Do I really need a spinal fusion?
Perhaps you have a painful spine condition and have seen a specialist who recommended a fusion but didn't offer you any alternatives to a spinal fusion. The first question that pops into your mind is “do I really need a fusion”? There is a “black and white” answer to this question,
as well as a number of grey areas.
What are the “black and white” conditions that require fusion?
There are four conditions where a fusion is absolutely indicated, and where there is very little debate about the need for a fusion.
- Spine Deformity that needs to be corrected, examples are severe scoliosis or kyphosis.
- Trauma that causes a fracture or dislocation of the spine will probably need a fusion.
- Tumor or other destructive process requires fusion.
- Excessive motion or “Instability” after previous surgery.
An example of “instability” is a nonunion of a fusion. A nonunion occurs If the fusion surgery doesn’t “take” or unite. This is another reason to avoid a fusion whenever possible. When a fusion fails, you are generally in need of an additional fusion surgery to stabilize the segment of the spine that moves too much (nonunion).
What are the “grey areas” that may require a fusion ?
- Deep midline back pain from a degenerated disc.
- Stenosis, either central or foraminal in the lumbar or cervical spine that causes shoulder, arm or hand pain or buttock, thigh, leg or foot pain.
- “Instability”. This is a nebulous term, since the spine is supposed to move, but how much? This is a common reason that a fusion is recommended and maybe not a very good one. A common example of a fusion for “instability” is a degenerative spondylolisthesis. Decompression without a fusion may be all you need.If you do not have a “black and white” condition, the chances are good that there are alternatives to a fusion to relieve your spine or extremity pain.
What is the underlying philosophy behind a fusion?
The underlying philosophy of a fusion is “No motion, no pain". The purpose of a fusion is to eliminate all motion at a particular disc level.
A fusion is accomplished by removing a disc that once provided motion. The disc is replaced with an implant and/or bone graft that will be incorporated between the vertebrae to eliminate motion. Rods and screws might also be necessary to hold the vertebrae still while the fusion heals, so it will go on to union and be solid.
What do I need to know about a fusion?
It is permanent and not reversible. There are two things that are going to happen when you have a fusion:
- There will be implants in your back - rods, screws, bone graft or disc implant/spacer.
- There will be complete loss of motion of the segments fused. If you don’t like your fusion, there is no going back. The only option is to revise the surgery, extend the fusion or try a spinal cord stimulator. Revision of fusion surgery does not have a very good track record of success.
Recovery and return to work is about 3-6 months
How successful is a fusion?
Success is a relative term, which means that we must look at the criteria used to determine a success or failure. For example, are we looking at correct hardware placement or examining the level of remaining pain? I have seen a lot of patients where the fusion and hardware looked perfect on the x-rays, but the patient was miserable.
This is a difficult question to answer since there are so many reasons that may result in a fusion. Dr. JA Turner did an article based on a review of 47 fusion articles and noted an average of 68% with satisfactory outcomes, with a wide range of outcomes.
He also noted that “for several low back disorders no advantage has been demonstrated for fusion over surgery without fusion, and complications of fusions are common”. If only 68% are satisfactory, what about the other 32%?
As an example, general health and bone hardness are important, but whether one smokes is also critical. In the Flum study a 45-year-old man with private insurance might have a 51% chance of minimal disability a year after surgery if he has never smoked, but that success rate plummets to 26% if he's a smoker.
What does “minimally invasive” really mean?
Nothing, it is a vague term used to describe a procedure that is usually performed through a smaller incision than “usual”. The minimally invasive procedure is usually done through a tube that acts as a soft tissue retractor (tubular retractor). The diameter of the tube is rarely mentioned and the procedure could be a fusion, even though I hardly consider a fusion a “minimally invasive” procedure. Remember that a 7 mm screw can be placed through a “minimally invasive” tube. It appears that a fusion performed through a tubular retractor (minimally invasive) does have a lower infection rate, but it is still a fusion.
Is a fusion minimally invasive?
Hardly. Even though an incision might be small enough to place the hardware, the goal of removing the motion from a segment of the spine (fusion) is hardly a minor procedure. A fusion is irreversible and can have life-long effects.
Is robotic spine surgery minimally invasive?
At this point in time, “robotic surgery of the spine” means that you are getting a fusion. The robot works in concert with imaging to ensure that the hardware is placed accurately. The procedure might be described as “minimally invasive” (small surgical incisions), but a fusion is not a minor procedure. If you have an option to avoid a fusion, take it. You can always do a fusion later as a last resort.
