patient guidelines for lumbar fusion - · pdf filepatient guidelines for lumbar fusion robert...

Patient guidelines for Lumbar Fusion

Robert S. Pashman, MDScoliosis and Spinal Deformity Surgery

www.eSpine.com 110/20/2014

As of 10/6/14: Pain Medication Update Medication classified as a triplicate (Vicodin, Percocet,

Oxycontin, etc). These prescriptions require a written prescription. We cannot call it into the pharmacy or fax it. You must plan ahead. Prescriptions are filled on Tuesdays morning when Dr. Pashman is in the office. The prescription can be picked up after Tuesday afternoon, or sent FedEx at the cost of the patient.

If you run out of medication you will have to visit your local ER.

By law the prescription is a maximum 30 day supply.

2

Surgical procedureDr. Pashman is performing an interbody fusion, either posterior, or anterior/posterior. The surgical plan is developed for each individual based on many factors.

The details of the surgical procedure will be reviewed during your pre-op appointment before you sign the consent form. Dr. Pashman will maximize the correction of your spine.

3

Surgical Procedure

• During your surgical procedure, your vertebrae will be fused together, and instrumentation will be used as an internal brace as the fusion grows over the next year. Only in rare cases is the hardware removed.

• More information about the surgical procedure can be found at www.eSpine.com

4

Three weeks before surgery You will see a Primary Care Physician with privileges

at Cedars Sinai Medical Center 7 to 10 days prior to surgery to obtain medical clearance for surgery. If you do not have one, we can assist you.

Dr. Pashman rarely requires patient’s to donate blood prior to surgery. If necessary, we will ask you to bank blood a few weeks before surgery.

Arrange for transportation home from the hospital. Check out time is normally 10am.

Arrange for a baby sitter and pet sitter if necessary.

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Items to stock up on: Stool Softener (NOT a Laxative). Long handled brush and shower gel (to reach your

legs and feet). Flat slip on shoes. Loose fitting clothes or sweats. Favorite foods and easy to prepare meals. Extra pillows. Books, magazines, and movies.

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Two weeks before surgery:Stop taking these medicationsYou can not take these medications for at least three months following surgery.

Advil, Aleve, Anacin, Alka-Seltzer, Anaprox, Arthrotec, Aspirin, Bayer, Butalbital, BuTrans patches, Clinoril, Darvon Compound, Daypro, Diclofenac, Dolobid, Ecotrin, Excedrin, Feldene, Fiorinal, Ginko Bilboa, Ibuprofen, Indocin, Indomethacin, Ketoprofen, Lodine, Lortab with ASA tabs, Midol, Mobic, Motrin, Naprosyn, Naproxen, Orudis, Oyxcodone with ASA tabs, Percodan, Piroxicam, Relafen, Sulindac, Talwin, Toradol, Trisilate, Vicoprofen, Vitamin E, Volraren.

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Acceptable Medications

Safe medications to take before surgery and during the three months following surgery :Acetaminophen (Tylenol), MS Contin, Norco, Oxycodone with cetaminophen, Oxycontin, Percocet, Roxicet, Soma, Ultracet, Ultram/Tramadol, Valium, Vicoden, Wygesic, Zydone.

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One week before surgery Stop taking any Laxatives, Stool Softeners or Fiber three

days prior to surgery. Have someone move furniture and rugs to make a clear

walking path. Put frequently used items at waist level to avoid bending

and squatting. Schedule your post-operative wound check appointment

with a nurse. Place a bathmat or non-stick decals in the shower or

bathtub.

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Day of Surgery Do not eat or drink anything after midnight the night before

surgery. The morning of surgery, it is ok to take your approved medications with a small sip of water.

Shower the morning of surgery. Do not bring medication, jewelry, money, or valuables with

you to the hospital. Bring your picture ID and insurance card with you.

Bring an overnight bag to the hospital with: tooth brush, toothpaste, slippers, robe, feminine hygiene products, a calling card if you need to make long distance calls.

10

Pain Scale You will frequently be asked to rate your pain on a scale

of 0-10. This chart will help you assess your pain level.

