COMPREHENSIVE ASSESSMENT

Lumbar Preoperative Assessment Patient Evaluation

Your Path to Surgical Confidence

The systematic clinical, diagnostic, and vascular evaluation process that determines whether you are a suitable candidate for lumbar disc replacement, what needs to be done surgically, and how to minimise risks and optimise outcomes.

Assessment Timeline

Comprehensive Evaluation

6–12 Weeks

Complete preoperative assessment from initial consultation through multidisciplinary review, vascular evaluation, and surgical optimisation.

Safety First

Critical Collaboration

Vascular

Mandatory vascular surgery collaboration for anterior approach ensuring optimal vessel safety and approach selection.

Patient Selection

Optimal Outcomes

Accuracy

Rigorous candidacy criteria ensuring only the most suitable patients proceed to surgery for superior long-term results.

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The Assessment Journey

Why Lumbar Preoperative AssessmentIs Different

The lumbar spine presents unique assessment challenges compared to cervical surgery. Understanding these differences helps you appreciate why your evaluation involves multiple specialists and typically requires 6–12 weeks from initial consultation to surgery.

Seven Key Differentiators

Vascular proximity

Lumbar approaches bring the surgeon near major vessels (aorta, iliac vessels, vena cava). Vascular complications are more common than in cervical surgery (1–3% vs. 0.5–1.5%).

Load-bearing role

The lumbar spine carries much greater axial loads. Biomechanical assessment and optimisation are more critical for long-term success.

Higher degeneration risk

Most humans experience some lumbar disc degeneration by age 60. Distinguishing pathological from incidental findings is crucial.

Adjacent-segment disease

Lumbar fusion has higher adjacent-segment degeneration rates (40–50% at 10 years) than cervical. Motion-preservation benefit is more significant long-term.

Functional limitations

Low back pain affects walking tolerance, sitting duration, and lifting capacity. Functional assessment is key to surgical planning.

Neurological patterns

Cauda equina involvement vs. single nerve root compression. Multilevel pathology is more common in the lumbar spine.

Psychological factors

Chronic low back pain often has a psychological component. Assessment is critical for outcome prediction and postoperative success.

The Assessment Timeline

6–12 Weeks
Lumbar preoperative assessment journey

Comprehensive assessment ensures optimal surgical outcomes

Stage 145–60 min

Initial Consultation

Comprehensive low back pain history and physical examination

Detailed low back pain history
Radiculopathy characterisation
Walking tolerance assessment (claudication-like symptoms)
Physical examination including gait, Trendelenburg sign, seated slump test
Red flag screening for serious pathology
Vascular Proximity
LUMBARMajor vessels nearby (aorta, iliac vessels, vena cava); vascular complications 1–3%
CERVICALVessels accessible but less complex; complication rate 0.5–1.5%
Lumbar requires mandatory vascular surgery collaboration
Load-Bearing Role
LUMBARCarries much greater axial loads; biomechanical assessment critical
CERVICALPrimarily supports head weight; less load-bearing stress
Bone quality and implant fixation more critical in lumbar
Degeneration Prevalence
LUMBARMost humans experience some degeneration by age 60
CERVICALCommon but typically less ubiquitous
Distinguishing pathological from incidental findings crucial
Adjacent-Segment Disease
LUMBARFusion has 40–50% ASD rate at 10 years
CERVICALFusion has 25–30% ASD rate at 10 years
Motion-preservation benefit more significant long-term for lumbar
Assessment Timeline
LUMBAR6–12 weeks (longer due to vascular assessment)
CERVICAL4–8 weeks typical
Additional time accounts for vascular safety protocols
Clinical Framework

Clinical Evaluation FrameworkFor Lumbar Pathology

Lumbar pain presentation is often complex. Detailed characterisation is essential to localise the problem, guide decisions, and predict surgical response.

