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Few structures of the human anatomy are as unique as the hand. The hand needs to be mobile in order to position the fingers and thumb. Adequate strength forms the basis for normal hand function. The hand also must be coordinated to perform fine motor tasks with precision. The structures that form and move the hand require proper alignment and control in order for normal hand function to occur.

This guide will help you understand:

• what parts make up the hand
• how those parts work together

There are 27 bones within the wrist and hand. The wrist itself contains eight small bones, called carpals. The carpals join with the two forearm bones, the radius and ulna, forming the wrist joint. Further into the palm, the carpals connect to the metacarpals. There are five metacarpals forming the palm of the hand. One metacarpal connects to each finger and thumb. Small bone shafts called phalanges line up to form each finger and thumb.

Carpals

The main knuckle joints are formed by the connections of the phalanges to the metacarpals. These joints are called the metacarpophalangeal joints  (MCP joints). The MCP joints work like a hinge when you bend and straighten your fingers and thumb.

Metacarpophalangeal Joints

The three phalanges in each finger are separated by two joints, called interphalangeal joints (IP joints). The one closest to the MCP joint (knuckle) is called the  proximal IP joint (PIP joint). The joint near the end of the finger is called the distal IP joint (DIP joint). The thumb only has one IP joint between the two thumb phalanges. The IP joints of the digits also work like hinges when you bend and straighten your fingers and thumb.

The joints of the hand, fingers, and thumb are covered on the ends with articular cartilage . This white, shiny material has a rubbery consistency. The function of articular cartilage is to absorb shock and provide an extremely smooth surface to facilitate motion. There is articular cartilage essentially everywhere that two bony surfaces move against one another, or articulate.

Articular Cartilage

Ligaments are tough bands of tissue that connect bones together. Two important structures, called collateral ligaments, are found on either side of each finger and thumb joint. The function of the collateral ligaments is to prevent abnormal sideways bending of each joint.

Collateral Ligaments

In the PIP joint (the middle joint between the main knuckle and the DIP joint), the strongest ligament is the volar plate. This ligament connects the proximal phalanx to the middle phalanx on the palm side of the joint. The ligament tightens as the joint is straightened and keeps the PIP joint from bending back too far (hyperextending). Finger deformities can occur when the volar plate loosens from disease or injury.

Volar Plate

The tendons that allow each finger joint to straighten are called the extensor tendons. The extensor tendons of the fingers begin as muscles that arise from the backside of the forearm bones. These muscles travel towards the hand, where they eventually connect to the extensor tendons before crossing over the back of the wrist joint. As they travel into the fingers, the extensor tendons become the extensor hood. The extensor hood flattens out to cover the top of the finger and sends out branches on each side that connect to the bones in the middle and end of the finger.

Extensor Hood

The place where the extensor tendon attaches to the middle phalanx is called the central slip. When the extensor muscles contract, they tug on the extensor tendon and straighten the finger. Problems occur when the central slip is damaged, as can happen with a tear.

Central Slip

Many of the muscles that control the hand start at the elbow or forearm. They run down the forearm and cross the wrist and hand. Some control only the bending or straightening of the wrist. Others influence motion of the fingers or thumb. Many of these muscles help position and hold the wrist and hand while the thumb and fingers grip or perform fine motor actions.

Most of the small muscles that work the thumb and pinky finger start on the carpal bones. These muscles connect in ways that allow the hand to grip and hold. Two muscles allow the thumb to move across the palm of the hand, an important function called thumb opposition.

Hand Muscles

Thumb Opposition

The smallest muscles that originate in the wrist and hand are called the intrinsic muscles. The intrinsic muscles guide the fine motions of the fingers by getting the fingers positioned and holding them steady during hand activities.

All of the nerves that travel to the hand and fingers begin together at the shoulder: the radial nerve, the median nerve, and the ulnar nerve. These nerves carry signals from the brain to the muscles that move the arm, hand, fingers, and thumb. The nerves also carry signals back to the brain about sensations such as touch, pain, and temperature

The radial nerve runs along the thumb-side edge of the forearm. It wraps around the end of the radius bone toward the back of the hand. It gives sensation to the back of the hand from the thumb to the third finger. It also supplies the back of the thumb and just beyond the main knuckle of the back surface of the ring and middle fingers.

Radial Nerve

The median nerve travels through a tunnel within the wrist called the carpal tunnel. This nerve gives sensation to the thumb, index finger, long finger, and half of the ring finger. It also sends a nerve branch to control the thenar muscles of the thumb. The thenar muscles help move the thumb and let you touch the pad of the thumb to the tips each of each finger on the same hand, a motion called opposition.

Median Nerve

The ulnar nerve travels through a separate tunnel, called Guyon’s canal. This tunnel is formed by two carpal bones, the pisiform and hamate, and the ligament that connects them. After passing through the canal, the ulnar nerve branches out to supply feeling to the little finger and half the ring finger. Branches of this nerve also supply the small muscles in the palm and the muscle that pulls the thumb toward the palm.

Ulnar Nerve

The nerves that travel to the hand are subject to problems. Constant bending and straightening of the wrist and fingers can lead to irritation or pressure on the nerves within their tunnels and cause problems such as pain, numbness, and weakness in the hand, fingers, and thumb.

Traveling along with the nerves are the large vessels that supply the hand with blood. The largest artery is the radial artery that travels across the front of the wrist, closest to the thumb. The radial artery is where the pulse is taken in the wrist. The ulnar artery runs next to the ulnar nerve through Guyon’s canal (mentioned earlier). The ulnar and radial arteries arch together within the palm of the hand, supplying the front of the hand, fingers, and thumb. Other arteries travel across the back of the wrist to supply the back of the hand, fingers, and thumb.

Radial Artery

The hand is formed of numerous structures that have an important role in normal hand function. Conditions that change the way these structures work can greatly impact whether the hand functions normally. When our hands are free of problems, it’s easy to take the complex anatomy of the hand for granted.

Biceps tendonitis, also called bicipital tendonitis, is inflammation of the tendon that attaches the biceps muscle to the shoulder or forearm. The tendon most commonly irritated is the one that attaches the top of the biceps muscle to the shoulder, so it is this injury that we will discuss here.

The most common cause of biceps tendonitis is overuse from certain types of work or sports activities. Biceps tendonitis may develop gradually from the effects of wear and tear, or it can happen suddenly from a direct injury. The tendon may also become inflamed in response to other problems that affect how you use the shoulder, such as rotator cuff tears, impingement in the shoulder, or shoulder instability (described below).

This guide will help you understand:

• what parts of the shoulder are affected
• the causes of biceps tendonitis
• ways to treat this problem
• what First Choice Physical Therapy’s approach to rehabilitation is

What parts of the shoulder are affected?

The biceps muscle goes from the shoulder to the elbow on the front of the upper arm. Two separate tendons (tendons attach muscles to bones) connect the upper part of the biceps muscle to the shoulder. The upper two tendons of the biceps are called the proximal biceps tendons, because they are closer to the top of the arm.

The main proximal tendon is the long head of the biceps. It connects the biceps muscle to the top of the shoulder socket, the glenoid. It also blends with the cartilage rim around the glenoid, which is called the labrum. The labrum is a rim of soft tissue that turns the flat surface of the glenoid into a deeper socket. This arrangement improves the fit of the ball of the humerus (humeral head) in to the socket.

Beginning at the top of the glenoid, the tendon of the long head of the biceps runs in front of the humeral head. The tendon passes within the bicipital groove of the humerus and is held in place by the transverse humeral ligament. This design of the anatomy keeps the humeral head from sliding too far up or forward within the glenoid.

The short head of the biceps connects onto the coracoid process of the scapula (shoulder blade). The coracoid process is a small bony knob just in from the front of the shoulder. The lower biceps tendon is called the distal biceps tendon. The word distal means the tendon is further down the arm. The lower part of the biceps muscle connects to the forearm by this tendon. The muscles forming the short and long heads of the biceps stay separate until just above the elbow, where they unite and connect to the distal biceps tendon.

Tendons are made up of strands of a material called collagen. The collagen strands are lined up in bundles next to each other. Due to the collagen strands in tendons lining up, tendons have high tensile strength. This means they can withstand high forces that pull on both ends of the tendon. When muscles work, they pull on one end of the tendon. The other end of the tendon pulls on the bone, causing the bone to move.

Contracting the biceps muscle can bend the elbow upward. The biceps can also help move the shoulder by lifting the arm up in front of the body, a movement called shoulder flexion. The biceps muscle can also rotate, or twist, the forearm in a way that points the palm of the hand up. This movement is called supination, which positions the hand as if you were holding a tray.

Why is my biceps tendon inflamed?

Continuous or repetitive shoulder actions can cause overuse of the biceps tendon. Damaged cells within the tendon don’t have time to recuperate or the cells are unable to repair themselves, leading to tendonitis. This is common in sport or work activities that require frequent and repeated use of the arm, especially when the arm motions are performed overhead. Athletes who throw, swim, or swing a racquet or club are at greatest risk.

Years of shoulder wear and tear can also cause the biceps tendon to become painful. Examination of the tissues in cases of wear and tear commonly shows signs of degeneration. Degeneration in a tendon causes a loss of the normal arrangement of the collagen fibers that join together to form the tendon. Some of the individual strands of the tendon become jumbled due to the degeneration, and other fibers break which both cause the tendon to lose strength. When this happens in the biceps tendon a rupture of the tendon may occur.

Biceps tendonitis can also happen from a direct injury, such as a fall onto the top of the shoulder. A torn transverse humeral ligament can also lead to biceps tendonitis.  As mentioned earlier, the transverse humeral ligament holds the biceps tendon within the bicipital groove near the top of the humerus.  If this ligament is torn, the biceps tendon is free to jump or slip out of the groove, irritating and eventually inflaming the biceps tendon.

Biceps tendonitis sometimes occurs in response to other shoulder problems which affect the way you use your shoulder, including rotator cuff tears, shoulder impingement, and shoulder instability.

Rotator Cuff Tears

Aging adults with rotator cuff tears commonly end up with biceps tendonitis. When the rotator cuff is torn, the humeral head is free to move too far up and forward in the shoulder socket and can impact the biceps tendon. The damage may begin to weaken the biceps tendon and cause it to become inflamed.

Shoulder Impingement

In shoulder impingement, the soft tissues between the humeral head and the top of the shoulder blade (acromion) get pinched or squeezed with certain arm movements. This pain affects the way you move your shoulder, and often the biceps muscle is overused to compensate or is physically pinched which causes it to become inflamed.

Shoulder Instability

Conditions that allow too much movement of the ball within the socket create shoulder instability. When extreme shoulder motions are frequently repeated, such as with throwing or swimming, the soft tissues supporting the ball and socket can eventually get stretched out. In other cases, the shoulder may become unstable from a traumatic event where the joint subluxes or has been dislocated.  Again, this instability then affects the way you use your shoulder, and the biceps muscle can be overused, leading to secondary pain and inflammation in the tendon.

With chronic instability of the shoulder the labrum (the cartilage rim that deepens the glenoid, or shoulder socket) may begin to pull away from its attachment to the glenoid, sometimes near where the biceps tendon attaches. A shoulder dislocation can also cause the labrum to tear. When the labrum is torn, the humeral head may begin to slip up and forward within the socket. Once again, the biomechanics of the shoulder joint are affected and the biceps tendon often becomes inflamed as a result.

What does biceps tendonitis feel like?

Patients generally report the feeling of a deep ache directly in the front and top of the shoulder. This area will also be sensitive to touch, especially in comparison to the other side. The aching may spread down into the main part of the biceps muscle. Pain is usually made worse with overhead activities. Resting the shoulder generally eases pain.
In addition, the arm may feel weak with attempts to bend the elbow or when twisting the forearm into supination (palm up). A catching or slipping sensation felt near the top of the biceps muscle may suggest a tear of the transverse humeral ligament.

How can my health care professional be sure I have biceps tendonitis?

The history and physical examination are probably the most important tools that health care professionals, including your Physical Therapist at First Choice Physical Therapy, will use to diagnose this problem. Your therapist will want to know exactly where your pain is, when it started, and what activities ease or aggravate your symptoms. If you are involved in sport, your training history including any increases in volume of activity or change in equipment will also be important for us to inquire about.

Next your Physical Therapist will physically examine your shoulder. First they will look at the way you hold your shoulder with your natural posture in sitting and standing. The positioning of your upper back and neck can also affect the functioning of your shoulder so they will also observe this.  Your therapist will touch, or palpate, around your painful area as well as other areas on your shoulder to help differentiate that it is truly your biceps tendon causing the pain. They will compare the tenderness you feel from side to side as often a normal biceps tendon can have some tenderness when palpated in the groove. Your problem side will feel more tender when touched than your normal side.

Next your Physical Therapist will ask you to move your arm in different directions to determine how much range of motion you can achieve on your own, to see how you move your shoulder, and also to determine how much strength you have in your shoulder.
They will then ask you to relax your arm while they move your arm themselves. It is imperative that you try to relax as much as possible during this motion and do not help with your muscles so that your therapist can determine how much discomfort you are in if you are not activating your own muscles.  Your Physical Therapist will then assess the resisted motions of your shoulder, including the strength of the rotator cuff and the biceps tendon itself. With biceps tendonitis there is not always an obvious decrease in strength of the biceps muscle itself. Pain when functionally using the muscle and associated tendon is a more common symptom than an obvious decrease in strength. However an associated decline in rotator cuff strength is quite common when the biceps tendon is irritated.

The next part of the physical assessment will include your Physical Therapist performing some special tests to confirm the diagnosis of biceps tendonitis. Other special tests can determine if nearby structures are causing problems, such as a tear in the labrum, a tear in the transverse humeral ligament, or if there are impingement or rotator cuff problems.

If biceps tendonitis is suspected X-rays are generally not needed right away.  If the shoulder doesn’t get better with treatment, however, they may be ordered.  An X-ray can show if there are bone spurs or calcium deposits near the tendon. X-rays can also show if there are other problems, such as a small fracture. Plain X-rays do not show soft tissues like tendons and will not show a biceps tendonitis specifically.

When the shoulder isn’t responding to treatment, a magnetic resonance imaging (MRI) scan may also be ordered. An MRI is a special imaging test that uses magnetic waves to create pictures of the shoulder in slices. This test can tell if there are problems in the rotator cuff or labrum, and can also show inflammation around the biceps tendon.

In rare instances, an injection of cortisone may be used to try to control pain. Cortisone is a very powerful steroid. However, cortisone is used very sparingly because it can weaken the biceps tendon, and possibly cause it to rupture.

Arthroscopy is an invasive way to evaluate shoulder pain that isn’t going away. It is not used as an initial investigative exam for biceps tendonitis. It may be used, however, for ongoing shoulder problems where a cause has not been identified in an X-ray or MRI scan, or for shoulders that are not responding to conservative treatment.  An arthroscope is a thin instrument that has a tiny camera on the end, which the surgeon uses to see inside the joint.   It can show if there are problems with the rotator cuff, the labrum, or the portion of the biceps tendon that is inside the shoulder joint.

What treatment options are available?

Nonsurgical Treatment

Whenever possible, doctors treat biceps tendonitis without surgery. Anti-inflammatory medicine may be prescribed to ease the pain and to help patients return to normal activity. These medications include common over-the-counter drugs such as ibuprofen.
A crucial part of non-conservative treatment for biceps tendonitis is Physical Therapy treatment.

Nonsurgical Rehabilitation

Physical Therapy at First Choice Physical Therapy can be extremely effective in treating biceps tendonitis.

Our initial aim with Physical Therapy treatment is to decrease the pain and inflammation around the tendon.  Your Physical Therapist may use electrical modalities for this purpose such as ultrasound or electrical current. Heat and/or ice can also be very useful in decreasing pain and inflammation so your therapist will encourage you to use heat or ice frequently at home; they can advise you on whether heat or ice is best for your particular injury. Your Physical Therapist may also use massage around the shoulder, into the biceps muscle, and up into your neck area to ease your discomfort and assist with the associated inflammation.

A period of relative rest will also make a notable improvement in your shoulder pain. Relative rest indicates that you do not have to stop doing all activity, but rather that you stop or limit the amount of those activities that aggravate your shoulder. Resting your shoulder is crucial, along with simultaneous Physical Therapy treatment, to calm the pain and inflammation associated with your injury.

Once the pain and inflammation are under control, your Physical Therapy treatment will focus on regaining the range of motion, strength, and coordination in your shoulder.  Your Physical Therapist at First Choice Physical Therapy will prescribe a series of stretching and strengthening exercises that you will practice in the clinic and also learn to do as part of a home exercise program.

It is easiest to move the shoulder joint through its full range of motion if it is done passively, which means that you don’t use the muscles on your injured side to lift the shoulder. Your therapist may ask you to use a pole or a pulley in order to lift your arm up overhead or behind your back. If you do not maintain the motion in your shoulder by at least passively moving it through its full range of motion, it is easy for a frozen shoulder to develop. With a frozen shoulder the tissues in the shoulder actually shorten and tighten up such that anatomically the full shoulder range is no longer possible. All passive range of motion exercises prescribed should be done within the limits of pain, however there may be a mild discomfort as you reach the end of your range of motion, and this is normal. This mild discomfort is not detrimental to your progress so long as the pain remains at a very mild level.  In some cases your Physical Therapist themselves may move your shoulder for you in order to stretch it; again, this is considered passive motion. An upper body bike may also be useful in the early stages of rehabilitation to improve range of motion and encourage coordinated movement of the entire upper limb, as long as it can be used without causing more than mild discomfort.

A crucial component to any shoulder rehabilitation program is the ability for you to regain what is called ‘proprioceptive control’ of your shoulder joint. Proprioception is the ability to know where your body is without looking at it. For example, normally each time you reach overhead with your hand, your mind does not consciously have to think about doing the action, yet all of the muscles of the shoulder (and elbow, wrist, and upper back) coordinate the action just right so you can perform the movement without any discomfort or pinching. When you have pain in a joint, or the tissues of the joint have been injured, your proprioception declines. Any period of decreased mobility of the joint will also add to this decline.  If the proprioceptive control of your shoulder is poor then the ability to use your shoulder naturally in all ranges of movement without causing any pain or pinching, or unnecessary motion, declines, and your shoulder is at risk of increased wear and tear, and developing another injury.  The biceps tendon is very susceptible to feeling the effects of poor shoulder proprioception, and inflammation in the tendon can easily occur.

