Spine Guide LEARN ABOUT YOUR SPINE, COMMON SPINE PROBLEMS, and the CARE YOU CAN EXPECT

Patient and Family Education intermountainhealthcare.org

Spine Guide LEARN ABOUT YOUR SPINE, COMMON SPINE PROBLEMS, AND THE CARE YOU CAN EXPECT

SPINE CARE AT INTERMOUNTAIN IS A MULTIDISCIPLINARY, INTEGRATED PRACTICE that provides comprehensive spine care services, including surgical and non-surgical treatment of all spinal conditions. Our staff includes specialists in physical and occupational therapy, physical medicine and rehabilitation, interventional and medical pain management, behavioral medicine, radiology, neurosurgery, and What’s Inside orthopedic surgery.

AS AN INTERDISCIPLINARY SPINE BASICS...... 4 Your spine...... 4 TEAM, WE PARTNER Common problems...... 7 WITH YOU to assess your spine condition, weigh treatment SPINE CARE AT INTERMOUNTAIN...... 10 options, and design a personalized Your team...... 10 treatment plan. We combine A team-based approach...... 11 clinical excellence with research, education, and advocacy — and ASSESSMENT AND we strive always to provide TREATMENT OPTIONS...... 12 healing with a human touch. Assessment...... 12 Treatment options...... 16

SURGICAL TREATMENT AND YOUR HOSPITAL STAY...... 18

Preparing your home...... 19 Packing your bag...... 20 Understanding the daily routine...... 21 Preventing complications...... 23 Recognizing and controlling pain...... 25 Understanding realistic expectations and potential complications...... 27 Preparing to go home...... 29

3 Spine Basics

Knowing about your spine — its parts, how they’re put together, and what can go wrong — can help you understand your diagnosis and treatment options. It can also help you protect your spine in the future. Your spine Your spine is made up of vertebrae [VUR-tuh-bray], discs, spinal cord and nerves, ligaments, and muscles.

Vertebrae Your spine is a column of 33 bones (vertebrae) stacked up on top of each other. As shown below, the spinal column is divided into 4 regions, and the vertebrae within each region are numbered.

Viewed from the side, the 4 regions all have natural curves (curvatures). These curves help balance and distribute the weight of your body.

Cervical. This is your neck area. The cervical vertebrae are numbered from C1 to C7.

Thoracic. This is your upper- and mid-back, from your chest to your waist. The thoracic vertebrae attach to the ribs and are numbered from T1 to T12.

Lumbar. This is your lower back area. The lumbar vertebrae are numbered from L1 to L5.

Sacral. This region of your spine is your buttock and “tailbone” area. It includes the sacrum (5 vertebrae that are naturally fused to form a triangular-shaped bone) and the four very small coccygeal vertebrae below that.

4 SPINE GUIDE Vertebra and disc: Top view (cross-section) Front

Disc nucleus Disc annulus

Spinal cord Nerve root

Vertebra

Back DISCS The vertebrae are separated by discs that cushion the vertebrae and allow them to move properly. Each disc is a small, circular capsule with a tough outer wall (the annulus) and a softer core (the nucleus). In children, this core is gel-like, but with age, the core tends to harden and become less elastic.

Spine and facet joints (view from the back)

Facet joint

Facet joint: Side view (cross section)

Spine section showing vertebrae, discs, and facet joints (side view) FACET JOINTS Each vertebra has 2 pairs of facet joints. These joints link the vertebrae together at the back of your spine. They stabilize the spine and allow you to bend and twist. To help the joints glide smoothly against each other as you move, the joint surfaces are covered by cartilage and the whole joint is covered by a capsule containing fluid. This joint capsule is made of ligaments and other connective tissue.

SPINE GUIDE 5 Spinal cord and nerves MUSCLES Besides supporting the weight of your body, the vertebrae also house The entire spinal column is and protect your spinal cord. The spinal cord is a network of nerves stabilized by muscles in your that extends from the base of your brain to your lower back. The back, sides, and abdomen. spinal cord passes through a tubular space — the spinal canal — These muscles maintain formed by the ring-shaped openings of the vertebrae. Smaller spinal your posture and help you nerves branch off of the spinal cord, exiting through smaller spaces to bend, twist, and move between your vertebrae to reach all areas of your body. your back. Ligaments The vertebrae are connected and supported by ligaments. The 2 main spinal ligaments run the length of the spinal column.

