Surgery with Dr. Spivak

Once you and Dr. Spivak decide to proceed with surgery, it is best to learn what to expect during the whole process from scheduling until final healing in order to navigate the process smoothly and end with the best possible surgical result. Preparing mentally and physically for surgery is an important step toward a success. Understanding the process and your role in it will help you recover more quickly and have fewer problems.

Preoperative Preparation

Along with the decision to go ahead with surgery should also be a thorough discussion with Dr. Spivak regarding the risks and benefits of the surgical procedure, a frank discussion of other possible surgical options (if more than one possibility exists), and a review of any nonoperative alternatives to surgery. If you are not confident that you have had sufficient discussion with Dr. Spivak regarding all or any of these issues, you should contact him to initiate further discussion either by phone or in person in the office with another visit. As a patient, it is your right and responsibility that you understand fully what your options are and the risks involved with each option.

Part of your discussions with Dr. Spivak should also include what to expect in terms of the surgical procedure, hospital stay, and recovery process including possible use of a brace and physical therapy. If your surgery involves operating in front of the lumbar spine through the abdominal area, we also recommend that you meet before surgery with the vascular or general surgeon involved in the surgical approach. He will examine you, discuss his role in the procedure, and go over the risks of the surgery in detail again. You should also have met with Susan Seewald, the office manager, either by phone or in person to go over any financial issues regarding health insurance, and to go over the process and scheduling of preoperative medical testing and any additional spine tests you may need before surgery.

Before surgery, Most patients will have to meet with their medical doctor to have a complete physical examination to make sure that all of their medical conditions are stable and optomized, and that no new medical issues exist. Routine tests, such as blood tests, electrocardiogram, and X-rays, are usually performed between 1 and 2 weeks before any major surgery and are done as part of the "preadmission testing" process at the hospital.

Here are a few general preoperative recommendations that apply to most patients:

• Discuss any medications you are taking with Dr. Spivak and your medical clearance doctor to see which ones (if any) that you should stop taking before surgery. For example, if you are taking aspirin or anti-inflammatory medications, which can increase the risk of bleeding, you will need to stop taking them one week before surgery to minimize bleeding. Patients on Plavix or Coumadin (warfarin) will also have to stop these medicines, but may need additional medications before surgery to minimize risks of medical complications. Stopping these anticoagulants should only be done under the direction of your medical doctor.
  
  
• Discuss with Dr. Spivak the possible need for blood transfusion during or after surgery, and the options for preparing for potential blood replacement, including donating your own blood, medical interventions and other treatments, prior to surgery.
  
  
• If you are overweight, losing weight before surgery can help decrease the rate of perioperative complications including wound healing issues and infection. Weight loss should be gradual and slow, and you should not be dieting during the weeks immediately before your surgery. Eating a balanced, healthy diet in the weeks before surgery helps place the body in a state of repair (anabolic state), not a state of breakdown (catabolic state) seen during active dieting.
  
  
• If you smoke, you should stop or cut down to reduce your surgery risks and improve your recovery. If you are having a fusion as part of your operation, smoking cessation without nicotine patch or gum use is critical to minimize the risk of non-healing of the fusion.
  
  
• Have any tooth, gum, bladder or bowel problems treated before surgery to reduce the risk of infection later.
  
  
• Eat a well-balanced diet, supplemented by a daily multivitamin with iron.
  
  
• Report any active or recent infections to Dr. Spivak. Elective surgery should not be performed until all infections have cleared up.
  
  
• If possible, arrange for someone to help out with everyday tasks like cooking, shopping and laundry for the first few days you are home after surgery. For larger reconstructive procedures, help may be very useful for the first few weeks after the initial hospitalization. In many cases, these services may be covered by your health insurance (a home health aid).
  
  
• Put items that you use often within easy reach before surgery so you won't have to reach and bend as often when you get home.
  
  
• Secure all loose carpets and tape down electrical cords to minimize the risk of tripping and falling.
  
  
• For sitting, try to have a stable chair of medium height with a firm seat cushion, a firm back, and two arms.

Recovery Following Surgery

As you prepare yourself mentally to undergo spinal surgery, you also need to prepare yourself for the recovery period that will follow your operation. While the surgery entails work on the part of Dr. Spivak and his team, after that, the brunt of the work is in your hands. To ensure a smooth and healthy recovery, it is important that, as a patient, you closely follow the set of instructions that your surgical team gives you.

Hospital Recovery

After the operation, you will be brought to the recovery room for observation. When you wake up from the anesthesia, you may be slightly disoriented, and not know where you are. The nurses and doctors around you will tell you where you are, and remind you that you have undergone surgery. As the effects of the anesthesia wear off, you will feel very tired, and, at this point, will be encouraged to rest.