The joint between your shoulder blade and your thoracic spine (called the scapulothoracic joint) is particularly important to the overall proprioceptive control of the shoulder joint.  The outer edge of the shoulder blade actually creates the socket of the shoulder joint. Together, the scapulothoracic joint and the shoulder joint itself (including the rotator cuff muscles) create the complete shoulder girdle; the entire shoulder girdle must operate together for normal shoulder motion.  Controlled shoulder girdle motion along with adequate rotator cuff strength keeps the ball of the shoulder joint properly centered in the socket of the joint and avoids any pain or undesired motion of the joint. This centered position of the ball in the socket also keeps the ball of the shoulder joint from drifting forward and pressing on the biceps tendon, which causes unnecessary pressure and irritation. The control and strength of the scapulothoracic joint is particularly essential when using your limb is near or above shoulder height and especially during rapid or repetitive arm movements such as throwing.

For this reason, your Physical Therapist will teach you how to properly control your shoulder girdle during your rehabilitation exercises but will also educate you on transferring this control to your everyday activities. Again, this will prevent excessive wear and tear on your shoulder joint even during the repetition of normal everyday tasks. Adequate control of the shoulder girdle is important to establish even before beginning any strengthening of the biceps muscle or the rotator cuff tendons.
In order gain the appropriate balanced strength in your rotator cuff muscles of the shoulder joint, as well as to address any biceps muscle weakness that may have developed your Physical Therapist at First Choice Physical Therapy will also prescribe strength specific exercises. Adequate strength in the rotator cuff can relieve pressure on the biceps tendon. Strength exercises may involve using light weights or Theraband to add resistance for your upper limb. As stressed above, an irritable biceps tendon can easily be made more irritable if your control and technique while performing strengthening exercises is poor, so your therapist will repeatedly focus on proper shoulder proprioception and exercise technique while you perform your exercises. Adequate strength and endurance in the rotator cuff muscles throughout a variety of ranges of motion, including above shoulder height, is needed to ensure full functioning of the shoulder.

As you improve with being able to control the shoulder girdle and as your strength improves your Physical Therapist will introduce more difficult dynamic exercises for your shoulder.  These may include exercises that simulate your daily tasks, or if you are a high-level  athlete or particpate in recreational sport, those shoulder motions that simulate your sport. Simple proprioceptive exercises might include activities such as rolling a ball on a surface with your hand, holding a weight up overhead while moving your shoulder, or even doing push-ups on an unstable surface. Advanced exercises may include activities such as ball throwing, catching overhead, or a simulated swimming stroke or overhead volleyball spike.

Finally, as part of your shoulder rehabilitation, your Physical Therapist will also remind you about maintaining good shoulder posture at all times even when just sitting or using your upper limb in activities below shoulder height, such as working on the computer. Rounded shoulders in any position crowds the shoulder joint and can lead to shoulder impingement, more pressure on the biceps tendon, poor recovery from your injury, or even the development of a new episode of shoulder pain. Simple changes in the way you sit or stand and how you use your shoulder, neck and thoracic spine throughout the day can ease your pain and help you avoid further problems.

In addition to rehabilitating your shoulder joint itself, at First Choice Physical Therapy we highly recommend maintaining the rest of your body’s fitness with regular exercise even while you recover from the biceps tendonitis in your shoulder. Cardiovascular fitness can be maintained with lower extremity fitness activities such as walking or using a stationary bike or stepper machine. None of these exercises should cause discomfort to your shoulder; if they do, discuss modifying the activity with your Physical Therapist.
You will notice improvements in the functioning of your shoulder even after just a few treatments with your Physical Therapist at First Choice Physical Therapy. If, however, your shoulder joint is not recovering as your % physiotherapist% would expect it should, or if your pain becomes unmanageable, your Physical Therapist will suggest that you return to your doctor and/or see an Orthopaedic Surgeon.  More radical treatment measures, such as surgery, may be needed in your case to deal with the problem.

First Choice Physical Therapy provides services for Physical Therapy in Lynn Haven and Panama City Beach

Patients who are improving with conservative treatments do not typically require surgery. Surgery may be recommended, however, if the problem doesn’t go away or when there are other shoulder problems present besides the biceps tendonitis.

Acromioplasty

The most common surgery for bicipital tendonitis is acromioplasty, especially when the underlying problem is shoulder impingement. This procedure involves removing the front portion of the acromion, which is the bony ledge formed where the scapula meets the top of the shoulder joint. By removing a small portion of the acromion, more space is created between the acromion and the humeral head. This takes pressure off the soft tissues in between, including the biceps tendon.

Today, acromioplasty is usually done using an arthroscope. An arthroscope is a slender tool with a tiny TV camera on the end. It lets the surgeon work inside the joint through a very small incision. This may result in less damage to the normal tissues surrounding the joint, leading to faster healing and recovery.

To perform the acromioplasty using the arthroscope, several small incisions are made to insert the arthroscope and other special instruments needed to complete the procedure. These incisions are small, usually about one-quarter inch long. It may be necessary to make three or four incisions around the shoulder to allow the arthroscope to be moved to different locations and to view different areas of the shoulder.

A small plastic or metal tube is inserted into the shoulder and connected with sterile plastic tubing to a special pump. Another small tube allows the fluid to be removed from the joint. This pump continuously fills the shoulder joint with sterile saline (salt water) fluid.

This constant flow of fluid through the joint inflates the joint and washes any blood and debris from the joint as the surgery is performed.

There are many small instruments that have been specially designed to perform surgery in the joint. Some of these instruments are used to remove torn and degenerative tissue. Some of these instruments nibble away bits of tissue and then vacuum them out of the joint. Others are designed to burr away and then vacuum up bone spurs that are rubbing on the tendons of the shoulder under the acromion.

If necessary, the acromioplasty can also be performed using the older, open method. The open method requires an incision in the skin over the shoulder joint.  Working through the incision, the surgeon locates the deltoid muscle on the outer part of the shoulder. Splitting the front section of this muscle gives the surgeon a better view of the acromion. Some surgeons also detach the deltoid muscle where it connects on the front of the acromion.

The bursa sac that lies just under the acromion is removed. Next, a surgical tool is used to cut a small portion off the front of the acromion. The ligament arcing from the acromion to the corocoid process (the coracoacromial ligament) may also be removed.

The surgeon then shaves the undersurface of the acromion to remove any bone spurs. A file is used to smooth the edge of the acromion. Next, a series of small holes are drilled into the remaining acromion. These holes are used to reattach the deltoid muscle to the acromion.

While inside the joint the surgeon inspects the rotator cuff muscle to see if any tears are present. Next the entire area is irrigated to wash away small particles of bone. Finally, the free end of the deltoid muscle is sutured back to the ridge of the acromion using the drill holes made earlier.

If upon internal examination the biceps tendon is severely degenerated, the surgeon may perform a biceps tenodesis (described next). The surgeon completes the procedure by closing the incision with sutures.

Biceps Tenodesis

Biceps tenodesis is a method of reattaching the top end of the biceps tendon to a new location. Studies show that the long-term results of this form of surgery are not satisfactory for patients with simple biceps tendonitis. However, tenodesis may be needed when the biceps tendon is severely degenerated or when shoulder reconstruction for other problems is needed.

A common method of performing a biceps tenodesis is called the keyhole technique. The keyhole describes the shape of a small hole made by the surgeon in the humerus. The end of the tendon is slid into the top of the keyhole and pulled down to anchor it in place.

This surgery can be done using the arthroscope. The tenodesis procedure is usually combined with other procedures such as acromioplasty which was described above. If this is the case, the surgeon will simply continue using the arthroscope to do the tenodesis procedure if possible. Again, the advantage of using the arthroscope is that less normal tissue is damaged and this may result in faster healing and recovery.

If the procedure is performed using the open method, however, the surgeon begins by making an incision on the front of the shoulder, just above the axilla (armpit). The overlying muscles are separated so the surgeon can locate the top of the biceps tendon. The end of the biceps tendon is removed from its attachment at the top of the glenoid. The tendon is prepared by cutting away frayed and degenerated tissue.

The transverse humeral ligament is split, exposing the bicipital groove and an incision is made along the floor of the bicipital groove.

The bleeding from the incision encourages scar tissue to form that will help anchor the repaired tendon in place.

A burr is used to form a keyhole-shaped cavity within the bicipital groove. The top of the cavity is round. The bottom is the slot of the keyhole, which is made the same width as the biceps tendon.

The surgeon rolls the top end of the biceps tendon into a ball. Sutures are used to form and hold the ball in place. The elbow is then bent, taking tension off the biceps muscle and tendon. Next the surgeon pushes the tendon ball into the top part of the keyhole.

As the elbow is gradually straightened, the ball is pulled firmly into the narrow slot in the lower end of the keyhole, which anchors the tendon.

Some surgeons recommend their patients start a gentle range-of-motion program immediately after surgery. If this is the case, your Physical Therapy at First Choice Physical Therapy can begin immediately. Other surgeons prefer to wait to allow the tissues to heal for a short time before any stress is added to them, even just gentle exercise. In this case, once your surgeon allows it, you will begin your rehabilitation at First Choice Physical Therapy.

Arthroscopic procedures that simply clean out the joint, such as acromioplasty (without a tenodesis,) progress very quickly with regards to rehabilitation and the shoulder requires minimal precautions. If you have had a tenodesis, however, whether it was done arthroscopically or with an open incision, you will need to be cautious with several shoulder activities and will need to avoid heavy arm activity for three to four weeks. This will allow the new site of the attached biceps tendon to heal adequately before it is stressed. You will likely need therapy at First Choice Physical Therapy for 6-8 weeks, but you will need to continue to do your home exercise program for 3-4 months or possibly longer to regain full functioning of your shoulder.

Your may be required to wear a sling to support and protect the shoulder for a few days after surgery whether you have had an open or arthroscopic procedure. Your surgeon or Physical Therapist will advise you when it is safe to stop using the sling; it is rarely used for long. If there is pain when you are not using the sling due to the weight of the shoulder, it can be protected from the hanging weight of the arm by slipping your thumb into the waist of your pants, or jeans pocket.

Good posture and adequate shoulder proprioception (discussed in detail above under non-surgical rehabilitation) is also crucial to post-surgical rehabilitation. Crowding the shoulder joint with slouched posturing or poor shoulder girdle control will add pressure to the biceps tendon will lead to ongoing inflammation, pain, and wear and tear in the shoulder joint. For this reason, posture and proprioception will be one of the first issues that your Physical Therapist at First Choice Physical Therapy addresses with you post-surgically.

During the initial stage of treatment at First Choice Physical Therapy after surgery your Physical Therapist may use ice and electrical modalities to help control pain and swelling from the surgery. They may also use massage and gentle mobilizations of your joint to ease any muscle spasm and pain.

Next your Physical Therapist will prescribe range-of-motion exercises for your shoulder, elbow, and hand.  Your range of motion may seem quite limited initially, especially in the end ranges of motion such as reaching over-shoulder height. Reaching behind your back should be avoided initially as this puts the maximum amount of stress on the biceps tendon. Getting the shoulder moving as soon as possible is important, however, this must be balanced with the need to protect the healing tissues. Your Physical Therapist will guide you through the appropriate exercises at the appropriate time and ensure that you are advancing your exercises as quickly as you can without putting unnecessary stress on the surgical site.

Range of motion exercises will first be done passively, which means you will use either your other arm to lift your surgical arm, or a pulley or pole to do the lifting rather than the muscles of your surgical shoulder. Your Physical Therapist may also do some passive stretching of your joint in the early stages of your rehabilitation. Early passive movement of your shoulder joint into its ranges of motions is crucial to full recovery of your shoulder joint after surgery. Proper posturing during the passive range of motion exercises will help the shoulder joint move most naturally and avoid any secondary pain and impingement.  As you are able, your Physical Therapist will advance your exercises so that you actively use your own muscle power to take your shoulder into the different ranges of motion. They will also inform you when it is safe to put more stress on the biceps tendon such as reaching high up overhead or behind your back.

Strengthening your shoulder after surgery will begin very early on but with only light isometric strengthening exercises.  Isometric strengthening exercises involve tightening your muscles without actually moving the associated joint. Isometric exercises work the muscles without straining the injured or painful tissues. Your Physical Therapist will teach you how to use your other hand or the wall for resistance while you flex and tighten your muscles, creating an isometric contraction of the shoulder muscles. Your shoulder joint should not move during isometric exercises, hence why they can be done early on post-surgically and do not harm the healing tissue. Pain should be used as a strict limit during these exercises.

You may begin early on to do isometric biceps strengthening, but your Physical Therapist will ensure that it is done with your elbow bent and with your shoulder in line with your body to protect the tenodesis site. Forceful tightening of this muscle even isometrically will not be encouraged initially, but as time heals the tissue, your therapist will allow you to progress this exercise so you are putting more stress through the biceps and the surgical site.

As soon as it is safe your Physical Therapist will then progress your exercises so that you are strengthening the muscles through their available ranges of motion rather than isometrically, including the biceps muscle. Depending on your progression, resisted exercises for the biceps may not be added even until one month after surgery. Resisted exercises may involve using light-weights or Theraband for your upper limb. Adequate strength and endurance in the rotator cuff muscles throughout a variety of ranges of motion, including over shoulder height, is needed to ensure full functioning of the shoulder.  Again, as mentioned above, adequate shoulder proprioception is crucial while strengthening the shoulder, so significant time during your rehabilitation sessions at First Choice Physical Therapy may be spent perfecting your shoulder girdle control.

As your shoulder strength improves, your Physical Therapist will start to introduce exercises that simulate the activities you regularly participate in, whether that be sporting activities, or work-related activities such as lifting or prolonged desk work. As you improve, you will no longer need to regularly attend Physical Therapy at First Choice Physical Therapy. Eventually your Physical Therapist will become more of a resource, while your home exercise program will be your main form of therapy. Your Physical Therapist will still be crucial, however, to guiding your progress and ensuring that you don’t do too much, too quickly and that the shoulder and its function recovers as it should post-surgically. As usual, your Physical Therapist will keep a close watch on your progression of improvement after surgery, and if you are not improving as we would expect, or your pain is not well controlled during your rehabilitation, we will ask you to return to your surgeon for follow-up to ensure there are no complicating factors impeding your recovery.

Osteonecrosis of the humeral head is a condition where a portion of the bone of the humeral head (the top of the humerus or upper arm bone) loses its blood supply, dies and collapses. Another term used for osteonecrosis is avascular necrosis. The term avascular means that a loss of blood supply to the area is the cause of the problem and necrosis means death.

This condition has been reported in all age groups but seems more common between the ages of 20 and 50. Men are affected by osteonecrosis of the shoulder twice as often as women but women with osteonecrosis from an autoimmune disease (e.g. lupus) develop this condition more often than men with the same disease.

This guide will help you understand:

• how osteonecrosis develops
• how health care professionals diagnose the condition
• what treatment options are available
• what First Choice Physical Therapy’s approach to rehabilitation is

Where does this condition occur?

The shoulder joint is a ball-and-socket joint. The ball portion of the joint is called the humeral head. The humeral head is the uppermost part of the humerus, or upper arm bone. The shoulder socket is called the glenoid fossa. This socket is shallow and is part of the scapula (shoulder blade). The surface of the humeral head and the inside of the fossa are covered with articular cartilage. Articular cartilage is a tough, slick material that allows the surfaces to slide against one another with very little friction. The cartilage is about one-quarter of an inch thick in most large weight-bearing joints, but a bit thinner in the shoulder, which generally doesn’t support much weight.

Large blood vessels supply the arm with blood. The large axillary artery travels through the axilla (armpit). If you place your hand in your armpit, you may be able to feel the pulsing of this large artery. The axillary artery has many smaller branches that supply blood to different parts of the shoulder. The shoulder has a very rich blood supply, but unfortunately if this blood supply is damaged, there is no backup.

What causes this condition?

Bone tissue is constantly being remodeled which means that old bone is removed and replaced with new bone. Osteonecrosis occurs when there is a loss of blood circulation in the bone of the humeral head. This causes the cells that remove and produce new bone to die in the area of lost circulation. New bone is no longer produced, but the old bone matrix still survives. Without the constant ability to repair itself through remodeling, the dead bone matrix eventually begins to lose strength and crumble. This causes the bone matrix to collapse. New blood vessels begin to grow into the area, but this is a slow process. The situation becomes a race to see whether new blood vessels will grow into the area and restore the ability to remodel the bone or whether bone collapse will occur.

The articular cartilage on the surface of the humeral head does not rely on the blood supply of the bone to survive. The articular surface is nourished by something called synovial fluid, which is within the joint, therefore the articular cartilage survives the loss of blood flow to the bone.  The articular cartilage, however, relies on the bone underneath to keep its round shape. When the bone underneath collapses, the articular cartilage loses its round shape and no longer fits, or matches, the shape of the glenoid socket.  The top of the humeral head (the ball portion) collapses and begins to flatten. The constant abnormal friction between the two mismatched joint surfaces causes mechanical wear and tear in both the humeral head and the glenoid socket, similar to two pieces of a mismatched piece of machinery.  Due to this friction the joint begins to wear itself out. This degeneration is called osteoarthritis.

There are two forms of humeral head osteonecrosis: traumatic and atraumatic. The traumatic type can develop after an injury such as a bone fracture or shoulder dislocation. The atraumatic form occurs with the use of corticosteroids, or it can be associated with other diseases or blood disorders (e.g., sickle cell disease, problems with coagulation or making blood clots). Sometimes it develops with no known cause. In those cases, it is termed idiopathic osteonecrosis (unknown cause).

There does seem to be a genetic link to developing osteonecrosis but exposure to certain risk factors is also part of the picture. For example, alcohol abuse, tobacco use, chemotherapy, radiation, pregnancy, inflammatory bowel disease, and organ transplantation are all considered associated risk factors. A clear link exists between osteonecrosis and alcoholism. Although the exact process is not known, excessive alcohol intake somehow damages the blood vessels and leads to osteonecrosis.

Another population at increased risk of developing osteonecrosis is organ recipients.  Organ recipient patients must be on lifelong steroids to prevent inflammation, infection, and rejection of the organ. Unfortunately, these medications have the adverse side effect of endangering blood supply and weakening the bone.

What does osteonecrosis feel like?

The first symptom of osteonecrosis of the humeral head is shoulder and arm pain. The location of the pain is difficult to isolate. You may not be able to point to it with one finger. You may feel like the pain is deep and throbbing. You may have difficulty reaching your arms out to the sides or overhead.

At first, the symptoms seem to come and go, but as the problem progresses the symptoms become more constant and stiffness develops in the shoulder joint. Pain may radiate, or travel, from your shoulder down to your elbow. There may be a sound and sensation of crunching in the joint (called crepitus) and the joint may feel like it locks.  With subsequent arthritic changes in the joint, range of motion decreases. Eventually, the pain will also be present at rest and may even interfere with sleep. In a small number of cases, there are no symptoms despite X-rays that show advanced disease.

How do health care professionals diagnose this condition?