Comprehensive clinical evaluation for lumbar pathology

Systematic Assessment

From symptom characterisation through comprehensive physical examination

Chief Complaint & Symptom Characterisation

Low Back Pain Characteristics

Location: Central, unilateral, bilateral?
Onset: Traumatic vs. insidious?
Progression: Worsening, stable, improving?
Triggers: What activities worsen pain? (lifting, bending, sitting, standing)
Relief: What helps? (rest, position change, heat, medication)
Radiation: Does pain go into legs? How far? (thigh vs. foot?)

Why This Detail Matters

Characterisation localises problem

L5 vs L4 radiculopathy vs facet pain diagnosed by specific patterns

Functional assessment guides decision

Severe disability may warrant earlier surgery; mild limitation may warrant continued conservative care

Prior response predicts surgery response

Good response to ESI suggests nerve root is pain generator; poor response raises diagnostic concerns

Physical Examination: The Lumbar Protocol

Inspection & Posture

Visual assessment of stance, gait, and overall presentation

Standing posture: Lumbar lordosis preserved or flattened?
Gait: Normal, antalgic (favouring one side), waddling, stiff?
Muscle atrophy: Visible leg muscle wasting? L5 (anterior lower leg) or S1 (calf)?
Skin: Scars from prior surgery? Skin integrity intact?
Palpation: Tenderness over spinous processes, paravertebral muscles, sacro-iliac joints?
Muscle/MovementNerve RootHow to Test
Hip flexionL2–L3Resist lifting leg straight up while sitting
Knee extensionL3–L4Resist straightening leg from bent position
Ankle dorsiflexionL4–L5Resist pulling toes upward
Great toe extensionL5Resist pulling big toe upward (specific L5 test)
Ankle plantarflexionS1Resist pushing foot downward (tiptoe walking test)
Hip abductionL5Resist spreading legs apart
Intrinsic foot musclesS1Assess toe spreading, foot intrinsic strength

Sensory Testing (Light Touch, Pinprick)

L4Medial leg, medial ankle, medial foot
L5Lateral leg, dorsum of foot, first web space
S1Lateral foot, sole, heel
Cauda equina syndromeSURGICAL EMERGENCY

Bilateral leg pain, saddle anaesthesia, loss of bladder/bowel control

CancerURGENT

History of cancer, unexplained weight loss, night pain, progressive neurological deficit

InfectionURGENT

Fever, IV drug use, immunocompromised, recent spinal procedure

FractureURGENT

Recent trauma, significant osteoporosis, on long-term steroids

Vascular diseaseIMPORTANT

Claudication symptoms (exertional), absence of pain at rest initially

Red flags warrant urgent imaging and specialist consultation before elective surgery planning.

Imaging Assessment

Diagnostic Imaging HierarchyStandard Imaging Modalities

A structured approach to imaging ensures we gather all necessary information for surgical planning while correlating findings with your clinical presentation.

Diagnostic imaging for lumbar assessment

Imaging Hierarchy

X-ray, MRI, CT, and CTA—each with specific diagnostic value

MRI Scan

Soft Tissue Gold Standard

Magnetic resonance imaging is the cornerstone of disc assessment, providing detailed visualisation of disc structure, hydration, and neural elements.

All surgical candidates—essential imaging
Disc degeneration (loss of T2 signal = dehydration)
Disc bulge, protrusion, extrusion, sequestration
Neural compression (central stenosis, foraminal narrowing)
Endplate changes (Modic changes)
Ligament integrity (ALL, PLL)
High-intensity zones (HIZ) — annular tears
Adjacent segment status
Spinal cord and cauda equina status

Key Imaging Principles

Clinical Correlation

Imaging findings must correlate with clinical symptoms. "Abnormal" MRI findings are common in pain-free individuals.

Weight-Bearing Assessment

Standing X-rays show true spinal alignment under load—different from supine imaging.

Multimodal Approach

X-ray, MRI, and CT each provide different information. The combination builds a complete picture.

