Advantage of Anterior
(Front) Approach vs. Posterior (Back) Approach
In the ALIF
approach, a three-inch to five-inch incision is made on the left side
of the abdomen and the abdominal muscles are retracted to the side.
Since the anterior abdominal muscle in the midline runs vertically, it
does not need to be cut and easily retracts to the side. The abdominal
contents lay inside a large sack (peritoneum) that can also be
retracted, thus allowing the surgeon access to the front of the spine.
The large blood
vessels that continue to the legs (aorta and vena cava) lay on top of
the spine; so we perform this surgery in conjunction with a vascular
surgeon who mobilizes the large blood vessels. After the blood vessels
have been moved aside, the disc material is removed and bone graft, or
bone graft and anterior interbody cages, are inserted.
The ALIF approach
has the advantage that, unlike the PLIF and posterolateral approaches,
both the back muscles and nerves remain undisturbed. Another advantage
is that placing the bone graft in the front of the spine places it in
compression, and bone in compression tends to fuse more readily. This
also allows for removal of the common source of pain, namely the disc.
However, there is
also a major risk that is unique to the ALIF approach. The procedure
is performed in close proximity to the large blood vessels that go to
the legs. Damage to these large blood vessels may result in excessive
blood loss. This is a rare complication.
For males, another
risk unique to this approach is that approaching the L5-S1 (lumbar
segment 5 and sacral segment 1) disc space from the front has a risk
of creating a condition known as retrograde ejaculation. This
condition causes ejaculation to go up into the bladder instead of out.
The sensation of ejaculating is largely the same, but it makes
conception more difficult. Fortunately, retrograde ejaculation
happens in less than 1% of cases and tends to resolve in 1 - 2 years.
Who will be involved
- The orthopedic spine surgeon that you have been seeing in our office
will be the primary surgeon, in charge of your surgery.
- Another orthopedic spine surgeon, usually from our office, will
assist your orthopedic surgeon with the procedure. This is done to
minimize the length of time you are under general anesthesia and to
provide the necessary assistance with the actual surgical procedure.
- The doctor who actually administers and monitors the anesthesia is a
critical part of the surgical team. You will normally meet with the
Anesthesiologist during your Pre Op appointment at the hospital.
Length of Surgery
One to two hours are
typical for one and two levels fused anteriorly.
With most spinal
surgeries, patients are up and walking within hours after their
procedure. It is no longer necessary, or recommended, that you lie in
bed for days or weeks after spine surgery. Nurses who are experienced
in working with spinal surgery patients will assist you during your
first few efforts at getting out of bed and walking.
Your doctor will
tell you when it is safe to shower after surgery. Showers are usually
allowed 2-3 days after surgery. Soaking in a bathtub is not
The nursing staff
at the hospital will show you how to keep the dressing dry and in
place to protect the incision while showering. The wound should not be
submerged in water (pool or tub) until it has healed and has been
cleared by your doctor. The nurse will change the dressing after your
shower, and again later if necessary.
Your surgical incision will be checked
during your first Post Op appointment. However, should your incision
become red and tender or drainage occur, prior to your first scheduled
Post Op visit, you should contact our office for instructions.
Liquids are allowed right
after surgery. Solid foods are not started for several days. Your doctor will give you specific instructions.
How much pain should
I expect and how is it treated?
Your doctor's goal is to keep you as
comfortable as possible. Almost all strong pain medications are
narcotics that tend to make you sleepy and can depress your breathing.
We must balance the side effects with our goal to relieve pain. In
the hospital (IV) patient controlled medications are given the first
day. We then switch to oral medications. You will have pain pills
for home use, also. We continue home medications as needed, with the
goal of weaning them as you recover. It is important to tell your
doctor of any allergies to medicines and to only use pain medications
as directed. Mixing medications can be dangerous. We do not
refill pain medications after hours or on weekends. You must ask
ahead 1-2 days if you are going to run out of pain pills. Refills of
medications are at your doctor's discretion.
Return to Routine of
Normal Daily Living
It normally takes approximately 3 to 6
months for the fusion to occur. During that time you should avoid
strenuous activities that might affect the fusion process.
During the rehabilitation process it
is important to recondition the muscles with exercise, stretching and
aerobic conditioning. Your doctor will give more specific
instructions during the course of your post-operative care during your
Driving is not allowed until after
your first post-op visit (Usually 7-10 days). Most patients are able
to go up and down stairs when they go home from the hospital. Some
patients may require additional assistance.
Return to Work
Return to work is determined for each
individual patient based upon several factors. The doctor's goal is
to help you return to work as soon as you can do so safely. If you
have a light or sedentary job or if light duty restrictions are
available, then return to work could occur in 10-14 days. If you are
able to work from home by phone, fax and computer, very early work may
be realistic. If your job is very heavy and strenuous, return to work
can take several months. Other factors that play a role in return
include your overall physical condition, tolerance of pain and need
for additional therapy.
Even the best results of surgery do
not mean that you will necessarily be able to return to your prior
type of job. Some patients are advised to go through job re-education
or find a lighter job for future back safety.
Risks and Potential
Complications from Anesthesia
Continued Low Back or Leg Pain