Your health care professional will conduct a thorough history and carry out a clinical exam. The history helps identify associated risk factors, which will have to be addressed during treatment in order to get the most successful results. Your health care professional will inquire about when the pain started and if it occurred due to an injury or whether it came on gradually. They will also ask you about what makes the pain better or worse, and if you feel that the pain is getting worse overall or staying the same.  Your health care professional will also check other joints for any signs of similar problems. In about half the patients, osteonecrosis is also present at the hip, knee, ankle, wrist, and/or elbow.

Lab studies can be done to rule out infection or test for systemic diseases or blood disorders that can cause osteonecrosis.

Standard X-rays are usually ordered to confirm the diagnosis. Several different views are needed. Besides the usual anterior-posterior (AP) views, radiographs should include views with the joint in external (outward) and internal (inward) rotation. These added X-ray views will help show all areas of the diseased humeral head, which is important information for planning treatment.

X-rays don’t always show all of the changes until the condition has been present for quite some time. MRIs may be used to define more clearly early changes in fat and water content of the bone marrow that won’t be seen on X-ray. Bone scans have fallen out of favor for the detection and diagnosis of osteonecrosis as studies show that only one-third of true cases are successfully identified with this imaging tool.

Treatment is based on the severity of disease, so part of the diagnosis is to identify what stage the disease is in. The stages range from stage I-V.  In stage I no changes are seen on X-ray images. In stage V (the most advanced disease) the humeral head is collapsed and the socket is damaged as well. There may also be soft tissue tears present in the more advanced stages.

What treatment options are available?

The first goal in treating osteonecrosis of the humeral head is to save the bone. Left untreated, the disease process will continue until the layer of bone just under the joint surface cracks causing small microfractures.

Once enough microfactures occur, the bone begins to collapse and the articular cartilage covering the joint surface also starts to collapse. Eventually, there will be damage to the entire shoulder joint.

The second goal is to keep the shoulder functional while relieving pain. Various nonsurgical and surgical methods have been used to treat this problem.

Nonsurgical Treatment

The first line of non-surgical treatment is medication to restore blood supply and allow new bone growth. Some of the more common drugs used include lipid-lowering (cholesterol-lowering) agents, vasodilators (to open up the blood vessels), anticoagulants (to prevent blood clotting), and bisphosphonates (to prevent bone loss). The type of medication used depends on the underlying systemic disease causing the bone problem. Nonsteroidal antiinflammatory drugs (NSAIDs) may provide some symptom relief of the osteoarthritis but they do not slow or stop the osteonecrosis.

Patients are advised to stop using tobacco or alcohol. Anyone taking corticosteroids should consult with the prescribing physician to review the need for and the use of these medications because of their possible adverse effects on bone.

Physical Therapy is helpful in all stages of the disease but particularly in stage I and stage II when there are few changes seen on X-ray.

Studies show that the overall results of nonsurgical treatment in the shoulder are satisfactory when the disease is caught during the early stages.

What should I expect during treatment?

Physical Therapy at First Choice Physical Therapy can be very useful for patients suffering from osteonecrosis of the shoulder, particularly if treatment is begun in the early stages of the disease.

The first goal of our treatment at First Choice Physical Therapy is to reduce pain and any inflammation around the shoulder.  The use of ice, heat, ultrasound, and other electrical modalities can be very useful as you begin your therapy. Your therapist may also use massage around the shoulder, neck or into the arm, which can help to ease pain and encourage blood flow to the affected area.  Gentle mobilizations of the shoulder joint can also be helpful to ease any muscle spasm or pain.

While your therapist is trying to reduce the pain in your shoulder and encourage early healing, they may ask you to avoid lifting your arm overhead or away from your body against resistance. They will also encourage you to avoid lifting or holding anything heavy. They may even give you a weight restriction (i.e., don’t lift anything more than two to five pounds or 1-2 kilograms). This restriction will include avoiding some everyday functional activities, such as putting away heavy groceries.

As soon as possible your therapist will begin to work on regaining your shoulder’s motion. They will teach you exercises that you can do yourself to assist with range of motion, which may include the use of sticks or pulleys to help raise the shoulder passively or your therapist may encourage you to partially use the muscles on your affected side (with the assistance of your good side) without causing discomfort. Doing pendular exercises can also help to maintain some shoulder range of motion and assist with pain at this stage. Pendular exercises are performed by leaning forward or to the side, letting the arm hang clear of the chest, and then initiating movement with your trunk so that the dangling limb passively and gently moves.  This action provides some traction to the shoulder joint, which aids in pain relief, and also assists the shoulder into a relatively elevated position (in relation to the trunk.) It is important that the pendular activity is done as passively as possible without initiating motion
from the shoulder muscles. The exercise should look similar to a weighted pendulum that randomly swings gently on the end of a piece of string.

Maintaining your neck range of motion is also very important when your shoulder is not moving well, so your therapist will also prescribe exercises to ensure you can move your neck well for all your daily activities, and that you don’t end up with a stiff neck along with your painful shoulder.

Your therapist may also manually assist your range of motion by stretching or mobilizing your shoulder.  Your therapist may need to work on any part of the shoulder joint including the glenohumeral joint, the joint between the shoulder blade and the thorax (scapulothoracic joint), or even the joints where your collarbone joins the trunk and the shoulder (sternoclavicular and acromioclavicular joints.) Your Physical Therapist will passively move these joints into their available ranges of motion while you try to relax the muscles of your shoulder completely.

Next, once your pain is under control and your shoulder range of movement is improving, your therapist will focus on strengthening exercises.  Your therapist will start by prescribing simple strengthening exercises that only involve isometric strengthening. Isometric strengthening exercises are done by tightening your muscles without actually moving the associated joint. Isometric exercises work the muscles without straining the injured or painful shoulder. Your Physical Therapist will teach you how to use your other hand or a wall for resistance while you flex and tighten your muscles, creating an isometric contraction of the shoulder muscles. Your therapist will then progress your exercises so that you are strengthening the muscles through their available ranges of movement, as you are able. More advanced exercises will involve the use of light weights or exercise band to add resistance for your upper limb.

As a result of any injury, the receptors in your joints and ligaments that assist with proprioception (your joint’s sense of position) decline in function. A period of decreased mobility will add to this decline. Proprioception is particularly important when any joint is bearing weight. Although your arm and shoulder girdle are not traditionally thought of as weight-bearing parts of the body, even an activity such as assisting yourself with your arms to get out of a chair or pulling a glass from a cupboard requires weight to be put through or lifted by your shoulder girdle and for your body to be proprioceptively aware of your limb.

Proprioceptive exercises might include activities such as rolling a ball on a surface with your hand, lying on your back while holding and moving a weight up overhead, or pushups on an unstable surface. Advanced exercises may include activities such as ball throwing or catching overhead once you have regained that range of motion.

The proprioceptive control of the shoulder blade (scapula) on the rib cage (scapulothoracic motion) is especially important in being able to use your shoulder girdle and upper limb effectively without causing further injury. Normal scapulothoracic motion is particularly essential once you are able to use your limb near or above shoulder height. For this reason, your Physical Therapist will teach you how to properly control your scapula during your rehabilitation exercises as well as during your everyday activities

Your Physical Therapist will also remind you about maintaining good shoulder posture even when sitting or using your upper limb during activities that are below shoulder height, such as working on the computer. Rounded shoulders in this position crowds the shoulder joint and can lead to shoulder impingement and pain. It should be noted that regaining proprioception of the shoulder girdle and upper limb requires concentrated work; most people have not previously needed to focus so intently on such controlled motion. The concentrated effort of these shoulder exercises, however, has a substantial reward as it plays a significant part in avoiding associated shoulder problems in the future once the original osteonecrosis problem has been dealt with.

It should be noted that Physical Therapy might be needed for extended periods of time. There are some patients whose osteonecrosis will continue to progress despite early conservative care. Unfortunately predicting who might develop a more advanced disease is difficult, so close monitoring is advised.  If conservative care fails or the breakdown is too advanced to trial conservative care, surgery may be required.

Core Decompression

Surgical intervention may be needed in the more advanced stages of osteonecrosis. When the condition is in the early stages, a procedure called core decompression is used to reduce bone marrow pressure and allow the formation of a new blood supply to the area. The new blood vessels help the necrotic area start to form new, healthy bone.

Core decompression is done by drilling small holes from the healthy bone to the area of necrosis in the humeral head. This creates channels that allow new blood vessels to grow into the necrotic area. The surgeon uses a special type of X-ray called fluoroscopy to guide the placement of the pins used to drill the holes. Removing some of the dead bone also causes bleeding into the region of necrotic bone and stimulates new bone growth. Many patients report immediate pain relief from this procedure.

Arthroscopy

If there are any loose bits of bone or cartilage in the joint, then the surgeon may have to perform arthroscopic debridement . The arthroscope is a small fiberoptic camera that can be inserted into the joint allowing the surgeon to see the inside of the joint. Other instruments can be inserted into the joint through small incisions to remove tissue and smooth the surface of the joint. The shoulder joint is cleaned up of any debris. Any frayed edges of joint cartilage are smoothed down. Sometimes the surgeon combines these two procedures (decompression and arthroscopy). The arthroscopic exam shows the location and extent of the disease in the joint while the decompression addresses the necrotic area of bone.

Bone Grafting

Bone grafting replaces the necrotic (dead) bone with donor bone that is usually taken from the patient’s own hip. This treatment approach is used for mild to moderate disease. It is not advised for late stage disease as studies show patients with more advanced disease do better with arthroplasty (joint replacement). The bone graft gives the joint surface support needed to keep it from collapsing, and with that support in place, the bone can begin to heal.

Arthroplasty

Joint replacement is used for more severe damage of the joint. A hemiarthroplasty (partial replacement) may be all that’s needed when only one side of the joint has been affected. Full joint replacement is reserved for patients with significant involvement of both the humeral head and the glenoid fossa (socket).

A newer procedure called humeral head resurfacing is gaining popularity and may help save the joint. Instead of removing the head of the humerus and replacing it, the bone is smoothed down and a metal cap placed over the smoothed head like a tooth capped by the dentist. The cap is held in place with a small peg that fits down into the bone. Joint resurfacing requires that the patient have enough healthy bone to support the cap.

What should I expect after treatment?

Depending on what you have had done during surgery will determine the appropriate time to begin post-surgical rehabilitation at First Choice Physical Therapy.  The goal of all therapy after surgery will be to decrease any residual surgical pain, regain range of motion, regain strength, and improve proprioception.

Despite what you have had done during surgery your therapist may use modalities such as ice, heat, ultrasound or electrical modalities to decrease any post-surgical pain or inflammation. They may also massage around your shoulder, into your neck or down your arm, which can also assist with pain and inflammation.

After core decompression surgery, you may be wearing a sling for a few days. Rehabilitation can progress relatively quickly with active-assisted motion being allowed nearly immediately in all directions. Active-assisted exercises are done by using your other hand or holding a stick or pulley to help guide the involved side through the motion and to take part of the weight of the surgical arm. Movements should not be forced and you should only go as far as you can comfortably.  Your therapist may mobilize your joint to help regain the needed movements of the shoulder. Strength exercises can begin early on as well and will start with either isometric exercises (see explanation under non-surgical rehabilitation) or by just lifting the weight of your arm. As able, you will progress to using small weights or exercise band for resistance.

After core decompression you will gradually resume all normal activities over a period of four or five weeks, as long as you remain pain free. More stressful activities that load the joint are not allowed for a full year following decompression.  Your therapist will be able to advise you over your recovery time when it is appropriate to start doing more stressful activities.

With any of the more invasive procedures, such as joint replacement, major muscles are cut and reattached during the operation therefore regaining motion is progressed more slowly to protect the healing soft tissues.  Passive range-of-motion where you do not lift the weight of the arm with the arm’s own muscles, but rather move it through the available range of motion using a pulley or with the other arm can be done early on.  Your therapist may also gently mobilize your shoulder joint to assist in gaining range of motion, however aggressive stretching is not allowed until around 12 weeks post-op.

As the shoulder begins to heal, you will be able to start to use the muscles to lift the arm. Generally your therapist will progress you from passive motion through to active-assisted motion and then to full active movement where you are taking the full weight of the arm with its own muscles over a period of approximately six weeks.

Strengthening exercises after one of the more invasive surgical procedures used for humeral head osteonecrosis won’t begin until around 12 weeks post-operatively.  At that time your Physical Therapist at First Choice Physical Therapy will progress you from isometric exercises to light strengthening exercises where you are using weights or exercise band to provide resistance. As tolerated your Physical Therapist will progress you to heavier weights and add endurance type exercises.

No matter which surgical procedure you have undergone, your Physical Therapist will prescribe proprioception type exercises as your shoulder tolerates it. As explained in detail under non-surgical rehabilitation, proprioception exercises assist your body in knowing where your joints and limbs are in space, and are crucial to returning your surgical joint back to its functional use.

Results of surgical treatment are often good but patients should be prepared for the possibility that osteonecrosis of the humeral head can progress over time and that further surgery may be needed. Sometimes for those patients who have had decompression or bone grafting, joint replacement may eventually be needed.  For these reasons, if your therapy is not progressing as your therapist would expect, they will ask you to follow up with your surgeon to ensure that there are no hardware issues inside the joint or other problems within the shoulder that are impeding your progress.

Dupuytren’s contracture is a fairly common disorder of the fingers. It most often affects the ring or little finger, sometimes both, and often in both hands. Although the exact cause is unknown, it occurs most often in middle-aged, white men and is genetic in nature, meaning it runs in families. This condition is seven times more common in men than women. It is more common in men of Scandinavian, Irish, or Eastern European ancestry. Interestingly, the spread of the disease seems to follow the same pattern as the spread of Viking culture in ancient times. The disorder may occur suddenly but more commonly progresses slowly over a period of years. The disease usually doesn’t cause symptoms until after the age of 40.

This guide will help you understand:

• how Dupuytren’s contracture develops
• what the symptoms are
• how the disorder progresses, and how you can measure its progression
• what options for treatment are available
• what First Choice Physical Therapy’s approach treatment is

What part of the hand is affected?

The palm side of the hand contains many nerves, tendons, muscles, ligaments, and bones. This combination allows us to move the hand in many ways. The bones give our hand structure and form joints. Bones are attached to other bones by ligaments. Muscles allow us to bend and straighten our joints. Muscles are attached to bones by tendons. Nerves stimulate the muscles to bend and straighten.

Blood vessels carry needed oxygen, nutrients, and fuel to the muscles to allow them to work normally and heal when injured. Tendons and ligaments are connective tissue. Another type of connective tissue, called fascia, surrounds and separates the tendons and muscles of the hand.

Lying just under the skin of the palm is the palmar fascia; a thin sheet of connective tissue shaped somewhat like a triangle. This fascia covers the tendons of the palm of the hand and holds them in place. It also prevents the fingers from bending too far backward when pressure is placed against them. The fascia separates into thin bands of tissue at the fingers. These bands continue into the fingers where they wrap around the joints and bones. Dupuytren’s contracture forms when the palmar fascia tightens, causing the fingers to bend.

The condition often first shows up as a thick nodule (knob) or a short cord in the palm of the hand, just below the ring finger. More nodules form, and the tissues thicken and shorten until the finger cannot be fully straightened. Dupuytren’s contracture usually affects only the ring and little finger. The contracture spreads to the joints of the finger, which can become permanently immobilized.

Why do I have this problem?

No one knows exactly what causes Dupuytren’s contracture. The condition is rare in young people but becomes more common with age. When it appears at an early age, it usually progresses rapidly and is often very severe. The condition tends to progress more quickly in men than in women.

People who smoke have a greater risk of having Dupuytren’s contracture. Heavy smokers who abuse alcohol are even more at risk. Recently, scientists have found a connection with the disease among people who have diabetes. It has not been determined whether or not work tasks can put a person at risk or speed the progression of the disease.

What does Dupuytren’s contracture feel like?

Normally, we are able to control when we bend our fingers and how much. How much we flex our fingers determines how small an object we can hold and how tightly we can hold it. This control  is lost as the disorder develops and the palmar fascia contracts, or tightens. The contracture is like extra scar tissue just under the skin. As the disorder progresses, the bending of the finger becomes more and more severe, which limits the motion of the finger.

Without treatment, the contracture can become so severe that you cannot straighten your finger, and eventually you may not be able to use your hand effectively. Being that our fingers are slightly bent when our hand is relaxed, many people put up with the contracture for a long time. Patients with this condition usually eventually seek medical advice for cosmetic reasons or because they lose use of their hand. At times, the nodules can be very painful. For this reason many patients are worried that something serious is wrong with their hand.

How do health care providers identify the problem?

When you visit First Choice Physical Therapy, our Physical Therapist will ask you the history of your problem, such as how long you have had it, whether you’ve noticed it getting worse, and whether it has kept you from doing your daily activities. We will then examine your hand and fingers.

Our Physical Therapist can tell if you have a Dupuytren’s contracture by looking at and feeling the palm of your hand and your fingers. Usually, special tests are unnecessary. Abnormal fascia will feel thick. Cords and small nodules in the fascia may be felt as small knots or thick bands under the skin. These nodules usually form first in the palm of the hand. As the disorder progresses, nodules form along the finger. These nodules can be felt through the skin, and patients can usually feel them themselves. Depending on the stage of the disorder, your finger may have started to contract, or bend.

The amount you are able to bend your finger is called flexion. The amount you are able to straighten the finger is called extension. Both are measured in degrees. Normally, the fingers will straighten out completely. This is considered zero degrees of flexion (no contracture). As the contracture causes your finger to bend more and more, you will lose the ability to completely straighten out the affected finger. The loss of ability to straighten out your finger is also measured in degrees.

Measurements we take at follow-up visits to First Choice Physical Therapy will tell us how well our treatments are working or how fast the disorder is progressing. The progression of the disorder is unpredictable. Some patients have no problems for years, and then suddenly nodules will begin to grow and their finger will begin to contract.

Our Physical Therapist may also do the tabletop test. The tabletop test will show if you can flatten your palm and fingers on a flat surface. You can follow the progression of the disorder by doing the tabletop test yourself. Our Physical Therapist will tell you what to look for and when you should return for a follow-up visit.

What can be done for the condition?

There are two types of treatment for Dupuytren’s contracture: nonsurgical and surgical. The best course of treatment is determined by how far the contractures have advanced.

Nonsurgical Treatment

The nodules of Dupuytren’s contracture are almost always limited to the hand. If you receive regular examinations, you will know when to proceed with the next treatment step. Dupuytren’s contracture is a progressive disease, early treatment, determined by the stage of the disease, is important to release the contracture and to prevent disability in your hand. Treatment is determined based on the severity of the contracture.