Spinal cord

Nerve roots Outer muscles (shown on the left side) Inner muscles (shown on the right side)

Ligaments

6 SPINE GUIDE Common Problems Back and neck pain is common. Most pain is temporary, but it can reoccur. It’s often caused by a strained muscle or sprained ligament — SOURCE OF perhaps from an activity you’re not used to doing, such as yard work, SYMPTOMS? moving furniture, or sitting for a long time. Less often, pain comes from damage to part of your spine or from Although your spine care team will provide a condition you were born with. The pain may accompany other a thorough assessment, symptoms such as stiffness, numbness, or weakness in your arms and it’s not always possible legs. Spine problems can cause bowel and bladder problems, but are not to pinpoint the source usually the primary cause. Some common problems are described in the of symptoms. Studies following pages. show many cases of Who has back and neck pain? back pain have no known cause. Anyone can have back or neck pain. Still, some things increase your chance of having pain, for example: • Getting older. The older you are, the more likely you are to have back or neck pain. • Poor physical fitness. Lack of exercise and poor posture increase your risk of back pain. • Being overweight. Extra weight puts extra stress on your spine. • Your job or hobby. A job or activity that requires you to bend, lift, twist, push, or pull can be risky. But desk work can also be hard on your back especially if you don’t sit up straight or get up very often. • Smoking. Studies show that smokers have more back pain and spinal conditions than non-smokers do. • Previous injury. An injury you had months or years ago may put you at risk for back problems later on. • Diseases. Arthritis, osteoporosis, and other diseases can increase your chance of having back pain. • Family history and genetics. Some conditions run in families.

SPINE GUIDE 7 Abnormal curvature Your spine’s natural curves help balance your body. If the curves become too pronounced — or if your spine develops a twist or an extra curve — it puts extra pressure on the vertebrae and discs. This can cause instability, pain, and bulging or herniated discs. Abnormal curvatures include those shown below.

ScoliosisScoliosisScoliosis KyphosisKyphosisKyphosis LordosisLordosisLordosis

Scoliosis (in red) Kyphosis (in red) Lordosis (in red) A side-to-side curve Increased curve (“hump”) Increased curve in your in your back in your upper back lower back (“swayback”)

(normal curvature shown in blue)

8 SPINE GUIDE FRACTURES Like any bones, your vertebrae can crack or break. Reasons for a spine fracture include an injury, repeated stress, or a condition like osteoporosis [os-tee-oh-puh-ROH-sis], which can Fracture make bones weak and brittle (breakable). DEGENERATED DISC Degenerative disc disease (DDD) is a catch-all term to Healthy describe changes — usually thinning, hardening, and drying disc out — in your spinal discs. Disc degeneration is part of the natural process of aging and wear-and-tear of the spine, Degenerated and often does not cause any symptoms. This process disc sometimes begins or speeds up with injury, disease, or unusual stress. Degenerated discs can irritate the spinal Bulging nerves and cause instability. They can be painful. disc BULGING DISC Herniated If the outer wall of a spinal disc weakens, it may push out disc (bulge) toward the nerves. This can cause nerve pain. HERNIATED DISC (also called ruptured disc) If the outer wall of a spinal disc tears (ruptures), the soft material inside the disc can squeeze out and press on Instability nearby nerves. This can cause pain, numbness, or weakness in your back, neck, legs, or arms. INSTABILITY Spinal instability is when adjoining vertebrae slip back and forth, or have permanently shifted out of position. This Herniated disc pressing on instability can be caused by a damaged spinal disc, a bone spinal cord injury, arthritis in the facet joints, or just something you Bone spur and nerves were born with. The slippage can irritate the bone, disc, causing spinal cord, and nerves. stenosis STENOSIS Stenosis is a narrowing of the spinal canal. Stenosis can press on the spinal cord and nerves and cause pain and other symptoms. Stenosis can be caused by enlarged ligaments, facets, or other abnormal bone growth such as bone spurs. NERVE PROBLEMS All of the conditions described above can irritate or press on (pinch) the spinal cord or nerves. This can cause pain, numbness, weakness, and other problems throughout your body. Common examples are lumbar radiculopathy [ruh-DIK-yoo-LOP-uh-thee] or sciatica [sy-AT-i-kuh] (nerve problems in your lower spine, causing leg pain) and cervical radiculopathy (nerve problems in your neck, causing arm pain). SYNOVIAL CYSTS Synovial cysts are abnormal fluid-filled sacs which can rise from the facet joints and develop as a result of degenerative changes. They do not cause cancer. While they can occur anywhere in the spine, they are most common in the lumbar region (lower back). If they grow large enough, they can pinch a nerve and cause nerve pain.

SPINE GUIDE 9 Spine Care at Intermountain

Spine treatment isn’t one size fits all. We work closely as an interdisciplinary team with you and each other to understand your condition and create a treatment plan that matches your needs and lifestyle. Your team During your treatment, you might encounter people from different specialties working together to help diagnose and treat you. Here are a few of the people who may be on your spine care team:

• Nurses, Nurse Practitioners, Physician Assistants. These experts can help assess your condition and coordinate your care. Working with the rest of your team, they can also directly provide much of the care you’ll receive at Intermountain.

