Anterior lumbar interbody fusion (ALIF) is a spine surgery that involves approaching the spine from the front of the body to remove disc or bone material from in between two adjacent lumbar vertebrae. The procedure may be performed either as an open surgery or using minimally invasive techniques.

What Is An ALIF?

Anterior lumbar interbody fusion (ALIF) is a spine surgery that involves approaching the spine from the front (anterior) of the body to remove all or part of a herniated disc from in between two adjacent vertebrae (interbody) in the lower back (lumbar spine), then fusing, or joining together, the vertebrae on either side of the remaining disc space using bone graft or bone graft substitute.

The graft material acts as a binding medium and also helps maintain normal disc height – as the body heals, the vertebral bone and bone graft eventually grow together and stabilize the spine. Instrumentation, such as rods, screws, plates, cages, hooks and wire also may be used to create an “internal cast” to support the vertebral structure during the healing process.

Depending on your condition and your surgeon’s training, experience and preferred methodology, an ALIF may be done alone or in conjunction with another spinal fusion approach. Please discuss your fusion approach options thoroughly with your doctor, and rely on his or her judgment about which is most appropriate for your particular condition.

Why Do I Need This Procedure?

There are a number of reasons your surgeon may recommend spinal fusion. This procedure is frequently used to treat:

• One or more fractured (broken) vertebrae
• Spondylolisthesis (slippage of one vertebral bone over another)
• Abnormal curvatures of the spine, such as scoliosis or kyphosis
• Protruding or degenerated discs (the cartilaginous “cushions” between vertebrae)
• Instability of the spine (abnormal or excessive motion between two or more vertebrae)

Patients with low back and/or leg pain due to degenerative disc disease, spondylolysis/spondylolisthesis, scoliosis, or other spinal instability that have not responded to non-surgical treatment measures (rest, physical therapy or medications) may be suitable candidates for an ALIF.

Patients without an excessive amount of spinal instability or slippage, and who have little to no spinal stenosis or nerve compression in the back of the spine, are generally the best candidates for an ALIF alone. However, ALIF as a stand-alone technique is usually not recommended for people whose bones have become very soft due to osteoporosis, or in patients with instability or arthritis.

Your surgeon will take a number of factors into consideration before recommending an ALIF, including the condition to be treated, your age, health and lifestyle and your anticipated level of activity following surgery. Please discuss this treatment option thoroughly with your spinal care provider.

How Is An ALIF Performed?

For an ALIF procedure, the patient is positioned on his or her back and sedated under general anesthesia. The surgeon then:

• Makes an incision in the abdomen and retracts the abdominal muscles, organs and vascular structures – including such major blood vessels as the aorta and vena cava - for a clear view of the front of the spine and access to the vertebrae. (This part of the procedure may be performed by a general surgeon or vascular specialist.)
• Removes all or part of the degenerated disc(s) from the affected disc space, and inserts bone graft or bone graft substitute into the disc space between the vertebral bodies, to support the disc space and promote bone healing.
• Returns the abdominal organs, blood vessels and muscles to their normal place, and closes the incision.

Surgeons typically perform an ALIF as a traditional, open procedure as described above; however, another option is to access the spine using minimally invasive (endoscopic) technologies that allow surgeons to reach the affected vertebrae through small incisions and intramuscular tunnels created to accommodate special guidance, illumination and surgical tools.

How Long Will It Take Me To Recover?

The recovery period for a spinal fusion procedure such as an ALIF will vary, depending on the procedure and your body’s ability to heal and firmly fuse the vertebrae together. One advantage of an ALIF is that the back muscles and nerves are undisturbed. 

Patients typically stay in the hospital for several days, longer if necessary for more extensive surgery. This may also include time in a rehabilitation unit. Your surgeon will prescribe pain medication as needed, and may recommend a brace and follow-up physical therapy.