Enzymatic Fasciotomy

Ongoing research of this condition has resulted in a less invasive nonsurgical method of treatment called an enzymatic fasciotomy.  If it is the main knuckle of the finger (at the base of the finger) that is contracted, and there are only one or two cords involved, this procedure may be possible. For this treatment, a new injectable drug, Xiaflex, which is gaining popularity and approval for use around the world, is used. By injecting an enzyme directly into the cords formed by the disease, the tissue dissolves and starts to weaken, most often the patients are able to break apart the cord by themselves.

With the injection of this new drug generally patients return within 24 hours for a recheck. If the cord hasn’t broken apart, your physician may have to numb the finger and then stretch it to break apart the cord and regain full motion of the finger. This technique sounds dramatic, but it’s not! The treatment so far has been deemed to be safe and effective.

There are a few possible (minor) side effects but very few major or long-term complications with this new treatment. During the control trials conducted with patients, most people had a local skin reaction (redness, skin tears, itching or stinging) where the injection went into the skin. A small number of more serious problems developed in a few patients including tendon rupture, finger deformity, and hives that had to be treated with medication. Further studies are needed to assess the long-term effects of this new treatment, especially to determine any recurrence rates.

Injection of this drug may eventually replace surgery. Until then, surgical release of the cords and removing a portion of the fascia will likely remain the gold standard.

The ability of nonsurgical treatments to slow or actually reverse the contracture is not all that promising. The contracture usually requires surgery at some point.
In the early stages of this disorder, frequent examination and follow-up is recommended. In addition to your Physical Therapy treatments at First Choice Physical Therapy, your doctor may want to inject cortisone into the painful nodules. Cortisone can be effective at temporarily easing pain and inflammation.

Heat and stretching treatments given by our Physical Therapist may also be done to control pain and to try to slow the progression of the contracture. Our Physical Therapist may advise you to wear a splint that keeps the finger straight. This splint is usually worn at night. The combination of heat, stretching, and a finger splint seem to be the most effective non-surgical treatments for Dupuytren’s contracture.

Although recovery times among patients varies, as a general rule, you may be advised to

attend our Physical Therapy sessions a few visits per week for up to six weeks. After that, our Physical Therapist will instruct you to continue using the splint and do the stretches as part of a home program for several months.

The nodules of Dupuytren’s contracture are almost always limited to the hand. If you attend Physical Therapy regularly and follow our Physical Therapist’s advice, you may be able to slow the problems caused by this disorder. Dupuytren’s contracture, however, is known to progress, so surgery may be needed at some point to release the contracture and to prevent disability in your hand.

No hard and fast rule exists as to when surgery is needed. Surgery is usually recommended when the joint at the knuckle of the finger reaches 30 degrees of flexion. When patients have severe problems and require surgery at a younger age, the problem often comes back later in life. When the problem comes back or causes severe contractures, surgeons may decide to fuse the individual finger joints together. In the worst case, amputation of the finger may be needed if the contracture restricts the nerves or blood supply to the finger.

Surgery for the main knuckle of the finger (at the base of the finger) has better long-term results than when the joint in the middle of the finger is affected. A contracture is more likely to return after surgery for the middle joint.

Tissue Release

The goal of tissue release surgery is to release the fibrous attachments between the palmar fascia and the tissues around it, thereby releasing the contracture. Once released, finger movement should be restored to normal. If the problem is not severe, it may be possible to free the contracture simply by cutting the cord under the skin. If the palmar fascia is more involved and more than one finger is bent, your surgeon may take out a large portion of the sheet of fascia.

Palmar Fascia Removal (partial palmar fasciectomy)

This remains the gold standard of treatment for Dupuytren’s contracture. Removal of the diseased palmar fascia will usually give a very good result. The cure is often permanent but depends a great deal on the success of doing the Physical Therapy post surgically as prescribed. Removing the palmar fascia causes little ill effect, although the fingers may bend backward slightly more than normal. If you decide to have this surgery, it is pertinent that you commit to doing the therapy needed to make your surgery as successful as possible.

Removal of the entire palmar fascia (radical fasciectomy) requires extensive removal of involved and non-involved palmar and digital (finger) fascia. This approach may be required but it has higher complications rates without providing better success rates so it is no longer done commonly.

Needle Aponeurotomy

A less invasive procedure called a needle aponeurotomy (also referred to as a percutaneous fasciotomy) is available when the disease is at an early stage. Under local anesthesia, the surgeon inserts a very thin needle under the skin. The sharp needle cuts a path through the cord, weakening it enough to stretch and extend it, or rupture it.
The advantage of this procedure is that it can be done on older adults who have other health issues that might make surgery under general anesthesia too risky. The disadvantage is a high recurrence rate and the potential for nerve injury, infection, and hematoma (pocket of blood) formation.This procedure, however, has replaced the fasciectomy in many practices.

Skin Graft Method

A skin graft may be needed if the skin surface has contracted so much that the fingercannot relax as it should and the palm cannot be stretched out flat. Surgeons graft skin from the wrist, elbow, or groin. The skin is grafted into the area near the incision to give the finger extra mobility for movement.

Your hand will be bandaged with a well-padded dressing and a splint for support after surgery. As stated above, your Physical Therapy at First Choice Physical Therapy is a very important part of your recovery. Physical Therapy treatments after surgery can make the difference to a successful result. The treatments applied by our Physical Therapist may include a program of heat, soft tissue massage, and vigorous stretching, as well as a home program which includes similar exercises that you will be required to do on your own.  Your Physical Therapist will keep a close watch on how your recovery is going, and will take ongoing measurements to mark the progress of your recovery.

Generally Physical Therapy at First Choice Physical Therapy occurs without any issues, and full recovery occurs provided our advice is closely followed. If, however, your recovery is not progressing as your Physical Therapist feels it should, we will ask you to return to your surgeon for a follow-up visit to ensure there are no complications, which are impeding your recovery.

When your recovery is well under way, regular visits to First Choice Physical Therapy will end. Although we will continue to be a resource, you will eventually be solely in charge of doing your own exercises as part of an ongoing home program.

Welcome to First Choice Physical Therapy’s patient resource about Anterior Lumbar Fusion with Cages.

Anterior lumbar fusion is an operation done on the front (the anterior region) of the lower spine. Fusion surgery helps two or more bones grow together into one solid bone. Fusion cages are new devices, essentially hollow screws filled with bone graft, that help the bones of the spine heal together firmly. Surgeons use this procedure when patients have symptoms from disc degeneration, disc herniation, or spinal instability.

Anterior Region

This article will help you understand:

• why the procedure becomes necessary
• what surgeons hope to achieve
• what to expect during your recovery

What parts of the spine are involved?

Since the surgeon needs to reach the front of the spine, this operation is done through the abdomen. The main structures involved in this procedure are the vertebral bodies and the intervertebral discs. The vertebral bodies are the large blocks of bone that make up the front section of each vertebra. The intervertebral discs are the cushions between each pair of vertebrae. The fusion cages help separate the vertebral bodies, taking pressure off the spinal nerves where they travel from the spinal canal through openings called the neural foramen.

Main Stuctures

Vertebra

What do surgeons hope to achieve?

In most cases, this procedure is used to stop symptoms from lumbar disc disease. The intervertebral discs in the spine degenerate as a natural part of aging. Daily wear and tear and certain types of vibration can also speed up degeneration in the spine. In addition, strong evidence suggests that smoking speeds up degeneration of the spine. Scientists have also found links among family members, showing that genetics plays a role in how fast these changes occur. When degeneration occurs, a problem disc begins to collapse, and the space decreases between the vertebrae.

When this happens, the opening around the spinal nerves (the neural foramen) narrows and may begin to put pressure on the nerves. The long ligaments in the spine slacken. They may even buckle and put pressure on the spinal nerves. The outer rings of the disc, the annulus, weaken and develop small cracks. The nucleus in the center of the disc presses on the weakened annulus and may actually squeeze through the annulus and press on ligaments or nerves. Fragments of the disc that press against the outer annulus and spinal nerves can be a source of pain, numbness, and weakness. Pressure on the spinal nerves can also produce problems with the bowels and bladder, requiring emergency surgery.

A fusion operation can reduce or eliminate the pain caused by a problem disc. If the fusion is successful, the vertebrae that are fused together no longer move against one another. Instead, they move together as one unit. This prevents the disc from causing pain.

Fusion cages are also designed to separate and hold the vertebrae apart. Enlarging the space between two vertebrae widens the opening of the neural foramina, taking pressure off the spinal nerves that pass through them. Also, the extra space pulls taut the ligaments inside the spinal canal so they don’t buckle into the spinal canal.

Fusion cages are most commonly made of metal, graphite, or bone. Many of these cages are shaped like cylinders. A few are rectangular in shape. They are usually threaded like a screw on the outside and hollow on the inside. The main purpose of the cage, regardless of the shape or material, is to hold the two vertebrae apart while the fusion becomes solid.

The surgeon packs the hollow center of the cage with bone. The graft is commonly taken from another part of the body, usually the top of the pelvis bone. Bone taken from another part of your own body is called an autograft. There is a risk of pain, infection, or weakness in the area where the graft is taken.

A new method to avoid this problem is with a bone graft substitute. By using gene therapy, scientists have produced bone graft substitutes called growth factors. These growth factors are natural proteins found in the human body. Genetic engineers have been able to clone proteins known as bone morphogenic proteins (BMPs). These proteins are then made available as powder, small particles, or chips. Hormones that circulate in the bloodstream act on the BMP molecules, causing them to build new bone tissue.

The growth factor that is approved for lumbar fusion with titanium cages is BMP-2. Substituting BMP-2 for an autograft eliminates the complications that go with harvesting autograft material from the patient’s own body. This allows for shorter operation times, less loss of blood during surgery, and quicker recovery times for patients. New research shows that BMP-2 is at least as good as, and maybe even better than, autograft for anterior lumbar fusion with cages.

The surgeon packs the hollow center of the fusion cages with bone graft, either in the form of an autograft or bone graft substitute. Two cages are placed side by side within the disc. The cages spread the vertebrae apart, and the threads bind the vertebrae to keep them from moving. After implanting the cages, most surgeons attach metal hardware on the vertebrae to rigidly lock them in place. This helps the bone graft heal, fusing the vertebrae together.

Once the bones fuse, they are prevented from moving against one another. This helps relieve the mechanical pain, which occurs in the moving parts of the back. Fusion also prevents additional wear and tear on the structures inside the section that was fused. By fusing the bones together, surgeons hope to reduce future problems at the spinal segment.

How will I prepare for surgery?

The decision to proceed with surgery must be made jointly by you and your surgeon. You should understand as much about the procedure as possible. If you have concerns or questions, talk to your surgeon.

Once you decide on surgery, your surgeon may suggest a complete physical examination by your regular doctor. This exam helps ensure that you are in the best possible condition to undergo the operation.

On the day of your surgery, you will probably be admitted to the hospital early in the morning. You shouldn’t eat or drink anything after midnight the night before.

What happens during the operation?

Traditionally, this operation requires a sizeable abdominal incision. Recently, however, surgeons have begun using a laparoscope in this operation. A laparoscope is a small television camera that lets the surgeon see inside the abdominal cavity to perform the operation. Several much smaller abdominal incisions are needed in the laparoscopic method. The smaller incisions allow patients to begin moving sooner and healing faster. However, performing anterior lumbar fusion with a laparoscope is difficult. It isn’t the right choice for all fusion surgeries.

Patients are positioned on their backs with a pad placed under the low back. They are given general anesthesia to put them to sleep. As they sleep, their breathing may be assisted with a ventilator. A ventilator is a device that controls and monitors the flow of air to the lungs.

In the traditional method, an incision is made through one side of the abdomen. Organs and blood vessels are gently moved aside to expose the front of the lumbar spine.

The problem disc is located with a fluoroscope, a special X-ray that shows images on a TV screen. The surgeon drills two large holes horizontally through the front of the disc. The fusion cages are sized to fit into the newly drilled holes. Bone graft may be taken from the top of the pelvis. The other option is for the surgeon to use a bone graft substitute. The bone graft material is packed into the hollow cages. Then the surgeon screws the cages into the holes in the disc. The threads of the cages clinch the vertebrae above and below, holding them rigidly in place. The fluoroscope is used to check the position and fit of the cages.

Bone Graft – Screwing Cages into Disc Holes

As mentioned earlier, the surgeon may also fix the vertebrae in place using metal screws or plates. One option is screwing a strap of metal across the front of the spine. A second method involves additional surgery through the low back. This may be done on the same day or during a later surgery. Metal plates or screws applied through the back of the spine lock the two vertebrae and prevent them from moving. This protects the graft so it can heal better and faster.

A drainage tube may be placed in the wound. The muscles and soft tissues are put back in place, and the skin is stitched together. The surgeon may place the patient in a rigid brace.

The threaded cages rigidly connect the vertebrae above and below. Small openings in the surface of the cages allow the bone graft inside to contact the surfaces of both vertebrae. As the new bone inside the cages heals to the nearby vertebrae, the two vertebrae become rigidly fused into one solid bone.

What might go wrong?

As with all major surgical procedures, complications can occur. Some of the most common complications following anterior lumbar fusion with cages include

• problems with anesthesia
• thrombophlebitis
• infection
• nerve damage
• blood vessel damage
• problems with the graft or hardware
• nonunion
• ongoing pain

This is not intended to be a complete list of the possible complications.

Problems with Anesthesia

Problems can arise when the anesthesia given during surgery causes a reaction with other drugs the patient is taking. In rare cases, a patient may have problems with the anesthesia itself. In addition, anesthesia can affect lung function because the lungs don’t expand as well while a person is under anesthesia. Be sure to discuss the risks and your concerns with your anesthesiologist.

Thrombophlebitis (Blood Clots)

Thrombophlebitis, sometimes called deep venous thrombosis (DVT), can occur after any operation. It occurs when the blood in the large veins of the leg forms blood clots. This may cause the leg to swell and become warm to the touch and painful. If the blood clots in the veins break apart, they can travel to the lung, where they lodge in the capillaries and cut off the blood supply to a portion of the lung. This is called a pulmonary embolism. (Pulmonary means lung, and embolism refers to a fragment of something traveling through the vascular system.) Most surgeons take preventing DVT very seriously. There are many ways to reduce the risk of DVT, but probably the most effective is getting you moving as soon as possible. Two other commonly used preventative measures include

• pressure stockings to keep the blood in the legs moving
• medications that thin the blood and prevent blood clots from forming

Infection

Infection following spine surgery is rare but can be a very serious complication. Some infections may show up early, even before you leave the hospital. Infections on the skin’s surface usually go away with antibiotics. Deeper infections that spread into the bones and soft tissues of the spine are harder to treat. They may require additional surgery to treat the infected portion of the spine.

Nerve Damage

Any surgery that is done near the spinal canal can potentially cause injury to the spinal cord or spinal nerves. Injury can occur from bumping or cutting the nerve tissue with a surgical instrument, from swelling around the nerve, or from the formation of scar tissue. An injury to the spinal cord or spinal nerves can cause muscle weakness and a loss of sensation to the areas supplied by the nerve.

Blood Vessel Damage

The abdominal aorta (the largest artery in the body) and the large veins that accompany it run in front of the spine as they split to run to each leg. These vessels must be moved aside to perform the anterior cage procedure. Because of this, the vessels may be injured, causing bleeding. When the procedure is performed using the laparoscope, too much bleeding may require opening the abdomen with a larger incision to repair the injured vessels.

Problems with the Graft or Hardware

Fusion surgery with cages requires bone grafting. The graft is commonly taken from the top rim of the pelvis (autograft). As mentioned earlier, there is a risk of pain, infection, or weakness in the area where the graft is taken. These risks are avoided when a bone graft substitute, such as BMP-2, is used in place of an autograft.

After the cages are in place, the surgeon checks their position before completing the surgery. However, the cages may shift slightly soon after surgery to the point that they are no longer able to hold the spine stable. Abnormal or excessive loads on the spine, for example from heavy lifting or carrying or from the impact of jumping from a high surface, can cause the cages to collapse. This shifting or collapsing of the cages can cause injury to the nearby tissues. If this happens, a second surgery may be needed to replace the cages and to apply additional instrumentation to lock the spine firmly in place.

Hardware can also cause problems. Screws or pins may loosen and irritate the nearby soft tissues. Also, the metal plates can sometimes break. If this happens, the surgeon may suggest another surgery either to take out the hardware or to add more hardware to solve the problem.

Nonunion

Sometimes the bones do not fuse as planned. This is called a nonunion, or pseudarthrosis. (The term pseudarthrosis means false joint.) When more than one level of the spine is fused at one time, there is a greater chance that nonunion will occur. Fusion of more than one level means two or more consecutive discs are removed and replaced with bone graft. If the joint motion from a nonunion causes pain, you may need a second operation.

In the second procedure, the surgeon may have to replace the cages. Metal plates and screws may also be added to rigidly secure the bones so they will fuse.

Ongoing Pain

Anterior lumbar fusion with cages is a complex surgery. Not all patients get complete pain relief with this procedure. As with any surgery, you should expect some pain afterward. If the pain continues or becomes unbearable, talk to your surgeon about treatments that can help control your pain.

What happens after surgery?

Patients are sometimes placed in a rigid body brace after surgery. This brace may not be needed if the surgeon attached metal hardware to the spine during the surgery.

Patients usually stay in the hospital after surgery for up to one week. During this time, a Physical Therapist helps patients learn safe ways to move, dress, and do activities without putting extra strain on the back. Patients may be instructed to use a walker for the first day or two. Before going home, patients are shown how to control pain and avoid problems.

Patients are able to return home when their medical condition is stable. However, they are usually required to keep their activities to a minimum in order to give the graft time to heal. Patients are cautioned against bending forward, lifting, twisting, driving, and prolonged sitting for up to six weeks. Activities and exercises that cause the spine to bend back place hazardous stress on the cages and should be avoided for at least six months. Outpatient Physical Therapy usually begins a minimum of six weeks after the date of surgery.

What should I expect as I recover?

Rehabilitation after anterior lumbar fusion with cages can be a slow process. Although recovery time is different for each paitent, the First Choice Physical Therapy outpatient Physical Therapy program usually begins a minimum of six weeks after surgery. This delay is needed to make sure the fusion is taking. You will probably need to attend Physical Therapy sessions for two to three months, and you should expect full recovery to take up to eight months. However, Physical Therapy can usually progress faster for patients who had fusion with instrumentation.

At first, our treatments are used to help control your pain and inflammation. Ice and electrical stimulation treatments are commonly used to help with these goals. Our Physical Therapist may also use massage and other hands-on techniques to ease muscle spasm and pain.

