Evo Terra (Host): Spinal surgery, something no one looks forward to. It's changed a lot over the years. Today, we'll find out just how much and what that means for a patient's recovery with Robin Fencel, an Orthopedic Physician Assistant at University of Maryland Medical Center, and Wendy Towers, a nurse practitioner at UM Shore Medical Group Neurosurgery, both are part of the UM Spine Network.

Welcome to the Live Greater podcast series, information for a healthier you, from the University of Maryland Medical System. I'm Evo Terra. Thanks for joining me today, Robin and Wendy.

Wendy Towers: It's good to meet you.

Robin Fencel: Very nice to meet you. Thanks for having us.

Host: So, let's start with a level set. I know that spinal surgery, just like every surgery probably, has evolved quite a bit from the beginnings. What does a typical recovery time look like today? And I guess when are patients ready to return to their normal activities after today's spinal surgery? And Robin, I'll start with you.

Robin Fencel: Sure. Thank you. So, the recovery timeline after spine surgery, it can vary widely depending on what type of surgery is performed, the patient's overall health going into the surgery, and their adherence to their postoperative care instructions. That said, generally, patients, depending on the complexity, may stay in the hospital for one to three days following their spine surgery. For minimally invasive procedures, the hospital stay is going to be shorter. They'll have pain commonly during the first few days, and they will be prescribed oral medications to manage their discomfort prior to being discharged from the hospital. Their initial mobility will be evaluated by physical therapists and occupational therapists while they're in the hospital stay. That will help with determining what level of care they will need after the hospital. Typical healing for wounds is about two weeks. During this time, we suggest rest and light exercises. those that they need for their activities of daily living. Following that, it's about six to eight weeks for bone healing, which they will be monitored in the postoperative setting by visiting our office.

Host: So, Wendy, I want to go to you for a moment, because what Robin was talking about was two different types of surgery. There's traditional surgery and minimally invasive surgery. Help me understand how the recovery time differs between those two.

Wendy Towers: Okay, sure. Minimally invasive surgery usually involves smaller incisions, less blood loss during the procedure shorter amount of recovery time, because you have less muscle, I don't know if I want to use the word destruction, but muscle damage, removal during a procedure. And because of that, the ability to get up and walk right away is lessened. Often our patients go home, same-day surgery after a lumbar fusion single level. So, the expectations are slightly different in the minimally invasive world, where the patients are in recovery room, they get up, they're on their oral medications. If they don't have any weakness on exam that's different from what they had preoperatively, then the expectation is that they go home. And they can be in the recovery room like one hour up to about three hours depending on having them get up and walk and be able to use the restroom, those types of things. So, what we find is that our patients are going home much quicker. Also for cervical fusions, our patients are going home same-day surgery also, except for if they have an anterior-posterior procedure or a simple posterior procedure, then they typically spend one night in the hospital.

But overall, just like Robin said, the recovery time is about two weeks. So even though you're leaving the hospital earlier, you still have that recovery time of about two weeks when you come see us in the office and get re-evaluated postoperatively. Your wounds are healing well. We're planning on x-rays and looking at those at three months and six months. Robin may have a different protocol for that. But in general, the minimally invasive portion gets you moving quicker, and we start our physical therapy about one week after surgery. So, we really want to get them moving a little bit quicker. But in the long term, the recovery is the same. So, there is no difference in one year out than it would be for us for the one week out.

Host: Okay, good. So, I guess that means we can't go back to playing volleyball, like two weeks after spine surgery. Got it. Thank you for that. Let's talk about the things we shouldn't talk about, or we probably should, but nobody wants to think about, I should say, and that is side effects or complications that patients might experience post-surgery. So, let's talk about pain management and other sorts of things. Robin, I'll start with you.

Robin Fencel: Sure. I mean, believe it or not, one of the most common side effects of having surgery is surgical site pain, being cut with a knife hurts. So, it's very common to have surgical site pain, to have muscle soreness, and sometimes even nerve-related pain that can all be common after spine surgery. It can last for some weeks or even months depends on the type of surgery and the patient's recovery process. But we do use multimodal approaches to treating someone's postoperative pain. What I mean by this is we use different types of medications. Yes, some include opioids for short-term use. We also use nerve pain medications and some anti-inflammatories, along with things that you can find in your home like ice and heat, and a physical therapist also working with you once your wound's nice and healed to be able to treat that postoperative pain.

Host: You brought up items from the home that can be helpful. I know that one of the things we think about is postoperative planning for things that we do at home and preparing our homes or even our lifestyles for the postsurgery recovery process. So, what should folks be thinking about for that at home, Wendy?

Wendy Towers: When we're looking at home care and planning for when you return home after surgery, one of the main things that we really want to make sure of is that you have someone there with you. So often we have elderly patients that don't have family nearby, that only have a neighbor that brought them to the hospital. The postoperative planning is key. So, one of the things that you want to start from the very beginning of deciding to have surgery and signing up to have the surgery is to start discharge planning that minute that they're signing up saying, "Yes, I want to have this procedure done because that sets them up for success postoperatively.

