Transpedicular Screw Fixation

How Dr. Salman Falak performs it

The operation is done under general anaesthesia with you lying face down. Screws can be placed through one open cut in the midline of the back, with the muscles lifted off the bone, or through several small cuts under X-ray guidance with the muscles pushed apart. A fracture or slip that also needs the nerves freed usually needs the open approach; a stabilisation on its own may suit the smaller cuts.

The screws are placed with the help of X-ray pictures taken during surgery, so that each one sits inside the pedicle and does not stray towards the nerves. If nerves are trapped, the bone and disc pressing on them are removed first. The rods are then fitted and tightened, with the alignment corrected where needed. Bone graft is packed alongside and the wound is closed in layers. The operation usually takes a few hours, depending on how many levels are fixed, and most patients stay in hospital for a few days.

What to expect from the operation

The first thing fixation gives back is stability. For a fracture, that means the broken bone is held in the right position while it heals, and you can sit and walk early instead of lying flat for weeks. For a slip, it means the vertebra can no longer creep forward and the pinched nerves are given room. Mechanical back pain usually settles as the fusion matures.

Two points need saying plainly. Leg symptoms caused by a trapped nerve usually improve, but a nerve that was damaged before surgery, for instance by a fracture fragment, may not recover fully, and no amount of metalwork can change that. And the fused segment no longer moves. In the lower back that is rarely noticed, but the neighbouring levels take a little more load over the years and some patients develop wear there later. Dr. Salman Falak fixes the fewest levels that will do the job for exactly this reason.

Who is a candidate, and when fixation is not the answer

Fixation is for a spine that is unstable or out of line. A spine that is merely worn does not need it. It helps most in these situations:

• A fracture that is unstable, or that is pushing bone towards the spinal cord
• A slipped vertebra that causes pain or nerve symptoms and has not settled with non-surgical care
• Movement between vertebrae that shows on bending X-rays and matches the pain
• A decompression wide enough that the spine would be weak without support

Patients with severe osteoporosis need special thought, because soft bone does not grip screws well. Ordinary chronic back pain with a mildly worn MRI is not helped by screws; fixing a painful but stable spine often leaves the same pain and a stiffer back. A stable compression fracture in an older person, with no nerve symptoms, usually heals in a brace. If the pictures do not show instability, Dr. Salman Falak does not recommend fixation.

Before surgery: tests and preparation

An MRI shows the nerves and whether anything is pressing on them. A CT scan shows the bone itself and the line of any fracture, and is often needed to plan the size and direction of the screws. Standing X-rays, with bending views where possible, show whether the bones move. Routine blood tests and an ECG are done, and the anaesthetist reviews you before the operation. Older patients may also be asked for a bone density scan.

Blood thinners are stopped in advance on your physician's advice. Smokers are asked to stop, because nicotine slows bone healing and can stop a fusion from taking. Bring your scans and reports. Patients from outside Lahore can send the reports on WhatsApp first, so that the tests are ordered before travelling; if you have a recent fracture, ask before making a long journey so that it can be planned safely.

Recovery, what to avoid and how to sleep

You will be out of bed on the first or second day with help from a physiotherapist. Walking is the main exercise for the first few weeks. Pain from the wound and the muscles is controlled with tablets and settles over a couple of weeks. A brace is sometimes used, and Dr. Salman Falak tells you whether you need one.

For the first few months, while the fusion is taking, avoid bending forward from the waist, lifting anything heavy, twisting the trunk, and sitting on the floor. Prayers can be said sitting on a chair during this period; ask before returning to full sajda. Do not drive until you are off strong painkillers and can turn comfortably to look behind you. Desk work is usually possible within a few weeks; heavy manual work and long motorbike rides wait until the X-ray shows the bone is joining.

Sleep on a firm mattress, on your back with a pillow under the knees or on your side with a pillow between the knees. Get out of bed by log-rolling: bend the knees, roll onto your side in one piece, drop the legs over the edge, and push up with the arms.

Follow-up is a wound check in the first couple of weeks, then X-rays at intervals to watch the fusion. Patients from other cities can do the later reviews by video consultation, with the X-ray films photographed and sent on WhatsApp. Call at once if you notice fever, discharge from the wound, new weakness or numbness in the legs, or trouble passing urine.

Where the operation is done

Dr. Salman Falak operates in Lahore. His main OPD is at Sharif Medical City Hospital in Jati Umra on Raiwind Road, and he also sees patients at Life Hospital in Bahria Town and at Doctor Care Hospital in Al Kabir Town. Patients from the Gujranwala side are seen at Gujranwala Medical Complex on G.T. Road on Fridays, and patients from Phool Nagar and the Kasur side at the Tuesday OPD there. The operation itself is carried out in Lahore. If a family member has a spinal fracture, send the CT or MRI on WhatsApp before travelling; Dr. Salman Falak will say whether the journey is urgent and how the patient should be moved.

Risks and how they are kept low

The risks include infection, which is a little more common than in disc surgery because the operation is longer and metal is left in; bleeding; a spinal fluid leak; injury to a nerve root or, rarely, the spinal cord; a screw that needs repositioning; and failure of the fusion to take, so that the rods carry the load for too long and loosen or break.

These are reduced in practical ways. Screws are placed under X-ray control and checked before the wound is closed. Antibiotics are given at the start of surgery. You are up and walking early to protect the lungs and the veins in the legs. Smoking is stopped and diabetes controlled to give the fusion every chance, and the number of levels fixed is kept to the minimum that gives stability.

Related conditions and procedures

Screw fixation is often combined with other procedures. A patient with a slipped disc and a slipped vertebra at the same level may have lumbar disc herniation surgery and fixation in one operation. Where the screws can be placed through small cuts, it is part of Dr. Salman Falak's minimally invasive spine surgery work. The spinal fracture and instability page explains the conditions themselves and which ones heal without an operation.