Members of your surgical team may ask you to respond to some simple commands, such as "Wiggle your fingers and toes" and "Take deep breaths." When you awaken, you will be lying on your back. This may seem surprising if you have had surgery through an incision in the back, but lying on your back is not harmful to the surgical area.

Prior to the surgery, an intravenous (IV) tube will be inserted into your arm to provide your body with fluids during your hospital stay. The administration of these fluids will make you feel swollen for the first few days after the operation.

When you awake from the anesthesia, you may feel the urge to urinate. Commonly, a catheter tube (also commonly called a Foley Catheter) will have been placed into your bladder to drain urine from your system after you went to sleep with anesthesia but before the operation began. The catheter serves two purposes: (1) it permits the doctors and nurses to monitor how much urine your body is producing, and (2) it eliminates the need for you to get up and go to the bathroom. Once you are able to get up and move around, the catheter will be removed, and you can then use the bathroom normally. If you underwent outpatient microsurgery, a catheter will likely not have been placed, and you will be encouraged to use a urinal or get up to a toilet early in recovery to be sure of no difficulty with urination.

During your hospital stay, you will get additional instructions from your nurses, the resident and fellow physicians, the medical specialists, and Dr. Spivak regarding your diet, activity, and the possible need for use of a postoperative brace.

Proper nutrition is an important factor in your recovery. Initially, you may be restricted from drinking and eating, depending on the surgical approach that was used during the operation. Calories and food intake are an important part of recovery. Some patients find that their physician orders are less restrictive than the diet they follow at home. After the surgery, you will continue to receive intravenous fluids until you are able to tolerate regular liquids, which typically involves gradually transitioning you from sips of clear fluids to full liquids (including gelatin). From there, you will be given small amounts of solid food until you are ready to return to a regular diet. Once able, you are encouraged to eat a full calorie diet in order to provide enough energy for the body during the acute repair phase following surgery.

With respect to physical activity, in most cases Dr. Spivak will want for you to get out of bed on the first or second day after your surgery. Nurses and physical therapists will assist you with this activity until you feel comfortable and confident enough to get up and move around on your own.

Home Recovery

Before you are discharged from the hospital, Dr. Spivak and his team will give you additional self-care instructions for you to follow at home - a list of "dos and don'ts," which you will be asked to follow for the first 6 to 8 weeks of your home recovery. This should include any activity restrictions, instructions on the care of surgical incisions, and medication usage. Following these instructions is crucial to your recovery. If you are unsure of any of these instructions, ask for clarification. If you are home and have additional questions, contact Jamie Santore-Arrigo, our physician assistant (212 598-2325), for additional information.

Reconstructive spinal surgery often involves more than one incision depending on the surgical approach used to perform the operation. When you are discharged home you may still have a surgical dressing on your incision(s). If needed, a nurse can be arranged to visit your home to change the dressing or a caregiver, such as one of your family members, will be taught to do it for you. It is important that the dressing be changed daily and kept dry. This is especially true if there is any persistent drainage from the wound itself.

If any signs of possible infection are observed, you should call Dr. Spivak's office to check in with him or a clinical staff member. These signs include

• Fever - a body temperature greater than 101°F (38°C)
• Persistent or worsening drainage from the incision(s)
• Opening of the incision(s), and
• Redness, warmth, or increased tenderness around the incision(s)

In addition, call Dr. Spivak to report any chills, nausea/vomiting, or if you suffer any type of trauma (e.g., a fall, automobile accident) which may have impacted the surgical area.

During this early recovery period, you will also be instructed to keep your incision(s) clean and dry, making sure only to use soap and water to cleanse the area. If there is any drainage from the wound when home, you should keep it dry, wash around it, and keep it covered with a sterile gauze dressing changed at least daily. Call Dr. Spivak's office to report any new drainage, to discuss and receive specific instructions for your particular situation. Showering and getting the wound wet is generally permitted once the wound is dry and without drainage, but the wounds should not be submerged in a tub, pool, or body of water. You should also avoid the use of skin lotions in the area of the incision(s) in the early postoperative period; you need to keep this area dry until it has had the opportunity to heal well.

In addition to caring for your incision(s), you will also be encouraged to

• Drink plenty of fluids
• Maintain a healthy diet (high in protein)
• Perform deep-breathing exercises regularly
• Gradually increase your physical activity

Activities to avoid usually include any heavy lifting, bending, or twisting, although specific activity instructions in your case should be discussed with Dr. Spivak and members of his team prior to hospital discharge.

The first office follow-up with Dr. Spivak will typically be 2-3 weeks after surgery to check the wounds and also check an ex-ray in fusion cases. This visit is usually performed by Jamie Santore-Arrigo in the Manhattan office on Tuesdays, but a visit with Dr. Spivak in White Plains on a Friday is also an option. Please be sure to call Dr. Spivak's office at any time if you have any urgent questions or concerns. There is always someone from his team covering his patient service at all times, if he is not directly available to respond.