As you recover, your Physical Therapist at First Choice Physical Therapy will slowly add active treatments, which may include exercises for improving heart and lung function. Short, slow walks are generally safe to start with. Swimming and use of a machine for cardiovascular exercise are helpful in the later phases of treatment. Our Physical Therapists also teach specific exercises to help tone and control the muscles that stabilize the low back.

We will also work with you on how to move safely and perform certain activities. This form of treatment, called body mechanics, helps you develop new movement habits. This type of training is designed to keep your back in safe positions as you go about your work and daily activities. Training includes positions you use when sitting, lying, standing, and walking. Our Physical Therapist will also help you work on safe body mechanics with lifting, carrying, pushing, and pulling.

As your condition improves, we will tailor your program to help prepare you to go back to work. Some patients are not able to go back to a previous job that requires strenuous tasks. Our Physical Therapist may suggest changes in job tasks that enable you to go back to your previous employer or to do alternate forms of work. We will help you learn to do these tasks in new ways that keep your back safe and free of strain.

Before your Physical Therapy sessions end, our Physical Therapist will teach you ways to avoid future problems.

Welcome to First Choice Physical Therapy’s patient resource about Anterior Lumbar Interbody Fusion.

Anterior lumbar interbody fusion (ALIF) is a procedure used to treat problems such as disc degeneration, spine instability, and deformities in the curve of the spine. In this procedure, the surgeon works on the spine from the front (anterior) and removes a spinal disc in the lower (lumbar) spine. The surgeon inserts a bone graft into the space between the two vertebrae where the disc was removed (the interbody space). The goal of the procedure is to stimulate the vertebrae to grow together into one solid bone (known as fusion). Fusion creates a rigid and immovable column of bone in the problem section of the spine. This type of procedure is used to try and reduce back pain and other symptoms.

This guide will help you understand:

• what surgeons hope to achieve
• what happens during surgery
• what to expect as you recover

What parts of the spine and low back are involved?

ALIF surgery is performed through the front (anterior). The structures in this area include the anterior longitudinal ligament, the vertebral bodies, and the intervertebral discs. The anterior longitudinal ligament attaches along the front of the spinal column. The vertebral bodies are the large blocks of bone that make up the front section of each vertebra. The intervertebral discs are the cushions between each pair of vertebrae.

Front (Anterior)

Structures

What do surgeons hope to achieve?

This procedure is often used to stop symptoms from lumbar disc disease. Discs degenerate, or wear out, as a natural part of aging and also from stress and strain on the back. Over time, the disc begins to collapse, and the space decreases between the vertebrae.

When this happens, the openings around the spinal nerves (the neural foramina) narrow and may put pressure on the nerves. The long ligaments in the spine slacken due to the collapse in vertebral height. These ligaments may buckle and put pressure on the spinal nerves.

Also, the outer rings of the disc, the annulus, weaken and develop small cracks. Tears in the outer annulus are painful because these tissues are rich with pain sensors. The nucleus in the center of the disc may press on the weakened annulus and actually squeeze out of the annulus (herniate). Inflammation from the nucleus as it escapes the annulus also causes pain. The nucleus normally does not come in contact with the body’s blood supply. However, a tear in the annulus puts the nucleus at risk for contacting this blood supply. When the nucleus herniates into the torn annulus, the nucleus and blood supply meet, causing a reaction of the chemicals inside the nucleus. This produces inflammation and pain.

If the nucleus presses against the spinal nerves, symptoms of pain, numbness, and weakness may occur where the nerve travels. Pressure on the spinal nerves inside the spinal canal can also produce problems with the bowels and bladder, requiring emergency surgery.

Discectomy is the removal of the disc (and any fragments) between the vertebrae that are to be fused. Taking out the painful disc is intended to alleviate symptoms. It also provides room for placing the bone graft that will allow the two vertebrae to fuse together. The medical term for fusion is arthrodesis.

Once the disc is removed, the surgeon spreads the bones of the spine apart slightly to make more room for the bone graft. The bone graft separates and holds the vertebrae apart. Enlarging the space between the vertebrae widens the opening of the neural foramina, taking pressure off the spinal nerves that pass through these openings. Also, the long ligaments that run up and down inside the spinal canal are pulled taut so they don’t buckle into the spinal canal.

If the fusion is successful, the vertebrae that are fused together no longer move against one another. Instead, they move together as one unit. This helps relieve the mechanical pain, which occurs in the moving parts of the back. Fusion also prevents additional wear and tear on the spinal segment that was fused. By fusing the bones together, surgeons hope to reduce future problems at the spinal segment.

How will I prepare for surgery?

The decision to proceed with surgery must be made jointly by you and your surgeon. You should understand as much about the procedure as possible. If you have concerns or questions, you should talk to your surgeon.

Once you decide on surgery, your surgeon may suggest a complete physical examination by your regular doctor. This exam helps ensure that you are in the best possible condition to undergo the operation.

On the day of your surgery, you will probably be admitted to the hospital early in the morning. You shouldn’t eat or drink anything after midnight the night before.

What happens during the operation?

Patients are given a general anesthesia to put them to sleep during most spine surgeries. As you sleep, your breathing may be assisted with a ventilator. A ventilator is a device that controls and monitors the flow of air to the lungs.

The patient is positioned on his or her back with a pad placed under the low back. An incision is made through one side of the abdomen. The large blood vessels that lie in front of the spine are gently moved aside. Retractors are used to gently separate and hold the soft tissues apart so the surgeon has room to work.

The surgeon inserts a needle into the disc. By taking an X-ray with the needle in place, the correct disc is identified. Forceps are used to open the front of the disc. Next, a tool is attached to the vertebrae to spread them apart. This makes it easier for the surgeon to see between the two vertebrae. A small cutting tool (a burr) is used to carefully remove the front half of the disc. A special surgical microscope may be used to help the surgeon see while removing pieces of disc material near the back of the disc space.

The surgeon shaves a layer of bone off the flat surfaces of the two vertebrae. This causes the surfaces to bleed. Bleeding stimulates the bone graft to heal and join the bones together.

The surgeon measures the depth and height between the two vertebrae. Making a separate incision, the surgeon takes a section of bone from the top of the pelvis to use as a graft. The graft is measured to fit snugly in the space where the disc was taken out. The surgeon uses a traction device to spread the two vertebrae apart, and the graft is tamped into place.

Traction is released. Then the surgeon tests the graft by bending and turning the spine to make sure the graft is in the right spot and is locked in place. Another X-ray may be taken to double check the location and fit of the graft.

Most surgeons apply some form of metal hardware, called instrumentation, to prevent movement between the vertebrae. Instrumentation protects the graft so it can heal better and faster. One option involves screwing a strap of metal across the front surface of the spine over the area where the graft rests. A second method involves additional surgery through the low back, either on the same day or during a later surgery. In this operation, metal plates and screws are applied through the back of the spine, locking the two vertebrae and preventing them from moving.

A drainage tube may be placed in the wound. The muscles and soft tissues are then put back in place. The skin is stitched together. The surgeon may place you in a rigid brace that straps across the chest, pelvis, and low back to support the spine while it heals.

What might go wrong?

As with all major surgical procedures, complications can occur. Some of the most common complications following ALIF include

• problems with anesthesia
• thrombophlebitis
• infection
• nerve damage
• blood vessel damage
• problems with the graft or hardware
• nonunion
• ongoing pain

This is not intended to be a complete list of possible complications.

Problems with Anesthesia

Problems can arise when the anesthesia given during surgery causes a reaction with other drugs the patient is taking. In rare cases, a patient may have problems with the anesthesia itself. In addition, anesthesia can affect lung function because the lungs don’t expand as well while a person is under anesthesia. Be sure to discuss the risks and your concerns with your anesthesiologist.

Thrombophlebitis (Blood Clots)

Thrombophlebitis, sometimes called deep venous thrombosis (DVT), can occur after any operation. It occurs when the blood in the large veins of the leg forms blood clots. This may cause the leg to swell and become warm to the touch and painful. If the blood clots in the veins break apart, they can travel to the lung, where they lodge in the capillaries and cut off the blood supply to a portion of the lung. This is called a pulmonary embolism. (Pulmonary means lung, and embolism refers to a fragment of something traveling through the vascular system.) Most surgeons take preventing DVT very seriously. There are many ways to reduce the risk of DVT, but probably the most effective is getting you moving as soon as possible. Two other commonly used preventative measures include

• pressure stockings to keep the blood in the legs moving
• medications that thin the blood and prevent blood clots from forming

Infection

Infection following spine surgery is rare but can be a very serious complication. Some infections may show up early, even before you leave the hospital. Infections on the skin’s surface usually go away with antibiotics. Deeper infections that spread into the bones and soft tissues of the spine are harder to treat. They may require additional surgery to treat the infected portion of the spine.

Nerve Damage

Any surgery that is done near the spinal canal can potentially cause injury to the spinal cord or spinal nerves. Injury can occur from bumping or cutting the nerve tissue with a surgical instrument, from swelling around the nerve, or from the formation of scar tissue. An injury to the spinal cord or spinal nerves can cause muscle weakness and a loss of sensation to the areas supplied by the nerve.

Blood Vessel Damage

The abdominal aorta is the largest artery in the body. This major artery and the large veins that accompany it pass in front of the spine and split to go into each leg. The surgeon has to move these vessels aside to perform the anterior interbody procedure. The vessels can be injured, causing internal bleeding.

Problems with the Graft or Hardware

Fusion surgery requires bone to be grafted into the spinal column. The graft is commonly taken from the top rim of the pelvis. There is a risk of having pain, infection, or weakness in the area where the graft is taken.

After the graft is placed, the surgeon checks the position of the graft before completing the surgery. However, the graft may shift slightly soon after surgery to the point that it is no longer able to hold the spine stable. If the graft migrates out of position, it can cause injury to the nearby tissues. A second surgery may be needed to align or replace the graft and to apply metal plates and screws to hold it firmly in place.

Hardware can also cause problems. Screws or pins may loosen and irritate the nearby soft tissues. Also, the metal plates can break. The surgeon may suggest another operation either to take out the hardware or to add more hardware to solve the problem.

Nonunion

Sometimes the bones do not fuse as planned. This is called a nonunion, or pseudarthrosis. (The term pseudarthrosis means false joint.) When more than one level of the spine is fused at one time, there is a greater chance that nonunion will occur. (Fusion of more than one level means two or more consecutive discs are removed and replaced with bone graft.) If the joint motion from a nonunion continues to cause pain, the patient may need a second operation.

In the second procedure, the surgeon usually adds more bone graft. Metal plates and screws may also be added to rigidly secure the bones so they will fuse together.

Ongoing Pain

ALIF is a complex surgery. Not all patients get complete pain relief with this procedure. As with any surgery, patients should expect some pain afterward. If the pain continues or becomes unbearable, talk to your surgeon about treatments that can help control your pain.

What happens after surgery?

Patients are sometimes placed in a rigid body brace after surgery. This may not be necessary if the surgeon attached metal hardware to the spine during the surgery.

Patients usually stay in the hospital after surgery for up to one week. During this time, patients work daily with a Physical Therapist. The Physical Therapist demonstrates safe ways to move, dress, and do activities without putting extra strain on the back. The Physical Therapist may recommend that the patient use a walker for the first day or two. Before going home, patients are shown ways to help control pain and avoid problems.

Patients are able to return home when their medical condition is stable. However, they are usually required to keep their activities to a minimum in order to give the graft time to heal. Patients should avoid activities that cause the spine to bend back for at least six weeks. Patients are also cautioned against bending, lifting, twisting, driving, and prolonged sitting for up to six weeks. Outpatient Physical Therapy is usually started a minimum of six weeks after the date of surgery.

What should I expect as I recover?

Rehabilitation after ALIF can be a slow process. Although recovery time is different for each patient, as a general rule, the outpatient Physical Therapy program at First Choice Physical Therapy begins a minimum of six weeks after Anterior Lumbar Interbody Fusion surgery. This delay is needed to make sure the graft has time to fuse. You will probably need to attend our Physical Therapy sessions for two to three months, and should expect full recovery to take up to eight months. However, Physical Therapy can usually progress faster in patients who had fusion with instrumentation.

At first, our treatments are used to help control your pain and inflammation. Ice and electrical stimulation are commonly used to help with these goals. Our therapist may also use massage and other hands-on treatments to ease muscle spasm and pain.

Your Physical Therapist at First Choice Physical Therapy will then slowly add active treatments, which may include exercises for improving heart and lung function. Short, slow walks are generally safe to start with. Swimming and use of a machine for cardiovascular exercise are helpful in the later phases of treatment. Our Physical Therapists also teach specific exercises to help tone and control the muscles that stabilize the low back.

We will also work with you on how to move safely and perform certain activities. This form of treatment, called body mechanics, is used to help you develop new movement habits. This type of training helps you keep your back in safe positions as you go about your work and daily activities. Training includes positions you use when sitting, lying, standing, and walking. Our Physical Therapist will also help you work on safe body mechanics with lifting, carrying, pushing, and pulling.

As your condition improves, we tailor your program to prepare you to go back to work. Some patients are not able to go back to a previous job that requires strenuous tasks. Our Physical Therapist may suggest changes in job tasks that enable you to go back to your previous employer or to do alternate forms of work. We’ll instruct you on to do these tasks in new ways that keep your back safe and free of strain.

Before your Physical Therapy sessions end, our Physical Therapist will teach you ways to avoid future problems.

Welcome to First Choice Physical Therapy’s patient resource about Lumbar Artificial Disc Replacement.

Artificial disc replacement (ADR) is a device or implant used to replace a diseased or damaged intervertebral disc.After removing what’s left of the worn out disc, the ADR is inserted in the space between two lumbar vertebrae. The goal is to replace the diseased or damaged disc while keeping your normal spinal motion. Artificial disc surgery is relatively new in the United States but has been used in Europe for many years. In the U.S., the first lumbar artificial disc surgery was done in clinical trials in October 2001. The Federal Drug Administration (FDA) approved the use of the lumbar ADRs in October 2004.

This guide will help you understand:

• what parts of the spine are involved
• what your surgeon hopes to achieve
• who can benefit from this procedure
• what happens during the procedure
• what to expect as you recover

What parts of the spine are involved?

The human spine is made up of 24 spinal bones called vertebrae. Vertebrae are stacked on top of one another to form the spinal column. The spinal column gives the body its form. It is the body’s main upright support. The section of the spine in the lower back is known as the lumbar spine. Lumbar disc replacement typically occurs in the lumbar spine (from L4-S1).

An intervertebral disc sits between each pair of vertebrae. The disc normally works like a shock absorber. It protects the spine against the daily pull of gravity. It also protects the spine during strenuous activities that put strong force on the spine, such as jumping, running, and lifting.

An intervertebral disc is made of two parts. The center, called the nucleus is spongy. It provides most of the disc’s ability to absorb shock. The nucleus is held in place by the annulus, a series of strong ligament rings surrounding it. Ligaments are connective tissues that attach bones to other bones.

Between the vertebrae of each spinal segment are two facet joints. The facet joints are located on the back of the spinal column. There are two facet joints between each pair of vertebrae, one on each side of the spine. A facet joint is made of small, bony knobs that line up along the back of the spine. Where these knobs meet, they form a joint that connects the two vertebrae. The alignment of the facet joints of the lumbar spine allows freedom of movement as you bend forward and back.

From the side, the spine forms three curves. The neck, called the cervical spine, curves slightly inward. The middle back, or thoracic spine, curves outward. The outward curve of the thoracic spine is called kyphosis. The low back, also called the lumbar spine, curves slightly inward. An inward curve of the spine is called lordosis.

What does the surgeon hope to achieve?

Disc replacement surgery is done to stop the symptoms of degenerative disc disease. Discs wear out or degenerate as a natural part of aging and from stress and strain on the spine. Eventually, the problem disc collapses, which causes the vertebra above to sink toward the one below. This loss of disc height affects nearby structures – especially the facet joints.

When the disc collapses it no longer supports its share of the load in the spine. The
facet joints of the spine begin to support more of the force that is transmitted between each vertebra. This increases the wear and tear on the articular cartilage that covers the surface of the joints. The articular cartilage is the smooth, slippery surface that covers the surface of the bone in any joint in the body. Articular cartilage is tough, but it does not tolerate abnormal pressure well for long. When damaged, articular cartilage does not have the ability to heal. This wear and tear is what is commonly referred to as arthritis.

Shrinking disc height also reduces the size of the neural foramina, the openings between each vertebral pair where the nerve roots leave the spinal column. The arthritis also results in the development of bone spurs that may protrude into these openings further narrowing the space that the nerves have to exit the spinal canal. The nerve roots can end up getting squeezed where they pass through the neural foramina.

Replacing the damaged disc with an artificial disc, or implant, called a prosthesis can restore the normal distance between the two vertebrae. The artificial disc sits between the two vertebrae and distracts or jacks up the upper vertebra. Enlarging the disc space relieves pressure on the facet joints. It also opens up the space around the spinal nerve roots where they pass through the neural foramina.

Another benefit of the artificial disc replacement is that it mimics a healthy disc. Natural motion is preserved in the spine where the new disc is implanted. And it helps maintain stability in the spinal joints above and below it.

For many years, the standard of care for chronic pain from a degenerated disc has been spinal fusion surgery. Bone graft donated by a bone bank or taken from your pelvic bone is used to fuse two or more vertebral bones together.The spine is stabilized but you will lose motion at that level. The increased stress on the next lumbar vertebra can cause problems later.

The artificial disc replacement is used to reduce or eliminate the pain while still allowing motion. One advantage of the artificial disc is that it may also prevent premature breakdown of adjacent levels of the lumbar spine.

You may be a good candidate for a lumbar artificial disc replacement if you have chronic pain and disability from lumbar disc degeneration despite nonoperative treatment for at least six months. The artificial disc replacement provides an alternative to spinal fusion. The device helps restore the normal space between two vertebrae. You will still have movement at the level where the ADR is implanted.

How should I prepare for surgery?

Knowing what to expect before and after surgery can help you plan for recovery at home. Once you and your surgeon have agreed that disc replacement surgery is indicated, certain preparations for the surgery are important.

You may need to visit your primary care physician or internal medicine specialist to obtain medical clearance for surgery. This will ensure that you are in the best medical condition prior to the surgery. A doctor who will be performing your anesthesia (an anesthesiologist) will evaluate and counsel you regarding anesthesia.

Certain factors put you at increased risk for problems during or after the operation. It’s best to reduce or eliminate as many of these risk factors as possible. For example, the use of alcohol or other drugs (including tobacco) can be major factors in how your body copes with anesthesia and the stress of surgery.

You should stop any anti-inflammatory medications 10 days before surgery. If you aren’t sure which medications this includes, ask your doctor. You should stop smoking or using tobacco as soon as possible but at least two weeks before surgery. This is very important to reduce complications from heart and lung problems. Smoking also decreases the success rate of spine surgery. Stopping smoking will increase your chance of a successful result.

