Back Pain Neurosurgeon
Dr W Adriaan Liebenberg
FC Neurosurgery (SA)
MMed Neurochirurgie (Stellenbosch)
MB. ChB (Stellenbosch)
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Before you come into hospital

Here are some things that you can do to prepare yourself and reduce the likelihood of difficulties with the anaesthetic. If you have asthma, emphysema, any heart condition or other chronic disease, you will be evaluated by the anaethetist or physician prior to surgery.
If you have loose or broken teeth, or crowns that are not secure, you may want to visit your dentist for treatment. The anaesthetist may need to put a tube in your throat to help you breath, and if your teeth are not secure, they may be damaged.

Pills, medicines, herbal remedies and allergies

If you are taking any pills, medicines, herbal remedies or supplements, it is important to bring these with you. A written list of everything you are taking, whether they have been prescribed or whether you have bought them over the counter, would be helpful. If you have any allergies, a note of these will also be helpful.

Your normal medicines
You should continue to take your normal medicines up to and including the day of surgery, unless your anaesthetist or surgeon has asked you not to.
However, there are exceptions. For example, if you take drugs to stop you getting blood clots (anticoagulants, Warfarin), aspirin, and drugs for diabetes or herbal remedies, you will need specific instructions. If you are not sure, your anaesthetist will advise you. If you are on Warfarin or Disprin, it is very important that you contact the anaesthetist at least a week before your operation.

On the day of your operation

You will be asked to come in well in advance of your scheduled operating time to allow enough time for your admission to the ward, and for the nurses to go through the anaesthetic check-list with you. Unfortunately it is not possible to give you an exact time that you would be going to theatre, and it may be that you wait a long time before you go to theatre, since operation time is very unpredictable.
The Anaesthetist will try to visit you on the ward before you go to theatre. If this is not possible, they would read your folder before you arrive in theatre, and discuss your anaesthetic with you once you are in the reception area.

Nothing to eat or drink - fasting ('Nil by mouth')
If there is any food or liquid in your stomach during your anaesthetic, it could come up into the back of your throat and then go into your lungs. This could cause serious damage to your lungs. You should not eat or drink at least 8 hours prior to surgery. If you have been told to arrive at 10h00, you may usually have some water at 06h00 the morning of your surgery.

Premedication (a 'premed') is the name for drugs (tablet) which are sometimes given before an anaesthetic, although today they are not always used.

The theatre

When you are taken into the operating theatre, your anaesthetist will prepare you for your anaesthetic. Several people will be there, including your anaesthetist and the anaesthetic assistant. All the checks you have just been through will be repeated once again.

To monitor you during your operation, your anaesthetist will attach you to
machines to watch:
Your heart: sticky patches will be placed on your chest (electrocardiogram or ECG)
Your blood pressure: a blood-pressure cuff will be placed on your arm
The oxygen level in your blood: a clip will be placed on your finger (pulse oximeter).

Setting up your cannula

Your anaesthetist will need to give you drugs into a vein. A needle will be used to put a thin plastic tube (a 'cannula') into a vein in the back of your hand or arm. This is taped down to stop it slipping out. A bag of sterile water with added salt or sugar (a drip) will be connected to the cannula.

What happens during a general anaesthetic?

Before starting the anaesthetic, you may be given oxygen through a facemask. This will be the last thing you remember before waking up. For some operations the anaesthetist will place a breathing tube down your windpipe once you are unconscious. You will not be aware of this tube being used. It is extremely unlikely that you will remember anything of your operation because your anaesthetist watches over you throughout to ensure safety. You will wake up in the Recovery Ward where you will be looked after by trained staff. You will have an oxygen mask on at first.

How will I feel afterwards?
Most people feel fine but occasionally you may find yourself shaking as though you are very cold. This is quite common and soon stops. Some patients may have a sore throat and dry lips, possibly because of the presence of the breathing tube. This usually clears up after a day or two. Rarely you may experience some muscle aches. These are most common across the shoulders and neck and may last for a few days. Ways of treating pain is discussed elsewhere in this pamphlet.
You may feel sick or vomit after operations although this is less likely with modern anaesthetics than in the past. Please let the anaesthetist know if this has been a problem for you before. We can take steps to reduce the chances of it happening, or treat it if it does.

Some people experience tiredness after an anaesthetic that may last several days. We will try to relieve any discomfort you may have. You might be repositioned before the onset of surgery. We take great care with positioning, and use padding for all pressure points. However, now and then patients have body aches from being in the same position for a long time.

