and factor V (clotting proteins); and decrease thrombin (clotting enzyme) generation in plasma

Vitamin E (olive oil, multivitamins) – Increases bleeding with warfarin, heparin and aspirin; inhibits platelet aggregation; antagonizes vitamin K-dependent clotting factors

Garlic (10 g or 4 cloves) – Inhibits platelet aggregation

Green tea – Inhibits thromboxane (clotting substance) and platelet aggregation; contains polyphenols, catechins, caffeine and vitamin K

Glucosamine – Elevates INR test result (indicating blood is clotting too slowly); enhances anticoagulant effects of warfarin

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Iron in animal foods (100g)Clams, steamed 22 0 mg Turkey meat, cooked 4 8 mgClams, cooked 8 5 mg Chicken liver, cooked 8 5 mgTuna in oil 1 2 mg Sardines 4 0 mgOysters, cooked 8 5 mg Shrimp, 4 large, cooked 0 7 mgOysters, raw 5 4 mg Halibut, cooked, dry heat 1 06 mgPork loin, broiled 1 05 mg Beef liver, cooked 6 3 mgEgg, 1 0 7 mg Beef, roasted 3 5 mgGround beef, cooked 2 2 mg Lamb, cooked 2 2 mgTurkey, white meat 1 6 mg Ham, 3 ounces 0 9 mgPork sausage, 1 link 0 2 mg Chicken breast, 4 2 ounces, roasted 0 9 mgIron in vegetables and fruit (1/2 cup)Sea vegetables 18 1 – 42 0 mg Pumpkin, cooked 1 7 mgSwiss chard 2 mg Potatoes, baked with skin 1 7 mgTurnip greens 1 6 mg Potato, 1 large 1 4 mgSweet potatoes, canned 1 7 mg Bok choy, cooked 0 7 mgBeet greens, cooked 0 60 mg Spinach, cooked 1 5 mgBroccoli, cooked 0 55 mg Peas, cooked 0 65 mgChickpeas 6 2 mg Tomato juice 0 6 mgOrange juice, 1 cup 1 1 mg Grapefruit juice, 1 cup, canned 1 1 mgPrune juice, 1 cup 3 0 mg Watermelon, 1/8 medium 0 5 mgPrune juice, 4 ounces 1 5 mg Cherries, 1 cup, water-packed 3 3 mgGreen beans, cooked 0 60 mg Pineapple, 1 cup, in heavy syrup 1 0 mgRaisins, 1 cup 3 0 mgIron in soy foodsTofu 6 6 mg Soybeans 4 4 mgTempeh 1 8 mg Soy milk, 1/2 cup 0 09 mgIron in legumes and lentils (1/2 cup) Lentils 3 2 mg Black-eyed peas 2 6 mgNavy beans 2 5 mg Pinto beans 2 2 mgLima beans 2 2 mg Kidney beans, Rajmah 1 5 mgIron in nuts and seeds (2 tablespoons)Pumpkin seeds 2 5 mg Figs, 5 dried 2 0 mgDried apricots 1 6 mg Almonds, 1/4 cup 1 3 mgTahini 1 2 mg Sesame seeds 1 2 mgSunflower seeds 1 2 mg Cashew nuts 1 0 mgIron in breads, cereals and grainsBran flakes , 1 cup 11 0 mg Oatmeal, 1 packet, instant 6 3 mgPasta, 1 cup cooked 1 7 mg Oatmeal, cooked 5 5 mgWhite bread, 1 slice 0 7 mg Whole wheat bread, 1 slice 0 9 mgBread crumbs, 1 cup, dry 4 1 mg Bagel, 1 plain 1 8 mgPita bread, 1 piece, enriched 1 4 mg Italian bread, 1 slice 0 8 mgRye bread, 1 slice 0 7 mg Pumpernickel bread, 1 slice 0 9 mgCheerios®, 1 1/4 cup 4 5 mg Cap'n Crunch®, 3/4 cup 7 5 mgFroot Loops®, 1 cup 4 5 mg Golden Grahams™, 3/4 cup 4 5 mgRice Krispies®, 1 cup 1 8 mg Total®, 1 cup 18 0 mgPancake, 1, four-inch 0 5 mg Waffle, 1 seven-inch 1 5 mg

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Blood Management Program glossaryWhole blood contains all of the components of blood, including plasma, white blood cells, platelets and red blood cells

Red blood cells normally make up about 45 percent of the whole blood They are disk-shaped cells in the blood that contain hemoglobin, lack a nucleus and transport oxygen and carbon dioxide to and from the tissues A red blood cell is also called an erythrocyte, a red cell or a red corpuscle It is formed in the bone marrow

Hemoglobin is a complex protein molecule found within the red blood cells that carries oxygen and releases it to the tissues For a male patient, the hemoglobin is 13 0 to 18 g/dl and for females, it is 12 0 to 16 g/dl The hemoglobin with oxygen attached makes the blood a bright red color

Hematocrit is the percentage by volume of packed red blood cells in a given sample of blood after centrifugation (separation by spinning at a high speed)

Anemia is the most common red blood cell disorder It is a decrease in the red blood cell numbers or a decrease in the amount of hemoglobin within the red cells There are many causes of anemia The Blood Management Program uses the following values to determine if anemia is present:

Male: Hemoglobin less than 13 g/dFemale: Hemoglobin less than 12 g/dl

White blood cells are components of the immune system They help protect all cells and tissues against foreign organisms and matter An increase white blood cell count is a classic sign of infection somewhere in the body A normal white blood cell count is between 4,500 and 11,000 per microliter

Plasma is the fluid part of the blood which carries the oxygen-rich red blood cells to the tissues and the tissue byproducts back to the kidneys/liver/lungs to be removed Important components of plasma include albumin, clotting factors, immunoglobulin and other proteins

Fresh frozen plasma (FFP) is frozen plasma that is thawed and serves as a source of plasma proteins for patients who are low in or have defective plasma proteins One use for FFP is to help control bleeding

Cryoprecipitate is prepared from FFP Clotting proteins are found in the plasma, and when certain proteins are separated out, they can be used to control bleeding caused by deficiency in those proteins

Liquid plasma serves as a source of plasma proteins, especially certain clotting proteins Plasma is used to help control bleeding when there is a deficiency of clotting proteins.

Platelets are part of a complex reaction when the blood vessel walls have been disturbed The platelets gather and adhere to the blood vessel wall to form a temporary plug (clot) to help control bleeding

Unit of blood is a way of saying a unit of whole blood, or a unit of packed red blood cells Transfusions are given in units Both should improve your hematocrit and hemoglobin when the count is low, as long as bleeding is controlled, and should also increase your body’s ability to improve oxygenation 24 to 48 hours after infusion Higher transfusion requirements can lead to immunosuppression, longer hospital stays and an increased postoperative infection rate

Autoimmune diseases are conditions when the immune cells cannot tell the body’s own tissue from foreign matter Antibodies are formed and attack the body’s own tissues Examples include systemic lupus erythematous, rheumatoid arthritis and multiple sclerosis

Immunodeficiency is a defect in the immune system. Secondary immunodeficiency is acquired and occurs with certain diseases, infections, chemotherapy, radiation therapy and immunosuppressive therapy following organ transplantation Examples include AIDS and leukemia

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Transfusion reaction is an adverse reaction to the transfusion of blood or blood products caused by an immune response Anaphylaxis is a serious type of reaction and can be life-threatening if not treated immediately Mild reactions may include a slight rise in body temperature, low back discomfort or itching

Volume expanders are a type of intravenous therapy that can provide volume for the circulatory system if fluids are lost and need to be replaced (in severe dehydration and shock from loss of blood) There are two types of volume expanders, called crystalloids and colloids. Crystalloids are IV fluids (mineral salts or sugars) Colloids are larger molecules, such as Hespan® (hetastarch), gelatin, dextran, pentastarch or blood