• Doctors. Your team may include doctors specializing in physical medicine and rehabilitation, radiology, interventional and medical pain management, or behavioral medicine. If surgery looks like it may be an option for you, your team will include a neurosurgeon or orthopedic surgeon. Your spine team will also consult with your primary care doctor as needed.

• Therapists and additional care providers. The treatment of spine and pain conditions often includes physical and occupational therapists. These experts help create individualized programs to improve or restore strength, flexibility, movement, and function.

10 SPINE GUIDE A team-based approach Our experts work as a team on each phase and aspect of your care. Here’s what you can expect:

• An initial assessment. When you first come to Intermountain Healthcare, a provider will work with you (and with your primary care provider as needed) to understand your previous care and your reasons for coming. The provider will consult with others on the interdisciplinary team to evaluate your case and assemble a team suited to your needs.

• Interdisciplinary care. We may recommend that you see more than one provider on our team. There are several reasons for this. First, we may need a range of medical perspectives to build a complete picture of your problem and treatment options. Second, you may need to see different providers at different stages of your care. Or, your care may require more than one type of treatment at a time — and thus more than one specialist.

• Care management. A nurse or other provider will help you to coordinate your care at Intermountain. Thanks to this coordination, everyone on your spine care team — including you — will have the full story of your problem. They’ll also know the treatment plan you’ve agreed to, and be able to do their part efficiently and effectively.

• Communication. You are the most important person on your spine care team. Throughout your treatment at Intermountain, we’ll do our best to explain our processes and give you the information you need to make decisions and help care for yourself. We welcome your questions and suggestions — in fact, we depend on them to help us work well with you and your family.

SPINE GUIDE 11 Assessment and Treatment Options

This section describes the common techniques used for diagnosis and treatment of spinal conditions. Assessment To learn about you and your condition, your spine team will discuss your symptoms with you, examine you, and obtain relevant diagnostic tests. Over the course of your care, these evaluations and tests may be repeated as part of follow-up care, or as other clinicians become involved in your care. Here are some of the evaluations and tests your team may use. Patient history Your care team will ask questions as part of their assessment. Possible topics are listed below.

• Pain and other symptoms. Your provider may ask: Where is your pain? How bad is it? How long have you had it? When did you first notice it? What makes it better, or worse? How is your life affected by your symptoms — have they changed your sleep habits, your work life, your recreation?

12 SPINE GUIDE Patient history (Continued)

• Previous spine care. Please bring prior imaging and medical records to your first appointment. The place where your studies were performed can help you obtain copies. What tests or treatments have you already had? What were the results? Have you had spine surgery previously? If so, can you provide the details of the surgery? • Previous medical care. Your provider may ask: Do you have any chronic conditions such as arthritis or osteoporosis? Have you had PATIENT HISTORY cancer, depression, or a recent infection? What medications do you QUESTIONNAIRES take? How would you rate your recent and current stress levels? What These questionnaires do you do for fun and relaxation? help providers continue • Lifestyle and daily habits. Your provider may ask: Do you smoke? to personalize your Exercise? What kind of work do you do? How do you usually sleep, care throughout sit, or stand? your treatment. • Family history. Your provider may ask: Does anyone else in your family have back problems or chronic pain?

“Taking a patient history” simply means asking questions. Besides talking with you, your providers may use a questionnaire (like the one shown at right). This will help them continue to personalize your care throughout your treatment.

SPINE GUIDE 13 PAIN IS NOT THE ONLY SYMPTOM WE CARE ABOUT Your medical assessment should cover a range of symptoms — not just pain — such as the following: • Numbness, tingling, “pins and needles” • Weakness, slow reflexes • Night pain • Fever, chills, sweating • Recent infections • Associated trauma • Stress or emotional Physical exam issues As part of a physical exam, your doctor will assess your physical body • Unusual weight gain and its movement. Below are some things your doctor may note. or loss • Weakness. Simple exercises can help test your strength. • Bowel or bladder problems • Range of motion. Your doctor may check your flexibility or watch • Headaches you bend and twist. • Sexual dysfunction • Tenderness. Your doctor may assess areas of soreness by touching Mention these or any parts of your body. other unusual changes • Sensation and sensitivity. Your doctor may check to see that you or symptoms to your care can feel heat, cold, or a pin prick on parts of your body. team. Even if it seems unrelated to your spine or • Reflexes and motor skills. Your doctor may ask you to walk on your doesn’t bother you, it will heels or toes, or do tests to check your body’s reactions. help your providers get a • Shape, tone, and position of the spinal bones and muscles. more complete picture of your health. Laboratory tests Sometimes back and neck symptoms can be caused — or made worse — by a systemic illness (an illness throughout your body, not just in your spine). To check for illness, your doctor may have a sample of your blood or urine tested. In addition, if surgery or other interventions will be part of your treatment, routine laboratory tests are usually ordered first.