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Day of Surgery Do not wear make-up the day of surgery Do not wear colored finger or toe nail polish the day of

surgery (clear polish and acrylic nails ok) Check into Cedars Sinai Medical Center South Tower –

8700 Beverly Blvd, Los Angeles, CA 90048 They will validate your parking for day of surgery and

day of discharge. Discounted parking passes are available at Cedars Sinai

Medical Center's Parking office located in Building 7, room 100. Office hours are M-F 7:30 am to 4:00 p.m. Phone number: 310-423-5535

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Day of Surgery Dr. Pashman or his assistant will call your family

member following your surgical procedure. Please designate who Dr. Pashman should speak with. If they are not in the waiting room, please give their phone number to Dr. Pashman’s assistant prior to surgery.

Following surgery you will go to recovery and then be moved to a private room approximately an hour later.

One family member or friend can stay with you in your room. Ask the nurse if there is a rollaway bed available as soon as you arrive in your room.

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While you are in the hospital Call Button – You can use the call button when you

need your caregiver. Pain, trouble breathing, or wanting to get out of bed are all good reasons to call.

Drains – These are thin rubber tubes put into your skin to drain the fluid from around your incision. The drain will be removed when the incision stops draining.

Foley Catheter – This is a tube that is put in your bladder to drain your urine. The catheter may make you feel like you have to urinate. Relax and it will drain the urine.

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While you are in the hospital, cont.

Breathing Exercises – Breathing exercises help to keep your lungs from getting infected after surgery. You will have a devise to blow into. You will be asked to do this once per hour.

Pressure stockings or Pneumatic Boots – The elastic stockings help keep blood from staying in your legs and causing blood clots. The boots are connected to an air pump. The boots inflate and deflate to push the blood out of your legs.

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While you are in the hospital, cont. Walking – You will get out of bed the day after surgery.

Each day you will walk a little further. The more you walk around, the sooner you will feel better. By the time you leave the hospital, you will be able to go up and down stairs.

Eating – You will be able to eat when bowel sounds are heard. (stomach growling). Ice chips are given first, then liquids (water, 7-up, apple juice, broth). If you do ok with that, the caregiver will give you soft foods (applesauce, jello, custard). If you do ok with that, then you can resume a regular diet.

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Post-operative Medications Dr. Pashman will write prescriptions to be given to the

patient upon discharge. There is a pharmacy in CSMC, in the Steven Spielberg

Bldg. They are open 830a-6pm M-F There is a Horton Converse in the East Tower adjacent

to the hospital. They are open M-F 9a-5:30p. (310) 659-6111

Dr. Pashman usually prescribes medication that is easily available and can be called into a pharmacy. The exceptions are: Percocet or Oxycontin. These must be written and picked up at the office.

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Visiting Hours The hospital visiting hours are from 10:00 a.m. to 9:00 p.m. Please limit your guests stay to 15-20 minutes. During Flu season, no visitors under the age of 18 are

allowed. Maximum number of visitors in the room is two at a time. Children under the age of 12 are not permitted in the

patient's room, nor may they wait unattended in the waiting areas.

A caregiver may interrupt your visit during some patient care routines.

If your guest is ill, please ask them not to visit.

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Volunteer ServicesCedars Sinai Medical Center Volunteers are available M-F 9a-5p to assist you. They can be reached at 310-423-5231.

The volunteers can:Provide Companionship.Assist with room amenities (flowers, tv, meal tray set up).Help with preparation for discharge Read to the patient, bring books, magazines.Assist patient with meal preparation/eating.The volunteers CANNOT pick up medications or withdraw money from the ATM.

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Post-Operative Appointments:

Approximately 10-12 days following your surgery, you will have a wound check appointment with a Nurse at Cedars Sinai Spine Center or your local Primary Care Physician.

Patient’s generally see Dr. Pashman at one and three months post-operatively. Sometimes he may ask to see a patient more or less frequently. At each visit you will have an x-ray to check the fusion status. Please call the office at (310) 423-9983 to schedule the appointments.

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Post-Operative Appointments:

If you require pain medication or non-surgical treatment beyond 3 months post-op, Dr. Pashman may refer you to pain management.

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Healing and RecoveryHealing is the body's natural process of restoring its own tissues to a normal or nearly normal state. Although healing may be improved by general good health, proper nutrition, rest, and physical fitness, it will occur without your having to work at it.

Recovery is the process during which you work to become well. It requires a gradual but persistent effort to increase physical strengths. Concentrate on improvement, not on what symptoms remain. This focus on progress, combined with the constant effort to improve, maintains the positive attitude that will speed your return to improved daily activity.