The length of time you will be off work will depend on a number of factors: your particular procedure and the physician’s approach to your spine, the size of your incision, and whether or not you experienced any significant tissue damage or complications. Another consideration is the type of work you plan to return to. Typically, you can expect to be on medical leave for 3 to 6 weeks; however, many innovations and advancements have been developed in the last few years that allow for improved fusion rates, shorter hospital stays and a more active and rapid recovery period.

Work closely with your spinal surgeon to determine the appropriate recovery protocol for you, and follow his or her instructions to optimize the healing process.

Are There Any Potential Risks Or Complications?

All treatment and outcome results are specific to the individual patient. Results may vary. Complications such as infection, nerve damage, blood clots, blood loss and bowel and bladder problems, along with complications associated with anesthesia, are some of the potential risks of spinal surgery. A potential risk inherent to spinal fusion is failure of the vertebral bone and graft to properly fuse, a condition that may require additional surgery.

Please consult your physician for a complete list of indications, warnings, precautions, adverse effects, clinical results and other important medical information that pertains to the ALIF procedure.

The materials on this Web site are for your general educational information only. Information you read on this Web site cannot replace the relationship that you have with your health care professional. We do not practice medicine or provide medical services or advice as a part of this Web site. You should always talk to your health care professional for diagnosis and treatment.

A lumbar laminectomy is a spine surgery that involves removing bone to relieve excess pressure on the spinal nerve(s) in the lumbar spine, or lower back. A lumbar laminectomy can be performed to relieve symptoms such as back pain and radiating leg pain.

What Is A Lumbar Laminectomy?

A lumbar laminectomy is a spine surgery that involves removing bone to relieve excess pressure on the spinal nerve(s) in the lumbar spine, or lower back. The term laminectomy is derived from the Latin words lamina (thin plate, sheet or layer), and -ectomy (removal). A laminectomy removes or “trims” the lamina (roof) of the vertebrae to create space for the nerves leaving the spine.

Why Do I Need This Procedure?

Spinal stenosis is a condition caused by a gradual narrowing of the spinal canal. This narrowing happens as a result of the degeneration of both the facet joints and the intervertebral discs. The facet joints also enlarge as they become arthritic, which contributes to a decrease in the space available for the nerve roots. Bone spurs, called osteophytes also can form and grow into the spinal canal.

These processes narrow the spinal canal and may begin to impinge upon and place pressure on the nerve roots and spinal cord, resulting in such symptoms as:

• Back pain
• Pain that radiates into the hips, buttocks and legs
• Numbness, tingling and muscle weakness in the back and/or lower extremities

The goal of a lumbar laminectomy is to relieve pressure on the spinal nerves by removing the part of the lamina that is the source of the pressure.

To determine whether your condition requires treatment with a lumbar laminectomy, your doctor will examine your back and your medical history, and may order an X-ray, computed tomography (CT) scan or magnetic resonance imaging (MRI) scan of your spine. A surgical procedure such as a lumbar laminectomy is typically recommended after non-surgical treatment options, such as medication, rest and physical therapy, fail to relieve symptoms after a reasonable length of time.

How Is A Lumbar Laminectomy Performed?

The operation is performed with the patient on his or her stomach, sedated under general anesthesia.

Through an incision made along the midline of the back over the vertebral level(s) to be treated, your surgeon will:

• Gently pull aside soft tissue – skin, fat and muscle – to expose the vertebral bone at the back (posterior) of the spine
• Cut away all or part of the lamina to relieve the source of compression
• Remove any other sources of compression; i.e., bone spurs and/or disc material (discectomy).
• Ease the soft tissues back into place and close the incision.

A lumbar laminectomy also may be performed in conjunction with spinal fusion. This involves placing bone graft or bone graft substitute between two or more affected vertebrae to promote bone growth between the vertebral bodies. The graft material acts as a binding medium – as the body heals, the vertebral bone and bone graft eventually grow together to join the vertebrae and stabilize the spine.

How Long Will It Take Me To Recover?

