Back Spinal Surgery

This guide provides information about what to expect during your hospitalisation and when you return home following your spine surgery. As spine surgery affects each person differently, some of the information included in this guide may not be applicable specifically to your condition, so it is important for you to discuss any questions or concerns with your doctor or nurse.

Reasons for spine surgery
Spine surgery may be recommended by your neurosurgeon to manage your condition and prevent it from getting worse. This could be for any of the following reasons:

• Reducing and managing symptoms such as pain, numbness, tingling and weakness
• Relieving pressure on nerves, for example by removing discs that have degenerated or tumours, nodules, cysts or bony growths (osteophytes)
• Stabilising the spine, e.g. after traumatic injury
• Draining an infection or abscess

No surgery is without risk, even for a healthy person. Your surgeon will discuss the risks and complications with you.
General complications:

• Allergic reaction to drugs, anaesthetic agents, blood transfusions and products
• Bleeding
• Infections
• Stroke
• Death

Specific complications related to spine surgery:

• Nerve or spinal cord damage, which can result in paralysis, numbness and/or limb weakness
• Persistent pain (or other abnormal sensations)
• Infection of the surgical wound
• Pressure ulcers/abrasion (position related)
• Leakage of cerebrospinal fluid (CSF)
• Bladder and bowel changes
• Spinal cord/nerve injury
• Visual impairment
• Need for additional unplanned procedures or revision surgery
• Unsatisfactory position or failure of spinal implants
• Failure of fusion
• Excessive bleeding or excessive blood clot formation
• Formation of blood clot within a major vein (Deep Vein Thrombosis or DVT)
• Major blood vessel injury
• Blood clot on the spinal cord (Spinal epidural haematoma)
• Paralysis from spinal cord reperfusion effect – this is an uncommon complication that causes a stroke-like effect in the spinal cord.

Pre-preparation for Surgery

• History – It is important for you to inform your doctor about your past medical and surgical history, your current regular medication especially blood thinning agents, such as aspirin, warfarin and drug allergy.
• Neurological examination – Physical and neurological examination may be performed as a baseline for post-operative comparison.
• Investigations / Tests – Diagnostic imaging studies of the spine, such as CT, MRI, spine angiography etc may be performed to provide your surgeon with anatomic details for surgery.
• Informed consent – Your neurosurgeon will discuss the potential benefits, risks and complications that may result from the surgery, any alternative treatments, operative procedure, peri-operative investigations and estimated duration of surgery to you. If the doctor uses term not familiar to you, please clarify with him. You will have to sign a consent form to show that you have understood what was told to you and have agreed for the procedure. You will also need to sign consent for receiving blood transfusion if needed.
• Financial counseling - You will be advised on the estimated cost of the surgery, implant (if any) and expected length of stay in hospital.
• Pre-operative education – It is normal to be fearful of the surgery and experience anxiety. You will be referred to nurse clinician who will provide explanation on what to expect before, during and after the surgery.

Pre-Admission Counselling and Evaluation (PACE) Clinic

Before any surgery, you will need to be assessed by an anaesthetist at the Pre-Admission Counselling and Evaluation (PACE) clinic. Please inform the anaesthetist if you have any medical illnesses or any of the following:

• History of allergy or reaction to any medication, drugs, or food.
• History of bleeding or clotting disorders.
• You are taking blood thinning drugs (e.g. warfarin, aspirin, Clopidogrel). If you are taking any of these medicines, the doctor at PACE clinic will advise if/when you need to stop taking them before the surgery.
• Traditional Chinese Medicine (TCM) or supplements (e.g Cordyceps, Ginkgo Biloba, Lingzhi, goji berries) may affect blood clotting and increase the risk of bleeding. You should stop taking TCM and supplements one month before your surgery.
• You are a smoker or have recently stopped smoking.

Most spinal surgery is done under general anaesthesia. This will be further discussed by the anaesthesiologists at the pre-admission clinic.
Sometimes, the doctor at PACE clinic may refer you to other specialists to investigate/optimise your medical condition(s) before surgery. This can result in postponement of your surgery.

Day of admission/surgery

• Bring along your own toiletries and all current medication.
• DO NOT bring valuables to the hospital.
• DO NOT drink/eat anything 6-8 hours prior to your surgery – hospital staff will call you with instructions the day before your surgery. You can still brush your teeth and rinse your mouth, just remember not to swallow any water.
• Do shower before coming to the hospital. 
• For your safety, you will be asked to remove your dentures, glasses, jewellery, hearing aids and nail polish. Please store them in containers or a plastic bag labeled with your name.
• Your family members may remain with you until you leave for the surgery.
• Depending on the type of surgery, the length of operation may range from 4 to 6 hours or possibly longer.  If there are other emergencies, your surgery may be delayed or postponed.
• Your family members may wait for you outside the ward waiting area while you are in surgery. They may leave their contact numbers with the ward staff so that they can be informed when you are out of the operating theatre.
• You will be asked to remove all your undergarments and change into an operating gown and to empty your bladder before you leave for the operating theatre.
• The operating theatre staff will fetch you on a trolley to the operating theatre.
• If you are unwell on the day of your surgery, please call the number given by PACE.