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Post-Surgery Brace

Dr. Pashman may prescribe a brace following surgery. If so, you will wear the brace at all times, except when you are in bed or in the shower. Dr. Pashman will determine how long you need to wear the brace. You may wear it from 1 month to 3 months.

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Post surgical care – the first week The first month following surgery you will rest as

needed, and increase activity (walking, puttering) as you can tolerate/ 10% per day.

It is important that you continue your short walks 3-4 times per day for 5-15 minutes each (on a level surface), as well as your normal daily activity.

It is very normal to experience abdominal discomfort and/or gas pain. Ensure you are drinking plenty of fluids. You may want to have a stool softener (not a laxative) at home.

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Post surgical care – the first week Do Not resume any exercise/activity other than gentle

walking until cleared by Dr. Pashman. Stairs at home are okay providing that you hold onto the handrail and to down gently toe first, then onto your heel. You are allowed a maximum of 3-5 trips up and down the stairs per day the first week.

The first week, do not lift anything heavier than a coffee cup. At one month post-op you may lift up to five lbs.

You may sleep on your side or back, do not sleep on your stomach.

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Post surgical incision care Do not use ice on the surgical area for 2 months

post-operatively.

Dr. Pashman takes great care with the closure. The incision should heal very nicely with time. The most important thing you can do is stay out of the sun. The sun will change the pigmentation and make the scar look darker and more prominent. Dr. Pashman recommends that you don't expose the incision to sun for at least 4 months. A plastic surgeon would say a year.

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Incision care, cont.

No creams or lotions of any kind (NO Neosporin, NO vitamin e, etc.) on the incision for 4 months post-op. We do not recommend any products for the incision. Although it is rarely a problem, you can consult a dermatologist if there is discoloration at 1 year post-op.

If there are Steri-Strips (white tapes) over the incision, don’t pull them off. Let them fall off on their own. If they’re peeling and snagging on clothing, trim the peeling portion with scissors.

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Incision care, cont. You will have subcutaneous sutures (sutures

underneath your skin). You must shower with your incision covered with plastic until the Nurse Wound Chcek. After the wound check you may shower with the wound uncovered.

Do not soak the incision. After 1 month you may take a bath.

Do not expose your wound to the direct sunlight for 3-4 months following surgery.

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Post surgical care – body mechanicsStand up straight to brush your teeth, don’t bend over the sink.

Don’t arch your back to stand under the shower water. If you’re tall bend slightly at the knee instead of arching back to wash your hair. Rubbermaid has an inexpensive shower extension hose.

When turning over in bed, “log roll”. Turn hips and shoulders together.

Limit sitting to 20-30 minutes, then changing positions. Reclining or lying down maybe done for longer periods.

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Post surgical care – eatingWe recommend that you eat foods high in protein and vitamin C .

Protein: Vitamin C: Meat & eggs Oranges, grapes.Milk & ice cream Tomatoes.Fish & Chicken.Beans & rice.Peanut butter.

You may want to avoid foods that cause constipation, like fresh apples, bananas, or cheese. If you like bran, be sure to drink lots of liquids (milk, juice, water, etc.). Without the extra water bran can be constipating.

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Post surgical care – after 1 month Let pain be your guide with activity. If you

experience discomfort, rest. Never take pain medication to allow you to complete any activity.

You must maintain good alignment, taking special care getting up or down from a lying/sitting position. Absolutely no bending, twisting or lifting.

Do not lift anything over 5 pounds in weight. No Bending, Lifting, or Twisting for 3 months

post-op Exhaustion and mood swings are common.

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Post surgical care – after 1 month cont. It is normal to have good and bad days. Listen to your

body and rest accordingly. If you do experience back or leg pain/numbness rest and it should go away.

Returning to work will be discussed with Dr. Pashman during your postoperative visit at one month.

Sexual activities can recommence approximately one month following discharge, provided you take the passive role and your back is supported: you do not need to be in your brace. Lying on your back or side appears to be the most comfortable position.

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Post surgical care – after 1 month cont. Always use good judgment. Be aware of good body

mechanics as you recover and get stronger. Abdominal muscle strength and good body mechanics will be very helpful in controlling and maintaining a pain free posture.