You may need to donate one or two units of your own blood. This blood will be stored in the blood bank until surgery. If you need a transfusion either during or after your surgery you will receive your own blood back.

On the day of your surgery, you will probably be admitted to the hospital early in the morning. You shouldn’t eat or drink anything after midnight the night before. Let your surgeon know if you have diabetes and how you manage it (insulin pump, insulin injections, diet, exercise). Your need for insulin can change as a result of the stress of hospitalization and surgery. Even if you are tightly controlled now, you should monitor your glucose levels closely for at least a week before surgery and continue to do so for several weeks after surgery.

What happens during the operation?

Before we describe the procedure, let’s look first at the artificial disc itself. The lumbar artificial disc has several different designs. They are made of metal, ceramic, and plastic. Some look like a sandwich with two endplates separated by a plastic spacer. The two endplates are made of cobalt chromium alloy, a safe material that has been used for many years in replacement joints for the hip and knee.

A plastic (polyethylene) core fits in between the two metal endplates. The core acts as a spacer and is shaped so that the endplates pivot in a way that imitates normal motion of the two vertebrae. There are small prongs or teeth on one side of each endplate. The teeth help anchor the endplate to the surface of the vertebral body.

Another way of anchoring the artificial disc replacement is the central keel or fin design. The implant is secured to the vertebral end plates by a thin, upright piece of metal that looks like the rudder on a boat or a shark’s fin.

Another artificial disc replacement design is a ball and socket articulation to allow for normal translation of motion at that segment. The implant may be made of titanium and polyurethane in a metal-on-plastic design. Some are made of stainless steel and are all metal-on-metal.

Inserted between two vertebrae, the prosthesis reestablishes the height between two vertebrae. As a result of enlarging the disc space, the nearby spinal ligaments are pulled tight, which helps hold the prosthesis in place. The prosthesis is further held in place by the normal pressure through the spine.

The lumbar artificial disc replacement comes in a variety of sizes and angles. There are constrained and unconstrained designs. The constrained devices provide a fixed center of rotation that doesn’t change. The unconstrained design allows the center of the implant to move forward and back slightly during lumbar motion. The surgeon can also choose an implant with the correct angle for each patient in order to build in the right amount of lordosis (spinal curvature).

Lumbar ADR is done through the anterior ( front) of the spine. For your safety there are usually two surgeons present; your spine surgeon and a general or vascular surgeon.

The new system is placed in the spine through an incision though the abdomen or belly. Working from the front of the spine through the abdomen, the organs are carefully moved to one side. This makes it easier to see the front of the spine. The spine surgeon removes a large section from the middle of the damaged disc.

Next, the bones of the spine are spread apart to make more room to see and work inside the disc space. Using a surgical microscope, any remaining disc material toward the back of the disc is removed. The surgeon will also remove any disc fragments pressing against the nerve and shave off any osteophytes (bone spurs).

The disc space is distracted (jacked up) to its normal disc height. This step helps decompressor take pressure off the nerves. At this point, x-rays or a fluoroscope, is used to insert the artificial disc device into the prepared disc space. The fluoroscope is an x-ray machine that allows the surgeon to actually see an x-ray image while doing the procedure. Using a fluoroscope, the surgeon is able to see where the implant goes as it is inserted. This makes the procedure much safer and much more accurate.

Finally, moving the spine in various positions tests the prosthesis. An X-ray may be taken to double check the location and fit of the new disc.

What might go wrong?

All types of spine surgery, including artificial disc replacement, have certain risks and benefits. Complications from any kind of surgery can also occur from anesthesia, infection, and development of blood clots (thrombophlebitis). Medical complications arising from spinal surgery are rare but could include stroke, heart attack, spinal cord or spinal nerve injury, pneumonia, or possibly death.

Your spine surgeon will discuss the most common complications with you. This document will help you prepare any questions you may have. It doesn’t provide a complete list of all the possible complications. Complications from the artificial disc replacement procedure are rare and are lower than for spinal fusion. Results continue to improve with advances in technology and better surgical techniques. The more common problems may include but are not limited to:

• problems with anesthesia
• thrombophlebitis (blood clots)
• infection
• nerve damage or paralysis
• spontaneous ankylosis (fusion)
• problems with the implant
• retrograde ejaculation (men only)
• ongoing pain

Anesthesia Complications

Problems can arise when the anesthesia given during surgery causes a reaction with other drugs you may be taking. In rare cases, a patient may have problems with the anesthesia itself. In addition, anesthesia can affect lung function because the lungs don’t expand as well while a person is under anesthesia. Be sure to discuss the risks and your concerns with your anesthesiologist.

Thrombophlebitis (Blood Clots)

Thrombophlebitis, sometimes called deep venous thrombosis (DVT), can happen after any operation. It occurs when blood in the large veins of the leg forms blood clots. This may cause the leg to swell and become warm to the touch and painful. If the blood clots in the veins break apart, they can travel to the lung, where they lodge in the capillaries and cut off the blood supply to a portion of the lung. This is called a pulmonary embolism. (Pulmonary means lung, and embolism refers to a fragment of something traveling through the vascular system.) Most surgeons take preventing DVT very seriously. There are many ways to reduce the risk of DVT, but probably the most effective is getting you moving as soon as possible after surgery. Two other commonly used preventative measures include

• pressure stockings to keep the blood in the legs moving
• medications that thin the blood and prevent blood clots from forming

Infection

Infection following spine surgery is rare but can be a very serious complication. Some infections may show up early, even before you leave the hospital. Infections on the skin’s surface usually go away with antibiotics. Deeper infections that spread into the bones and soft tissues of the spine are harder to treat. They may require additional surgery to treat the infected portion of the spine.

Nerve Damage or Paralysis

Any surgery that is done near the spinal canal can potentially cause injury to the spinal cord or spinal nerves. Injury can occur from bumping, stretching, or cutting the nerve tissue with a surgical instrument. Nerve involvement can cause nerve pain, muscle weakness, and a loss of sensation to the areas supplied by the nerve.

These symptoms are usually temporary and will gradually go away in one to three months’ time. Swelling around the nerve or the formation of scar tissue can also result in pressure or traction on the nerve. Scar tissue called fibrosis does not always resolve resulting in chronic pain and long-term weakness and sensory changes.

Spontaneous Ankylosis

Scientists aren’t sure why but sometimes the spine fuses itself, a process called spontaneous ankylosis. Loss of spinal motion is the main side effect of this problem. Bone may also form in the soft tissues around the vertebrae. For example, cartilage turns to bone or bone-like tissue. This process is called ossification. Ossification may or may not affect the implant or your final results in terms of motion or function.

Problems with the Implant

The prosthesis itself can sometimes be a source of complications. Although rare, the prosthesis can shift out of its normal position and even dislocate. If the implant migrates out of position, it can cause injury to the nearby tissues. A second surgery may be needed to align or replace the implant.

And similar to other types of joint replacements, the artificial disc may fail over time if the parts wear out. Your ADR is estimated to last 15 to 20 years. If the disc moves out of position or wears out, it can be removed. When surgery is done to take out the original prosthesis, a fusion surgery will most likely be recommended.

Subsidence is another possible problem. The implant actually sinks down into the vertebral body above or below it. This results in a loss of the normal disc height. Neurologic compression with neurologic symptoms can occur.

Over time, wear and tear just from the physical process of motion across a bearing surface can cause tiny bits of debris to flake off the implant. The body may react to these particles with an inflammatory response that can cause pain, implant loosening, and implant failure. So far, significant inflammatory reactions have not been reported for spinal ADRs.

Retrograde Ejaculation

Lumbar disc replacement surgery carries risks associated with operating from the front of the spine. In men, the anterior approach can also sometimes result in a complication called retrograde ejaculation.

Tiny nerves in front of the lower spine may be damaged during the anterior approach. If so, semen enters the bladder instead of going out through the urethra during ejaculation. Male patients planning a family might wish to consider donating sperm before surgery. Studies have not reported cases of sexual dysfunction but it is a potential risk.

Ongoing Pain

Not all patients get complete pain relief with this procedure. As with any surgery, patients should expect some pain afterward. If the pain continues or becomes unbearable, talk to your surgeon about treatments that can help control your pain.

What happens after surgery?

You may have immediate relief from your painful symptoms, but many people notice a gradual improvement over the next weeks to months. Many patients are able to reduce or eliminate the use of pain medication as well.

Your hospital stay will depend on how quickly you recover but most people are able to go home by the third day after surgery. You may require an extra day or two if for some reason you’re having extra pain or unexpected difficulty.

Most people recover quickly after the artificial disc procedure. You will be getting up out of bed and walking the same day as your surgery. You may even be able to get out of bed and walk within a few hours. Move carefully and comfortably, and avoid extending your back (bending backward). You probably won’t need a back brace or other support while the tissues are healing.

When you go home, you should be safe to sit, walk, drive, and ride a bike. Lifting anything more than eight to 10 pounds should be avoided for at least four weeks. To help you gauge what you can and can’t lift, keep in mind that a gallon of milk weighs about eight pounds.

Your surgeon will continue to follow-up with you. X-rays will be done from time to time to make sure the implant is still in its proper place. Your surgeon will let you know when you can return to work. Depending on the type of work you do, this should be in about two to four weeks. If your job requires moving and lifting heavy items, you may need a longer period of recovery. Your surgeon may give you the okay to do all your activities by the sixth week after surgery. You can expect to return to previous recreational activity by the end of three months.

What should I expect as I recover?

After you leave the hospital, your Physical Therapist at First Choice Physical Therapy can develop a personalized home program of exercises and activities to help you regain motion and function. It’s important to continue with your walking program on a daily basis when you go home. Your goal should be to walk at least 30 minutes at a moderately brisk pace at least five days each week.

Although the time required for recovery is different for each patient, as a general rule, our patients recovering from Lumbar Artificial Disc Replacement attend Physical Therapy two to three times each week for about four to six weeks.

Our Physical Therapist will recommend active treatments to improve flexibility, strength, and endurance. Gentle stretching exercises for the back are commonly prescribed. We will have you begin a series of strengthening exercises to help tone and control the muscles that stabilize the trunk and back. It is also important to build strength in your legs. The endurance exercises that we recommend may include treadmill walking, swimming, or stationary biking.

When your symptoms are under control and you’re comfortable doing your exercises, your formal therapy sessions at First Choice Physical Therapy will end. Although we will continue to be a resource, you will be in charge of doing your exercises as part of an ongoing home program.

Artificial disc replacement may offer an alternative to spinal fusion for some patients who have chronic back pain from degenerative disc disease. While fusion stops pain by eliminating movement in the problem spinal segment, artificial disc replacement allows natural motion in the part of the spine where the disc is implanted. This is because the prosthesis is designed to restore normal motion and height between adjacent vertebrae. Artificial disc replacement allows for an early return to function.

The implant is designed to withstand bending, twisting, compression and repeated loads during movement. For active adults, successful disc replacement should endure years of high loads without mechanical failure.

Long-term studies to assess the safety and effectiveness of artificial disc replacements are ongoing. Researchers are looking at the impact of the ADR on other discs and on the bony structures of the spine. So far results show a low rate of complications. There have been no reports of death, significant infection, or major neurological problems. Patient satisfaction is good to excellent in most, but not all, cases.

Welcome to First Choice Physical Therapy’s patient resource about Lumbar Laminectomy.

Lumbar laminectomy is a surgical procedure to relieve pressure on the spinal nerves. Degeneration, or wear and tear,in the parts of the spine may narrow the spinal canal. This puts pressure on the nerves in the canal. This condition is called spinal stenosis. A laminectomy involves removing a section of the bony covering over the back of the spinal canal. This takes pressure off the spinal nerves.

This article will help you understand:

• why the procedure becomes necessary
• what surgeons hope to achieve
• what to expect as you recover

What parts of the spine are involved?

Surgeons perform lumbar laminectomy surgery through an incision in the low back. The surgery involves the pedicle and lamina bones. These bones attach to the back of the spinal column, forming a bony ring that encloses the spinal canal. Surgeons may remove bone spurs from the facet joints along the back of the spine during the laminectomy procedure, taking pressure off the spinal nerves.

Pedicle and Lamina Bones

Bony Ring

What do doctors hope to achieve?

Lumbar laminectomy can alleviate the symptoms of spinal stenosis, a condition in which the spinal nerves become compressed inside the spinal canal. Wear and tear on the spine from aging and from repeated stresses and strains can cause a spinal disc to weaken. The outer rim of the disc bulges outward, and the disc may eventually protrude or even rupture into the spinal canal, narrowing the size of the canal. As a result, the nerves inside the canal are squeezed, leading to symptoms of spinal stenosis.

Degeneration also causes bone spurs to develop. These spurs commonly occur around the facet joints and along the edges of the vertebrae. When these spurs point into the spinal canal, they may squeeze against the spinal nerves. In a laminectomy, the surgeon removes a section of the lamina bone and any bone spurs, taking pressure off the spinal nerves. This enlarges the spinal canal so the spinal nerves have more room.

How will I prepare for surgery?

The decision to proceed with surgery must be made jointly by you and your surgeon. You should understand as much about the procedure as possible. If you have concerns or questions, talk to your surgeon.

Once you decide on surgery, your surgeon may suggest a complete physical examination by your regular doctor. This exam helps ensure that you are in the best possible condition to undergo the operation.

On the day of your surgery, you will probably be admitted to the hospital early in the morning. You shouldn’t eat or drink anything after midnight the night before.

What happens during the operation?

Patients are given a general anesthesia to put them to sleep during most spine surgeries. As you sleep, your breathing may be assisted with a ventilator. A ventilator is a device that controls and monitors the flow of air to the lungs.

Some surgeons have begun using spinal anesthesia in place of general anesthesia. Spinal anesthesia is injected in the low back into the space around the spinal cord. This numbs the spine and lower limbs. Patients are also given medicine to keep them sedated during the procedure.

This surgery is usually done with the patient kneeling face down in a special frame. The frame supports the patient so the abdomen is relaxed and free of pressure. This position lessens blood loss during surgery and gives the surgeon more room to work.

The surgeon makes a short incision down the middle of the low back. The skin and soft tissues are separated to expose the bones along the back of the spine. An X-ray of the low back ensures the surgeon works on the right vertebra. Some surgeons use a special surgical microscope during surgery to magnify the area they’ll be working on.

In a complete laminectomy, the spinous process (the bony projection off the back of the vertebra) and the lamina on each side are removed over the area where stenosis is occurring. To accomplish this, the surgeon cuts along the inside edge of the facet joint on each side and detaches the lamina bone completely from the pedicle bones. This opens a section in the bony ring. A small portion of the ligamentum flavum is removed. The ligamentum flavum runs all the way down the spinal canal between the lamina bones and the spinal cord. Removing a small section of this ligament exposes the nerves inside the spinal canal.

The surgeon may use small cutting instruments to carefully remove soft tissues near the spinal nerves. Then the surgeon takes out any disc fragments and scrapes off nearby bone spurs. In this way, the nerves inside the spinal canal are relieved of additional tension and pressure. The surgeon also enlarges the neural foramina, if needed. The neural foramina are the small openings between the vertebrae where the nerves travel out of the spinal canal.

The muscles and soft tissues are put back in place, and the skin is stitched together.

What might go wrong?

As with all major surgical procedures, complications can occur. Some of the most common complications following lumbar laminectomy include

• problems with anesthesia
• thrombophlebitis
• infection
• nerve damage
• segmental instability
• ongoing pain

This is not intended to be a complete list of the possible complications.

Problems with Anesthesia

Problems can arise when the anesthesia given during surgery causes a reaction with other drugs the patient is taking. In rare cases, a patient may have problems with the anesthesia itself. In addition, anesthesia can affect lung function because the lungs don’t expand as well while a person is under anesthesia. Be sure to discuss the risks and your concerns with your anesthesiologist.

Thrombophlebitis (Blood Clots)

Thrombophlebitis, sometimes called deep venous thrombosis (DVT), can occur after any operation. It occurs when the blood in the large veins of the leg forms blood clots. This may cause the leg to swell and become warm to the touch and painful. If the blood clots in the veins break apart, they can travel to the lung, where they lodge in the capillaries and cut off the blood supply to a portion of the lung. This is called a pulmonary embolism. (Pulmonary means lung, and embolism refers to a fragment of something traveling through the vascular system.) Most surgeons take preventing DVT very seriously. There are many ways to reduce the risk of DVT, but probably the most effective is getting you moving as soon as possible. Two other commonly used preventative measures include

• pressure stockings to keep the blood in the legs moving
• medications that thin the blood and prevent blood clots from forming

Infection

Infection following spine surgery is rare but can be a very serious complication. Some infections may show up early, even before you leave the hospital. Infections on the skin’s surface usually go away with antibiotics. Deeper infections that spread into the bones and soft tissues of the spine are harder to treat. They may require additional surgery to treat the infected portion of the spine.

Nerve Damage

Any surgery that is done near the spinal canal can potentially cause injury to the spinal cord or spinal nerves. Injury can occur from bumping or cutting the nerve tissue with a surgical instrument, from swelling around the nerve, or from the formation of scar tissue. An injury to the spinal cord or spinal nerves can cause muscle weakness and a loss of sensation to the areas supplied by the nerve.

Segmental Instability

Laminectomy surgery can cause the spinal segment to loosen, making it unstable. Each spinal segment includes two vertebrae separated by an intervertebral disc, the nerves that leave the spinal cord at that level, and the small facet joints that link each level of the spinal column.

The facet joints on the back of the spine normally give enough stability, even when the lamina is taken off. This is why surgeons prefer not to remove the facet joints. But these joints may have to be removed if they are enlarged with arthritis or are pushing on the spinal nerves, as explained earlier. When the facet joints must be removed, additional surgery (a fusion) may be needed to fix the loose segment.

Ongoing Pain

Many patients get nearly complete relief of symptoms from the lumbar laminectomy procedure. As with any surgery, however, you should expect some pain afterward. If the pain continues or becomes unbearable, talk to your surgeon about treatments that can help control your pain.

What happens after surgery?

Patients are usually able to get out of bed within a few hours after surgery. However, you will be instructed to move your back only carefully and comfortably. Patients are able to return home when their medical condition is stable.

Most patients leave the hospital the day after surgery. They are safe to drive within a week or two. People generally get back to light work by four weeks. Heavier work and sports should wait two to three months. Workers whose jobs involve strenuous manual labor may be counseled to consider different work.

Outpatient Physical Therapy usually starts four to six weeks after surgery.

What should I expect as I recover?