After the operation

After the operation you will be moved, to a Recovery Room for your condition to be monitored. The 'drip' is not usually needed for any longer than about 24 hours after the operation. Your scar will naturally be quite painful at first; initially you may be given injections to ease the pain (or a PCA - see the section in this pamphlet); when the pain has lessened tablets can be given. Your surgery will be discussed with you on the ward by the surgical team.

What are the risks?

Anaesthesia is safer than it ever has been before, but all medical treatments carry some risk. Some nerves are at risk of being compressed due to the position you lie in when unconscious. Very rarely, numbness and weakness may persist for several weeks. If you or anyone in your family has had a problem with an anaesthetic you must discuss this with the anaesthetist. If you have any worries or if you have any side effects after your operation, please tell the nurse looking after you, who can refer you to an anaesthetist if appropriate.

How long am I going to stay in hospital?

One of the main reasons for staying on hospital is to control post-operative pain. You may go home as soon as the surgeon is satisfied and you are comfortable enough, sooner for minor operations than for major operations.
You will be given painkillers to take home. Do not drive a motor vehicle, operate dangerous equipment, use any alcohol or makes any important decisions for 24 hours after surgery.

Pain relief after your back operation

There are various forms of pain relief after surgery. Depending on your operation and individual circumstances the anaesthetist may recommend one particular method of pain relief for you.

Am I going to have a lot of pain afterwards?

Certain back operations are known to cause a fair amount of pain. There are three options available after these operations: intrathecal morphine, Intramuscular or intravenous painkillers and oral tablets for less severe pain.

Intrathecal Morphine
This is a very effective way of pain relief and involves your surgeon injecting morphine directly into your spinal cord and is done at the time of surgery. Following this, you will have to stay in the high care unit so that your breathing can be monitored.

How often will I need painkillers?
The anaesthetist will prescribe painkillers to be taken orally, or intramuscular injections. As soon as you start feeling uncomfortable, you should ask the nursing staff to give you tablets or an injection.
You are in the hospital after your back operation partly to control your pain, and there is no need to have severe pain. In some cases we will use a PCA (see below), which allow you to control the amount of painkiller you receive.

Patient Controlled Analgesia (PCA)
This is a method of pain relief (usually with morphine) which allows you to control the amount of painkiller you receive.

Why is this better than the nurse or doctor controlling it?
Because patients vary enormously in how much painkiller they need. We use either an electronic PCA machine, which has a button similar to a bell, or a special PCA syringe, which has a simple lever, which is pressed.

The PCA machine (or PCA syringe) allows you to give yourself the right amount for you. You do this by pressing the button (or lever) on the handset, if you have pain.

How does it work?
As soon as you feel pain, you press the button (or the lever) on the handset. This is connected to the PCA machine (or PCA syringe) and you will hear a bleep (with the electronic PCA) to confirm that the machine is working. It will then deliver a small amount of painkiller into your drip. This acts quickly and also avoids the need for painful injections.

Does the machine always give painkiller when I press the lever?
No. It only gives painkiller every few minutes (usually seven), however many times you press the button. This is to ensure that one dose has had time to take effect before another dose is given and to avoid complications such as depression of your breathing.

Can I have too much painkillers?
PCAs are generally very safe and can provide good pain relief, which is beneficial to your recovery. You will be regularly observed while you are on the PCA. It is important only you press the button (or lever), (not relatives or friends), and only for pain from your operation site.

Will I get addicted?
No. Addiction does not happen when you are taking painkillers for a few days to treat pain from an operation, no matter how much you need.

How often should I press the lever?
As often as you need to keep yourself comfortable. You should use as much painkiller as necessary, so that you can move around comfortably, take a deep breath and are able to cough. There is no right number of times to push the button - only you know how much effect you are receiving from the medication.

Are there any side effects to PCA?
Sometimes. You will normally feel mild sleepiness, if this is excessive you will be treated for it. You may feel sick or itchy.

If you experience any of these effects tell your nurse, as treatment is available is not uncommon to have some nausea or vomiting after having an operation and there are many reasons for this including some pain relieving medicines.
If you have nausea or vomit then tell the nurses and an injection of an anti-nausea drug will be given. If nausea is an ongoing problem then further changes can be made to treat it. Sometimes people may feel itchy when getting pain treatment. Often this is only mild, but it can be treated with anti-itching medication or a change to a different pain relieving medicine.

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