Your surgeon will have a specific postoperative recovery/exercise plan to help you return to your normal activity level as soon as possible. Following a lumbar laminectomy, you may notice an immediate improvement of some or all of your symptoms; other symptoms may improve more gradually.

The amount of time that you have to stay in the hospital will depend on your treatment plan. You typically will be up and walking in the hospital by the end of the first day after the surgery. Your return to work will depend on how well your body is healing and the type of work/activity level you plan to return to.

Work closely with your spinal surgeon to determine the appropriate recovery protocol for you, and follow his or her instructions “to the letter” to optimize the healing process.

To determine whether you are a candidate for a lumbar laminectomy, please talk to your doctor.

Are There Any Potential Risks Or Complications?

All treatment and outcome results are specific to the individual patient. Results may vary. Complications such as infection, nerve damage, blood clots, blood loss and bowel and bladder problems, along with complications associated with anesthesia, are some of the potential risks of spinal surgery. A potential risk inherent to spinal fusion is failure of the vertebral bone and graft to properly fuse, a condition that may require additional surgery.

Please consult your physician for a complete list of indications, warnings, precautions, adverse effects, clinical results and other important medical information that pertains to the lumbar laminectomy procedure.

The materials on this Web site are for your general educational information only. Information you read on this Web site cannot replace the relationship that you have with your health care professional. We do not practice medicine or provide medical services or advice as a part of this Web site. You should always talk to your health care professional for diagnosis and treatment.

What is it?

Pain in the lower back (lumbar spine) and legs, among other symptoms, may occur when an intervertebral disc herniates - when the annulus fibrosus (tough, outer ring) of the disc tears and the nucleus pulposus (soft, jelly-like center) squeezes out, and places pressure on, or "pinches," an adjacent nerve root.

Lumbar microdiscectomy is an operation that involves using a surgical microscope and microsurgical techniques to access and treat the lumbar spine. By providing magnification and illumination, the microscope allows for a limited dissection. Only that portion of the herniated disc, which is pinching one or more nerve roots, is removed. The term discectomy is derived from the Latin words discus (flat, circular object or plate) and -ectomy (removal).

Why is it done?

Pressure placed on one or more nerve roots by a herniated disc may irritate these neural structures and cause:

• Debilitating leg pain
• Weakness and/or numbness in the legs and/or feet, and
• Bowel/bladder incontinence.

Patients who suffer from these symptoms as a result of a pinched nerve are potential candidates for this operation.

The Operation

An understanding of what a lumbar microdiscectomy involves will help you to approach your operation and recovery with confidence.

Incision

The operation is performed with you lying on your stomach. Because the operation is viewed through a microscope, this approach only requires a small incision. Your surgeon makes an incision in your lower back. Through this incision, microsurgical instruments are then inserted.

Removal

Once your pinched nerve is located, the extent of the pressure on the nerve can be determined. Using microsurgical techniques, your surgeon removes the herniated portion of the disc as well as any disc fragments that have broken off from the disc. The amount of effort required to complete the microdiscectomy depends, in part, on the size of the disc herniation, the number of fragments present, and the difficulty presented in finding and removing these fragments.

Closure

The operation is completed when your surgeon closes and dresses the incision.

Recovery

Your surgeon will have a specific post-operative recovery/exercise plan to help you return to normal life as soon as possible. The amount of time that you have to stay in the hospital will depend on this treatment plan. You will normally be up and walking in the hospital on the same day after your surgery. Lumbar microdiscectomy is usually performed on an outpatient basis, with no overnight stay in the hospital.

As you read this, please keep in mind that all treatment and outcome results are specific to the individual patient. Results may vary. Complications, such as infection, blood loss, and bowel or bladder problems are some of the potential adverse risks of spinal surgery. Please consult your physician for a complete list of indications, warnings, precautions, adverse events, clinical results, and other important medical information.

What is it?

The procedure using the METRx™ System is an operation on the lumbar spine performed using microscope and microsurgical techniques.

The METRx™ System procedure requires only a very small incision and will remove only the portion of the ruptured disc, which is "pinching" one or more spinal nerve roots.