Although the time required for recovery is different for each patient, at First Choice Physical Therapy, outpatient Physical Therapy usually begins within six weeks after surgery. As a general rule, Physical Therapy after lumbar laminectomy is generally only needed for a total of four to six weeks. You should expect full recovery to take up to four months.

At first, our treatments are used to help control pain and inflammation. Ice and electrical stimulation treatments are commonly used to help with these goals. Our Physical Therapist may also use massage and other hands-on techniques to ease muscle spasm and pain.

Your Physical Therapist at First Choice Physical Therapy will then slowly add active treatments. These include exercises for improving heart and lung function. Walking and swimming are ideal cardiovascular exercises after lumbar laminectomy surgery. We also teach patients specific exercises to help tone and control the muscles that stabilize the low back.

Our Physical Therapist will also work with you on how to move properly and perform certain activities. This form of treatment, called body mechanics, is used to help you develop new movement habits. This type of training helps you keep your back in safe positions as you go about your work and daily activities. At first, this may be as simple as helping you learn how to move safely and easily in and out of bed, how to get dressed and undressed, and how to do some of your routine activities. Then we will instruct you on how to keep your back safe while you lift and carry items and as you begin more challenging activities.

As your condition improves, your Physical Therapist tailors your program to help prepare you to go back to work. Some patients are not able to go back to a previous job that required strenuous tasks. We may suggest changes in job tasks that enable you to go back to your previous employer. Our therapist can also suggest alternate forms of work. We will teach you how to do your tasks in ways that keep your back safe and free of extra strain.

Before your Physical Therapy sessions end, our Physical Therapist will teach you a number of ways to avoid future problems.

Welcome to First Choice Physical Therapy’s patient resource about Posterior Lumbar Fusion.

A posterior lumbar fusion is the most common type of fusion surgery for the low back. A fusion is a surgical procedure that joins two or more bones (in this case vertebrae) together into one solid bone. The procedure is called a posterior fusion because the surgeon works on the back, or posterior, of the spine.

Posterior fusion procedures in the lumbar spine are used to treat spine instability, severe degenerative disc disease, and fractures in the lumbar spine.

Other procedures are usually done along with the spinal fusion to take the pressure off nearby nerves. They may include removing bone spurs and injured portions of one or more discs in the low back. Most surgeons also apply metal screws and rods, called instrumentation, to hold the bones securely while they fuse.

This article will help you understand:

• what surgeons hope to achieve
• what happens during the procedure
• what rehabilitation is like after surgery

What parts of the back and spine are involved?

Surgeons perform this procedure through an incision in the low back. The incision reaches to the spinous processes, the bony projections off the back of the vertebrae. The surgeon must move aside the muscles along the spine, called the paraspinal muscles. The fusion itself involves the lamina bone, the protective roof over the back surface of the spinal cord. In some cases, the surgeon may enlarge the neural foramina, the tunnels where the nerve roots leave the spinal cord.

What do surgeons hope to achieve?

The main goal of the spinal fusion (also known as an arthrodesis) is to stop movement of one or more vertebrae. Keeping the fused section from moving helps stop mechanical pain. Mechanical pain occurs when damaged discs and joints that connect the vertebrae become inflamed from excessive motion between the vertebrae. This type of pain is commonly felt in the low back and may radiate into the buttocks and upper thighs.

The spinal nerves are also affected by too much vertebral motion. They begin to rub where they pass through the neural foramina and become swollen and irritated. Also, the neural foramina narrow when a vertebra slides too far forward or backward over the vertebra below. This immediately pinches the nerves where they pass through the neural foramina. Nerve swelling, irritation, and pinching produce neurogenic pain. This type of pain often radiates down one or both legs below the knee. Fusion stops this harm to the nerves.

Pinched Nerve

By fusing the vertebrae together, surgeons hope to slow down the process of degeneration at the fused segments and prevent future problems.

How will I prepare for surgery?

The decision to proceed with surgery must be made jointly by you and your surgeon. You should understand as much about the procedure as possible. If you have concerns or questions, talk to your surgeon.

Once you decide on surgery, your surgeon may suggest a complete physical examination by your regular doctor. This exam helps ensure that you are in the best possible condition to undergo the operation.

On the day of your surgery, you will probably be admitted to the hospital early in the morning. You shouldn’t eat or drink anything after midnight the night before.

What happens during the operation?

Patients are given a general anesthesia to put them to sleep during most spine surgeries. As you sleep, your breathing may be assisted with a ventilator. A ventilator is a device that controls and monitors the flow of air to the lungs.

During surgery the patient usually kneels face down on a special operating table. The special table supports the patient so the abdomen is relaxed and free of pressure. This position lessens blood loss during surgery. It also gives the surgeon more room to work.

An incision is made down the middle of the low back. The tissues just under the skin are separated. Then the small muscles along the sides of the low back are lifted off the vertebrae, exposing the back of the spinal column. Next, the surgeon takes an X-ray to make sure that the procedure is being performed on the correct vertebrae.

The surgeon first removes any pressure from nearby nerves. This may involve removing part or all of the lamina bone. (The lamina forms the back portion of the bony ring covering the spinal canal.) Then the surgeon takes out any disc fragments and scrapes off nearby bone spurs. In this way, the nerves inside the spinal canal are relieved of additional tension and pressure. The nerve roots are checked to see if they move freely in the spinal canal and as they leave the spine through the small holes between the vertebrae, the neural foramina. If not, the surgeon may cut a larger opening in the neural foramina. This procedure is called foraminotomy.

To prepare the area to be fused, the surgeon shaves a layer of bone off the back surfaces of the spinal column. The cut bone bleeds. The surgeon makes a second incision at the hip. Small strips of bone are removed from the top rim of the pelvis. This is called a bone graft. The surgeon lays the bone strips over the back of the spinal column. When the bone graft contacts the bleeding area, the body heals (or fuses) the bones together just as it would a fractured bone.

Healing (Fusing)

During posterior spinal fusion, the surgeon also fixes the bones in place using a combination of metal screws, rods, and plates. This instrumentation (or hardware, as it is sometimes called) holds the vertebrae to be fused together and prevents them from moving. The less motion there is between two bones trying to heal, the higher the chance they will successfully fuse. The use of instrumentation has increased the success rate of spinal fusions considerably.

A drainage tube may be placed in the wound. The muscles and soft tissues are put back in place, and the skin is stitched together. The surgeon may place you in a rigid brace to support your spine while it heals.

What might go wrong?

As with all major surgical procedures, complications can occur. Some of the most common complications following posterior lumbar fusion include:

• problems with anesthesia
• thrombophlebitis
• infection
• nerve damage
• problems with the graft or hardware
• muscle disruption
• nonunion
• ongoing pain

This is not intended to be a complete list of the possible complications.

Problems with Anesthesia

Problems can arise when the anesthesia given during surgery causes a reaction with other drugs the patient is taking. In rare cases, a patient may have problems with the anesthesia itself. In addition, anesthesia can affect lung function because the lungs don’t expand as well while a person is under anesthesia. Be sure to discuss the risks and your concerns with your anesthesiologist.

Thrombophlebitis (Blood Clots)

Thrombophlebitis, sometimes called deep venous thrombosis (DVT), can occur after any operation. It occurs when the blood in the large veins of the leg forms blood clots. This may cause the leg to swell and become warm to the touch and painful. If the blood clots in the veins break apart, they can travel to the lung, where they lodge in the capillaries and cut off the blood supply to a portion of the lung. This is called a pulmonary embolism. (Pulmonary means lung, and embolism refers to a fragment of something traveling through the vascular system.) Most surgeons take preventing DVT very seriously. There are many ways to reduce the risk of DVT, but probably the most effective is getting you moving as soon as possible. Two other commonly used preventative measures include:

• pressure stockings to keep the blood in the legs moving
• medications that thin the blood and prevent blood clots from forming

Infection

Infection following spine surgery is rare but can be a very serious complication. Some infections may show up early, even before you leave the hospital. Infections on the skin’s surface usually go away with antibiotics. Deeper infections that spread into the bones and soft tissues of the spine are harder to treat. They may require additional surgery to treat the infected portion of the spine.

Nerve Damage

Any surgery that is done near the spinal canal can potentially cause injury to the spinal cord or spinal nerves. Injury can occur from bumping or cutting the nerve tissue with a surgical instrument, from swelling around the nerve, or from the formation of scar tissue. An injury to these structures can cause muscle weakness and a loss of sensation to the areas supplied by the nerve.

Problems with the Graft or Hardware

Posterior fusion surgery requires bone to be grafted onto the spinal column. The graft is commonly taken from the top rim of the pelvis. There is a risk of pain, infection, or weakness in the area where the graft is taken.

Sometimes the strips of bone graft don’t take and end up dissolving. A second surgery may be needed to remove the strips and apply more graft material. The doctor may need to apply additional metal hardware to hold the new grafts firmly in place.

When instrumentation is used, the screws, rods, or plates can also cause problems. They can loosen and irritate the nearby soft tissues. In rare cases, they may actually break. If your hardware loosens or breaks, the surgeon may suggest another surgery either to take out the hardware or to add more hardware to solve the problem.

Muscle Disruption

During the operation, the surgeon lifts off the small muscles that run along the back of the spinal column. Some of the nerves going to the muscles are cut. Lifting the muscles away from the bone impairs the blood supply to the muscles. Disruption of the nerve and blood supply can cause the muscles to fatigue easily, especially during a long work day and with heavy or repeated lifting. Exercises designed by a Physical Therapist boost strength and endurance in the nearby muscles, reducing symptoms from this problem.

Nonunion

Sometimes the bones do not fuse as planned. This is called a nonunion, or pseudarthrosis . (The term pseudarthrosis means false joint.) When more than one level of the spine is fused at one time, there is a greater chance that nonunion will occur. Fusion of more than one level means that two or more consecutive discs are removed and replaced with bone graft. If the joint motion from a nonunion causes pain, you may need a second operation.

In the second procedure, the surgeon usually adds more bone graft. Metal plates and screws may also be added to rigidly secure the bones so they will fuse together.

Ongoing Pain

Posterior lumbar fusion is a complex surgery. Not all patients get complete pain relief with this procedure. Successful fusion occurs in more than 80 percent of surgeries. But a solid fusion does not guarantee freedom from pain or the ability to return to normal activity. If you have pain that continues or becomes unbearable, talk to your surgeon about treatments that can help control your pain.

What happens after surgery?

Patients may be placed in a rigid body brace after surgery. This brace may not be needed if the surgeon attached metal hardware to the spine during the surgery. The drain tube is removed from the wound within 24 to 48 hours.

Patients usually stay in the hospital after surgery for up to one week. During this time, a Physical Therapist helps patients learn safe ways to move, dress, and do activities without putting extra strain on the back. Patients may be instructed to use a walker for the first day or two. Before going home, patients are shown how to help control pain and avoid problems.

Patients are able to return home when their medical condition is stable. However, they are usually required to keep their activities to a minimum in order to give the graft time to heal. Patients should avoid bending, lifting, twisting, driving, and prolonged sitting for up to six weeks. Outpatient Physical Therapy usually starts a minimum of six weeks after surgery.

Patients gradually do more activities and exercise with the goal of getting back to a normal and productive life.

What should I expect as I recover?

Rehabilitation after posterior lumbar fusion can be a slow process. Although time required for recovery is different for each individual, at First Choice Physical Therapy, our outpatient Physical Therapy typically begins a minimum of six weeks after surgery. This delay is needed to make sure the fusion is taking. As a guideline, you will probably need to attend Physical Therapy sessions for about two to three months, and should expect full recovery to take up to eight months. Physical Therapy can usually progress faster in patients who had an instrumented fusion.

At first, our treatments are used to help control your pain and inflammation. Ice and electrical stimulation treatments are commonly used to help with these goals. Our Physical Therapist may also use massage and other hands-on techniques to ease muscle spasm and pain.

We will then slowly add active treatments to your therapy program. These include exercises for improving heart and lung function. Short, slow walks are generally safe to start with after posterior lumbar fusion. Swimming and the use of a machine for cardiovascular exercise are helpful in the later phases of treatment. Our therapists also teach patients specific exercises to help tone and control the muscles that stabilize the low back.

Your Physical Therapist at First Choice Physical Therapy will work with you on how to move properly and perform certain activities. This form of treatment, called body mechanics, is used to help you develop new movement habits. This type of training helps you keep your back in safe positions as you go about your work and daily activities. Training includes positions you use when sitting, lying, standing, and walking. Our Physical Therapist will also help you work on safe body mechanics for lifting, carrying, pushing, and pulling.

As your condition improves, we tailor your program to help prepare you to go back to work. Some patients are not able to go back to a previous job that requires strenuous tasks. Our Physical Therapist may suggest changes in job tasks that enable you to go back to your previous employer or to do alternate forms of work. You’ll learn to do these tasks in new ways that keep your back safe and free of strain.

Before your Physical Therapy sessions end, our Physical Therapist will teach you how to avoid future problems.

Welcome to First Choice Physical Therapy’s patient resource about Posterior Lumbar Interbody Fusion.

Posterior lumbar interbody fusion (PLIF) is a procedure used to treat problems
such as disc degeneration, disc herniation, and spine instability. In this procedure, the
surgeon works on the spine from the back (the posterior) and removes a spinal disc
in the lower (lumbar) spine. The surgeon inserts bone graft material into the
space between the two vertebrae where the disc was removed (the interbody space).
The graft may be held in place with a special fusion cage. The goal of the procedure is
to stimulate the vertebrae to grow together into one solid bone (known as a
fusion). A fusion creates a rigid and immovable column of bone in the problem section
of the spine.

This guide will help you understand:

• what surgeons hope to achieve
• what happens during surgery
• what to expect as you recover

What parts of the spine and low back are involved?

This surgery is done through an incision in the low back. The incision reaches to the spinous processes, the bony projections off the back of the vertebrae. A large block of bone, called the vertebral body makes up the front section of each vertebra. The vertebral bodies are separated by a soft cushion called an intervertebral
disc.

Low Back

On the back of the vertebral body, the lamina and pedicle bones form a protective ring around the spinal canal. The spinal nerves are enclosed in the spinal canal and exit through small openings on the sides of each vertebral pair, one on the left and one on the right. These passageways are called the neural foramina. (The term neural foramen describes a single passageway).

What do surgeons hope to achieve?

This procedure is often used to stop symptoms from lumbar disc disease. Discs degenerate,
or wear out, as a natural part of aging and also from stress and strain on the back. Over time, the disc begins to collapse, and the space decreases between the vertebrae.

When this happens, the openings around the spinal nerves (the neural foramina) narrow and
may put pressure on the nerves. The long ligaments in the spine slacken due to the collapse in vertebral height. These ligaments may even buckle and put pressure on the spinal nerves.

Pain from disc degeneration can come from a tear in the outer portion of the disc, from chemical inflammation inside the disc, or from a herniated disc that pushes on a nearby spinal nerve. Mechanical pain can also occur from excess movement within the problem part of the spine.

Discectomy is the removal of the disc and any fragments between the vertebrae that are to be fused. Taking out the painful disc is intended to relieve symptoms. It also provides room for placing a graft that will allow the two vertebrae to fuse together.

Once the disc is removed, the surgeon spreads the bones of the spine apart slightly to make room to implant bone graft material. Bone graft is commonly taken from the rim of the pelvis and packed in a special case, called a fusion cage. Bone taken from your own body is called autograft. Bone substitutes are also being used and avoid the need for taking bone from your pelvis.

Another option is to use a wedge of hard, cortical bone taken from preserved human bone. This source of bone graft is called allograft. During the PLIF procedure, the cage or bone wedge is implanted into the interbody space. The PLIF method provides a large surface area for fusion to occur.

The graft creates a solid spacer to separate and hold the vertebrae apart. Enlarging the space between the vertebrae widens the opening of the neural foramina, taking pressure off the spinal nerves that pass through these openings. Also, the long ligaments that run up and down inside the spinal canal are pulled taut so they don’t buckle into the spinal
canal.

View animation of creating a spacer

The surgeon also fixes the bones in place using pedicle screws. This instrumentation (or hardware, as it is sometimes called) holds the vertebrae together and prevents them from moving. The less motion there is between two bones trying to heal, the higher the chance they will successfully fuse. The use of instrumentation has increased the success rate of spinal fusions considerably.

During the PLIF procedure, surgeons also commonly add bone graft material along the back sides of the spine. This step is called posterolateral bone grafting. When combined with instrumentation, this approach helps fuse a large surface area on the back (posterior column) of the spine.

Instrumentation

In a successful fusion, the vertebrae that are fused together no longer move against one another. The fusion creates one solid bone. No movement happens within the bones that are fused. Instead, they move as one unit. This helps stop the mechanical pain that was coming from the moving parts of the back. Fusion also prevents additional wear and tear on the spinal segment that was fused. By fusing the bones together, surgeons hope to reduce future problems at the spinal segment.

View animation of fusion

How will I prepare for surgery?

The decision to proceed with surgery must be made jointly by you and your surgeon. You should understand as much about the procedure as possible. If you have concerns or questions, you should talk to your surgeon.

Once you decide on surgery, your surgeon may suggest a complete physical examination by your regular doctor. This exam helps ensure that you are in the best possible condition to undergo the operation.

On the day of your surgery, you will probably be admitted to the hospital early in the morning. You shouldn’t eat or drink anything after midnight the night before.

What happens during the operation?

Patients are given a general anesthesia to put them to sleep during most spine surgeries. As you sleep, your breathing may be assisted with a ventilator. A ventilator is a device that controls and monitors the flow of air to the lungs.

During surgery the patient usually kneels face down on a special operating table. The special table supports the patient so the abdomen is relaxed and free of pressure. This position reduces blood loss during surgery. It also gives the surgeon more room to work.

Two measurements are made before surgery begins. The first measurement ensures that the surgeon chooses a fusion cage or bone wedge that will fit inside the disc space. To correctly size the fusion cage or bone wedge, the surgeon uses an X-ray image to measure the disc space in a healthy disc, above or below the problem segment.

Second, to size the length of the pedicle screws, a CT scan is used to measure the length of the pedicle bone on the back of the vertebrae to be fused. The CT scan is a special type of X-ray that lets doctors see slices of bone tissue. The machine uses a computer and X-rays to create these slices.

To begin the procedure, an incision is made down the middle of the low back. The tissues just under the skin are separated. Then the small muscles along the sides of the low back are moved aside, exposing the back of the spinal column. Next, the surgeon takes an X-ray to make sure that the procedure is being performed on the correct vertebrae.

The bone graft is prepared. When autograft (bone taken from your body) is used, the same incision made at the beginning of the surgery can be used. The surgeon reaches through the first incision and opens the tissues that cover the back of the pelvis. An osteotome is used to cut the surface of the pelvis bone. An instrument is used to gather a small amount of the pelvis bone. The graft material is prepared and will later be packed into the fusion cages. The tissues covering the pelvis bone are sutured.