Do not swim or sit in a spa until cleared by Dr. Pashman, usually at 2 months when the fusion is well healed. Do not take a bath for one month following surgery. This is to insure that your incision heals properly.

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Post surgical care: guidelines for taking pain medication

Take medications as needed and wean yourself as soon as possible. Pain medications can affect your body’s natural ability to cope with pain and often increases depression associated with chronic pain syndrome. Here is a guideline for taking pain medication.

Weeks 1-4: Take 1-2 tablets every 4-6 hoursWeeks 2-4: Take 1 tablet every 12 hours

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Pain medication and Refills Usually as a patient feels better, they cut back on the pain

medicine. As they become more active, they hurt more, take more medicine. Then they adjust, cut back the medicine, become more active, etc. It is important to gradually reduce the amount of medicine. If you abruptly discontinue, you will go through withdrawals.

If your prescription requires a Triplicate (Oxycontin, Percocet, etc.) please allow sufficient time to pick-up a prescription or for mail delivery. These prescriptions can not be called into your pharmacy.

Please allow 24-48 hours for prescription refills. Your pharmacy can fax the request to: 310-423-9963 or call us at 310-423-9983. Prescriptions are refilled Monday thru Friday only. 35

When to call Dr. Pashman: If you are experiencing a high fever over 101.9. If the incision is red, oozing, or there are bumps or

blisters. If you are experiencing symptoms that were not

present before surgery, there is an dramatic increase in pain, weakness, or numbness which persists for more than 3-5 days with no improvement despite bed rest.

In the case of after hours emergencies, in most cases the physician on call will direct you to be evaluated at the ER.

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When to call your primary care physician:Please call your primary care physician for any symptom that is not spine related. (Ex: constipation, blood pressure, nausea, ear aches, etc.)

It is common to become constipated with pain medications. Here are the steps in order:

1. Drink prune juice, eat prunes, drink water

2. Take a stool softener

3. Use a Fleet enema or suppositories

4. Contact your primary care physician

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Urgent Problems

If you have an urgent problem that requires immediate care (Chest pain, Shortness of Breath/Difficulty breathing, Severe Abdominal Pain, Fainting, etc.), please call 911 or go to the nearest Emergency Department.

In the case of after hours emergencies, in most cases the physician on call will direct you to be evaluated at the ER.

6/20/2013 38

MDA Donation Program

Upon your discharge from the hospital, home health care may arrange for one or all of the following items: walker, commode, grabber/reaching device.

The Muscular Dystrophy Association is in need of used medical equipment. If you would like to donate your items, please call (310) 450-9032. MDA will pick your donations up.

You can also contact a local nursing home or church to determine if they need donations

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Frequently Asked Questions:Q: After surgery, will I go off in the metal detector at

the airport? A: Each airport maintains their own metal detectors,

and sets the sensitivity level. Rarely do patient’s report any problems. The FFA recommends that you notify the airport screener of your metal implants prior to screening.

Q: When can I fly? A: Approximately 10 days after surgery, as long as you

don’t lift your luggage (including into the overhead compartment.)

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Frequently Asked Questions:Q: Do I need antibiotics before a dental appointment?A: High risk patients undergoing higher risk dental

procedures may benefit from antibiotic prophylaxis.

High risk patients include:1) All patients during the first two years following surgery2) Immunocompromised/immunosupressed patients, 3) Patients with certain comorbid conditions such as

a) Previous prosthetic joint infections b) Malnourishment c) Hemophilia d) HIV Infectionee) Type 1 Diabetes f) Malignancy

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Frequently Asked Questions:

High risk dental procedures include:1) Dental extractions, 2) Prophylactic cleaning of teeth or implants were bleeding is anticipated, 3) Periodontal procedures, 4) Root canal procedures, 5) Dental implant placement and reimplantation of a avulsed teeth, 6) Interligamentary and intraosseous local anesthetic injections

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Frequently Asked Questions:

Your Dentist will prescribe one of the followingmedications :

1) Amoxicillin or cephalexin 2g orally one hour prior to dental procedure (if not allergic to penicillin) OR2) Clindamycin 600 mg or orally one hour prior to dental procedure

Dr. Pashman does not write these prescriptions.