Why is it done?

Lumbar microdiscectomy using the METRx™ System is usually recommended only when specific conditions are met. In general, surgery is recommended when a ruptured disc is pinching a spinal nerve root(s) and you have:

• Leg pain which limits your normal daily activities
• Weakness in your leg(s) or feet
• Numbness in your extremities
• Impaired bowel and/or bladder function

The Operation

Incision

In the operating room, the METRx™ System begins with a small incision in your lower back. Through this opening, your surgeon will insert the endoscope and surgical instruments. Because the work is viewed through an endoscope, this approach requires a relatively small incision.

Reaching the "Pinched" Nerve

Guided by diagnostic studies, your surgeon may remove a small portion of bony material from the back of your vertebra. Once this material is removed, the surgeon can locate the exact area where the nerve root is being pinched.

Identifying the Cause of the Pressure

Once the "pinched" nerve is located, the extent of the pressure on the nerve can be determined. Using endoscopic microsurgical procedures, your surgeon will remove the ruptured portion of the disc and any disc fragments which have broken off from the main disc.

Closing the Incision

The operation is completed when the endoscope is removed and the incision is closed with suture materials and a bandage.

A posterior lumbar interbody fusion (PLIF) is a type of spine surgery that involves approaching the spine from the back, or posterior, of the body to place bone graft between two vertebrae. The procedure may be performed using minimally invasive surgical techniques.

What Is A Minimally Invasive PLIF?

Posterior lumbar interbody fusion (PLIF) is a type of spine surgery that involves approaching the spine from the back (posterior) of the body to place bone graft material between two adjacent vertebrae (interbody) to promote bone growth that joins together, or “fuses,” the two structures (fusion). The bone graft material acts as a bridge, or scaffold, on which new bone can grow. The ultimate goal of the procedure is to restore spinal stability.

Today, a PLIF may be performed using minimally invasive spine surgery, which allows the surgeon to use small incisions and gently separate the muscles surrounding the spine rather than cutting them. Traditional, open spine surgery involves cutting or stripping the muscles from the spine. A minimally invasive approach preserves the surrounding muscular and vascular function and minimizes scarring.1, 2

Why Do I Need This Procedure?

A spinal fusion procedure such as a PLIF may be recommended as a surgical treatment option for patients with a condition causing spinal instability in their lower back, such as degenerative disc disease, spondylolisthesis or spinal stenosis, that has not responded to conservative treatment measures (rest, physical therapy or medication). The symptoms of lumbar spinal instability may include pain, numbness and/or muscle weakness in the low back, hips and legs.

Your surgeon will take a number of factors into consideration before recommending a PLIF, including the condition to be treated, your age, health and lifestyle and your anticipated level of activity following surgery. Please discuss this treatment option thoroughly with your spinal care provider.

How Is Minimally Invasive Lumber Interbody Fusion Performed?

Spinal Access and Bone Removal

First, your surgeon will make a small incision in the skin of your back over the vertebra(e) to be treated. Depending on the bone graft to be used, the incision could be as small as approximately 3 centimeters. In a traditional open PLIF, a 3- to 6-inch incision is typically required.

The muscles surrounding the spine will then be dilated to allow access to the section of spine to be stabilized. After the spine is accessed, the lamina (the “roof” of the vertebra) is removed to allow visualization of the nerve roots. The facet joints, which are directly over the nerve roots, may be trimmed to give the nerve roots more room.

Bone Graft Placement

The nerve roots are then moved to one side and disc material is removed from the front (anterior) of the spine. Bone graft is then inserted into the disc space. Screws and rods are inserted to stabilize the spine while the treated area heals and fusion occurs.

Your surgeon will then close the incision, which typically leaves behind only a small scar or scars.

How Long Will It Take Me To Recover?

This minimally invasive procedure typically allows many patients to be discharged the day after surgery; however, some patients may require a longer hospital stay. Many patients will notice immediate improvement of some or all of their symptoms; other symptoms may improve more gradually.