Recent Imaging

Imaging should be within 6–12 months of surgery for accurate surgical planning.

Advanced Diagnostics

Advanced Diagnostic ModalitiesBeyond Standard Imaging

When standard MRI and CT don't provide definitive answers, advanced diagnostic technologies can distinguish painful pathology from incidental findings and guide precise surgical planning.

Advanced diagnostic imaging technologies

Advanced Diagnostics

SPECT/CT, DEXA, Nociscan, and specialised testing for complex cases

SPECT/CT

Metabolic Activity Imaging

Single Photon Emission CT fused with CT reveals bone metabolic activity—which joints are actively inflamed versus inactive.

How It Works

1Patient receives IV injection of bone-seeking radioactive tracer (Tc-99m)
2Gamma camera detects radioactivity in bone
3SPECT images show areas of high uptake (metabolic activity)
4CT fusion provides precise anatomical localisation
5Result: Identifies which facet joints are "hot" (painful) vs. "cold" (not painful)

When It's Indicated

Severe facet arthritis on imaging; unclear if symptomatic
Mixed presentation (disc and facet pathology both present)
Patients with multilevel disease; need to prioritise levels causing pain
Prior surgery with unclear pain generator
Candidacy determination for arthroplasty uncertain

Advantages

Distinguishes structural vs. functional pathology
Guides surgical level selection
Identifies asymptomatic degeneration (common on MRI)
Changes surgical planning in 30–40% of complex cases
T-ScoreClassificationArthroplasty Candidacy
> -1.0Normal boneExcellent
-1.0 to -2.5OsteopeniaGood
-2.5 to -3.5Moderate osteoporosisQuestionable
-3.5 to -4.0Severe osteoporosisMarginal
< -4.0Very severe osteoporosisContraindicated

Management if osteoporosis found: Bone-strengthening medications (bisphosphonates, denosumab, teriparatide) can be started 3–6 months before surgery. Repeat DEXA shows if improvement sufficient for arthroplasty candidacy.

Three-level lumbar degeneration

MRI shows herniations at L3-L4, L4-L5, L5-S1. Patient has generalised low back pain; unclear which level causes pain.

Nociscan Results:

L3-L4
20
Low — Not Painful
L4-L5
85
High — PAINFUL
L5-S1
75
High — PAINFUL
Surgical Decision:Address L4-L5 and L5-S1; leave L3-L4 alone

Better outcomes than treating all herniations blindly

Nociscan MRI Spectroscopy

Non-invasive—no needle, no pain
No infection risk
No accelerated disc degeneration
Objective biochemical analysis
Done during standard MRI
FDA approved, increasingly covered
High accuracy, fewer false positives

Traditional Discography

Invasive—needle through tissue
Infection risk (discitis 0.1–0.5%)
May accelerate degeneration
Subjective patient response
Separate procedure required
30–40% false positive rate
Declining use due to alternatives

Current Status: Discography is becoming less common because of high false positive rates, invasive risks, and emerging non-invasive alternatives like Nociscan that provide similar or better information without complications.

Critical Partnership

Vascular Surgery CollaborationIn Lumbar Disc Replacement

Lumbar disc replacement, particularly via the anterior approach, requires vascular surgeon expertise and collaboration. This partnership ensures optimal safety when operating near the body's major blood vessels.

Vascular anatomy for lumbar spine approach

Vascular Roadmap

CTA imaging maps vessel position relative to surgical targets

Why Vascular Surgeons Are Essential

Surgical Approach Proximity

Anterior approach brings the surgeon within millimetres of major vessels (aorta, vena cava, iliac vessels).

1–3%Vascular complication rate

Real Complications

Though rare, vascular injury during lumbar spine surgery can be life-threatening and require immediate repair.

15–20%Have anatomical variants

Underlying Vascular Disease

Aortic atherosclerosis, aneurysm, or prior vascular surgery changes the surgical risk profile significantly.