Reference: American Dental Association; American Academy of Orthopedic Surgeons. Antibiotic Prophylactics for Dental Patients with Total Joint Replacement (Advisory Statement) JADA 2003: 134, 895 –899

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Recovery Calendar:The following calendar is a sample guideline of the recovery period . This is only a guideline and coversanterior, posterior, anterior/posterior and multi-level lumbar fusions.

Dr. Pashman’s individualized instructions supersede thisdocument.

Each patient is unique, and will recover from surgery in their own time frame.

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Recovery Calendar – Month One1 2 3 4

Surgery5 Walk

6 7

8Shower, Walk up and down stairs

9Release from Hospital

10 11 do not lift anything heavier than a coffee cup

12 13 14 walking 5-20 minutes 3x per day

15 16 Stair only 3-5 times per day

17Nurse Wound Check

18Can shower

without wound covered

19 20 21

22Walk 1 block

23 24 25 26 27 28

29 30

45


Surgery5 Walk

6 7






17Nurse Wound Check

18Can shower


19 20 21

22Walk 1 block

23 24 25 26 27 28

29 30

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The Day after surgery the physical therapist will get you out of bed to walk.

The sooner you get up and walk, the sooner you will feel better.


Surgery5 Walk

6 7






17Nurse Wound Check

18Can shower


19 20 21

22Walk 1 block

23 24 25 26 27 28

29 30

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The day before you are discharged from the

hospital, you will shower and walk up and down

stairs on your own.


Surgery5 Walk

6 7






17Nurse Wound Check

18Can shower


19 20 21

22Walk 1 block

23 24 25 26 27 28

29 30

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The Wednesday following your discharge from the

hospital, you will see a nurse at Cedars Sinai Spine Center for a wound check. Please

call 310-423-9983 to schedule your appointment.


Surgery5 Walk

6 7






17Nurse Wound Check

18Can shower


19 20 21

22Walk 1 block

23 24 25 26 27 28

29 30

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You can shower without covering the wound


Surgery5 Walk

6 7






17Nurse Wound Check

18Can shower


19 20 21

22Walk 1 block

23 24 25 26 27 28

29 30Appt with Dr. Pashman

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First post-op appointment with Dr. Pashman. X-rays will be taken to

evaluate the fusion growth

Recovery Calendar – Month One1 Surgery 2 3 4 Stage 2

Surgery5 Walk 6 7

8 9Shower, Walk up and down stairs


11 do not lift anything heavier than a coffee cup

12 13 14 90% of time in bed, walking 5 minutes 3x per day


17 18Nurse Wound Check

19 Can shower without wound covered

20 21

22Walk 1 block

23 24 25 26 27 28

29 30

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Recovery Calendar – Month Two31 Can resume sexual activity

32 Can lift up to 5 pounds

33 Can Drive car

34 35 36 37

38 39 40 Decrease pain medication

41Can Drive car – w/o pain meds

42 43 44

45 46 47 48 49 50 51


55 56 57 58 Ok to go up and down stairs unlimited

59 60

52



33 34 35 36 37



42 43 44

45 46 47 48 49 50 51



59 60

You can resume sexual activity, provided you take the passive role and your back is supported: you do not need to be in your brace. Lying on your back or side appears to be the most comfortable position.

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33 Can Drive car

34 35 36 37


41 42 43 44

45 46 47 48 49 50 51



59 60

You can lift up to 5 pounds.

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33 Can drive car

34 35 36 37


41 42 43 44

45 46 47 48 49 50 51



59 60

Can Drive car. Please take care to not to drive while taking pain medication.

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33 Can drive car

34 35 36 37


41 42 43 44

45 46 47 48 49 50 51



59 60

Decrease Pain Medication

56



33 34 35 36 37



42 43 44

45 46 47 48 49 50 51



59 60Decrease Pain Medication

57

Recovery Calendar – Month Three61 62 63 64 65 66 67


71 72 73 74

75 76 77 78 79 80 81

82 83 84 85 86 87 88

89 Pain medication only as needed

90 Appt with Dr. Pashman

Decrease Pain Medication

58

Recovery Calendar – Month Three61 62 63 64 65 66 67


71 72 73 74

75 76 77 78 79 80 81

82 83 84 85 86 87 88



Take Pain Medication as needed for pain

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Recovery Calendar – Month Three61 Patient can use ice on surgical area

62 63 64 65 66 67


71 72 73 74

75 76 77 78 79 80 81

82 83 84 85 86 87 88



Post-op appointment with Dr. Pashman. X-rays will be taken to assess fusion mass.