During surgery

You will receive medication(s) in the operating theatre to make you sleep unless your neurosurgeon has told you otherwise.

After you are asleep, one or more of these catheters/tubes may be inserted:

• Breathing tube – Breathing tube will be inserted into your throat to help you breathe during the surgery.
• Monitoring devices – Wires will be attached to your hand and body. These are connected to automated machines that will continuously check your breathing, heart rate, blood pressure and oxygen saturation throughout the surgery.
• Intravenous (IV) line – One or more intravenous lines for medications, fluid administrations or blood transfusions will be inserted before or during surgery.
• Arterial catheter (IA) – A catheter may be inserted into an artery in your wrist in order to measure your blood pressure more accurately and allow blood sampling to be taken.
• Urinary catheter – A urinary catheter may be inserted into the bladder to drain and monitor the urine output.
• Intra operative spinal cord and nerve monitoring (IOM) – May be used by your surgeon to monitor spinal cord and nerve root function during your surgery.

After Surgery​

Monitoring
You will be monitored in the Intensive Care Unit, High Dependency ward, or general ward until all acute risks of infections and bleeding have passed. This will include frequent questions and requests to move your arms and legs to assess your limb strength and sensation. It is important for you to respond even if you think it is repetitive. Blood pressure level, pain level, temperature, blood sugar, oral intake and output may also be checked.

You may also be monitored closely for other potential complications as a result of decreased movement and presence of invasive tubes or catheters e.g. chest and urinary tract infections, deep vein thrombosis etc.

Catheters / tubes/ collar

Depending on the type of spine condition, various tubes, drains and intravenous lines may be placed temporarily for a few days after the surgery:

• Monitoring devices attached to your body and hands – To check your breathing, heart rate, blood pressure and oxygen saturation continuously or at regular interval.
• Oxygen face mask / Nasal prong – An oxygen face mask or nasal prong is usually given to you when you are more alert and able to breathe better.
• Intravenous (IV) lines – One or more intravenous lines will be inserted and kept in for fluid, blood transfusion and medication until you can take oral fluids well.
• Urinary catheter – A urinary catheter may be inserted into your bladder to drain and monitor your urine output. The urine will be drained through the tube into a plastic bag which will be hung low by the foot of the bed. It is usually removed the day after your surgery; unless you are unable to pass urine and/or empty your bladder completely. You may feel the urge to urinate which is caused by feeling the catheter against the bladder neck. Upon its removal, you may feel a stinging sensation for 2 to 3 days, which is normal.
• Surgical drain – A tube may be placed in the surgical site to drain blood and fluid. It is usually removed on the 2nd or 3rd day after operation when the drainage is reduced to an insignificant amount.
• Anti-embolic stockings – Tight thigh-high stockings are usually worn to promote blood circulation in the lower legs and to minimise the risk of blood clots forming in the deep veins of both legs. Before you are allowed out of bed, you are encouraged to perform leg exercises every one to two hours. The stockings may be removed once you start walking.

Brace Application – As determined by your surgeon.

• Lumbar brace
  Your team will advise you if you need to wear a lumbar brace and for how long – do follow their advice.

Investigations / Tests
Repeat x-rays may be needed to assess the spine condition after surgery. Repeat blood tests may be performed to detect or correct any abnormalities if any.

Diet
Your team will advise you when you can start drinking and eating again. Most patients are able to eat after they are transferred to the ward. No special diet is usually needed after spine (back) surgery. A normal well balanced diet is recommended for recovery. The use of painkillers often causes constipation. You may need to drink more water, increase fibre in your diet and take a stool softener or laxative.