So in our paperwork that we give all of our patients spine network-approved paperwork, one of the things in there is who's going to be with you after surgery? Do you need acute care possibly? Here are a list of acute care rehab facilities for you to look into on your own or ask us about. So that way, there's some sort of plan in place in case you need the acute rehab or subacute rehab in your area. And talking with the family members about, okay, yes, the 80-year-old man is having surgery and his 81-year-old wife is his main caregiver. Is she going to be able to handle that? And do they need to bring somebody into the home? Do they need to look at calling their neighbors and saying, "Hey, I'm going to have this done"? And neighbors are wonderful. I mean, we've seen in close-knit communities where people really step up and help and families coming in from far away to help take care of. And it could just be for a week, but it's that enough support that they have.

The other thing is just looking at your home in general. Do you have-- I like to call them slip rugs, because it's like you're tripping over them and slipping on them, and, you know, do you have those things in your home? Those need to be removed. Do you need some other additional support? Like, even though Insurance may not cover some of these things, do you need to buy a grab bar, you know, buy grab bars for your bathroom? Do you need to have a raised toilet? Those types of things and kind of thinking about that ahead of time is really key.

Host: Yeah. That all sounds very, very smart. And I'm thinking about this personally from my father-in-law is about to face spinal surgery coming up. And a lot of the things you just said right there really hit home. I'm wondering, Robin, thinking about that, obviously, medicine has advanced greatly and things typically go well from surgery, but are there certain symptoms that should prompt a patient like my father-in-law or the caregivers, because he would certainly won't. When he sees these challenges, you know, what's normal to recovery? And then, when is the time to reach out to the healthcare provider?

Robin Fencel: Yeah, sure. Well, I would suggest if you are sitting at home and you are wondering, are things going well? Or is something not going completely right? I would tell them to phone our office right away. It's better that they immediately contact us and have their worries, sort of put to ease or get their questions answered than just sit at home and kind of, you know, be dwelling in anything. They should expect, in general, a decrease in the intensity and frequency of their pain, especially nerve-related pain, if the surgery was intended to address any nerve compression. They should be able to stand, walk longer without fatigue or weakness. And as they regain strength, they may experience even less pain from muscle imbalance. They should gradually be able to increase their activity from day-to-day tasks without significant discomfort. And their incision should show signs of steady improvement, minimal swelling, no discharge. Their wounds still might be tender but not excessively painful after the first few weeks, once we've said that that skin has healed up in the first two to three weeks.

So, things that would be some red flag symptoms is if their pain is getting worse. It's not better, and it is even with taking their postoperative medications that it is different or more intense than their pre surgical pain. Or if they feel something that's just totally different in nature, they should call us right away.

Other things is if they are having any warning signs for infections. So, thinking about fevers, chills, right? If your family member is having a lot of discharge at their incision site, they should definitely be calling us in. Or if there is any new weakness or numbness or anything like that, they should definitely call us immediately too so we can speak with them.

There's a couple things that you don't want to sit on the phone and wait for the office for these. If they're having any issues as far as shortness of breath or chest pain or loss of bowel or bladder control, then you should immediately seek medical care. And instead of phoning the office, we would suggest that those patients call 911 or go to the emergency room right away.

Wendy Towers: I'm in total agreement with that, Robin. When you're looking at those red flag symptoms, one of the other things that I thought would be good to mention is that occasionally patients will have a thrombosis in their leg and they may develop DVT. And when that occurs, that's going to be a different type of pain also. So, they may have redness in their calf, tenderness, can't take a step without getting pain. Those are things that are also red flags that patients would want to, you know, call the office or go right to the hospital to get worked out. Normally, when there's a change, unless it's something that's life-threatening or neurologically-threatening, then they call the office and we talk them through or order a test to make sure that we know that they're safe and doing well.

Robin Fencel: Yeah. It can be a lot operating very close to that spinal cord. So, another thing that I didn't mention would be if they experience a severe persistent headache that doesn't respond to typical headache treatments, or if they haven't had headaches in the past, it could be related to leakage of some cerebrospinal fluid. So, they should definitely be phoning our office right away if they're at home and they're having this headache that is associated with light sensitivity or it gets worse when they are in a certain position, whether it be standing up or laying down.

Host: Yeah, definitely good points to remind people. We've got a couple of questions left. I want to get to physical therapy and rehabilitation. Yeah, sure, for afterwards, I know that's going change a lot, but what about even before surgery? Are there important things we should be doing to help with our recovery before we even begin the process?

Wendy Towers: Well, first of all, when patients are evaluated in the preoperative setting, they are examined to see if they have weakness on exam, where their pain is located, what have they tried, physical therapy, have they done pain management with injections. If they failed everything, then surgery is the next option. And oftentimes, these patients may have weakness on exam or have noticed a foot drop, something like that, where they've been working with physical therapy, but nothing is improving.