>3cmAAA requires intervention

Vascular Surgery Assessment Process

Imaging Review

CTA or MRA imaging reviewed in detail
Vessel position, size, patency assessed
Anatomical variants identified
Atherosclerotic disease burden quantified
Risk of injury with planned approach assessed

Risk Stratification

Low Risk
Good vessel anatomy
No atherosclerotic disease
No prior vascular surgery
Anterior approach safe; standard precautions
Intermediate Risk
Mild atherosclerosis
Variant anatomy manageable
Prior vascular surgery
Anterior approach possible; enhanced monitoring
High Risk
Severe atherosclerosis
Aneurysm present
Extensive prior vascular surgery
Very limited vessel space
Consider lateral approach; vascular intervention may be needed first

Approach Selection

If aorta/vena cava position unfavourable: Consider lateral transpsoas approach (avoids anterior vessels)
If vessel anatomy favourable: Anterior approach remains optimal

Retraction Strategy

Gentle, limited retraction of vessels
Vascular surgeon may assist with vessel retraction for safety

Need for Vascular Intervention

Aneurysm present (>3cm aortic diameter): May need aneurysm repair before or concurrent with spine surgery
Severe atherosclerosis: May need vascular optimisation (stenting, endarterectomy) before spine surgery
Usually staged: Vascular repair first, spine surgery 4–6 weeks later

Anticoagulation Management

Patients with vascular disease may be on aspirin, clopidogrel, or anticoagulation
Perioperative management planned to balance bleeding risk vs. thrombotic risk

Collaboration on the Day of Surgery

When the vascular surgeon is involved in the surgical procedure

May be present in operating room
Assesses vascular access before incision
Available if vascular injury occurs
Assists with vessel retraction/dissection if needed

Communication between surgical teams: Position patient safely (avoid compression of vessels), communicate retraction needs and tolerances, establish plan if vascular injury occurs (direct repair vs. urgent vascular team notification).

Candidacy Assessment

Patient Selection CriteriaFor Lumbar Disc Arthroplasty

Not every patient with lumbar disc problems is a candidate for disc replacement. Careful selection ensures optimal outcomes and avoids complications in those better suited to fusion or conservative care.

Patient selection process for lumbar arthroplasty

Detailed Patient Selection

Rigorous criteria ensure the right procedure for each individual

12
Ideal Candidates
10
Relative Contraindications
8
Absolute Contraindications

Ideal Candidates for Lumbar Disc Arthroplasty

Patients meeting these criteria typically have excellent outcomes

Clinical Decision Guidance

Patient selection is individualised. Some patients with relative contraindications can become excellent candidates after appropriate optimisation (weight loss, smoking cessation, bone strengthening). Your surgeon will discuss your specific situation and determine if disc replacement, fusion, or continued conservative care is the most appropriate path.

Medical Assessment

Comorbidity ScreeningSystem-by-System Assessment

We screen for conditions that might affect surgical safety or outcome. This ensures optimal preparation and allows us to modify the surgical plan if needed.

Comprehensive comorbidity screening

Holistic Health Assessment

Eight major body systems evaluated for surgical readiness

Cardiovascular Assessment

The most critical preoperative assessment. Cardiac events are a major cause of perioperative morbidity.

Screening Questions

Prior myocardial infarction (heart attack)?
Angina (chest pain with exertion)?
Heart failure (shortness of breath, leg swelling)?
Irregular heartbeat (atrial fibrillation, arrhythmias)?
Prior cardiac surgery or stent placement?
Can you climb stairs without chest pain or severe shortness of breath?
Can you walk one block without stopping for symptoms?
ECG for all patients
Echocardiogram if cardiac history
Stress test if intermediate risk
Cardiology referral if significant history

If significant cardiac disease, may need surgery at hospital with full cardiac backup, or optimisation (stent, medication adjustment) before elective surgery.

Care Team

Multidisciplinary TeamCollaboration

Lumbar disc replacement is a team effort. Multiple specialists work together to ensure safe surgery and optimal outcomes.