Minor blood fractions is a term used to describe specific products derived from blood that may not be objectionable to certain religious groups who do not accept whole blood transfusions The most common blood fractions, also known as personal choices for those religious groups, are Procrit®, albumin, platelet gel, cryoprecipitate, ANH and cell saver/cell salvage There are other, more specialized fractions that may be recommended in certain specific isolated instances on occasion, some of which include prothrombin complex concentrate, clotting factors (if derived from blood products), serum immune globulin and interferon, which the blood conservation nurse can discuss with you if your doctor recommends them for you

Iron is essential for forming complexes with molecular oxygen in hemoglobin and myoglobin; these two compounds are common oxygen transport proteins in people Iron is the biggest building block our bodies have for increasing blood levels (hemoglobin and hematocrit) These levels are part of what a surgeon looks at before and after surgery to ensure that you are in an ideal condition and will have a successful outcome Iron also aids in immune function, cognitive development, temperature regulation, energy metabolism and work performance Iron may be taken by mouth (pill or liquid) or intravenously

Vitamin B12 is a nutrient that helps keep the body’s nerve and blood cells healthy and helps make DNA, the genetic material in all cells Vitamin B12 also helps prevent anemia, especially when given with folic acid. Vitamin B12 is most effective when given by injection, because a number of foods, medicines and medical conditions will affect its absorption when the vitamin is taken by mouth

Ascorbic acid, also known as vitamin C, is a water-soluble nutrient found in some foods The main reason for recommending vitamin C is to help with iron absorption Iron requires a more acidic environment to be absorbed Vitamin C and iron must be taken together The body needs vitamin C to make collagen, a protein required to help wounds heal In addition, vitamin C helps the immune system work properly to protect the body from disease Vitamin C is usually given by mouth in pill form, or it may be added to intravenous fluids.

Folate is a water-soluble B vitamin that is naturally present in some foods and added to others, and is available as a dietary supplement also known as folic acid Folic acid is required for DNA and RNA synthesis and red blood cell formation Folate is usually given by mouth, but may also be added to intravenous fluids.

Revised 1/2013

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Spine anatomy, spine conditions and surgical definitions

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Anatomy

Understanding the anatomyA healthy spineTo best understand your surgery, it is important to know about your spine The spine surrounds and protects your spinal cord and gives the body its form Your spine is made up of vertebrae (bones), plus the sacrum and the coccyx (tailbone)

The spine consists of 24 vertebrae: • 7 cervical (neck)• 12 thoracic (chest)• 5 lumbar (lower back)

Your vertebrae are separated by shock-absorbing discs These discs give your spine the flexibility to move and bend. The firm, fibrous outer layer of a disc is called the annulus The soft center of the disc is called the nucleus

The stacked vertebrae for a tunnel called the spinal canal The opening between the vertebrae on either side of the spinal canal is called the foramen

Nerves run though the spinal canal They branch out from your spinal canal and pass through the foramen to other parts of your body The spinal cord extends down to the L2 vertebra Below this level, the spinal canal encloses a bundle of nerves that goes to the lower limbs and pelvic organs The Latin term for this bundle of nerves is the cauda equina, meaning horse’s tail

The lamina is the arched part of each vertebra that forms the back of the spinal canal Facet joints are the joints where the vertebrae meet

A painful spineBack or neck pain can be caused by problems with any part of the spine A disc can herniate (push out) and press on a nerve Vertebrae can rub against each other or slip out of space This can irritate facet joints and nerves It can also lead to stenosis, a narrowing of the spinal canal or foramen

Pressure from a discConstant wear and tear on a disc can cause it to weaken and push outward Part of the disc may then press on nearby nerves

Pressure from boneWith age, a disc may thin and wear out Vertebrae above and below the disc may then begin to touch This can put pressure on the nerves It can also cause bone spurs to form where the bones rub together Stenosis results when bone spurs narrow the foramen or spinal canal This also puts pressure on nerves

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An unstable spineIn some cases, vertebrae become unstable and slip forward This is called spondylolisthesis Slipping vertebrae can irritate nerves and joints

Disc degeneration Herniated disc

Understanding the procedures

Spinal decompressionDecompression is a type of surgery that takes pressure off a nerve. This can be done by removing bone from the vertebrae

The laminectomy procedureA laminectomy removes the entire lamina (the back part of the vertebrae) The opening created takes pressure off the nerve by enlarging your spinal canal If needed, your surgeon can also remove any part of a disc or bone spur that presses on a nerve He or she may also enlarge the foramen to ease pain cause by stenosis After the procedure, the new opening in the spine is protected by the thick back muscles

The laminotomy procedureA laminotomy removes a portion of the lamina (the bone at the back of the spinal canal) The small opening that is created is sometimes enough to take pressure off a nerve. In most cases, part of a disc or a bone spur that is pressing on a nerve is also removed

Spinal fusionSpinal fusion is a type of surgery used to make the spine more stable During surgery, two or more vertebrae are fused (locked together) using a bone graft This keeps the bone from shifting and pressing on nerves

The fusion procedureFusion surgery can be done using several methods Talk with your doctor if you have questions about the steps of your procedure

• Part or all of a disc may be removed from between the vertebrae to be fused

• Bone graft is packed between vertebrae In time, the graft and nearby bone grow into a solid unit

• To keep the spine stable, metal supports may be used along with the bone graft The supports are left in place after surgery

• The incision is closed with stitches or staples

Understanding bone graftsBone grafts are very small pieces of material used to fuse vertebrae together Grafts can come from your own body, a bone bank or artificial sources. In some cases, bone protein (BMP) may be used

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Conditions and surgical definitions Anterior cervical discectomy and fusion (ACDF)This procedure is commonly used to treat neck problems The surgeon works from the front (anterior) of the neck ACDF is performed to relieve pressure on nerves from disc herniation Removing the ruptured disc removes pressure from the nerves or spinal cord, which usually relieves most of the pain in the arms A bone graft is placed between two vertebral bodies (interbody area) to replace the disc that normally sits between them A metal plate is placed over the bone graft and screws are applied to the bones above and below The metal plate provides support while the bone graft grows in place and fuses the bones

Anterior lumbar interbody fusion (ALIF)This procedure involves approaching the spine from the abdomen to remove disc or bone material from between the two vertebrate A cage and bone graft material is placed in the disc space and the vertebrae are fused together This is generally performed to treat lower back pain

CervicalRefers to the neck The cervical spine is the upper portion of the spine, consisting of seven vertebral bodies that make up what we know as the neck

Cervical myelopathyCompression of the spinal cord in the neck causing pain, numbness and weakness in the neck or arms and problems in coordination

Cervical stenosisStenosis refers to narrowing of the spinal canal Symptoms of stenosis often cause pain or numbness in the arms and/or hands Neck pain often accompanies cervical stenosis as the joints in the spine become arthritic and stiff. As the stenosis worsens, it may cause compression of the spinal cord itself This can cause symptoms such as numbness and weakness in the arms and/or legs, loss of dexterity in the hands (such as difficulty buttoning shirts) or loss of balance

DecompressionRemoval of bone, disc or calcified ligaments that are pressing on nerves of the spinal cord

Degenerative disc diseaseChanges that occur in the intervertebral disc during the normal aging process, making the disc increasingly brittle

Disc The cushion between each of the vertebral bodies

Disc bulge A small disc herniation which can irritate a nerve, but usually does not require surgery

Disc protrusionA larger disc herniation which often presses on nerves going to the arms and legs, causing pain

Disc herniationWhen a disc wears out, it can bulge Sometimes when a disc bulges, it presses on the nerves exiting the spinal column A herniation, or a rupture of the disc material in the neck, is a very common problem that can cause pain in the legs or arms Discs are soft material found between bones that act as shock absorbers People suffering from this type of pain often describe it as a “pinched nerve ” Pressure on a spinal nerve causes discomfort in one or both legs You may have shooting pain, weakness and/or numbness

DiscectomyRemoval of a portion of a disc

FusionOccurs when cadaveric bone is placed between two vertebrae and the bones grow together After fusion is complete, there is no movement between these two vertebral bodies. Different fusion approaches are Posterior Lumbar Interbody Fusion (PLIF), Anterior Lumbar Interbody Fusions (ALIF) and Transforminal Lumbar Interbody Fusion (TLIF)

LaminaThe bone located in the back part of the vertebra

LaminectomyThe removal of the lamina, frequently done to relieve pressure on the nerves

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LumbarRefers to the lower portion of the spine There are five lumbar vertebrae in the low back.