Then the surgeon prepares to implant bone graft into the space between the vertebral bodies. The surgeon removes the lamina bones that cover the back of the spinal canal. Next, the surgeon cuts a small opening in the ligamentum flavum, an elastic ligament separating the lamina bones and the spinal nerves. Removing the ligamentum flavum allows the surgeon to see inside the spinal canal. The nerves are checked for tension where they exit the spinal canal. If a nerve root is under tension, the surgeon enlarges the neural foramen, the opening where the nerve travels out of the spinal canal.

The surgeon locates the spot where the pedicle screws are to be placed. A fluoroscope is used to visualize the pedicle bones. A fluoroscope is a special type of X-ray that allows the surgeon to see an X-ray picture continuously on a TV screen. The surgeon uses the fluoroscope to guide one screw through the back of each pedicle, one on the left and one on the right.

The nerve roots inside the spinal canal are then pulled aside with a retractor so the problem disc can be examined. With the nerves held to the side, the surgeon is able to see the disc where it sits just in front of the spinal canal.

A hole is cut into the rim of the back of the disc. Forceps are placed inside the hole in order to clean out disc material within the disc. Reamers and scrapers are used to open up and remove additional disc material.

Forceps

The surgeon prepares the disc space where the fusion cages or bone wedges are to be inserted. Special spreaders hold the two vertebral bodies apart. A layer of bone is shaved off the flat surfaces of the two vertebrae, causing the surfaces to bleed. Bleeding stimulates the bone graft to heal the bones together.

Adequate room is needed to get the bone graft implants through the spinal column and into the disc space. The nerve roots must be pulled as far to the side as possible to open up enough space.

With the disc space held apart by the spreaders, the surgeon has enough room to place the bone graft between the two vertebral bodies. For the fusion cage method, the surgeon packs two cages with bone taken from the pelvis bone or with a suitable bone substitute. Two cages are inserted, one on the left and one on the right. When allograft bone wedges are used, the surgeon inserts the wedges and aligns them within the disc space.

Inserting Cages

Allograft

The surgeon uses a fluoroscope to check the position and fit of the graft.

The spreaders used to hold the disc space apart are released. Then the doctor tests the graft by bending and turning the spine to make sure the graft is in the right spot and is locked in place.

Some surgeons add strips of bone graft along the back of the vertebrae to be fused. This is called posterolateral fusion. The bones that project out from each side of the back of the spine are called transverse processes. The back surface of the transverse processes are shaved, causing the surfaces to bleed. Small strips of bone, usually taken from the pelvis bone at the beginning of the surgery, are placed over the transverse processes. The combination of this graft material with the pedicle screws helps hold the spine steady as the interbody fusion heals.

A drainage tube may be placed in the wound. The muscles and soft tissues are then put back in place. The skin is stitched together. The surgeon may place you in a rigid brace that straps across the chest, pelvis, and low back to support the spine while it heals.

What might go wrong?

As with all major surgical procedures, complications can occur. Some of the most common complications following PLIF include

• problems with anesthesia
• thrombophlebitis
• infection
• nerve damage
• problems with the implant or hardware
• nonunion
• ongoing pain

This is not intended to be a complete list of possible complications.

Problems with Anesthesia

Problems can arise when the anesthesia given during surgery causes a reaction with other drugs the patient is taking. In rare cases, a patient may have problems with the anesthesia itself. In addition, anesthesia can affect lung function because the lungs don’t expand as well while a person is under anesthesia. Be sure to discuss the risks and your concerns with your anesthesiologist.

Thrombophlebitis (Blood Clots)

Thrombophlebitis, sometimes called deep venous thrombosis (DVT), can happen after any operation. It occurs when the blood in the large veins of the leg forms blood clots. This may cause the leg to swell and become warm to the touch and painful. If the blood clots in the veins break apart, they can travel to the lung, where they lodge in the capillaries and cut off the blood supply to a portion of the lung. This is called a pulmonary embolism. (Pulmonary means lung, and embolism refers to a fragment of something traveling through the vascular system.) Most surgeons take preventing DVT very seriously. There are many ways to reduce the risk of DVT, but probably the most effective is getting you moving as soon as possible. Two other commonly used preventative measures include:

• pressure stockings to keep the blood in the legs moving
• medications that thin the blood and prevent blood clots from forming

Infection

Infection following spine surgery is rare but can be a very serious complication. Some infections may show up early, even before you leave the hospital. Infections on the skin’s surface usually go away with antibiotics. Deeper infections that spread into the bones and soft tissues of the spine are harder to treat. They may require additional surgery to treat the infected portion of the spine.

Nerve Damage

Any surgery that is done near the spinal canal can potentially cause injury to the spinal cord or spinal nerves. Injury can occur from bumping or cutting the nerve tissue with a surgical instrument, from swelling around the nerve, or from the formation of scar tissue.

The nerve roots inside the spinal canal are especially at risk during the PLIF procedure. Retractors are used to hold the nerves aside and may cause muscle weakness and a loss of sensation to the areas supplied by an injured nerve. Pressure on the nerves that supply the bowels and bladder can cause incontinence. However, these types of nerve problems after PLIF usually go away soon after surgery.

Problems with the Implant or Hardware

Fusion surgery with cages requires bone grafting. The graft is commonly taken from the top rim of the pelvis (autograft). There is a risk of pain, infection, or weakness in the area where the graft is taken. These risks are avoided when a bone graft substitute is used in place of an autograft.

After the interbody implant is placed, the surgeon checks the position of the fusion cage or bone wedge before completing the surgery. However, the implant may shift slightly soon after surgery to the point that it is no longer able to hold the spine stable. If the implant migrates out of position, it can cause injury to the nearby tissues. A second surgery may be needed to align or replace the implant.

Hardware can also cause problems. Screws or pins may loosen and irritate the nearby soft tissues. Also, the metal plates can sometimes break. If this happens, the surgeon may suggest another surgery either to take out the hardware or to add more hardware to solve the problem.

Nonunion

Sometimes the bones do not fuse as planned. This is called a nonunion, or pseudarthrosis. (The term pseudarthrosis means false joint.) When more than one level of the spine is fused at one time, there is a greater chance that nonunion will occur. (Fusion of more than one level means two or more consecutive discs are removed and replaced with bone graft.) If the joint motion from a nonunion continues to cause pain, the patient may need a second operation.

In the second procedure, the surgeon usually adds more bone graft. Additional instrumentation may also be needed to rigidly secure the bones so they will fuse together.

Ongoing Pain

PLIF is a complex surgery. Not all patients get complete pain relief with this procedure. As with any surgery, patients should expect some pain afterward. If the pain continues or becomes unbearable, talk to your surgeon about treatments that can help control your pain.

What happens after surgery?

Patients are sometimes placed in a rigid body brace after surgery. The surgical drain is removed within one to two days.

Patients usually stay in the hospital after surgery for three to five days. During this time, patients work daily with a Physical Therapist. The Physical Therapist demonstrates safe ways to move, dress, and do activities without putting extra strain on the back. The Physical Therapist may recommend that the patient use a walker for the first day or two. Before going home, patients are shown ways to help control pain and avoid problems.

Patients are able to return home when their medical condition is stable. However, they are usually required to keep their activities to a minimum in order to give the fusion time to begin healing. Patients are cautioned against bending, lifting, twisting, driving, and prolonged sitting for up to six weeks. Outpatient Physical Therapy is usually started a minimum of six weeks after the date of surgery.

What should I expect as I recover?

Rehabilitation after PLIF can be a slow process. Although recovery time varies, at First Choice Physical Therapy, our outpatient Physical Therapy program typically begins a minimum of six weeks after PLIF surgery. This delay is needed to make sure the graft has time to begin to fuse. You may need to attend Physical Therapy sessions for two to three months. You should expect full recovery to take up to eight months.

At first, our treatments are used to help control pain and inflammation. Ice and electrical stimulation are commonly used to help with these goals. Our Physical Therapist may also use massage and other hands-on treatments to ease muscle spasm and pain.

As you recover, we will slowly add active treatments, such as exercises for improving heart and lung function. Short, slow walks are generally safe to start with. Swimming and the use of a  machine for cardiovascular exercise are helpful in the later phases of treatment. Our Physical Therapists also teach specific exercises to help tone and control the muscles that stabilize the low back.

Your First Choice Physical Therapy Physical Therapist will work with you on how to move and do certain activities safely and correctly. This form of treatment, called body mechanics, is used to help you develop new movement habits. Training in proper body mechanics helps you keep your back in safe positions as you go about your work and daily activities. Training includes positions you use when sitting, lying, standing, and walking. You’ll also work on safe body mechanics with lifting, carrying, pushing, and pulling.

As your condition improves, we will tailor your program to prepare you to go back to work. Some patients are not able to go back to a job that required strenuous tasks. Our Physical Therapist
may suggest changes in job tasks that enable you to go back to your previous employer or to do alternate forms of work. You’ll learn to do these tasks in new ways that keep your back safe and free of strain.

Before your Physical Therapy sessions end, our Physical Therapist will teach you ways to avoid future problems.

Welcome to First Choice Physical Therapy’s patient resource about from Lumbar Discectomy.

Lumbar discectomy is a surgical procedure to remove part of a problem disc in the low back. The discs are the pads that separate the vertebrae. This procedure is commonly used when a herniated, or ruptured, disc in the low back is putting pressure on a nerve root.

This article will help you understand:

• what surgeons hope to achieve
• what happens during surgery
• what to expect as you recover

What parts of the spine and low back are involved?

Surgeons perform lumbar discectomy surgery through an incision in the low back. This area is known as the posterior region of the low back. The main structure involved is the intervertebral disc, which acts as a cushion between each pair of vertebrae. The two main parts of the disc are the annulus and the nucleus. The lamina bone forms the protective covering over the back of the spinal cord. During surgery, this section of bone is removed over the problem disc. The surgeon also checks the spinal nerves where they travel from the spinal canal through the neural foramina. The neural foramina are small openings on each side of the vertebra. Nerves that leave the spine go through the foramina, one on the left and one on the right.

What do surgeons hope to achieve?

Lumbar discectomy can alleviate symptoms from a herniated disc in the low back. The main goal of discectomy surgery is to remove the part of the disc that is putting pressure on a spinal nerve root. Taking out the injured portion of the disc also reduces chances that the disc will herniate again.

These goals can be achieved using a traditional procedure, called laminotomy and discectomy, or with a newer method called microdiscectomy. The traditional method requires a larger incision and tends to require a longer time to heal.

Microdiscectomy is becoming the standard surgery for lumbar disc herniation. Since the surgeon performs the operation with a surgical microscope, he or she needs to make only a very small incision in the low back. Categorized as minimally invasive surgery, this surgery is thought to be less taxing on patients. Advocates also believe that this type of surgery is easier to perform, prevents scarring around the nerves and joints, and helps patients recover more quickly.

How will I prepare for surgery?

The decision to proceed with surgery must be made jointly by you and your surgeon. You should understand as much about the procedure as possible. If you have concerns or questions, you should talk to your surgeon.

Once you decide on surgery, your surgeon may suggest a complete physical examination by your regular doctor. This exam helps ensure that you are in the best possible condition to undergo the operation.

On the day of your surgery, you will probably be admitted to the hospital early in the morning. You shouldn’t eat or drink anything after midnight the night before.

What happens during the operation?

Patients are given a general anesthesia to put them to sleep during most spine surgeries. As you sleep, your breathing may be assisted with a ventilator. A ventilator is a device that controls and monitors the flow of air to the lungs.

Some surgeons have begun using spinal anesthesia in place of general anesthesia. Spinal anesthesia is injected in the low back into the space around the spinal cord. This numbs the spine and lower limbs. Patients are also given medicine to keep them sedated during the procedure.

Discectomy surgery is usually done with the patient kneeling face down in a special frame. The frame supports the patient so the abdomen is relaxed and free of pressure. This position lessens blood loss during surgery and gives the surgeon more room to work.

The two main discectomy procedures are

• laminotomy and discectomy
• microdiscectomy

Laminotomy and Discectomy

Laminotomy and discectomy is the traditional method of removing the disc. Laminotomy is taking off part of the lamina bone (the back of the ring over the spinal canal). This allows greater room for the surgeon to take out part of the disc (discectomy).

An incision is made down the middle of the low back. After separating the tissues to expose the bones along the low back, the surgeon takes an X-ray to make sure that the procedure is being performed on the correct disc. A cutting tool is used to remove a small section of the lamina bone.

Next, the surgeon cuts a small opening in the ligamentum flavum, the long ligament between the lamina and the spinal cord. This exposes the nerves inside the spinal canal. The painful nerve root is gently moved aside so the injured disc can be examined. A hole is cut in the outside rim of the disc. Forceps are placed inside the hole in order to clean out disc material within the disc. Then the surgeon carefully looks inside and outside the disc space to locate and remove any additional disc fragments.

Finally, the nerve root is checked for tension. If it doesn’t move freely, the surgeon may cut a larger opening in the neural foramen, the nerve passage between the vertebrae.

Before closing and suturing the wound, some surgeons will implant a special foam pad or a piece of fat over the nerve root to keep scar tissue from growing onto the nerve. Some surgeons also insert a small drain tube in the wound.

Microdiscectomy

The surgeon performs microdiscectomy using a surgical microscope. A two-inch incision is made in the low back directly over the problem disc. The skin and soft tissues are separated to expose the bones along the back of the spine. An X-ray of the low back is taken to ensure the surgeon works on the right disc.

A retractor is used to spread apart the lamina bones above and below the disc. Then the surgeon makes a tiny slit in the ligamentum flavum, exposing the spinal nerves. A special hook is placed under the spinal nerve root. The hook is used to lift the nerve root, so the surgeon can see the injured disc.

Next, the annulus (outer ring) of the disc is sliced open. Material from inside the disc is scooped out to ensure the disc doesn’t herniate again. Since only the injured portion is removed, the disc is left intact and functioning. Then the surgeon inspects the area around the nerve root and removes any loose disc fragments. Finally, the nerve root is gently wiggled to make sure it is free to move. If it can’t move, the surgeon also cleans around the neural foramen, the nerve passage between the two vertebrae. When the nerve moves freely, the muscles and soft tissues are put back in place, and the skin is stitched together.

What might go wrong?

As with all major surgical procedures, complications can occur. Some of the most common complications following lumbar discectomy include:

• problems with anesthesia
• thrombophlebitis
• infection
• nerve damage
• ongoing pain

This is not intended to be a complete list of possible complications.

Problems with Anesthesia

Problems can arise when the anesthesia given during surgery causes a reaction with other drugs the patient is taking. In rare cases, a patient may have problems with the anesthesia itself. In addition, anesthesia can affect lung function because the lungs don’t expand as well while a person is under anesthesia. Be sure to discuss the risks and your concerns with your anesthesiologist.

Thrombophlebitis (Blood Clots)

Thrombophlebitis, sometimes called deep venous thrombosis (DVT), can occur after any operation. It occurs when the blood in the large veins of the leg forms blood clots. This may cause the leg to swell and become warm to the touch and painful. If the blood clots in the veins break apart, they can travel to the lung, where they lodge in the capillaries and cut off the blood supply to a portion of the lung. This is called a pulmonary embolism. (Pulmonary means lung, and embolism refers to a fragment of something traveling through the vascular system.) Most surgeons take preventing DVT very seriously. There are many ways to reduce the risk of DVT, but probably the most effective is getting you moving as soon as possible. Two other commonly used preventative measures include:

• pressure stockings to keep the blood in the legs moving
• medications that thin the blood and prevent blood clots from forming

Infection

Infection following spine surgery is rare but can be a very serious complication. Some infections may show up early, even before you leave the hospital. Infections on the skin’s surface usually go away with antibiotics. Deeper infections that spread into the bones and soft tissues of the spine are harder to treat. They may require additional surgery to treat the infected portion of the spine.

Nerve Damage

Any surgery that is done near the spinal canal can potentially cause injury to the spinal cord or spinal nerves. Injury can occur from bumping or cutting the nerve tissue with a surgical instrument, from swelling around the nerve, or from the formation of scar tissue. An injury to the spinal cord or spinal nerves can cause muscle weakness and a loss of sensation to the areas supplied by the nerve.

Ongoing Pain

Discectomy is especially helpful for patients whose main complaint before surgery is leg pain. When back pain has been the main complaint, however, surgical results vary. If the pain continues after surgery or becomes unbearable, talk to your surgeon about treatments that can help control your pain.

What happens after surgery?

Patients are usually able to get out of bed within a few hours after surgery. However, you will be instructed to move your back only carefully and comfortably. The drain tube is normally taken out the day after surgery. Patients are able to return home when their medical condition is stable.

Most patients leave the hospital the day after surgery. They are usually safe to drive within a week or two. Bending and lifting should be avoided for four to six weeks. People generally get back to light work in two to four weeks and can do heavier work and sports within two to three months. Workers whose jobs involve strenuous manual labor may be counseled to consider a less strenuous job.

Patients usually begin outpatient Physical Therapy two to three weeks after the date of surgery.

What should I expect as I recover?

Many surgeons prescribe outpatient Physical Therapy within three weeks after surgery. Although the time required for recovery varies, Physical Therapy at First Choice Physical Therapy after lumbar discectomy is generally only needed for six to eight weeks. You should expect full recovery to take up to four months.

At first, our Physical Therapy sessions will focus on controlling pain and inflammation. Ice and electrical stimulation treatments are commonly used to help with these goals. Our Physical Therapist may also use massage and other hands-on techniques to ease muscle spasm and pain.

We will slowly add active treatments to your rehabilitation program. These include exercises for improving heart and lung function. Walking and swimming are ideal cardiovascular exercises after this type of surgery. Our Physical Therapists also teach specific exercises to help tone and control the muscles that stabilize the low back.

Our Physical Therapist will work with you on how to move and do activities. This form of treatment, called body mechanics, helps you develop new movement habits. Training in body mechanics helps you keep your back in safe positions as you go about your work and daily activities. At first, this may be as simple as learning how to move safely and easily in and out of bed, how to get dressed and undressed, and how to do some of your routine activities. Then we will instruct you on how to keep your back safe while you lift and carry items and as you begin to do more strenuous activities.

As your condition improves, our Physical Therapist tailors your program to help prepare you to go back to work. Some patients are not able to go back to a previous job that required strenuous tasks. However, our Physical Therapist may suggest changes in job tasks that enable you to go back to your previous employer. We may also suggest alternate forms of work. You’ll learn to do your tasks in ways that keep your back safe and free of extra strain.

Before your Physical Therapy sessions at First Choice Physical Therapy end, our Physical Therapist will teach you a number of ways to avoid future problems.