Multidisciplinary surgical team collaboration

Expert Collaboration

Five core surgical team members working together for your care

Core Surgical Team

Spine Surgeon (Orthopaedic or Neurosurgical)

Primary surgeon performing the disc replacement procedure

Key Responsibilities:

Overall surgical planning and decision-making
Anterior or lateral approach for disc removal and implantation
Implant sizing and positioning
Decompression of nerve roots if needed

Cardiology

If significant cardiac history (prior MI, heart failure, arrhythmias)

Preoperative cardiac risk assessment
Stress testing if intermediate risk
Optimisation of cardiac medications
Recommendations for surgical safety

Pulmonology

If moderate-severe COPD, poorly controlled asthma

Pulmonary function testing
Optimisation of respiratory medications
Smoking cessation support
Recommendations for anaesthesia considerations

Endocrinology

If poorly controlled diabetes (HbA1c >9%) or thyroid disease

Glycaemic control optimisation
Insulin protocol planning
Thyroid management
Metabolic stabilisation

Psychology / Pain Medicine

If chronic opioid use, depression, anxiety, or pain catastrophising

Psychological assessment and screening
Chronic pain management consultation
Opioid weaning protocol if appropriate
Expectations counselling and mental health support

Haematology

If on complex anticoagulation or bleeding history

Anticoagulation bridging planning
Bleeding disorder assessment
Thrombophilia workup if DVT history
Transfusion planning if anticipated

For complex cases—multilevel disease, significant comorbidities, prior spinal surgery, or borderline candidacy—a formal multidisciplinary team (MDT) meeting may be held where all relevant specialists review your case together.

Shared Decision-Making

Multiple experts contribute to the surgical plan, ensuring all angles are considered

Risk Identification

Potential complications are identified early and mitigation strategies planned

Coordinated Care

All specialists aligned on timeline, goals, and postoperative expectations

Optimised Outcomes

Evidence shows multidisciplinary planning improves surgical outcomes

Case presentation includes: Complete history, imaging review, specialist recommendations, patient goals, and discussion of surgical options (arthroplasty vs. fusion vs. continued conservative care).

Functional Baseline

Functional & Activity AssessmentEstablishing Your Baseline

Understanding your current functional capacity helps us set realistic recovery goals and measure your improvement after surgery.

Functional assessment for lumbar surgery

Baseline Metrics

Walking, sitting, standing tolerance and daily activity assessment

Key Functional Metrics

Walking Tolerance

Key Assessment Question

"How far can you walk before pain forces you to stop?"

Response Categories:

1
Less than 100 metres
2
100–500 metres
3
500 metres to 1 kilometre
4
Greater than 1 kilometre

A structured walking program before surgery improves cardiovascular reserve, muscle strength, and mental readiness. This makes recovery faster and reduces complications.

Weeks 1–2Baseline measurement

Establish baseline

Walk at comfortable pace until symptoms start
Note distance and time
Rest until symptoms subside
Repeat 2–3 times daily
Weeks 3–4+10–20% from baseline

Gradual increase

Add 10% distance every 3–4 days
Focus on quality walking posture
Rest before symptoms force stopping
Track progress in walking diary
Weeks 5–6+30–50% from baseline

Building endurance

Continue gradual distance increases
Add second daily walk if tolerated
Introduce gentle inclines
Maintain core awareness during walking
Weeks 7–8Maximum improvement achieved

Peak preparation

Achieve target walking distance
Demonstrate cardiovascular readiness
Final baseline for postoperative comparison
Confidence in recovery capability

Core Stabilisation Exercises

Combined with walking, these exercises prepare your core for surgery and recovery:

Abdominal bracing

Gentle contraction of deep abdominal muscles without breath-holding

Pelvic tilt

Lying flat, gently flatten lower back against floor by tilting pelvis

Bird-dog

On hands and knees, extend opposite arm and leg while maintaining stable spine

Bridge

Lying on back with knees bent, lift pelvis keeping spine neutral

Why Baseline Matters

Your preoperative functional baseline becomes your comparison point for recovery. A 50% improvement in walking tolerance is more meaningful when we know you started at 200 metres and can now walk 300 metres. These objective measures help us track your success beyond subjective pain scores.