Wound management
Your wound is covered with a dressing and will be changed when dirty or loose. Keep your wound clean and dry until the stitches have been removed. Do not apply any lotions, ointments or other products to your wound unless specifically instructed to do so by your doctor. Notify your doctor or nurse clinician if you notice any of the following:

• Pain
• Redness
• Swelling
• Discharge
• Fluid leakage
• Skin breakdown
• Temperature >38 degree Celsius

Removal of stitches / Steri-strips / Prineo
Some patients have stitches and others may have Steri-strips (thin plaster strips) or Prineo (clear, waterproof dressing) to close the wound. Stitches and Steri-strips need to be kept dry. Your surgeon will decide when your stitches or Steri-strips can be removed – this is normally about 10 to 14 days after surgery and will be done in the ward or outpatient clinic. Patients are allowed to shower after their stitches and Steri-strips have been removed. If you have a Prineo dressing, you will be advised when you are allowed to shower. Prineo dressings are usually removed 14 days after surgery at the outpatient clinic.

Spine implants
Spine implants include metal or synthetic plates, rods, wires, screws and devices that are designed to stabilise the spine. Therefore, implants are only used when the goal of surgery is to restrict excessive movement between two or more segments of the spine.
If spine implants are used in your surgery, you may need to have x-rays and/or scans to check on their condition.  Your surgical team will advise how often this needs to be done based on your condition and implant.
Implants used in spine surgery may be detected by airport security checkpoints. You will receive an implant card after your operation which states that you have an implant. This card should be kept in your wallet and shown to security staff during airport security checks.
Implants are usually safe for Magnetic Resonance Imaging (MRI) scans, however you should always inform staff if you have such implants before going for an MRI scan and show them your implant card.

What to expect after surgery

Pain
Sometimes, spine surgery cannot completely eliminate the pain experienced before the operation. Pain may persist for many reasons, for example:

• The spine may have multiple abnormalities which surgery cannot completely address.
• The nerves may already be irreversibly damaged by the disease condition and cannot recover even after surgery
• Scar tissue (which develops around the nerves) can also cause pain.
• Pain, tingling and numbness on the front and side of the thigh(s) may be experienced, however this is usually temporary and can be treated.

Tell staff if you are suffering from pain. Taking painkillers as prescribed by your doctor will help manage the pain and you should need fewer painkillers as the wound heals.

Tiredness
Most people feel tired and need more rest than usual, but this will gradually improve.  Even sitting up in the first few days after surgery may require more effort than you expect. Don’t be afraid to ask for help if you cannot do these tasks on your own. Most importantly, remember to “listen to your body” and take each step of the healing process at your own pace. As you begin to feel stronger you should gradually resume your previous activities, building up as you feel able. Try to avoid doing too much too soon.

Altered sleep patterns
It is not uncommon to find that your sleep patterns change after surgery, such as having difficulty falling asleep at night, or waking up often during the night. This will gradually return to normal. A portable music player with some soothing music may help you to relax.

Changes in sensation
Surgery may not completely reverse injuries to spinal cord and nerves. Some patients feel numbness and weakness in their legs which could improve over time.

Medications
You may be given some new medications for your condition after your spine surgery. You will receive instructions from the pharmacist explaining what, why and how you should take your medication upon discharge. It is important you know which drugs you will need to continue to take and the dosage. Check you have enough drugs till you see your doctor again. If you were taking blood thinning medication (e.g. warfarin, aspirin) before the spine surgery, your doctor will advise you when to re-start the medication after the operation.

Your recovery journey
Recovery and the benefits from spine surgery are different for each person and depend on various factors, including:

• The underlying disease or condition you had
• How severely the spinal cord or nerve roots were compressed
• Complications of the injury
• The presence or absence of neurological problems
• The type of surgery you had
• Complications of the surgery
• Side effects or complications of postoperative treatments
• Your age and general health, including other medical conditions you have

Patients who have significant medical problems before their surgery, may take longer to recover and their recovery can be unpredictable.

Some patients may have temporary or permanent problems after spine surgery, such as:

• Weakness of hands and legs
• Numbness of hands and legs
• Poor balance or lack of coordination

Recovery and rehabilitation

After any surgery, it is not unusual, at first, to feel worse than you did before.  This can be depressing if you are not prepared for it.  Dizzy spells may also occur. These episodes can come and go and may be upsetting for you and your relatives.

The nurse and therapist will assist you in getting out of bed as soon as your condition allows. Early activity after surgery is extremely important to help prevent complications from decreased mobility, such as pressure sores, constipation and urine retention. It also promotes recovery and relieves muscle stiffness.

Rehabilitation can help you regain independence in your daily activities, such as walking, getting dressed, eating and bathing. This starts as soon as possible in the ward and can include physiotherapy, occupational therapy and/or speech therapy. Some patients may require longer rehabilitation and will be transferred to a community hospital.  Once discharged from hospital or community hospital, patients may still require rehabilitation at outpatient clinics or at home.

When you return home after your surgery, you may need help with simple household tasks, looking after yourself, and travelling to the hospital for appointments.