Lumbar spinal stenosisLumbar spinal stenosis occurs when the space for nerves is decreased in the lower back The nerves traveling through the lumbar spine to the legs become compressed It is usually caused by degeneration and can be part of the normal aging process Common symptoms of stenosis include pain or cramping in the lower back or buttocks, which may radiate down one or both legs and worsens with walking or other activity Symptoms are usually relieved through sitting or lying down or by bending at the waist

Micro-discectomyRuptured disc removal through a small incision with the aid of a microscope

PlateA flat metal object usually made of titanium with holes for screws to be used in the front of the spine

Posterior cervical fusionA cervical laminectomy removes the spinous process (bony projection) and lamina from a vertebra to decrease pressure on the spinal cord The source of the pressure is often spinal stenosis, a condition in which there is a narrowing of the spinal canal that causes pressure on the spinal cord or nerves After removing bone, bone grafts can be added to fuse the vertebrae and provide stability to the spine The goal of spinal fusion is to stop the movement caused by instability This reduces the neck pain caused by too much motion in the spinal segment

Posterior lumbar interbody fusionA posterior interbody fusion is performed to remove the disc that is causing back and/or leg pain and to fuse the spinal bones with bone grafts The procedure is done through an incision on the back Part of the lamina (the back part of the vertebra) is removed in a process called laminectomy Then the disc is removed, relieving the pressure on the compressed nerve and allowing it to return to its proper position A bone graft or spacer will replace the disc, and rods and screws will keep the bones in place and stabilize the spine during the fusion process

RadiculopathyA pinched or irritated nerve in the neck or lumbar back causing pain, numbness or weakness radiating into the arms (cervical) or legs ((lumbar)

RodA cylindrical metal object usually made of titanium that connects the screws in the vertebrae

ScrewA metal object usually made of titanium that is used to grip a vertebra Placed either in the front or the back of the spine

SpondylolisthesisSpondylolisthesis is a condition that occurs when the vertebral body slips forward It can happen anywhere in the spine, but usually occurs in the lower or lumbar region Symptoms may vary Some people have no pain, but often people have mild to moderate low-back pain If the forward slippage compresses a nerve, you may have leg pain Most cases occur when the facet joints, which allow the spine to bend forward (face joints), wear with age or arthritis and cause one vertebra to slip over the other

ThoracicRefers to the middle portion of the spine There are 12 thoracic vertebrae

Transforaminal lumber interbody fusion (TLIF)A TLIF is performed to remove the disc that is causing back and/or leg pain and to fuse the vertebrae with bone grafts The procedure is done through an incision on the back and approached from outside the facet joint

VertebraA spinal bone

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Your hospital stay

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Hospital stay What to expectNursing:Your floor nurse will perform regular vital signs, pain evaluations, neurological testing, medication administration, self care and mobility during your stay They will also relay any concerns you may have to the surgery team

Surgeon:You will be visited daily by the physician assistant, resident or nurse practitioner and your surgeon to evaluate your recovery and your recovery needs They will discuss your symptoms, examine you, review your medications, goals for the day and discharge planning

Mobility:You will be mobilized by the nursing staff and physical therapy after surgery until you are able to mobilize independently safely

Therapy:Physical and occupational therapy will see you 1-2 times per day to assess your discharge needs (discharge home without services, home with home health/therapy, inpatient rehab or skilled nursing facility with therapy)

Consultants:The surgery team may also ask additional teams to assist in your care Such teams may include: medicine, endocrinology, pain management, blood conservation and nutrition

Care Management:A care manager will visit you in the hospital to discuss your needs for discharge including facility preferences, home health preferences and medical devices (walker, cane, etc)

Diet:After surgery, a diet will be started You will start with clear diet (liquid, soup, jello) then progress to regular food after you are able to tolerate the clear diet Your diet will be based on your medical history: (Ex: Heart healthy diet, diabetic diet, etc)

Bathroom:If you had a urinary catheter for surgery, the first few urinations after surgery may cause some discomfort Most catheters that are placed during surgery while you are asleep are removed before you wake up You may have your urinary catheter overnight after your surgery if we feel you may have decreased mobility after surgery

Pain control:Your surgical pain will be treated with pain medication, (both pills or intravenous) based on your pre-hospital medications and surgical procedure You will also be given ice and muscle relaxants as needed for incisional pain

Smoking:There is no smoking permitted on the Geisinger campus or anytime during your surgical stay We will provide you with a nicotine patch if needed

After your surgery• You will be taken to a medical-surgical unit

after leaving the Post-Anesthesia Care Unit (PACU)

• You will have a drain that will be removed before you are discharged from the hospital

• You may have staples closing your incision • You may have an indwelling catheter in your

bladder • Your pain will be managed with IV pain

medication delivered through a patient-controlled analgesia pump (PCA) for 48 hours, and then you will be transitioned to pain medication by mouth

• You will be getting out of bed very soon after your surgery

• You will wear a brace for comfort • A member of Physical Therapy will evaluate

you You may be a candidate for inpatient rehabilitation Your care manager will discuss these options with you

• You may shower on post-op day 2 Do not apply any soaps, creams or ointments Follow the directions given to you by your doctor.

• You will be in the hospital for one to three days, based on your surgery and recovery

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• You will return to see your physician in the clinic at Geisinger Medical Center within 10 to 14 days after your surgery We will make this appointment at the time of discharge and notify you by mail At this visit, your staples will be removed We will give you a referral for physical therapy and assess you for your return to driving and work (if applicable)

Pain reliefEach patient’s pain tolerance is different, therefore it is important for you to ask your nurse for pain medication when you need it We will give you plenty of pain medication Pain control makes your coughing and deep breathing efforts more effective and allows you to rest more comfortably. Also, adequate pain management will help you to walk more and progress in your self-care activities

During hourly rounds your nurse will:• Ask you about your pain • Help you set goals and expectations for

pain management • Help you record the time of your last

pain medication dosage, the name of the medication, and when you can expect your next dose

Nonverbal indicators of pain:• Vocal complaints – nonverbal expression

of pain demonstrated by moans, groans, grunts, cries, gasps, sighs

• Facial grimaces and winces – furrowed brow, narrowed eyes, tightened lips, dropped jaw, clenched teeth, distorted expression

• Bracing – clutching or holding onto side rails, bed, tray table, or affected area during movement

• Restlessness – constant or intermittent shifting of position, rocking, intermittent or constant hand motions, inability to keep still

Additional ways to manage pain with or without medication:

• Relaxation therapy – visualization, breathing, light massage

• Changing position • Taking a walk • Education; understanding why you are

having pain – very helpful if the pain is not directly from your surgery

• Distraction – music, TV, walking, socializing

• Understanding sources of, and finding ways to reduce stress See guidelines for your recovery in this book

Visiting hoursThe medical/surgical unit supports open visiting hours 24/7 This means that your loved ones can visit any time during your hospital stay Your nurse will provide your family members with guidelines for visiting that will help promote healing We ask that you, your family, and visitors consider these guidelines when deciding to visit:

• If any family members or visitors are ill, please have them refrain from visiting you

• Limit visitors to immediate family and/or special friends

• Have only one family member as the primary contact person for your care

• Keep visits short (frequent short visits are less stressful and most beneficial).