14 SPINE GUIDE Imaging studies There are several technologies that allow your spine team to take pictures of the inside of your body. Depending on what they need to see, they may suggest one of the imaging studies listed below. • X-ray: Beams of low-dose radiation create pictures of tissues, bones, and organs on film. • MRI: Magnetic Resonance Imaging (MRI) uses a magnetic field and radio waves to create images. MRI is very useful for evaluating details of soft-tissue structures, like nerves, in and around your spine. • CT scan: Computed tomography (CT) uses a computer and x-rays to create cross-section views (“slices”) of areas of the body. It’s especially useful for highlighting abnormal tissue and clearly showing bone detail. • Bone density scan: This scan uses x-ray or ultrasound to measure the amount of bone in a particular area. It can detect and assess osteoporosis (thinning bones). If the assessment shows Electrodiagnostic testing a problem in your spine, it doesn’t necessarily The term “electrodiagnostic testing” covers a range of tests that mean that you won’t measure electrical activity in nerves and muscles. Two common get better. Many electrodiagnostic tests are the electromyogram (EMG) and the nerve people with arthritis, conduction study (NCS). Results from these tests help your doctor disc degeneration, and assess nerve and muscle function and locate any damage. other problems may have less pain when treated Other procedures effectively. Other procedures, such as spinal injections and discography, may be useful in evaluating sources of back pain that cannot be seen on other common imaging studies. Your care team will provide information on these procedures if needed.

SPINE GUIDE 15 Treatment options Your care may include one or more of the treatments described below.

Education and activity For more information Your care team can teach you what you can do on your own to relieve about your spinal pain, regain strength, and increase flexibility. For example, they may injections, ask your advise you on proper body mechanics (how to sit, sleep, move, and lift) or provider for the patient handout, how to use ice and heat to reduce inflammation (swelling). Much of this Spinal Injections. education can help you prevent spine pain in the future — as well as treat it today. Physical therapy Physical therapy encompasses a variety of treatments to promote healing, relieve pain, build strength and flexibility, and help prevent future injuries. For example, your physical therapist may create and supervise a program of exercises and make suggestions to help improve body mechanics (how to sit, sleep, lift, and move). Other physical therapies include spinal manipulation (applying force to a spinal joint) and traction. Traction Traction is a non-surgical method for decompressing the vertebrae. It’s done either manually by a specially trained provider, or mechanically with braces or devices that gently elongate the spine. Spinal injection Your doctor may recommend a spinal injection to treat inflammation or ease pain. An injection can deliver medication directly to the source of your symptoms. Common injections include: • Epidural steroid (cortisone) injections. Injections near specific nerves or directly into the epidural space (the area around the nerves within the spinal canal) can help diagnose and treat pain. • Facet joint injections and nerve branch blocks. Injections in or near the facet joints can treat arthritic joint pain. • Sacroiliac (SI) joint injections. Injections at the SI joint, where the spine and pelvis join, can diagnose and treat pain in that area.

• Trigger point injections. Injections into tight, irritated muscle areas (trigger points) may help the muscle relax and ease pain.

16 SPINE GUIDE Oral medication (pills) Your doctor may prescribe medication to reduce inflammation, relax muscles, and ease pain. Take the medication exactly as your doctor or pharmacist advises — and let your doctor know about other medications, herbs, or supplements you take. Opioids Prescription opioids are medications used to help relieve severe pain. They may be prescribed after a surgery or injury, or for certain health problems. Some common opioid medications are codeine, hydrocodone, methadone, morphine, and oxycodone. If you are prescribed opioids for pain: • Keep your prescription in the bottle it came in. For more information • Don’t take more pain medicine, or take it more often, than prescribed. about your opioid prescription, ask your • Follow up with your primary care provider or pain specialist. provider for the patient • Ask your doctor or pharmacist if you should get a naloxone kit. handout, Prescription This can save your life if you have an accidental overdose. Opioids: What you need to know. • Lock them up in a safe place and out of reach of others. Know your options Talk to your healthcare provider about ways to manage your pain without opioids. Other methods may actually work better and have fewer risks and side effects. Options may include: • Other pain relievers, such as acetaminophen (Tylenol), ibuprofen (Advil, Motrin), or naproxen • Physical therapy and exercise • Working with a therapist to help learn ways to change the triggers of pain and stress • Other medications Other non-surgical procedures Other procedures — such as neurotomy and radiofrequency ablation — use heat, cold, chemicals, or radiofrequency energy to destroy nerves near a problem joint. This relieves symptoms by preventing pain signals from traveling to the brain. Additional treatments for chronic pain include spinal pumps and stimulators that are implanted under the skin. A pump can put medication directly into the spinal fluid at just the right place in your spine. A spinal stimulator delivers a small electric pulse on the surface of the spinal cord to help mask pain.