The only way it's really going to be improved is once surgery is occurs, the nerve gets decompressed. And then, the nerve is available to the patient to start acting the way it should. The nerve starts to function and fire into the muscles that haven't been able to be fired into for a long period of time.

So, I do think that when you're getting ready for surgery, physical therapy is not a bad thing. So if your insurance company allows you to continue with physical therapy and you're finding that it does seem to help with certain things like back pain, it might not be improving the weakness that you have, but it may be improving your overall symptoms, it's not harmful, so you can continue to do it.

Other things to look at preoperatively to get you ready for surgery is optimizing your health. So, making sure that you're eating good proteins, you're looking at your nutrition, you're increasing maybe your vitamin D or calcium intake. So that way, your bones are healing better after surgery. So, really looking at your overall health is really an important piece of it.

Host: That makes sense. I'm going to cut that snippet out and send it to my father-in-law, because that's his problem. Anyhow, not to dwell on those sorts of things, let's switch topics for a moment and talk about everything's great and fine. It's wonderful. We are out of our spine surgery and we're doing great. What should we be doing as patients, changes in our habits, so that we don't have to do it again? Robyn, I'll let you take that one.

Robin Fencel: Yeah. I mean, I would say these are the same things that all of us should be doing as I adjust my shoulders here and pull them back from looking at my computer, but preventing future spine issues after surgery involves adopting a combination of healthy lifestyle habits like Wendy was talking about and making careful choices about the daily activities to protect their spine.

What I mean by that is, again, pulling the shoulders back, practicing good posture, maintaining a neutral spine position when they're sitting, standing, or walking, avoiding any slouching or hunching over that puts unnecessary pressure on the spine and that beautiful hardware that may have just been placed, working on core strengthening, so exercising regularly, doing activities like swimming, walking, or even yoga that focuses on strengthening the back and the abdominal muscles.

Maintaining that healthy weight is going to be crucial for this too. Especially carrying extra weight around the abdomen, this can increase the load for the spine to have to carry. And practicing safe lifting techniques. So, using those assistive devices that you may have been given by the occupational therapist when you're in the hospital and always bending at your knees, not from your waist when lifting objects, avoiding lifting and twisting when possible, especially with heavy objects.

Physical therapy, as Wendy was talking about, will really help teach you these stretching and lifting to maintain those in your regular routine and using. These are kind of silly ones, but not necessarily silly, but using appropriate footwear. A lot of people think, you know, I can go back to right away wearing my high heels, but maybe using the supportive footwear that helps you maintain that posture is a good or better option. And then, avoiding high-impact activities. Like if you are in a recreational tackle football league, maybe you are going to be shifting to doing something else that isn't as high impact. And regular checkups, following up with your doctor, making sure that you are staying on top and being proactive in your healthcare team. So, attending your postop appointments, getting those x-rays as recommended, all those things are going to be crucial, lifestyle changes and habits to prevent further issues in the spine.

Wendy Towers: You know, to go along with that, Robin, one in four people will develop degenerative disc disease at the level above or below where the fusion has occurred, and they may already have started that process, but it hasn't developed neural compression to the point where it needs to have surgical intervention. So, you're already at a higher risk once you need to have surgery. You know that you already have degenerative disc disease in one or more areas of your spine. So, just being aware of good body mechanics, like Robin said. Not doing heavy weightlifting over your head for that axial load is really going to be an important piece.

A lot of times we see young guys come in, and they're 30 years old with a herniated disc. They end up needing spine surgery, and they continue doing things that increase that axial load. So, just being mindful that you can do other types of exercises with weightlifting, just not doing it over your head. So, like Robin said, modifying some of your activities. Not changing your lifestyle per se, but understanding that your lifestyle changes can improve not just your outcome from your surgery, but improve your overall well being. So, thinking about it in that light too.

Robin Fencel: Yeah, agreed. And what you were touching on, the adjacent segment, degeneration, another big component of that is smoking. So, making sure that people are not smoking preoperatively and especially continuing to not smoke postoperatively because smoking has also been associated with a higher risk for adjacent segment degeneration postoperatively.

Host: All excellent advice. Any final thoughts?

Robin Fencel: Really just to have everybody reach out if they have any questions, please don't hesitate to make sure that they're reaching out to their surgeons and advanced practice providers and getting their questions answered.

Wendy Towers: Yes, pre-op and post-operatively. So that way, they are well prepared throughout the whole process.

Host: Excellent information. Thank you very much for joining me and sharing with all this information with everyone today.

Robin Fencel: Thank you for having us.

Wendy Towers: Well, we appreciate you. Thank you.

Host: I want to thank both Robin Fencel and Wendy Towers for sharing that information with us, and you can find more episodes just like this one at umms.org/podcast, or on our YouTube channel. Thank you for listening to Live Greater, a health and wellness podcast brought to you by the University of Maryland Medical System. I'm Evo Terra. And we look forward to you joining us again, and please share this on your social media. Thanks for listening.