A positive attitude, reasonable expectations and compliance with your doctor's post-surgery instructions all may contribute to a satisfactory outcome. Many patients are able to return to their regular activities within several weeks.

To determine whether you are a candidate for minimally invasive surgery, talk to your doctor.

Are There Any Potential Risks Or Complications?

All treatment and outcome results are specific to the individual patient. Results may vary. Complications such as infection, nerve damage, blood clots, blood loss and bowel and bladder problems, along with complications associated with anesthesia, are some of the potential risks of spinal surgery. A potential risk inherent to spinal fusion is failure of the vertebral bone and graft to properly fuse, a condition that may require additional surgery.

Please consult your physician for a complete list of indications, warnings, precautions, adverse effects, clinical results and other important medical information that pertains to a minimally invasive PLIF procedure.

1 Stevens KJ, Spenciner DB, Griffiths KL, Kim KD, Zwienenberg-Lee M, Alamin T, Bammer R. Comparison of minimally invasive and conventional open posterolateral lumbar fusion using magnetic resonance imaging and retraction pressure studies. J Spinal Disord Tech. 2006 Apr;19(2):77-86.

2 Khoo LT, Fessler RG. Microendoscopic decompressive laminotomy for the treatment of lumbar stenosis. Neurosurgery. 2002 Nov;51(5 Suppl):S146-54.

A transforaminal lumbar interbody fusion (TLIF) is a type of spine surgery that involves approaching the spine from the back, or posterior, of the body to place bone graft between two vertebrae. The procedure may be performed using minimally invasive surgical techniques.

What Is A Minimally Invasive TLIF?

Transforaminal lumbar interbody fusion (TLIF) is a form of spine surgery in which the lumbar spine is approached through an incision in the back. The name of the procedure is derived from: transforaminal (through the foramen), lumbar (lower back), interbody (implants or bone graft placed between two vertebral bodies) and fusion (spinal stabilization).

The TLIF is a variation of the posterior lumbar interbody fusion (PLIF), in that it provides 360-degree fusion, avoids anterior access and associated complications, decreases manipulation of neural structures, reduces damage to ligamentous elements, minimizes excessive bone removal, enhances biomechanical stability, and provides early mobilization.

Traditional, open spine surgery involves cutting or stripping the muscles from the spine. But today, a TLIF may be performed using minimally invasive spine surgery, a treatment that involves small incisions and muscle dilation, allowing the surgeon to gently separate the muscles surrounding the spine rather than cutting them. A minimally invasive approach preserves the surrounding muscular and vascular function and minimizes scarring. 1, 2

Why Do I Need This Procedure?

A spinal fusion procedure such as a TLIF may be recommended as a surgical treatment option for patients with a condition causing spinal instability in their lower back, such as degenerative disc disease, spondylolisthesis or spinal stenosis, which has not responded to conservative treatment measures (rest, physical therapy or medication). The symptoms of lumbar spinal instability may include pain, numbness and/or muscle weakness in the low back, hips and legs.

Your surgeon will take a number of factors into consideration before recommending a TLIF, including the condition to be treated, your age, health and lifestyle and your anticipated level of activity following surgery. Please discuss this treatment option thoroughly with your spinal care provider.

How Is A Minimally Invasive TLIF Performed?

Spinal Access and Bone Removal

First, your surgeon will make a small incision in the skin of your back over the vertebra(e) to be treated. Depending on the instrumentation to be used, the incision could be as small as approximately 3 centimeters. In a traditional open TLIF, a 3- to 6-inch incision is typically required.

The muscles surrounding the spine will then be dilated to allow access to the section of spine to be stabilized. After the spine is accessed, the lamina (the “roof” of the vertebra) is removed to allow visualization of the nerve roots. The facet joints, which are directly over the nerve roots, may be trimmed to give the nerve roots more room.