SPINE GUIDE 17 Surgical Treatment and Your Hospital Stay A PARTNER IN HEALING Surgical treatment It is important to identify The care team may decide that surgery is the best treatment plan for a committed partner in healing long before your you. Common spine surgeries performed are laminectomy [lam-uh-NEK- surgery. Your partner tuh-mee], discectomy [dis-KEK-tuh-mee], fusion, along with many others. in healing should be Work with your care team to learn about the specifics of your surgery. able to stay with you for a few days after you Getting your body ready for surgery go home. Talk to your Here are some things you can do to get your body ready for family and friends about surgery, making it easier to come out of anesthesia and to heal getting the support you faster after surgery: need at home. If you smoke, chew tobacco, or vape, QUIT! Smoking can adversely impact your healing. Except for emergency surgery, you should quit smoking 6 weeks before surgery and for at least 6 weeks after. For fusion surgeries, you should quit smoking until the bones have fused, which is generally one year. Smokers have decreased fusion rates unless they quit smoking for surgery. Get control of any other health conditions you have. Managing your blood pressure, blood sugar, and other conditions are essential to a successful surgery. If you have diabetes, make sure your A1c is less than 8.0 to help your wound heal faster. DO NOT USE alcohol or street drugs, including marijuana. These substances can seriously impact how you react to anesthesia and medications. If you use alcohol regularly, you should receive medical help on how to gradually stop. Quitting suddenly, or “cold turkey,” can lead to alcohol withdrawal, which can be dangerous. Do daily strengthening exercises for your body to give your muscles a head start on your recovery. Try walking, water aerobics, or swimming for about 30 minutes a day, 5 days a week. If you are overweight, try to lose a few pounds. For every pound you lose, you take pressure off of your spine, which will make it easier to get around after surgery. Eating more fruit, vegetables, and whole grains and less fat, sugar, and red meat will help speed up your recovery. If you need any invasive medical or dental procedures, ask your surgeon how far in advance you should schedule these. Talk to your surgeon BEFORE getting a steroid injection into the spine. This can increase the risk of infection and related complications. If you take any opioid pain medications, try to cut back. Decrease your use of these medications as much as possible so your care team can effectively control your pain after surgery. If your body is tolerant of high doses of pain medication, discuss this with your surgeon. Your pain may be more difficult to control.

18 SPINE GUIDE Preparing your home ARRANGE FOR When you come home after surgery, you will need to be extra careful ASSISTIVE to prevent falls and injuries while you recover. There are a lot of small EQUIPMENT changes you can make at home now to make your recovery as safe DO NOT expect people to and speedy as possible. These changes mostly apply to major surgeries lift or move you — they and fusions. could get injured. Use the prescribed assistive equipment instead. Set up your recovery space Leave space around furniture for using a walker. Place a sturdy chair with arms near a table. Ensure that chair seats are high enough to get into and out of easily. Add cushions if necessary. Plan on needing a front-wheeled walker. You may also want a raised toilet seat or toilet safety frame and a shower chair. Reduce tripping hazards Remove throw rugs or small objects on the floor. Tack down or tape carpet edges. Remove clutter. Clear pathways of furniture and electrical cords. Improve lighting Use night lights and add lamps if necessary. Make sure your stairs and hallways are well lit. Manage pets Make a plan to keep your pets from tripping you once you come home. For example, you could keep pets in a different area of the house or put a bell on each pet’s collar to alert you when they are near. Consider boarding your pets or having them stay with a friend or family member when you first come home. Prepare your kitchen and bathroom Stock up on supplies and groceries. Prepare and freeze meals ahead of time to warm up while you are recovering. Store commonly used items on lower shelves or on countertops in your kitchen and bathroom. Place items where you can reach them without bending below your waist, reaching, or lifting. DO NOT USE step stools.

SPINE GUIDE 19 Packing your bag Check the items below that you need to pack.