Informed Choice

Shared Decision-MakingYour Treatment Options

Surgery is one option on a spectrum of treatments. Understanding all options—and the risks and benefits of each—helps you make an informed choice that aligns with your goals and values.

Shared decision-making in spine surgery

Treatment Pathway

From conservative care to surgical options

The Treatment Ladder

Most patients begin with conservative care, progressing to more invasive options only when simpler treatments have failed. Surgery is usually considered after 6 months of appropriate non-surgical treatment.

1

Conservative Care

First-Line Treatment

3–6 months minimum
Physical therapy and core strengthening
Activity modification and ergonomics
Pharmacotherapy (NSAIDs, muscle relaxants, neuropathic agents)
Weight management
Cognitive behavioural therapy for chronic pain
2

Interventional Procedures

Diagnostic & Therapeutic

As needed
Epidural steroid injections
Facet joint injections / medial branch blocks
Transforaminal nerve root blocks
Provocative discography (when indicated)
3

Surgical Options

When Conservative Care Fails

Definitive treatment
Lumbar disc replacement (arthroplasty)
Lumbar fusion (ALIF, PLIF, TLIF, XLIF)
Decompression alone (laminectomy, microdiscectomy)

Disc Arthroplasty

Replaces damaged disc with artificial disc that preserves motion

Motion preservation
Lower ASD risk
Faster recovery
Better for active patients

Spinal Fusion

Eliminates motion by fusing vertebrae together with bone graft

Decades of data
Eliminates instability
Broader candidacy
Well-understood revisions
Motion Preservation
ARTHROPLASTYMaintains motion at the treated level
FUSIONEliminates motion completely (creates bone fusion)
Motion preservation reduces stress on adjacent segments
Adjacent Segment Disease
ARTHROPLASTYLower incidence long-term (15–25% at 10 years)
FUSIONHigher incidence (40–50% at 10 years)
May reduce need for future surgery at other levels
Return to Activity
ARTHROPLASTYOften faster recovery, fewer restrictions
FUSIONLonger recovery, more activity restrictions initially
Important for active patients and workers
Bone Healing Required
ARTHROPLASTYNo fusion needed—implant integrates with bone
FUSIONRequires bone to heal/fuse—affected by smoking, diabetes, etc.
Fusion failure (pseudarthrosis) is a risk
Revision Surgery
ARTHROPLASTYChallenging if needed, but rarely required
FUSIONMore straightforward if needed, but needed more often
Both have specific revision considerations
Long-Term Data
ARTHROPLASTYExcellent 10–15 year outcomes, 20+ year data emerging
FUSIONDecades of long-term data available
Both are well-established procedures

Reoperation Rates at 10 Years

3–5%

Arthroplasty

10–15%

Fusion

1–3%

Overall Serious Complication Rate

Comparable to Hip/Knee replacement

Risk Mitigation:Careful patient selection, vascular surgery collaboration, intraoperative neuromonitoring, and experienced surgical team minimise these risks significantly.

The Shared Decision

Your surgeon will present the options, risks, and expected outcomes based on your specific situation. The final decision is made together—considering your goals (return to work, sports, daily activities), your values (willingness to accept risk, importance of motion preservation), and your life circumstances. There is no single "right" answer—only the right answer for you.

Surgical Preparation

Preoperative OptimisationSetting You Up for Success

The weeks before surgery are an opportunity to actively improve your surgical outcome. Optimising your health reduces complications and speeds recovery.