• Keep conversation supportive • Step out of the patient’s room, if asked,

so we can provide appropriate care • Remember – sleep, rest and nutrition are

very important for your family, visitors, and partner in care so they can help you recover after your surgery is complete and you are ready to go home

Breathing and keeping your lungs healthy A qualified respiratory therapist will meet with you to assess your post-extubation pulmonary needs and educate you on the following:

Taking care of your lungs provides these benefits:

• Keeps the lungs expanded • Helps remove secretions by

encouraging coughing • Prevents respiratory infection • Vital to a fast recovery

Cough and breathe deeply every hour while you are awake

• Use a pillow (any pillow) • Hold the pillow firmly against your chest

to ease some of the discomfort

How to use the incentive spirometer • Sit up straight as much as possible If

you’re in bed, sit up as much as you can • Hold the incentive spirometer upright • Breathe out normally • Put the mouthpiece in your mouth and

tightly seal your lips around it • Breathe in slowly and deeply This will

raise the blue piston to the top of the column The blue indicator should be in the little blue box

• Hold your breath as long as possible (at least five seconds), allowing the piston to fall to the bottom of the column

• Position the blue indicator on the outside of the column to mark your best effort. This should be your goal to reach with each repetition

• Rest for a few seconds and repeat steps 1-7 at least 10 times an hour

• After each set of 10 breaths, try to cough in order to clear your lungs If you have an incision, support your incision by placing a pillow against it

• Once you are able to get out of bed, walk in the hallway and cough heartily

How to use the Aerobika® (flutter)1 Assure proper setting of the dial on the end

of the Aerobika This is the end opposite the mouthpiece

2 Your healthcare provider will set the dial when you get your Aerobika Rotate the end toward the + (plus) to increase resistance Rotate the end toward - (minus) to decrease resistance

3 Sit up with good posture to use the Aerobika 4 Take a deep breath and hold it for about 3

seconds 5 Place the Aerobika mouthpiece in your mouth 6 Seal your lips tightly around the mouthpiece 7 Exhale as much as possible (but not too

forcefully) through the mouthpiece You should feel a vibration when used properly

8 Keep your cheeks as firm as possible when you exhale

9 Repeat this maneuver for 10-12 breaths 10 Try to resist coughing during this phase 11 After these 10-12 breaths, perform 3-4 huffs and

then a big cough to bring up mucus If you have an incision, support your incision by placing a pillow against it

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Therapy for your spineSpine care tips: When doing self-care activities

Precautions, per physician’s directions, to be aware of (to be checked by therapist): No rotation movement allowed for spinal surgeries Avoid excessive trunk bending/extending Maintain a neutral spine Limit lifting to less than 8 to 10 pounds (about the weight of a gallon of milk) Wear a cervical collar 20 hours per day Wear a back brace at all times when up and out of bed Log-roll to a side-lying position to sit up Sit down and lean to a side-lying position, and then log-roll onto back Do not use a pillow underneath your head (cervical spine surgery patients) unless your physician gives you permission Other:

Bathing and dressing It is very important to keep your spine in proper alignment when completing these activities The following are some tips to follow to maintain this alignment • Bring your legs up to you to wash and dress

with your back straight This is most easily done by sitting, such as on a tub bench If you cannot sit, using a long-handled device may help Whenever possible, do activities while seated to save energy

• If you are wearing a cervical collar, you will need to remove the front of the collar holding the back on Wash the front of your neck Then replace the front of the collar and remove the back part to wash Check with your doctor if you have surgical sites in these areas

Grooming This can be especially difficult for those wearing a cervical collar • Sit at the sink to comb your hair, brush your

teeth and shave • Tuck a washcloth between your chin and your

collar to protect it while brushing your teeth • When rinsing out your mouth, expectorate into

a cup Do not lean over the sink, as this may put stress on your cervical spine

• To shave your face, lie back in a recliner or on the bed Remove the front of the collar to shave. You may need help, as it is difficult to see Check with your doctor before shaving if you have surgical sites in this area

Eating (For those with cervical collars)• It may be difficult to see down to table

height to eat While you are in the hospital, raise up the bedside table At home, place your plate on a stack of books This will put less strain on your cervical spine

Functional mobility• If you are using a walker, tie a basket or

bag on the front to transport items Apron pockets, canvas tool belts or fanny packs also work well

• Use a travel mug or a thermos for transporting drinks or soups

• Place one hand on a stable surface (e g , countertops, tables) when reaching for items

• Remove throw rugs • Slide dishes and pans along countertops

instead of carrying them

Document created by LLH, COTAIL and ORR, P T Dec 2005, KWM, MSOTR/L Editorial assistance HMF, P T , ORR, P T

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Lumbar surgery(Back)

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Lumbo-sacral orthosis (back brace)Following surgery, you will be instructed to wear a back brace (orthosis) anytime you are out of bed The brace will support and protect the surgical site and usually makes you feel more secure and comfortable with movement It will also serve as a reminder not to bend or twist This type of brace is called a lumbo sacral orthosis, commonly known as a “warm and form” brace It is made with an elastic fabric, Velcro closures and a custom-molded plastic and foam back insert It is easy to apply and requires very little care once it has been fitted to your size and shape. You will be fitted with this brace before the day of your surgery so that it is available for you to use immediately after your procedure

The brace will be fitted by a specialist known as an orthotist, who is located in the Orthotics Department on the fourth floor of the Bush Pavilion (570-271-5139) A waist and hip circumference will be obtained and the proper-sized brace will be applied Once the brace is fitted, the plastic and foam insert is heated and softened and placed in a pocket in the back of the brace Then the brace is reapplied As the heated insert cools, it hardens and conforms to the shape of your lower back This provides a custom-molded back support

Other types of braces may be used as per ordered by your surgeon

Brace application The brace is usually worn over a cotton undergarment such as a T-shirt Do not wear a silky or satiny undergarment, as the brace will tend to slip and slide on your body We do not recommend wearing it against bare skin or over your outer clothes The orthosis may be applied while lying down in bed or while standing, with the assistance of another person — it can be difficult to apply yourself when standing, as you can lose your balance and fall. The brace should be applied firmly, stretching the elastic fabric and attaching the Velcro Be sure to smooth out many wrinkles as possible in the undergarment inside the brace, as these may result in skin pressure and cause discomfort

Place the brace over your lower back with the plastic insert centered over your spine When seated, the lower edge of the brace should be two to three inches above the seat of the chair in the back and just touching or slightly curling up on top of the thighs in the front You should not be sitting on the brace in the back and it should not be digging uncomfortably into your thighs in the front If so, it is too low Depending on your size and shape, the brace may have a tendency to ride up your body as you move about This can be eliminated or reduced by attaching the Velcro straps tightly

Brace careIf the brace becomes soiled, it can be hand-washed using a mild detergent Remove the plastic insert before washing Place the brace on a towel or hang it over a line to air dry Do not machine wash or dry When you are not wearing the brace, stick the Velcro to itself to prevent the hook side from becoming clogged with hair and lint

Thoracic and lumbar (back) spine precautionsTo maximize your recovery, follow these precautions for three months after back surgery, or as directed by your surgeon

To help you remember your precautions, we use the acronym BLT:

B – No bending forward at your waist; avoid slumped posture and rounding of your back L – No lifting more than 8 to 10 pounds, or as directed by your surgeon A gallon of milk weighs about 8 pounds T – No twisting at the waist

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Other precautions• If a back brace is ordered, always wear it as

prescribed by your surgeon • Follow exercise and activity guidelines

prescribed to you by your surgeon or physical/occupational therapist

• “Log roll” to get in and out of bed • No driving until cleared by your surgeon or

home provider You should not drive if taking narcotics

• Limit stair climbing to once or twice a day This amount may increase as your endurance increases

• Do not sit for long periods of time After 60 minutes, you should stand, walk or lay down You are encouraged to sit up for all meals You may sit in a recliner fully reclined (with your back brace on if ordered by your surgeon)

• The head of your bed should not be raised more than 30 degrees while lying down without your brace (if ordered by your surgeon)

You will receive spine precaution instructions that are specific to your surgical procedure at the time of your discharge

If you have any questions or concerns about your spine precautions, contact your surgeon’s office

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Cervical spine(Neck)