WHAT NOT What to bring to the hospital TO BRING TO ••Your Spine Guide booklet. THE HOSPITAL ••A partner in healing who can stay with you until the time of DO NOT bring valuables surgery and will be responsible for taking you home afterward. such as: ••A small bag of personal items with: • Cash or jewelry A pair of fully-fitted, non-skid shoes or slippers. You’ll need these • Medications or during physical therapy. supplements Loose, light-weight clothing, such as T-shirts and shorts or sweat (unless otherwise pants, that will fit easily over bulky dressings (bandages). directed) Personal care items, such as a toothbrush and deodorant. Your cell phone, e-reader, laptop, or book if you choose. Don’t forget the charger for your electronic devices. Your CPAP and mask if you use one. FACTORS THAT A “rescue inhaler” if you use one. MAY DELAY YOUR A case for glasses, contacts, or hearing aids. SURGERY Your picture ID, insurance card, and a form of payment Several factors may for prescriptions (if you choose to fill them at the cause your surgery hospital pharmacy). to be rescheduled. They include: A list of all medications you take including herbal supplements and over-the-counter medications. ••Eating or drinking after a specified time A list of any questions or new concerns you want to discuss with your surgeon or anesthesia provider. ••Any respiratory A copy of your advance directive form. (airway or lung) illness ••Any open wounds or breaks in the skin near where your surgery will take place ••Fever of 101° F (38.3° C) or higher ••Failure to stop taking medication as directed by your surgeon before surgery (for example, aspirin or other blood- thinning medications)

20 SPINE GUIDE Understanding the daily hospital routine If you are admitted to the hospital after surgery, your goal is to build your strength and independence enough that you’ll be able to continue your recovery outside of the hospital. Our goal is to help you become more mobile, prevent complications, and keep you safe. Physician or provider rounding Your surgeon or their assistant will visit you each day you are in the hospital. Most providers start their “rounds” in the mornings, but depending on their schedules, they may not come until later in the afternoon. In addition to seeing you, they will review your clinical notes, physical therapy progress, laboratory information, imaging studies, and coordinate a plan for your discharge from the hospital. Hourly rounding A care team member will check on you in your room every hour. Please take advantage of this time to have them assist you with any needs, especially when you feel you may need to go to the bathroom. Bedside reporting When a nurse goes home and transfers your care to another nurse, both nurses will generally meet at your bedside to discuss your progress. You can participate in this conversation to help make the best plan for your recovery. Daily care Your nurses will regularly check your vital signs, how much fluid you drink, and how much you eat. They will monitor your incision for drainage, increased pain, and swelling. Please report to your nurse any neurological [noo-rol-OJ-ik-uhl] changes (such as numbness and tingling). In addition to your home medications, you will receive other medications to prevent blood clots, control pain, and prevent infection. You may have your blood drawn to ensure you are recovering well. Your care team will also offer help with getting dressed, changing your linens, ordering food, preparing you for physical therapy, and any nighttime care you may need.

SPINE GUIDE 21 Getting out of bed Building strength also involves getting up and out of bed as soon as possible after surgery. You will get out of bed to go to the bathroom, to do physical therapy, and to start moving on your own. However, you must NOT get up without a staff member with you. Remember: Your care team wants to help you get out of bed and become more mobile. You are never “bothering” your care team!

• DO NOT: –– Get up by yourself. –– Have family members help you up. • DO: –– Call staff at least 15 to 20 minutes before your urge to “go” is immediate. –– Expect a staff member to stay in the bathroom with you. Safety comes before privacy. Communication There are 2 very important ways that you and the hospital staff will be able to communicate during your stay: 1 The communication board. Your caregivers will help you understand this board that is located in your room. It will include the names of those caring for you and other information depending on the facility and your needs. 2 The call button. The nursing call button at your bedside is an important communication tool for you when you need assistance. Don’t forget: You MUST HAVE a staff member with you EVERY time you get up.

Physical and occupational therapy The goal at Intermountain is to have you out of bed on the day of your surgery. A physical therapist will evaluate your mobility as soon as you are able. The therapist will have you sit on the edge of the bed, move to a chair, walk in your room, or walk in the hallway. You will learn a series of exercises prescribed for you to help with recovery both in the hospital and when you go home. If you need to use stairs at home, the therapist will teach you how to go up and down them safely. Plan on 1 or 2 daily sessions of physical therapy. Your partner in healing is encouraged to attend at least 1 inpatient physical therapy session. You may have an occupational therapist (OT) visit you to help make sure you can complete activities of daily living (such as dressing and personal hygiene tasks). The OT will teach you how to use adaptive equipment safely for transferring on and off the bed and toilet, and into and out of tubs and showers.

22 SPINE GUIDE Preventing complications You will be asked to get up out of bed soon after your surgery. Movement and pain management allow your mind and body to focus on healing and preventing possible complications.