What can you expect after a spinal fusion? Problems.
The main problem with a fusion is that it is not uniformly successful and if it fails (failed back syndrome), there is no going back; the only way to fix a problem is more surgery.
The problems with a fusion are short term and long term. Short term problems after a fusion are the issues usually that occur in the first few months after the surgery.
Short term problems
- Spinal Fluid Leak 4.5% Your nerves are floating inside a sac covered with delicate tissue called the dura. The dura can be torn inadvertently during spinal surgery. Although this can be repaired at surgery, there is a risk that the initial repair will not work and subsequent surgeries will be needed. Spinal Fluid Leak 4.5% / 2.7 - 3.7 % Dr. Muller
- Excessive bleeding that requires transfusion 4% to 8% Unfortunately, significant blood loss remains a major concern in spine surgery. According to Dr. Ristagno, lumbar spine fusion has been recognized to be among the top 10 surgical procedures that necessitate blood transfusion, with a rate that increased from 4% to 8% in the United States from 2000 to 2009, and as high as 18% in many instances during the most recent years .
- Misplaced hardware - Accounts for 1 %
- Nerve damage. Many people worry about nerve damage. While this risk is always a consideration, nerve damage occurring during a spinal fusion surgery is rare and permanent nerve damage is extremely unlikely.
- Surgical site infection Deep 1% and Superficial 1% Although a risk with any surgery, infection is uncommon. Antibiotics are administered at regular intervals before and during the surgery to help eliminate the possibility of an infection developing in or near the surgical site. Surgical site infection 2-6% / 0.1% Dr. O’Toole
- Graft site pain 15-39% This is when bone graft is harvested from the iliac crest of the pelvis. Dr Sasso noted a 15-39% incidence of donor site pain 2 years out
- Formation of blood clots in legs - 11.8% Another risk many people worry about is the formation of post-surgical blood clots in the legs. Clot formation is possible with any surgery, and precautions are always taken to prevent this occurrence. If you are aware of a clotting condition in yourself or in family members, be sure to mention it to your surgeon before the surgery date. https://www.ncbi.nlm.nih.gov/pubmed/3020077
- Development of pseudoarthrosis Cervical 1.2% / Lumbar 1.8% - 8.8% People who smoke have a much higher chance of developing a condition called pseudoarthrosis. When this condition occurs, bone formation is not adequate in the surgical area and additional surgeries may be required to achieve a solid bone fusion. https://www.ncbi.nlm.nih.gov/pubmed/31913178
- Long term opioid use after Lumbar fusion surgery 32.2% https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5955818/
Long Term Problems
- ADD (Adjacent disc disease)
The spine was designed to move and if you fuse a part of the spine, the remaining parts that do move, will have to do extra work to compensate. This can cause premature “wear and tear” problems and is referred to as “Adjacent Disc Disease”.
Adjacent Disc Disease which occurs at the ends of the solid fusion. In other words, the remaining levels of the spine that can move, will have to move more to make up for the levels that were fused. This results in premature wear and it occurs at a given rate. Degenerative
changes of adjacent levels occur at a rate of 5% per year after a lumbar spine fusion and 2.5% per year after a cervical fusion.
It should be obvious that the younger you are when you have a fusion, that the more likely it is that you will have “adjacent disc disease”. If you have adjacent disc disease, it doesn’t necessarily mean that you will need more surgery, but it certainly points you in that direction. The fact is that ten years after you have a lumbar fusion, there is a 50% chance of radiographic evidence of degeneration of joints adjacent to the fusion levels because of compensation and overwork. A fusion will cause adjacent disc disease, the question will be whether it will require additional surgery. Often the “solution” will be more fusion surgery; it can be a slippery slope.
What is the rate of reoperation after a fusion for lumbar spinal stenosis after 10 years?
- Incidence of reoperation was 20.6% after anterior fusion
- Incidence of reoperation was 12.6% after posterior fusion
Which gives better results for lumbar spinal stenosis, a decompression alone or with a fusion?
This is a very difficult question to answer since there are large review articles that have opposite conclusions about decompression alone versus decompression with a fusion. When I see such discrepancies, my take is probably there is not much difference between the decompression alone or decompression and a fusion. Dr. Chen et al, concluded that decompression and fusion surgery did not yield better clinical outcomes than decompression alone surgery. Also, the complication rate and reoperation rate were comparable between treatment groups. However, patients who had undergone decompression alone had a shorter operation time, less intraoperative blood loss, and shorter hospital stay. (https://www.ncbi.nlm.nih.gov/pubmed/29248779)
Dr. Ahmed et al, concluded that decompression with fusion is a 3.5-times better surgical technique than decompression alone for spinal stenosis.(https://www.ncbi.nlm.nih.gov/pubmed/30345192)
I’m not even sure how you’d measure a 3.5-times better outcome, so it sounds a little odd right there.
