Surgery - The Process

Surgical Theatre

Surgery takes place at The Gold Coast Private Hospital in the new medical precinct in Parkwood on the Gold Coast in Queensland Australia. The contact details of the hospital can be found on the "Contact Us" page and further information is available on the hospital at the Healthscope Hospitals website.

The Gold Coast Private Hospital has 24-hour emergency care facilities and an ICU department equipped to handle complex medical patients following surgery if required.

Planning surgery is a complex process these days. Quite apart from the clinical decision making process where the surgeon has to decide if a patient is a good candidate for surgery and deciding exactly what surgery to perform and how to do it, is the 'behind the scenes' logistics of preparing someone for surgery, booking it with the hospital and preparing necessary equipment and implants. This all takes time and protocols have to be followed both for your safety and for legal reasons.

Consent

Consenting someone for surgery means essentially getting permission from the patient to perform surgery after the procedure has been described, all relevant risks and complications have been discussed, including the 'risks' of not having surgery, and allowing the patient sufficient time to digest the information, ask appropriate questions and be given a 'cooling off' period during which to explore other options, seek second opinions or whatever. This cannot be accomplished in 10 minutes as you might imagine. For this reason, and to comply with Royal College of Surgeons guidelines, a totally separate appointment will be made for this consenting process. You should allow for a few hours of your time to be spent in this regard. As well as medical consent which deals with all the issues mentioned above it is now a legal requirement that the patient be given fully informed financial consent. Modern, minimally invasive spine surgery is so far ahead of the administrative side of Medicare and the department of health and ageing, that many prostheses and procedures have no valid rebate codes, which necessitates complex communications to obtain special permissions and/or funding. In contrast to the legal requirement for consent, the consent form itself has no legal value at all. It has no standing in a court of law, and implies absolutely no obligation on behalf of the patient to or for anything.

Pre-Op Assessment

Once a decision has been made to proceed to surgery and consent obtained, a date is usually given to the patient at that time. One week prior to surgery an appointment is made to have blood tests, chest X-Rays, ECG etc. at the hospital. Any complex medical issues may require extra consultations with a physician / surgeon prior to surgery. Issues relating to risks of anaesthesia may require a brief consultation with my anaethetist.

Surgery

Except in extremely complex cases, patients are admitted to hospital on the day of surgery. Having been through this process as a patient myself I know very well that this is a nervous day. It is entirely natural to feel anxious and nervous the night and morning before surgery. Before you are taken into the operating theatre I will come and see you and make sure that you are ok. It is my experience that most patients by the time they get to this stage are simply looking forward to getting the whole event over with. I have found that most patients are more anxious about finding out that they need an operation in my clinic rather than actually having the operation itself. One of the most terrifying thoughts patients have is the thought of something going wrong during surgery. No surgeon would be so bold as to lie and say that this never happens. The last ten years or so has seen such dramatic improvements in equipment, lighting, retractors, prostheses, imaging and surgical experience that the chances of something 'going wrong' during surgery are extremely small. It is my feelings, echoed by colleagues, that the most difficult and challenging aspect of being a spine surgeon is actually not the surgery itself, but the decision making prior to surgery - i.e. working out who to offer surgery to, what to do and how to do it is far more intellectually challenging, time consuming and complex than surgery itself - most of the time! The surgical team I work with comprise nursing staff, anaethetists, technicians, radiographers, assistants and representatives from the industry all of whom are highly skilled and a pleasure to work with.

Prior to being taken into the operating theatre my anaethetist will also come and talk to you. You will usually be given some intra-venous medications including antibiotics.

After Surgery

Immediately after surgery you will be taken to the recovery area. You will probably not remember much about this stage. The first real memory most patients have following surgery is on the ward that evening or the next morning. I see every patient whilst they are in the recovery area but most don't remember this. Most patients will have a PCA (patient controlled analgesia) pump with which to control the pain from the surgical site. A complex situation may spend the night on the intensive care unit. You will usually receive some intravenous antibiotics for at least 24 hours following surgery and as much pain relief as you need. Solid foods can be ingested once the bowels and started to work (usually 24-hours) and you will have a catheter in your bladder draining your urine.

Rehabilitation

Rehabilitation following reconstructive surgery to the lumbar or cervical spine starts the very next day. Because every patient's pathology and surgery is subtly different it is not possible to describe exactly what course your rehabilitation will take. A few general principles apply however. Rehabilitation is extremely important following surgery. Patients who for whatever reason are not able to complete their rehabilitation do not get the same result as those that do. For some patients, rehabilitation simply means lots of walking and mobilisation exercises under the jurisdiction of a physiotherapist. For others it may stretch to aggressive pilates and exercise regimes. It will be tailor made depending on your situation. A physiotherapist will look after you on the ward.

Once you have been discharged from hospital and your wounds are well on the way to healing and maturing, physiotherapy if needed begins in earnest. Patients who have had a total disc replacement generally need to get their core stability under control within the next month or so. Patients who have had extensive reconstructions for deformity usually have a physiotherapy regime focused more on regaining confidence and strength than core stability.

The Gold Coast Private Hospital also has an independent rehabilitation ward for patients that need some extra looking after in terms of being able to care for themselves prior to going home. A 'half-way house' also exists called Spendlove House, in Southport nearby, for those patients who may need the security of knowing help is nearby and on hand whilst being encouraged to be independent with respect to activities of daily living.