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Cervical collarSoft cervical collarSoft cervical collars are used following cervical surgery These collars don’t completely immobilize the neck, but they restrict motion and remind you to avoid excessive neck movement It is recommended that they be worn 20 hours a day until your first follow-up visit with the neurosurgeon Soft collars are made of foam covered with fabric They are shaped to taper under the ears and fasten with Velcro at the back of the neck They are available in a number of different sizes and shapes. You will be fitted with this brace before the day of your surgery so that it is available for your use immediately following your procedure. The brace will be fitted by a specialist known as an orthotist, who is located in the Orthotics Department on the fourth floor of the Bush Pavilion (570-271-5139)

Miami J cervical collarAfter your posterior cervical surgery, you may need to wear a Miami J cervical collar This is a hard plastic collar with soft foam on the inside that provides support and decreases range of motion while you are healing from surgery

You can clean the plastic shell with soap and water The inside pads can be washed or replaced as needed

Brace application and careThe brace is applied with the straight side down and the tapered areas under the ears The soft part of the Velcro should face toward the skin (not the scratchy hook part) It should be wrapped tightly under the chin and around the neck with the Velcro fastened securely in the back If you can slide your chin down inside the brace, it is not tight enough

The brace will absorb your perspiration, and can be laundered as needed It may be hand- or machine-washed Use a delicate cycle and lukewarm water with a mild detergent Do not use bleach Tumble dry on low heat

Cervical (neck) spine precautionsTo maximize your recovery, follow these precautions for three months after neck surgery, or as directed by your surgeon

To help you remember your precautions, we use the acronym BLT:

B – No bending of your neck, forward or backward L – No lifting more than 5 pounds, or as directed by your surgeon A gallon of milk weighs about 8 pounds T – No twisting of your neck

Additionally, some cervical spine patients are not allowed to lift both arms up above the head

Other precautions• If a cervical collar is ordered, always wear it as

prescribed by your surgeon • Follow exercise and activity guidelines

prescribed to you by your surgeon or physical/occupational therapist

• “Log roll” to get in and out of bed • No driving until cleared by your surgeon or

home provider You should not drive if taking narcotics

• Limit stair climbing to once or twice a day This amount may increase as your endurance increases

• Do not sit for long periods of time After 60 minutes, you should stand, walk or lay down You are encouraged to sit up for all meals You may sit in a recliner fully reclined (with your back brace on if ordered by your surgeon)

• The head of your bed should not be raised more than 30 degrees while lying down without your brace (if ordered by your surgeon)

You will receive spine precaution instructions that are specific to your surgical procedure at the time of your discharge

If you have any questions or concerns about your spine precautions, contact your surgeon’s office

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Hospital discharge Going home

Instructions: Your discharge instructions will be reviewed with you by the neurosurgery team and nursing staff. You will be given a paper copy of all your instructions at discharge

Medications: You will be discharged home with pain medication, stool softener and a muscle relaxant If you have any of these medications already at home, you will continue your current prescriptions If you do not have another narcotic agreement outside of neurosurgery, we will provide pain medications for 90 days from surgery to cover your surgical pain You will be weaned off these in this time frame.

Pharmacy: Reminder that if you signed a narcotic agreement with our department, to only use the pharmacy that was listed

Transportation: You will be expected to have transportation at the time of discharge Please plan ahead accordingly

Clothing: Please make sure you have a set of regular clothing and shoes for your time of discharge

Appointment: If your follow up appointment is not already scheduled and included on your discharge instructions, a follow up appointment will need to be arranged after discharge by calling scheduling directly at 800-275-6401

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Guidelines for your recovery

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After surgeryOnce you’re homeIncision: Your surgical site will be sore and may take a few weeks to gradually improve Take your pain medication as needed and try not to let the pain get too far ahead of you early on Apply ice as needed for relief Have your caregiver keep an eye out for redness, swelling, drainage/discharge

Activity: Once you go home, you should be able to get out to bed, walk and use stairs Gradually increase your activity as tolerated

Intake: Make sure to drink plenty of fluids and eat a fiber full diet as pain medications can be constipating Walking will also improve bowel function as well You will be given a stool softener at discharge and it is recommended that you take it as long as you are taking narcotic pain medication

Medications: Take medications only as prescribed If you need a refill, please contact our office 1-2 days prior (exception weekends) Reminder that if you signed a narcotic agreement with our office, you may only use one provider and one pharmacy Pain medications cannot be called into the pharmacy and a paper script will be issued in the office for pick up.

Avoid: Do not smoke or drink alcohol We can provide a nicotine patch for you at discharge if needed

Appointments: You will follow up with the neurosurgery team to evaluate your progress/recovery and return to work plan

Paperwork: Our office does not complete permanent disability paperwork We will be glad to complete FMLA and short term disability paperwork for your surgical recovery If after surgery, you feel you cannot return to work, you will be referred to a specialist for functional capabilities testing

Guidelines for your recoveryThis section will help you be an active participant in your recovery from spine surgery. You’ll find important information about diet, exercise, and preventing infection, plus removable charts to help you keep track of your recovery progress, appointments and activities Keep them readily available so that you remember to record the information

In this section, you’ll find:• Things to remember• My notes on recovery• Follow-up appointments

• Important numbers and follow-up appointments

• Return appointments• Rehabilitation• Going home/recovery

• Preventing infection• Bathing and self-care• Incision care

• Resting and eating• Sleeping and emotions • Tips on relieving stress • Nutrition• My notes on nutrition

• Physical therapy and resuming physical activity

• Activity restrictions/helpful tips• Physical activity• My notes on physical activity• Sexual activity• Exercises to do every day

• Monitoring your condition• Things to do at home• Temperature and incision• My notes on recovery

• Important precautions• Visitors and phone calls at home• Driving and returning to work• Alcohol use• Smoking/tobacco use

• Pain and medications• Medications after surgery• My new medications• My notes on medications

• Additional information• Using the internet for additional

information

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Follow-up appointmentsMy notes on recovery:

Important phone numbers and follow-up appointmentsImportant phone numbers:Geisinger’s Department of Neurosurgery570-271-6437Geisinger’s Department of Orthopaedic Surgery570-271-7969Geisinger Medical Center operator570-271-6211

Appointments:Primary care physician Date/time:Rehabilitation Other appointments

Return appointments:• Your follow-up appointments will be scheduled

by department secretaries • Your surgeon will send a report of your surgery

and hospitalization to your family physician and referring doctor

Follow-up appointment:Primary care

Surgeon

Rehabilitation• We encourage you to enroll in a physical

therapy program two weeks following your procedure This program will combine core strengthening, stabilization and gentle range of motion for the region of your spine on which your procedure was completed

• You will need to contact an appropriate facility offering therapy services. Be sure to take the physical therapy order you receive at discharge Your primary care physician can help provide locations that are close to where you live

My physical therapy program (if already scheduled) is:

Post-surgery travel to homeWhether you are driving or flying home after your stay in Danville, there are some important precautions you should take Read this section for important information about traveling after your spine surgery

For patients and caregivers returning home by car:

• In the event that shortness of breath or chest pain occurs, contact 911 immediately and provide information regarding patient’s surgery to emergency personnel

• Patient may not lift more than 10 pounds

• Patient may not operate a motor vehicle during the drive home

• Patient should wear compression stockings during the entire trip home

• Patient should stop to walk every one to one-and-a-half hours

• Patient should take pain medication as recommended per discharge planning instructions; patient should not wait until pain is present to take medication

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• Patient and caregiver should each have contact information for the Geisinger Spine Team loaded into their cell phones

• Patient should not consume caffeine.• Patient should not consume alcohol

while taking prescription pain medication

For patients and caregivers returning home by airplane:

• Provide the flight attendant with information regarding patient’s surgery upon boarding the airplane

• In the event that shortness of breath or chest pain occurs, contact the flight attendant immediately

• Patient may not lift more than 10 pounds

• Patient should wear compression stockings during the entire trip

• Patient should take pain medication as recommended per discharge planning instructions; patient should not wait until pain is present to take medication

• Patient and caregiver should each have contact information for the Geisinger Spine Team loaded into their cell phones

• Patient should stay hydrated as prescribed by the Geisinger Spine Team

• Patient should not consume caffeine.• Patient should not consume alcohol

while taking prescription pain medication

• Patient must travel with all medications in carry-on baggage

• Patient should not be left alone or unattended during travel

• Patient should sit in an aisle seat, if possible, to have opportunity to stretch and move

• Patient should walk every one to one-and-a-half hours, when possible If walking is not possible due to flight restrictions, patient should stretch his or her legs and change leg positions at regular intervals

• Patient should perform recommended exercises during flight as listed below.