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This is a guideline for activities following an Anterior Spinal Fusion, a Posterior Spinal Fusion, or both. This is only a guideline. Each patient recovers at their own rate. Dr. Pashman may change the time frame based on a patient's individual needs.Aerobics 1 year

Anti-inflammatory medications (Aspirin, Aleve, NSAIDs) 3 months

Baseball/softball 1 year

Basketball 1 year

Bath 1 month

Bending, Lifting, or Twisting 3 months

Bicycling 6 months

Bowling 9 months

Bungee Jumping never

Carry school Books 2 months

Creams or lotions on incision 3 months

Diving 9 months

Driving a car 3-4 weeks

Football 1 year

Gardening 3 months

Golf 6 months

Gymnastics 1 year

Hiking 6 months

Horseback Riding 1 year

Housework, Light (dusting, washing dishes) 6 weeks

Housework, Moderate (ironing, lifting grocery bags) 2 months

Housework, Moderate (ironing, lifting grocery bags) 3 months

Ice – patient can use ice on surgical area 2 months

Isometric trunk exercises 3 months

Jacuzzi 2 months

Jogging 6 months

Lift 5 pounds 1 week

Lift 10 pounds 3 months

Lifting weights 9 months

Martial Arts 1 year

Massage 3 months

Motorcycling never

Movies 2 weeks

Pilates 4 months

Pregnancy 1 year

Return to School 1 month

Roller Coasters 1 year

Roller Skating 1 year

Rowing 1 year

Sexual activity without pelvic motion 2 weeks

Sexual activity with pelvic motion 1 month

Shopping 3 weeks61

This is a guideline for activities following an Anterior Spinal Fusion, a Posterior Spinal Fusion, or both. This is only a guideline. Each patient recovers at their own rate. Dr. Pashman may change the time frame based on a patient's individual needs.Shower 1 week

Sky Diving never

Snow Skiing 1 year

Soccer 1 year

Stairmaster 3 months

Stationary bike 3 months

Suntan 4 months

Surfing 1 year

Surgery (elective) 6 weeks

Swimming 6 months

Tennis 9 months

Track (jumping) 1 year

Treadmill 3 weeks

Walking immediate

Walking in water 6 weeks

Waterskiing 1 year

Work 2 months

Yoga 6 months

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FormsDisability forms or documents/letters are $50.00 per document. This includes supplemental forms and or private disability forms. You may drop off, mail, fax, or email the forms. Payment can be made by cash, check or credit card payment here:http://www.espine.com/current-patients

Paperwork must be completed and signed by patient (if applicable) and payment processed prior to the office completing physician portion, no exceptions. Please include all pertinent dates or special indications.

Your primary care physician or pain management physician can also process your forms.

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FormsPlease note paperwork will be processed within 7days of receipt. Paperwork must be completed and signed by patient (if applicable) prior to the office finishing physician portion, no exceptions, please include all pertinent dates or special indications.

If you would like a copy of this paperwork to be forwardto you, please enclose a self addressed stamped envelope with your completed forms.

A copy of your paperwork will be placed in the electronic chart after the doctor has signed it and will remain a part of your permanent record. This applies to ALL forms.

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FormsPlease refer to the type and category that applies to your paperwork.● EDD (State of California Employment Development Dept.):

Pick up a form at your local EDD office, or call 1-800-480-3287 so that a form can be mailed to your home or you may obtain through the internet at www.edd.ca.gov under Disability Insurance Application.

● DMV, PLEASE NOTE: DR. PASHMAN DOES NOT PRESCRIBE DMV DISABLED PERSON PLACARDS.

● Upon completion, all forms will be mailed appropriately.

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Forms● Medical Certificate for Temporary Total Disability or

Return to Work:

Specify the type of letter required, to whom letter will be addressed, include address, phone or fax numbers, if applicable. Include pertinent information such as your last day worked and when you expect to return to work. If you feel you will need restrictions, e.g. bending, lifting, twisting, pushing pulling or carrying, please include this information. We will forward this information directly to your HR Dept or employer.

● Jury Duty:

Jury Duty excuses will be processed only if you have had surgery within one year with Dr. Pashman and at the doctor’s discretion.

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