Why not just fix the problem in the spine instead of fusing it ?
This is the same question I asked myself over 20 years ago and there are many reasons, some of them are medical and some are not. With endoscopic spine surgery techniques and equipment, it is really possible to fix or repair things that were difficult to address in the past. So if you can fix or repair things to a point where nature can finish the healing process, isn’t that preferable to removing motion with a fusion? As with most things in the body, motion is good.
Endoscopic spine surgery is decompressive (no fusion) in nature and requires minimal disturbance or collateral damage of tissues that surround the problem. It solves a pain problem by removing the source of the pain. Endoscopic spine surgery is performed through a tube size that is well defined depending on what type of surgery is being performed. The tube size ranges from 3mm to 10 mm. The tubes are so small that they are sealed with the skin, so no air ever reaches the operative site! The mechanics of endoscopic spine surgery are different, in that water pressure is used to retract the soft tissues in a closed system so there is no exposure to any air (in the operating room). This means there is a continuous flow of sterile water flowing across the operative site to help remove any debris. Since there is no contact with room air (unlike open or “minimally invasive” surgery with larger tubes), there is almost no possibility for infection! You can preserve your spine range of motion with an outpatient procedure that has minimal blood loss (2-3cc), and almost no infection rate. Endoscopic spine surgery should be considered first for any cervical, thoracic, or lumbar spine problem that causes pain before resorting to a fusion. Remember a fusion can always be performed at a later date if necessary.
Why isn’t Endoscopic Spine Surgery more commonly recommended?
When a patient is seeking treatment for a medical condition, who are they going to ask? The first person they will ask is the specialist. In the case of endoscopic spine surgery, there is very little formal training available and I will be the first to tell you that it is not easy to learn. In fact, just because you have an MD after your name, doesn’t mean that you will be able to master this technique. Not everyone has the three-dimensional skills necessary to do this surgery.The result of this is that it stays relatively unknown as a technique to treat painful conditions of the spine. I only know of one place in the US where it is a part of a regular spine training program (University of New Mexico).
The second group many ask for a recommendation is the primary care physician. However, when a doctor wants to know something about a topic outside of their specialty, they will usually ask someone in that specialty, so if the specialist doesn’t have any training or knowledge about a procedure, it follows that they won’t say much about it.
Of course, the next question is why it remains relatively unknown even though it has a lot of benefits for the patient. There are three main reasons for this and they are mainly related to reimbursement. The fact of the matter is that reimbursement directs what many people do in the medical arena. If the reimbursement doesn’t cover the cost of doing something (equipment, personnel, and time in the operating room), it won’t be done for very long. And in the case of endoscopic spine surgery, it is all outpatient, which means that the hospital doesn’t get the extra reimbursement from an overnight stay, not to mention the operating room reimbursement for equipment, time, and personnel for a decompression code. The surgeons are reimbursed at a much higher rate for a fusion than a decompression procedure.
The implant companies would also lose a large revenue stream since endoscopic spine surgery doesn’t emphasize fusions that require their equipment. These are the companies that sponsor medical meetings and conferences, as well as support research papers and projects. The implant business is a multi billion dollar industry that would suffer if decompression became the mainstay of treatment for painful spines. If you don’t think the implant companies have a large stake in directing the reimbursement for fusions, consider this. Lumbar fusion surgery for degenerative spinal disorders is usually undertaken to treat chronic back pain, and is more invasive than decompression surgery alone. Nationally, the number of spinal fusion operations has tripled in the past 2 decades HCUPnet. Agency for Healthcare Research and
Quality; [Accessed May 24, 2017].
12 Benefits w endoscopic spine surgery
- Outpatient procedure with short recovery (4-6 weeks)
- Actual problem addressed
- No fusion
- Leaves you options if not satisfactory
- Is the ultimate in “minimally invasive spine surgery”
- Incision less than ½ “
- No air contact with the operative site
- Short recovery with minimal or no physical therapy post op
- Less surgery means less pain
- Less narcotic use post op
- Minimal if any “Failed back surgery syndrome”
- Minimal scar tissue formation