Try to plan ahead and make arrangements with your family, so help is available when you return home from hospital. Knowing who will accompany you to your medical/physiotherapy appointments and assist you with bathing and cooking can help you to avoid some possibly difficult situations after your surgery. It will also make it easier for your family members to share the tasks and manage their time.

Recovery is a natural process and it takes time. Some patients see quick improvements at the start, but their progress slows down over time and continues at a very slow rate for years.

Family and friends
Support from family and friends is very important for a person recovering from spine surgery. At times, adjustments may need to be made in the family depending on the person’s condition and progress. It is helpful to maintain a realistic and positive attitude towards recovery and rehabilitation and make plans for the short and long-term care of the person in consultation with the healthcare team.

The family should appoint one or two people to be the family spokesperson. They should be the key point of contact for the Doctor and healthcare team and pass information on to other members of the family to ensure consistency of information. This helps to avoid misunderstandings that can arise if there are many different people asking questions.

Preparation for home
We will discuss plans for continuing your recovery at home. These include if you need help with activities of daily living or other similar issues. We will provide information and training to your carer if you require assistance or special equipment upon discharge. To ensure a smooth transition to your discharge destination, we will assist you by mobilising community resources and making referrals for follow-up therapy if needed.

Research studies
Your doctor may discuss the feasibility of you participating in some research studies. Before conducting medical research involving people, medical staff are required to obtain the written consent of the patient or their legal representative to participate in the research project. The Doctor will explain the purpose of the study to you, including any hoped-for-benefits or potential side effects.

If you agree to take part, you will be asked to sign a consent form. After giving your written consent, you can still choose to refuse to participate or to opt out at any point during the research project. Your decision not to participate will not affect the care you receive. Some of research studies require follow-up appointments at the clinic or telephone calls to check on your progress.

Follow-up studies / visits
Your first follow-up appointment will be scheduled 2 to 8 weeks after you are discharged from hospital. This will include consultations with the neurosurgeon as well as spinal assessments and wound reviews with specialist nurses. Histology findings (test results), further surgery if needed or any additional treatment such as radiation therapy and chemotherapy in cases of spine cancer may be discussed in the outpatient clinic. Further follow-up appointments will be planned according to your condition and recovery.

Leave
You will usually be given hospitalisation leave to recover at home. The duration of your leave will depend on the type of surgery you had and your recovery progress.

​Activity
Restrictions
For the first 4 to 8 weeks after surgery:

• Do not lift anything heavier than 5kg
• Do not do any kind of heavy exercises or activities that cause you to hold your breath and push, for example weight lifting, lifting or moving heavy objects.

Contact sports should be avoided for at least 3 months after your spine surgery.

Driving
Depending on your condition, your neurosurgeon may advise you to stop driving temporarily if you continue to have weakness and numbness of your limbs. Your doctor will advise if/when you can start driving again.

Sexual activities
You may like to discuss this with your doctor.

Air travel
Please seek advice from your neurosurgeon.

Brace application
You should continue wearing your brace until you are told to remove it by your doctor at outpatient clinic visit. You should not drive when you are still on brace.

Return to work/school
The type of work you do and the demands of your job, as well as your recovery will determine when you are able to return to work. Your doctor will discuss this with you during your follow-up appointment.

Rest, proper nutrition and a positive attitude will promote healing, but recovery does take time and patience. Recovering after surgery may be a challenging experience. You and your family may find talking to someone or attending a support group helpful. If you would like contact details of associations, organisations and support groups, please ask your nurse. 

When to seek medical attention?

Call your doctor or nurse or go to the nearest hospital if you experience new or worsening symptoms:

• Increased weakness/numbness
• Persistent fever
• Wound breakdown or discharge

YOUR HEALTHCARE TEAM
Our doctors, nurses and other members of the healthcare team will guide you and your family members during your road of recovery. If you have any questions, concerns or comments, please feel free to contact us.

For Surgery & Wound related matters
6357 7545 (Neurosurgery Nurse)

Monday to Friday (excluding Public Holiday), 8.00am to 5.30pm

For appointment and other related matters
6330 6363 (Neuroscience Clinic)

Monday to Wednesday, Friday: 8.00am to 5.30pm
Thursday: 8.00am to 5.00pm Saturday, Sunday, Public Holidays: Closed

National Neuroscience Institute
11 Jalan Tan Tock Seng Singapore 308433
Main Fax : 6357 7016
Appointment Line : 6330 6363

Website: www.nni.com.sg
Email: [email protected]

NOTE: This brochure is given as a guide only and does not replace professional advice and care from your doctor.  You should seek the advice of your doctor before starting any treatment or if you have any questions related to your health, physical fitness or medical condition.