Preoperative optimisation program

Optimisation Program

Six key areas for preoperative preparation

Physical Therapy Program

Builds strength and endurance for surgery and recovery

4–8 weeks
Core stabilisation exercises (abdominal bracing, pelvic control)
Walking program with progressive distance goals
Flexibility exercises (hamstrings, hip flexors)
Postural awareness training
Cardiovascular conditioning (stationary bike, water exercise)
Education on postoperative movement patterns

Target Metrics

Walking distance

Increase by 50% from baseline

Core strength

Hold plank for 30+ seconds

Cardiovascular

Walk 20 minutes without stopping

Optimisation Timeline Summary

6–8 Weeks Before
  • Stop smoking
  • Begin PT program
  • Start weight loss
4–6 Weeks Before
  • Optimise HbA1c/BP
  • Nutrition supplements
  • Psychological prep
2 Weeks Before
  • Final labs/imaging
  • Medication review
  • Pre-op visit
Final Synthesis

Final Assessment SynthesisBringing It All Together

All assessment components are synthesised to determine candidacy, approach, and surgical plan. This comprehensive review ensures optimal outcomes.

Final assessment synthesis for surgery

Comprehensive Review

Six assessment domains synthesised for surgical planning

Assessment Domain Review

Discogenic pain confirmed by history and examination
Red flags excluded
Neurological examination documented
Physical examination findings correlate with imaging
MRI confirms disc pathology at planned levels
X-rays show preserved lordosis and motion
CT shows no severe facet arthritis
Advanced imaging (if indicated) completed
CTA reviewed for vessel anatomy
Vascular surgeon consulted (anterior approach)
Risk stratification completed
Approach strategy confirmed
Ideal candidate criteria met
No absolute contraindications
Relative contraindications addressed
Candidacy confirmed
Comorbidities screened and managed
Smoking cessation achieved (if applicable)
Weight and metabolic targets met
Psychological readiness confirmed
Treatment options discussed
Risks and benefits explained
Patient questions answered
Informed consent obtained

Candidacy Determination

Excellent Candidate

All criteria met, optimal timing for surgery

Proceed to surgical scheduling

Good Candidate (Optimisation Needed)

Candidate with modifiable factors requiring attention

Complete optimisation protocol, then proceed

Marginal Candidate

Significant concerns requiring careful consideration

MDT review, extended discussion, possible alternatives

Not a Candidate

Absolute contraindications or better alternatives exist

Alternative treatment pathway (fusion, conservative care)

Once candidacy is confirmed, the surgical team meets to finalise the operative plan. This ensures all team members are aligned on approach, technique, and contingencies.

Surgical Approach

Anterior (ALDR)
Lateral (LLDR)
Approach determined by vascular anatomy and surgeon preference

Levels to Address

Single level (L4-L5 or L5-S1)
Two-level (L4-L5 and L5-S1)
Levels confirmed by clinical-imaging correlation

Implant Selection

Implant size based on templating
Device selection based on motion characteristics
Bone quality considerations

Intraoperative Monitoring

MEP and SSEP monitoring planned
EMG for nerve root protection
Continuous neuromonitoring throughout

Anaesthesia Plan

General anaesthesia
Hypotensive anaesthesia for reduced bleeding
Airway management strategy confirmed
Informed consent signed

Documentation

Insurance/funding approval

Administrative

Blood type and screen

Laboratory

Recent labs within 30 days

Laboratory

Imaging available in theatre

Imaging

Implants ordered and confirmed

Equipment

Medication reconciliation

Medications

Anticoagulation management plan

Medications

Preoperative shower/skin prep

Preparation

Fasting instructions confirmed

Preparation

Transport and support arranged

Logistics

Post-op recovery plan in place

Discharge

Ready for Surgery

Once all assessment components are complete and optimisation targets are met, you're ready for surgery. Your surgeon will confirm the date, provide final instructions, and answer any remaining questions. The journey from preoperative assessment to surgical readiness is complete—now it's time to focus on recovery and achieving your goals.