Recommended in-flight exercises• Ankle circles: Lift one foot off the floor

and draw a circle in the air with your toes pointed Continue for 30 seconds Repeat with your other foot

• Foot pumps: While keeping your heels on the floor, point your toes up as high as possible toward your head Put both feet back down flat on the floor. While keeping the balls of your feet on the floor, lift both heels high Continue for 30 seconds

• Knee lifts: While seated, “march” slowly in place by contracting each thigh muscle Continue for 30 seconds

Going home/recoveryThe average stay in the hospital after spine surgery is about two to four days You may be happy to go home, but do not be surprised if you and your caregiver feel anxious These are normal feelings as you adjust to leaving the hospital Some patients may need to transition to a physical rehabilitation center for one to two weeks to get stronger prior to returning home, though this is not common The spine surgery team will review the following information with you to prepare you and your family for the transition from hospital to home This information will also be provided in your discharge instructions

Daily guidelinesWhen at home, you can perform most of your daily activities with little or no assistance from others Recovering from spine surgery is like recovering from any other major surgery

• Get up in the morning and dress in your everyday clothes

• During the first week home, keep your activities similar to the activities in the hospital

• Gradually get back into your daily routine • Ordinary activities, such as dressing,

showering and combing your hair, may be difficult and cause discomfort during your first days at home.

• Spread your activities out over the day • Take frequent rest periods • The more active you are, the quicker you

will be able to resume your daily activities • You may perspire more than normal during

the first few weeks after surgery.

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Call the Geisinger Spine Institute if:• Your incision opens• Your incision has more than a drop or two

of fluid (drainage) flowing from it• Your temperature is higher than 100 5º F for

24 hours or is higher than 101 5º F at any time

• You have leg swelling and pain to the touch in the calves

• You have shortness of breath or chest pain when resting

Bathing and self-careYou may shower regularly once you return home, your surgical team will provide specific instructions

• Initially, you may want someone nearby for assistance

• Use warm water • Do not let the water spray directly on the

incision, but water may run down over the incision

• Wash around the incisions gently with antibacterial soap and water

• Pat your incisions dry • Do not use creams, powders, lotions

or perfumes on the incision until it is completely healed

• You may use underarm deodorant • You may use a dry dressing over an area

that is draining, but otherwise it is not required

Preventing infection/incision careExpect your incision to be a bit tender Your incision may also have discomfort, itching, tightness, or numbness This is normal To help with aching, you may take a pain pill, as directed, or acetaminophen (Tylenol®) as needed Taking it at bedtime may help you to relax and rest more comfortably

• You should contact the Geisinger Spine Institute with any of the following concerns:

• Swelling, redness or tenderness around your incision increases

• Drainage from your incision increases It is normal to have a few drops of clear, straw-colored or reddish-brown drainage from an incision, but if there is more drainage than that or if it turns to a cloudy, white, yellow or green drainage, this could be a sign of infection

• Your temperature gets higher than 100 5º F for 24 hours or higher than 101 5º F at any time

Resting, eating and sleepingTo sleep better and get the rest you need, follow these guidelines:

• Break your day into thirds Spend one-third in bed, mainly sleeping overnight Spend one-third sitting in a chair or recliner relaxing Spend one-third up walking or on your feet

• You may want to take a nap daily upon returning home If so, try to take one in the late morning or early afternoon Do not take a nap too late in the day, as it may be difficult to sleep at night.

• Do not eat a large meal before going to sleep

• Develop a regular sleep routine to help your body get ready for sleep

• Refrain from caffeinated beverages.• Take a short walk and do your

breathing exercises before going to sleep

EmotionsYou may feel tired, irritable and depressed You may experience an inability to concentrate, have some sleeplessness or even have some temporary memory loss as a side effect of some medications you may be prescribed (but not generally from spinal surgery) As the healing process moves along, you will begin to feel more in control and these feelings should disappear If they do not, discuss them with your family physician Seek the support of a friend or family member to share your feelings, thoughts or concerns. You may find that your family is experiencing similar emotions

Here are some tips to improve your mood:• Get dressed every day • Walk regularly • Avoid long periods of inactivity, but

follow your documented restrictions • Start hobbies • Share your feelings with a loved one • Get a good night’s sleep • Take a shower for a fresh start

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Tips on relieving stressTo get your stress level under control, you first need to understand what causes stress and how you react to it Do you react physically? For example, do you feel your stomach jump or do you clench your teeth? Do you react emotionally? For example, do you yell or hold back your thoughts? If so, try to develop ways to relieve stress, when possible, and to manage unavoidable stress

Here are ways to reduce stress:• Listen to relaxing music • Focus on a peaceful scene or place

Try to use all of your senses — see the place, listen to its sounds, imagine how it feels and smells Taste what there may be to taste

• Learn relaxation techniques. Kick off your shoes and get comfortable As you inhale and exhale with your eyes closed, take slow, deep breaths and concentrate on your body from your toes to the top of your head

• Get outdoors and enjoy nature, weather permitting

• Spend quiet time alone • Get into a daily walking program • Spend time with people who care about

you

If the stress reducers listed are not helpful, talk to your family physician

These factors make you more likely to develop stress and spine disease:

• A family history of spine disease• Physical inactivity• Using tobacco products• Excess weight• Diabetes mellitus

I am going to reduce my stress by:

NutritionYour appetite may decline for several weeks after surgery, but should improve with time Keep in mind that your surgeon does not recommend a diet restricted in nutrients during the initial recovery period (four to six weeks after surgery) You should eat a balanced diet with adequate calories and protein This will promote healing and speed recovery

Here are some good general recommendations:• Limit salt use If you have heart disease, try

using less than 2,400 mg a day • Cut back on sugars and sweets • Limit red meat to 6 ounces a day • Eat a variety of fruits and vegetables every

day • Eat whole grains, which are a good source

of fiber and nutrients.• Read nutrition labels Make a habit of

reading labels when you shop • Pay attention to the cholesterol, saturated

and trans-fat in the foods that you eat • Eat low-fat, high-protein foods (e g ,

skinless chicken or turkey, fish or lean cuts of meat)

• Reduce portion size Go to ChooseMyPlate gov for advice

• Plan your meals to build menus with healthy ingredients like fruits, vegetables, whole grains, lean meat, fish or poultry.

• Fat intake should be 30 percent or less of your total calories

• Trim fat from meat and poultry Broil, bake, boil, roast, poach, steam, sauté, stir-fry or microwave instead of frying

• Maintain or reduce your weight to a healthy weight

• Say “no” to fried or breaded items, and avoid larger portions

My notes on nutrition:

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Activity restrictions/helpful tips• Do not lift more than 10 to 15 pounds for

2 to 4 weeks or when your surgical team tells you that you can increase your weight restrictions

• Avoid activities that require you to push, pull or tug (e g , vacuuming, raking leaves, sweeping, mopping, forcing windows open, moving furniture, carrying heavy bags of groceries, picking up small children, shoveling snow, playing golf, mowing grass, fishing, shooting a gun).

• When you use the muscles in your upper body, turn your head, twist or bend, it may cause stress on the incision, regardless of the location along your spine

• Avoid deep bending at the waist • Do not drive until the surgeon clears

you (approximately two to six weeks, depending on your procedure and post-operative recovery)

• You may ride in a car Use your seat belt At first, long trips will be uncomfortable. Stop and rest for 5 to 10 minutes for every 45 minutes to an hour of travel time

• Avoid crossing your legs • There are no restrictions on stair climbing

Climb them at a comfortable pace

Physical therapy and physical activityDuring your recovery, you will follow a walking routine to help condition your body, to improve the way you feel about yourself, to improve independence and to shorten your recovery time You may feel a little tired and achy at first.