Bone Graft Material Placement
The nerve roots are then moved to one side and the disc material removed from the front (anterior) of the spine. A bone graft is then inserted into the disc space. The bone graft material acts as a bridge, or scaffold, on which new bone can grow. Screws and rods are inserted to stabilize the spine while the treated area heals and fusion occurs, and the ultimate goal of the procedure is to restore spinal stability.

Your surgeon will then close the incision, which typically leaves behind only a small scar or scars.

How Long Will It Take Me To Recover?

This minimally invasive procedure typically allows many patients to be discharged the day after surgery; however, some patients may require a longer hospital stay. Many patients will notice immediate improvement of some or all of their symptoms; however, other symptoms may improve more gradually.

A positive attitude, reasonable expectations and compliance with your doctor’s post-surgery instructions all may contribute to a satisfactory outcome. Many patients are able to return to their regular activities within several weeks.

To determine whether you are a candidate for minimally invasive surgery, talk to your doctor.

Are There Any Potential Risks Or Complications?

All treatment and outcome results are specific to the individual patient. Results may vary. Complications such as infection, nerve damage, blood clots, blood loss and bowel and bladder problems, along with complications associated with anesthesia, are some of the potential risks of spinal surgery. A potential risk inherent to spinal fusion is failure of the vertebral bone and graft to properly fuse, a condition that may require additional surgery.

Please consult your physician for a complete list of indications, warnings, precautions, adverse effects, clinical results and other important medical information that pertains to a minimally invasive TLIF procedure.

1 Stevens KJ, Spenciner DB, Griffiths KL, Kim KD, Zwienenberg-Lee M, Alamin T, Bammer R. Comparison of minimally invasive and conventional open posterolateral lumbar fusion using magnetic resonance imaging and retraction pressure studies. J Spinal Disord Tech. 2006 Apr;19(2):77-86.

2 Khoo LT, Fessler RG. Microendoscopic decompressive laminotomy for the treatment of lumbar stenosis. Neurosurgery. 2002 Nov;51(5 Suppl):S146-54.

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 the surgeon, 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 or intensive care unit (ICU) 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, which may seem surprising, if you have had surgery through an incision in the back; however, 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. So, in addition to the IV, a catheter tube (also commonly called a Foley Catheter) may be placed into your bladder to drain urine from your system. 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.

During your hospital stay, you will get additional instructions from your nurses and other members of your surgical teams regarding your diet and activity.

Proper nutrition is an important factor in your recovery. Your surgeon may restrict what you drink and eat, or place you on a special diet, 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 JELL-O® gelatin). From there, you will be given small amounts of solid food until you are ready to return to a regular diet.

With respect to physical activity, in most cases, your surgeon 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 enough to get up and move around on your own.

Home Recovery

Before you are discharged from the hospital, your doctor and other members of the hospital staff 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. So, if you are unsure of any of these instructions, ask for clarification. Following these instructions is crucial to your recovery.

Nowadays, surgery involves one or more incisions depending on the surgical approach used to perform the operation. Therefore, when you are discharged home you may still have a surgical dressing on your incision(s). Either a nurse will 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.

If any signs of infection are observed while changing the dressing, call your doctor. These signs include:

• Fever - a body temperature greater than 101°F (38°C)
• Drainage from the incision(s)
• Opening of the incision(s), and
• Redness or warmth around the incision(s).

In addition, call your doctor if you experience chills, nausea/vomiting, or suffer any type of trauma (e.g., a fall, automobile accident).

During this recovery period, you will also be instructed to keep your incision(s) clean, making sure only to use soap and water to cleanse the area. In general, you should not shower until your doctor has permitted you to do so.

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)
• Walk or do deep-breathing exercises, and
• Gradually increase your physical activity.

Activities to avoid include any heavy lifting, climbing (including stairs), bending, or twisting. You should also avoid the use of skin lotion in the area of the incision(s); you need to keep this area dry until it has had the opportunity to heal well.

Follow up with your doctor on a regular basis during this post-operative period, and make sure to call your doctor if you have any concerns or questions.