Blood clots Blood needs to be pumped through the vessels in your legs to prevent blood clots or deep vein thrombosis (DVT). To prevent blood clots from forming: • Participate in physical therapy, do ankle pumps, and use the devices that are designed to help prevent clots, such as sequential compression devices (SCDs) and the TED hose. • Walk as often as recommended. Respiratory precautions To prevent low oxygen levels and pneumonia: • Use incentive spirometry [spy-ROM-i-tree] to exercise your lungs. • Cough and take deep breaths. • Eat meals sitting up. FALL PREVENTION • Do not take sleep medication unless it is approved by your doctor. After surgery, you are at a higher risk of falling. • Report any difficulty with breathing or awakening from sleep. You may be attached to • Understand that some pain medications can slow your breathing. tripping hazards, such as IV lines, oxygen tubing Wound infection and sensors, and SCDs. To reduce your risk of injury To prevent infection: and a longer hospital stay: • Keep any dressings on as ordered by your doctor. • Do not get up without • Keep your dressing clean and dry. Notify your nurse if the dressing assistance. Use your appears soiled or is coming off. call light and only get up with the help of a • Do not touch the incision area. caregiver. Notify your • Wash hands with soap and water before touching your incision. nurse if you can’t use the call light. • Use non-slip footwear and a walker, if needed. • Use grab bars and assistive devices.

SPINE GUIDE 23 Recognizing and controlling your pain WHAT CAUSES PAIN AFTER Why is pain management important? YOUR SURGERY? You will have pain after surgery. Many things can The goal is to reduce your pain contribute to the pain enough that you can rest and do the activities that will help you recover. you feel. These include: To best manage pain, your healthcare providers will consider 3 factors:

••The surgical cut. 1 What recovery activities you need to do. These include ••Muscle spasms or coughing or breathing deeply to prevent complications, physical cramps near the site therapy exercises, and self-care activities. of the procedure. 2 What level of pain you can manage and still do needed ••Tubes inserted into activities. Everyone’s ability to tolerate pain is different. You will rate the body during your surgery or your pain on a scale of 0 to 10 and identify the level of pain you can that remain after manage and still do your recovery activities. the procedure. 3 What will help you to be comfortable. When you’re ••Muscle pain as a result uncomfortable, your pain can feel even worse. Being comfortable of the position you may include listening to music, staying warm, sleeping without had to lie in during the interruption, or quickly managing feelings of nausea. procedure, or lying in bed for a long time With these factors identified, your healthcare providers will help after the procedure. you determine your best level of pain control. This is your pain ••Constipation. management goal.

24 SPINE GUIDE BEFORE TAKING MORE PAIN Pain control without medication MEDICATION Without medication, pain is best controlled by using ••Re-position yourself the B.R.I.N.E. method (shown below): in the bed for comfort or sit in B reathing. Use incentive spirometry 10 times per hour the bedside chair. for deep, controlled breathing. This will help you feel ••Get up and walk more relaxed. or exercise. ••Apply ice. R est. Getting enough rest will help your body heal and reduce swelling.

I ce. Use an ice pack to help with inflammation. Your physical therapist will tell you how long to keep using ice.

N utrition. Be sure to eat healthy foods and drink plenty of fluids. Proper nutrition promotes healing.

E xercise. Get some light, physical activity (like walking).

How do I talk about pain to my nurse? It’s not always easy to describe pain. Your care providers will likely use some type of a pain rating scale — a tool to help you describe how much pain you’re feeling.

SPINE GUIDE 25 ADDITIONAL How is my pain controlled? METHODS TO Your pain may be controlled using the multimodal [mull-tye-MODE-uhl] CONTROL PAIN approach or other methods. The multimodal approach means using different types of medications that all work to manage pain. It may Cold therapy include the use of one or more of the following medications: (ice) • Pain relievers, such as acetaminophen (Tylenol) • Non-steroidal anti-inflammatory drugs (NSAIDs), Massage or including ibuprofen (Motrin, Advil), naproxen (Aleve, Naprosyn), therapeutic Celebrex, Meloxicam, or Toradol touch • Opioids, including oxycodone (Roxicodone), hydromorphone (Dilaudid), hydrocodone (Norco, Lortab), and tramadol (Ultram)

Spiritual or • Muscle relaxers, including diazepam (Valium), cyclobenzaprine emotional (Flexeril), or methocarbamol (Robaxin) counseling • Nerve pain treatments, including gabapentin (Neurontin)

How can I stay ahead of the pain? Distraction (music, TV, If your pain starts to increase, let your healthcare providers know. games) It’s easier to control the pain before it gets too strong. If you wait until it’s severe, it may be harder to get under control. Also, if you used opioids to manage pain before the surgery, it may make it more Relaxation or difficult to manage your pain afterward. meditation techniques

26 SPINE GUIDE Understanding potential complications Talk to your caregivers if you are experiencing side effects so they can treat them appropriately.

Nausea Nausea can be a problem with any surgery. It can be caused by anesthesia or pain medication. To prevent nausea: • Alert your nurse when you are feeling nauseated. Nausea medication is generally available as ordered by your healthcare provider. • Avoid taking pain medication on an empty stomach. While you may not feel like eating, it’s important to refuel your body. • Drink small amounts of 100 % fruit juice or broth. Eat or drink something small every few hours. Constipation Bowels need to move. However, inactivity and certain pain medications may cause constipation. To prevent constipation: • Eat more whole grains, fruits, and vegetables as they contain higher levels of fiber. • Walk! Be sure to have a caregiver with you at all times. • Stop taking opioids as soon as possible. • Drink plenty of fluids unless your doctor says otherwise.