Here are some general guidelines:• Look for opportunities to move and

increase your activity level • During the first few weeks of recovery,

space your activity throughout the day and rest between sessions

• Walk on a level or flat surface as often as possible for the first one to two weeks.

• Concentrate initially on increasing the time you are walking, not the speed

• Walk outside, weather permitting

Most patients will be recommended to have outpatient physical therapy after surgery at a location convenient to them

Here are some general guidelines on how your physical therapy may progress. Having spine surgery is a major undertaking, and rehabilitation plays an important role in helping patients get the most successful outcome from their surgery The management of activities and needs after a spinal stabilization surgery gradually progress over time to avoid injuring your back or neck The following is what a typical patient can expect Keep in mind that that there are different recommendations based on the spine surgeon’s preference, the patient’s needs and the type of spinal stabilization surgery performed Phase I: Discharge and transition from the hospital to homeOnce you are discharged from the hospital and you arrive home, it is important to protect the surgical region and promote healing You need to avoid activities such as heavy lifting, twisting or bending to control pain and inflammation. It is recommended that you avoid lifting more than 10 to 15 pounds for the first 2 to 4 weeks, then progress slowly under the recommendations made by your surgeon You should continue to use log-rolling when getting in and out of bed The use of a long-handled reacher may also be recommended to avoid excessive bending or reaching It is important to be cautious going up and down stairs for the first two to three weeks, and you may find you need to go slowly and take one step at a time When resting in bed, change your position every 45 minutes Manage any muscle cramps with gentle stretching

In this phase, you need to gradually increase your activity tolerance to prevent excessive stiffness. We recommend that you continue performing a gentle home exercise program that was provided to you in the hospital These exercises include gentle pelvic tilts, quadriceps sets, gluteal sets, hamstring sets and ankle pumps You should continue to perform these exercises hourly Two to three times a day, you should also continue to perform the gentle range-of-motion exercises provided while you were in the hospital These include heel slides and hamstring stretching, as well as standing leg-strengthening exercises, such as wall

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slides, active leg marching, toe and heel raises and leg curls

You can perform these standing exercises at the kitchen counter for safety if you feel unbalanced

Pain control is an important part of your recovery In addition to any prescribed pain control medications provided to you by your surgeon, relaxation exercises can be a helpful tool in the early stages of your recovery to better manage your initial postoperative pain

You will also need to begin an active walking program You should choose a safe, paved area and avoid any hills for the first two to three weeks We recommend that you gradually increase your walking tolerance, by walking shorter distances at first at a comfortable pace You may start out walking 5 minutes in one direction and 5 minutes back, gradually increasing your time up to 30 minutes a day

Always allow pain to be your guide in your activities during this phase Pay attention to your body’s painful warning signs If any of the above exercises cause increased pain that remains constant, it may indicate overactivity or too much stress to the surgery site

Phase II: Initiation of outpatient physical therapyThe start of outpatient physical therapy (PT) typically occurs anywhere between two and six weeks after surgery, depending on your surgeon’s recommendation Most patients typically attend PT two to three times a week, depending on the individual patient’s needs It is the goal in this phase of recovery from your spinal stabilization surgery to improve your overall flexibility, initiate basic core stabilization, further increase activity tolerance and introduce safe body mechanics and patient education regarding good posture The therapist will develop a training program tailored to you, considering your specific surgery, body type and tissue conditions

PT will help improve any loss in range of motion and flexibility. You will be taught how to help move the affected joints and muscles in a safe manner to restore normal movement PT

will also focus on targeting the muscles that need special retraining to gain strength and provided stability after you have had your spinal surgery This is often referred to as “core stabilization ” These core-stabilizing muscles are the small muscles that work around the vertebrae in your back and neck to help stabilize the spine Most people do not use these muscles properly — even those without back pain Through core stabilization, these muscles will be properly trained to protect the spine and the newly operated area to prevent future problems

You will also begin light resistive training for your arms and legs in neutral spine Neutral spine is a specific position you will be taught to maintain during all exercises and any activity It is important that you learn how to maintain neutral spine, as it is the position that puts the least amount of pressure on the structures throughout your back, including the discs You will also start light balance exercises, as well as cardiovascular training

Attending outpatient PT can also provide better pain management This can be achieved through the application of techniques that can provide analgesic (pain) relief, including moist heat, ice and electrical nerve stimulation

Phase III: Advanced physical therapyAdvanced PT will often occur anywhere from 8 to 10 weeks after surgery and will build upon core stabilization achieved in Phase II of recovery There will be a focus on increased arm and leg strengthening in neutral spine, increased balance retraining exercises and advanced mobility exercises throughout your spine Your exercises will progress to train you for specific activities and/or necessary job requirements Cardiovascular exercise for overall conditioning, posture and body mechanics training will also be advanced during this phase

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Phase IV: Functional rehabilitationThis phase of recovery, which usually occurs between 10 and 12 weeks after your surgery, will focus on return to recreational activities, return to work and a transition to an independent exercise program There will be an intensive review of postural considerations and safe body/lifting mechanics If indicated, a return-to-work program may be initiated during this phase During this phase of your recovery, the main goal is for a successful return to gainful employment The independent program will be all-inclusive of posture, strength, flexibility and lifting needs. It will be a program that may be home-based or gym-based, depending on the goals of the individual patient

Resuming physical activityHere is a good general walking program:

• Week 1: 15 minutes 2 to 3 times per day• Week 2: 20 minutes 2 to 3 times per day• Week 3: 25 minutes 2 to 3 times per day• Week 4: 30 minutes daily• Week 5: 45 minutes daily• Week 6 (and for the rest of your life): 45–60

minutes daily My notes on physical activity:

Sexual activityIt is normal to feel some anxiety about resuming intimacy and sexual activity Keep in mind that anxiety, as well as some medications, may interfere with sexual performance, but uncomplicated spinal surgery will not affect your sexual performance or desire

The amount of energy you expend during sexual intercourse is comparable to climbing two flights of stairs. In time, you will find that you and your partner will return to a satisfying emotional and physical relationship

Here are some helpful tips:• Talk openly with your partner about

your feelings • Avoid sex until cleared with your

surgical team Upon resuming, avoid sexual positions that apply pressure on the incisional area or strain on your surgical levels for six to eight weeks

• Relax and give yourself and your partner time to recover

• Discuss any difficulties with your family physician

• Contact your family physician before starting or restarting over-the-counter or prescription sexual enhancement medications

Exercises to do every dayOnly do the following exercises while lying on your back in bed Do at least three sets of each per day, starting one week after surgery:

• Quad sets – Tighten the muscles in the front of your thigh Hold for 3 seconds and then relax Repeat 5 times and work up to 10 times

• Abdominals – Tighten your stomach muscles Hold for 3 seconds and then relax Repeat 5 times and work up to 10 times

• Ankle pumps – With straight knees, pull your toes back toward your head as you feel your calf muscle stretch, then point your toes down toward the floor. Repeat 10 times and work up to 20 times

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Things to do at home• Take over-the-counter daily stool

softeners and laxatives as needed to prevent narcotic-caused constipation Some medications prescribed will cause a decrease in the motility of the bowel

• Develop a system to help remind you to take your medications For example, use a “days of the week” pillbox or an index card

• Use your incentive spirometer or flutter valve as directed, and cough and deep-breathe frequently every day

• Check your incisions every day • Weigh yourself every few days if you

have had appetite changes • Increase your activity every day • Exercise inside if it is too hot or too cold

outside • Do not lift anything heavier than 10

to 15 pounds for 6 to 8 weeks, or as instructed by your surgical team

• Make healthy food choices • Do not smoke • Go to your scheduled follow-up doctor

visits • Go to physical therapy as directed

If you have not been referred or scheduled, ask your nurse navigator

• Do not drive until cleared by a doctor (approximately two to six weeks, depending on your procedure and postoperative recovery)

• Resume sexual activity when you and your partner feel ready, but not before discussing with your surgical team Avoid sexual positions that apply pressure on the incisional area or strain on your surgical levels for six to eight weeks