Following Surgery

Patients are discharged from hospital when it is safe to do so. A patient who has had a single extreme lateral total disc replacement (XL-TDR) for example may go home the next day. An elderly patient who has had a large, complex reconstruction with some medical issues to deal with as well may find themselves on a rehabilitation ward until their wound has fully healed which may be 2 or 3 weeks. The weeks and months following surgery are variable and depend on what your surgery comprised. Your stitches will often be dissolving ones but if they are not then they need to be removed 14 days following surgery by either a home visit from a nurse, your GP or my office.

As a very general rule however patients tend to fall into one of two categories following minimally invasive, reconstructive surgery.

The majority of patients (about 85%) have a tough few weeks while the pain of surgery settles and then dramatically turn a corner and rapidly improve. These patients often return to work on light duties within 4-5 weeks, are able to exercise in a gym, get into a swimming pool, and drive and/or fly locally within Australia in a similar time frame. Restrictions in terms of forward bending, lifting, overhead work, and using complex / dangerous machinery remain in place until the surgery has 'matured' or 'stabilised' which is usually about 6 months, but during this time a normal life can be maintained.

About 10% of patients do it really tough for 6 months or more following surgery. This can be for a variety of reasons. The most common reason however simply reflects the fact that in a very short space of time your spine has been restored to a position it hasn't been in for many years - even decades. For some people a considerable period of time has to elapse before things settle down. Ligaments, muscles, tendons and nerves all have to get used to being in a new position and sometimes they react badly for a while. Patients who have had a lumbar reconstruction with a restoration of lordosis will suddenly find that they are sitting on a different part of their butt. This can also cause some tenderness for a while. Patients in this category get investigated thoroughly in the post-op period to ensure that nothing is amiss. Usually time, patience, painkillers, rehabilitation, and faith are all that are needed to get you through this rough period.

The remaining 5% of patients are a mixed bag of situations were sometimes further surgery is needed (either planned this way for all sorts of reasons, or unplanned - a wound problem, osteoporosis (soft bone) and seroma formation are rare but the biggest culprits), where drug dependency is encountered, medical complications become evident, or where frankly the surgery has simply failed to resolve the painful situation.

Common symptoms in the 6-8 month period following surgery that usually mean nothing is wrong but need to be brought to my attention are:

  1. Leg Pain - if you have pre-existing nerve damage diagnosed either on clinical examination or with nerve conduction studies then radicular pain can remain until that nerve has healed or fully regenerated. Usually this pain is less than the pain you had before surgery but in some cases it can be severe. Various injections or medications can help but usually it is just time. Occasionally further surgery may be contemplated to explore a nerve which may remain compressed either from scar tissue or some spinal structure. The reconstructive process usually puts each nerve root on stretch a few millimetres, which can take a bit of getting used to. Leg pain which starts about 10-14 days following surgery is usually a sign of nerves starting to regenerate.
  2. Back / Neck Pain - most patients experience a dramatic improvement in their back or neck pain following surgery. It is unrealistic however to expect it to disappear straight away or even completely. The goal of spine surgery is to alleviate severe disabling, pathological pain. It cannot get rid of normal aches and pains which would be considered non-pathological. If your pain is worrying though it may indicate that something more needs to be done and so should be brought to my attention. In the 6 months following surgery symptoms wax and wane as rehabilitation starts, painkillers are gradually reduced, activity levels increase and the spine gets used to it's new position.
  3. Weight Loss - surgery generally takes about 6 months to fully stabilise and mature. This process can be a hungry one in the sense that it utilises a lot of the bodies resources.
  4. Fever / Night Sweats - If you find this constellation of symptoms you must contact my office immediately. It is most likely simply a reaction to the biologics used in the surgery and should settle down but in rare instances may indicate an active infection and needs to be investigated.
  5. Difficulty Swallowing - if you have had a neck reconstruction then everyone for a few weeks has this symptom as well as a bit of a hoarse voice. Severe symptoms need to be investigated. Anyone who has had a general anaesthetic however may experience this for a few weeks.
  6. Wound Redness - there is probably nowhere on the body more inconvenient to have a wound than on the front of your abdomen underneath your belly button. It gets irritated by clothes, belts, sitting up, and any coughing or straining - which is not uncommon following surgery - puts some strain on it. For this reason, minor wound problems are really common and often need some minor treatments. You need to contact my office if this is a concern.
  7. Thigh Pain and Hip Weakness - if you have had anterior or lateral surgery then these symptoms are almost 100% guaranteed and will last a few weeks, and sometimes a few months. It is related to the surgical approach and takes some time to heal. In men the testicles can also be sore, swollen and bruised.
  8. Hot / Cold Feet - this is a common symptom following to anterior spine surgery, relate to the approach and takes a few weeks (rarely months) to resolve.

6 Months Following Surgery

Most patients at 6-8 months following surgery have the desired result. Patients are followed up regularly in my office with x-rays and other tests as necessary. At 9 months usually a CT scan is performed. Provided everything is going well patients are then instructed to come see me on a purely 'as required' basis. Patient's who have had a total disc replacement usually get assessed with flexion and extension x-rays 6 months following surgery to make sure the prosthesis is movement properly.

123 Nerang Street, Southport
07 5532 7506