Opioids and constipation: What you need to know

Opioids are usually safe when used exactly as ordered by your doctor, but they do have many side effects. One major side effect is constipation (can’t poop). This is caused by opioids slowing down the movement of your bowels. About 6 out of every 10 people who take opioids after surgery have constipation.

It’s important to prevent constipation following surgery to prevent having to go back to the hospital or the emergency room. See the steps on the next page to help you trigger a bowel movement (BM) and stay regular while taking opioids. Continue to follow your bowel care plan until you are done taking opioids, you have regular BMs without treatment, or you get diarrhea.

SPINE GUIDE 27 Getting things moving Follow these steps to find relief and prevent constipation while taking opioids following surgery. The medications for constipation on this list are available over-the- counter at most drug or grocery stores.

TEP S GET THINGS MOVING TAKE 1 capful or packet of Miralax (polyethylene glycol) mixed with at least 8 ounces of water or juice 2 times daily, AND / OR TAKE 1 tablet of Senna-S (sennosides / docusate) 2 times daily. ••Once you are regular, you may adjust as needed (for example, stop Senna-S and continue Miralax). ••If you don’t have a BM for a total of 3 days, move to Step 2.

STEP KEEP THINGS MOVING INCREASE Senna-S to 2 tablets 2 times daily, AND CONTINUE Miralax, taking 1 capful or packet mixed with at least 8 ounces of water or juice 2 times daily. ••Once you are regular, you may adjust as needed. ••If you don’t have a BM for a total of 5 days, begin Step 3.

TEP S REALLY GET THINGS MOVING ADD 1 dose (30 milliliters [ml]), of Milk of Magnesia (magnesium hydroxide). ••If you are able to have a BM, return to Step 2 until you are done using opioids or you have constipation or diarrhea. If you don’t have a BM within 8 hours,

ADD 1 tablet (10 milligrams [mg]) of Dulcolax (bisacodyl) OR 1 rectal suppository. ••If you are able to have a BM, return to Step 2. ••If you don’t have a BM, TAKE another dose of Milk of Magnesia and 1 tablet of Dulcolax. ••If you are able to have a BM, return to Step 2. ••If you don’t have a BM or have continued symptoms, move to Step 4. E ST P REALLY, REALLY GET THINGS MOVING Take ½ to 1 bottle of magnesium citrate. ••Once you finally have a BM, return to Step 2. ••If you don’t have a BM while you are using opioids or have continued symptoms of constipation, call your doctor.

28 SPINE GUIDE Preparing to go home MY GOALS FOR Surgery patients usually recover best at home with fewer WHEN I GO HOME complications. For some patients, a stay at a rehab center or Be able to get into skilled nursing facility may be important for their recovery. and out of bed, up Your care team (such as your surgeon, nurse, care manager, physical from a chair, into therapist, and social worker) will decide when it is safe for you to and out of the shower, and on recover at home. You will receive specific guidelines from your care and off the toilet providers about your surgery, including precautions and rehab without assistance. exercises. Talk to your family and friends about getting the support you need at home. Go up and down stairs safely. Your surgeon may recommend that you continue with outpatient physical therapy once you go home. If you are unable to leave home to Be able to put on go to outpatient physical therapy, or if you go home with medications socks and shoes and safely walk at least that require assistance or monitoring, you may need to have home 50 to 100 feet on my health services. own with crutches or Discharge from the hospital to home requires that you: a walker. • Are medically healthy. Perform therapy • Have achieved your personal goals for discharge. exercises on my own or with help from my • Have completed your home health arrangements, if appropriate. partner in healing. • Have a family member or partner in healing to take you home. (Your partner in healing should be able to stay with you for a few Manage pain so that I days after you go home.) can complete exercises and daily activities. When all hospital discharge criteria have been met, your Eat and drink without surgeon will discharge you with: difficulty. • Prescriptions for the medications you need. Some medications may Have necessary be new to you, so be sure to ask any questions you have about them. support and • Any orders for home health or outpatient physical therapy based on equipment at home. the type of spine surgery you had and your individual needs. Before you are discharged, your nurse will meet with you to review your discharge instructions, discuss your medications, and answer your questions. You may be discharged to a Skilled Nursing Facility, or Rehabilitation Hospital instead of going home. These can provide additional support and resources to help you recover. Criteria for these are different than going home, and can be discussed with your care team if needed.

SPINE GUIDE 29 Notes:

30 SPINE GUIDE Notes:

SPINE GUIDE 31

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