• Contact your family physician before starting or restarting any over-the-counter or prescription sexual enhancement medications

• Find activities to keep your emotions positive

Temperature, weight and incision appearance chartTemperature:

• Check your temperature twice daily for one week

• Check in the morning, before breakfast and in the evening near the same time each night

Call your surgeon if your temperature is higher than 100 5º F for 2 or more days or if your temperature is higher than 101 5º F at any time

Incision appearance:• Call your surgeon if you have any

increased swelling or redness or if there is increased drainage from the incision It is normal to have straw-colored or reddish-brown drainage If the drainage turns cloudy, white, yellow or green, this could be a sign of infection

Visitors and phone calls at home• Entertaining visitors and talking on the

phone may initially tire you, so limit the number and duration of visits and calls

• Ask friends and relatives to call before visiting

• If you are tired or become uncomfortable during a visit, excuse yourself for a rest

• During your recovery, you are more likely to catch a cold or get ill due to the increased stress on your immune system Discourage visits from others if they are sick

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Driving and returning to workDrivingYou will not be able to drive for at least two to six weeks depending on your procedure and postoperative recovery and as determined by your surgical team

Reasons for not driving include:• Pain medications causing sleepiness,

decreased concentration and decreased reactions

• Limited flexibility due to stiffness and soreness

• Possible impaired braking time if you have residual pain with movements of your legs

• Discomfort and inability to perform twisting movement of the neck and back

Returning to workDuring your first follow-up appointment, you and your physician and surgical team will discuss when you can return to work The decision about when to return to work will depend upon:

• Your general physical condition, including how long you have been inactive and how long you were having problems before surgery

• The type of work that you do• The emotional and physical demands of

the work

My potential date of return to work is:

Alcohol use • Check with your physician regarding alcohol

intake • While you are on pain medications, avoid any

alcohol intake

Smoking/tobacco use • If you use tobacco and or nicotine products,

including chewing tobacco, stop If you need help stopping, visit DetermlnedToQuit com

• Medications are available from your family physician to help quit

• Ask family members and friends not to smoke around you

Important facts you should know about the hazards of smoking: • Just one to four cigarettes a day will increase

both your systolic and your diastolic blood pressure (top and bottom numbers)

• If you have any degree of peripheral vascular disease (disease of blood vessels in your legs), there is no safe level of nicotine

• Smoking has been known to inhibit the human body’s natural healing process, and has been well documented in scientific studies to be a leading cause of non-union in spinal fusion surgical cases

Managing post-op pain at home: Medications Pain after an operation, or post-op pain, is normal and expected These guidelines can help you stay as comfortable as possible

Taking pain medications

• Take medications on time Do not take more than prescribed

• Take only the medications that your healthcare provider tells you to take

• Take pain medications with some food to avoid an upset stomach

• Don’t drink alcohol while using pain medications

• Take medications on time Do not wait until the pain is severe

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Types of pain medications

Non-opioid:• These can include over-the-

counter medications (such as acetaminophen and ibuprofen) or prescription medications

• All relieve mild to moderate pain, and some reduce swelling

• Possible side effects include stomach upset and bleeding

Opioid:• These medications are by

prescription only • Opioids relieve severe pain • Possible side effects include

stomach upset, nausea, and itching

• Opioids may cause constipation, so eat high-fiber foods and drink plenty of water

Call your doctor if you notice any of these symptoms:

• Nausea, vomiting, diarrhea, lasting constipation or stomach cramps

• Breathing problems or a fast heart rate• Feeling very tired, sluggish or dizzy• Skin rash

© 2000 • 2008 The StayWell Company, 780 Township Line Road, Yardley, PA 19067 All rights reserved

Managing post-op pain at home: Non-medication reliefMedications are not the only way to manage pain after surgery Try the following techniques

Ice or heatUse the one checked below as needed (but for no longer than 20 minutes at a time):

• Ice pack or bag of frozen peas wrapped in a thin cloth

• Covered heating pad (not too hot)

VisualizationVisualization helps take your mind off the pain:

• Close your eyes Breathe deeply • Picture yourself in a quiet, peaceful

place • Imagine how you feel in that place • If other thoughts enter your mind, take a

deep breath and try again

Progressive body relaxationRelaxation helps relieve stress and pain:

• Close your eyes Clench your foot muscles • Hold for a few seconds Release • Repeat with the muscles in your calves • Work slowly up your body

Deep breathingDeep breathing relaxes your whole body:Inhale slowly and deeply as you count to 5 Hold your breath for a couple of seconds Exhale through your mouth as you count to 10

© 2000-2008 The Stay Well Company, 780 Township Line Road, Yardley, PA 19067. All rights reserved.

Commonly prescribed medications after spinal surgeryOxycodone (Oxycontin) 5 mg tablets for incisional painHydrocodone-Acetaminophen (norco) for incisional painDiazepam (Valium) for muscle spasmsMethocarbamol (Robaxin) for muscle spasmsTizanidine (Zanaflex) for muscle spasms

My new medications:• •

When do I take this? Why am I using this medication?

• Ask your nurse or physician for educational materials for all your medications

Keep all of your prescription medications, and in particular any medications for pain, in a safe, secure location and away from children

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My notes on medications:

Additional questions for my spine surgery team:

Using the internet for additional informationThe following websites offer valuable information relevant to your health and spine disease.Geisinger’s website enables you to sign up for MyGeisinger This site will help you meet your healthcare needs quickly and conveniently by providing a secure, confidential and efficient way to view your health information anywhere you have internet access Your nurse navigator or patient liaison can help you obtain access

geisinger orghealth nih govnutrition govWebMD com

Additional We believe in measuring and assessing the degree of improvement our patients experience as one means of continuously improving the care you and others receive from us Geisinger Health System is one of several leading groups participating in the Quality and Outcomes Database, a national clinical registry sponsored by the American Association of Neurological Surgeons The main objective of this registry is to assess how spinal surgery benefits patients and to determine how much surgery improves pain, disability and quality of life

Patients who are having surgery will be asked to participate before and after surgery using the patient portal MyGeisinger org Before surgery, and then again at three months, six months and one year after surgery, we will ask you questions about your symptoms, pain, satisfaction with care and quality of life. We hope to find out whether your surgical outcome met your expectations. Your participation in answering these questions is voluntary, but important to your care team’s ability to gauge your progress. If you do not have internet access or have difficulty answering the questions online, one of our nurse navigators can assist you with these questions by phone

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84428-1-7/16-KG/DS

Lumbar spine surgeryPatient course access

Own an iPhone or an iPad? Get all your lumbar spine surgery care materials on your mobile device!

Don’t forget friends and family helping you with your surgery preparations and recovery. They can also download the materials and follow along!

If you prefer to download the iBook and apps separately:1. From your iPhone or iPad,

go to the iBooks App.

2. Tap Search.

3. Enter “Geisinger.”

4. Select Your Guide for Lumbar Surgery and download.

5. From your iPhone or iPad, go to the App Store.

6. Tap Search.

7. Enter “MyChart” and download. Choose Geisinger Health System.

8. Search again, enter “MySurgery: Lumbar Spine” and download the reminder app.

Steps to get this guide:

1. Steps to get this guide:

2. Tap Search.

3. Enter “Geisinger” in search field and tap Search button.

4. Look for “Geisinger Neurosurgery Lumbar Spine Surgery.”

5. Tap Subscribe.

6. Tap Get Course.

7. Review the subscribed course under the “My Courses” section of the iTunes University App.

Any questions? Call your nurse navigator: Joyce 570-214-2179 or Melinda 570-271-6541.

Access the Lumbar Spine Surgery course on iTunes University for prep and recovery materials, including:

✓ Meeting your care team ✓ Learning about your surgery ✓ Diet and medication guidelines ✓ What to do before your surgery

✓ What to expect the day of your surgery and how to prepare

✓ What to expect after your surgery ✓ Surgery recovery guidelines

Notes:

Notes:

Notes:

A-650-747-F Dev 12/17

Source Information: Health information provided by healthcare professionals at Geisinger