To Fuse Or Not to Fuse – The Spinal Question

Spinal fusion is one of the most feared and misunderstood surgical procedures for the spine. Everyone has heard some kind of frightening story about a distant family member who had back surgery and was never the same afterward. Many patients think a spinal fusion will cause their spine to become completely rigid, and they envision a future of robot-like stiffness with the inability to bend their backs or touch their toes, after surgery. Over the past decade, spinal fusion has also had a less than bright reputation as a treatment for pain. Given the overall perception that fusion of the spine is a delicate surgery with questionable outcomes, patients are quite concerned about proceeding with a fusion. This article will help to dispel many of the misconceptions that surround this treatment and why it is important to understand the procedure, when it should be performed and who might benefit from a spinal fusion.

What is Spinal Fusion?
Spinal fusion is a surgical procedure designed to provide stability to an area of ​​the spine that has too much movement or movement that causes pain, tingling, numbness or weakness in the arm or leg. The object of a spinal fusion is to connect the bones (vertebrae) that were previously too mobile and form a connection of bone in the spine that is more rigid.

A History Lesson
Orthopaedic surgeons have long applied casts to broken bones to provide support to fractures and allow the bones to heal. The addition of this external support keeps the bones from moving. Why is this important? When there is too much movement between broken bones or bone fragments, the repair cells are prevented from being able to connect the bone fragments together, so their process of healing will stop.

As orthopaedic surgeons have progressed in the use of technology, plates and screws, called internal fixation devices, are now applied to fractured bones. These rigid internal fixation devices are stronger and add more support to the fractured bone. Plates and screws have been able to replace bulky external casting in a large group of fracture types.

The same treatment principles are used by the orthopaedic spine surgeon. There was a time when fusions were supported with external bracing. This external support, provided by casting or rigid bracing, has now been replaced with internal rods and screws. Using these internal supports provides stronger bone connections that decrease motion even more. As a result, the number of successful fusions has increased. The internal support of the spine is stronger, allowing patients to get up and out of bed and walk the day of surgery and to return to their usual activities in 6 weeks. This is a far cry from the days of original spinal fusions that were supported with a cumbersome hard plastic brace or cast, leaving patients with limited mobility or bed rest for many months.

Spine surgeons are now better able to determine which patients will be helped with a spinal fusion. Advanced imaging studies, including MRI and bone scans, as well as the use of diagnostic injections, help today's spine specialist more accurately diagnose patients whose conditions would benefit from spinal fusion. Advances in surgical techniques and components, including the development of better screws and rods, also have greatly improved patient results. Improved diagnostic and surgical training, including advanced training in spine fellowship programs, has helped spine surgeons interpret and use these advances in technology to obtain better outcomes for patients.

Who Needs a Spinal Fusion?
As with all surgeries, there are proper uses that will result in good outcomes for patients with spinal fusion.
In patients where the spinal bones have begun to slip and cause pressure on the spinal nerves (spondylolisthesis), this excessive movement may need to be stopped to prevent worsening of the nerve pressure. During surgery, these patients will have the bone spurs and disc protrusions removed from around the nerve roots and spinal cord, which may destabilize the bones of the spine and cause the bones to slip more. Inserting screws and rods in these bones will prevent the bones from slipping any further after surgery and also may be used for correction of the original slippage.

Use of screws and rods can also provide stability and correction for patients with scoliosis. Scoliosis is the bending of the spine in an abnormal direction. The curve of the spine may increase with time or may be painful as the curvature of the spine increases. If the patient has a large curve or the curve is continuing to get worse, screws and rods are used to correct the position of the spine and prevent the curve from worsening.

In patients with obvious bone destruction from fracture, tumor or infection, stabilizing the bones with screws and rods will provide the support that is needed so the underlying disease can be addressed. The structure of the spine can be improved while the patient receives chemotherapy or radiation. By removing the tumor in the spine, the back pain related to an expanding tumor can be relieved and the patient can remain mobile, which helps to prevent pneumonia and blood clots. Being ambulatory, while receiving chemotherapy and radiation, also improves the patient's mood and outlook while coping with their disease.

Who is Not a Candidate for Spinal Fusion?
Most patients with disc herniations or pinched nerves will not need a spinal fusion. These conditions can be treated with simpler procedures that allow the removal of pieces of discs or bone spurs that do not increase the movement in the bones.

The more difficult indication for spinal fusion is in the patient with severe pain in the back. Degenerative disc disease is still the leading cause of back pain in the United States, but back pain can have many underlying causes. One of the reasons that spinal fusion developed a bad reputation is that they were performed as a remedy for back pain that did not respond to other forms of treatment. Older fusion methods and inadequate diagnostic approaches left surgeons with few options for treating these patients, so some patients were given fusions as a last attempt to improve their pain. Most patients with lower back pain and degenerative disc disease will not need a spinal fusion.

What Can Be Expected From Spinal Fusion?
It is expected that most patients will be back to their usual state of health and activity at approximately 6-8 weeks after their fusion surgery. Most patients will be pain-free after their spinal fusion. It is important to choose a well-trained surgeon to make educated decisions about your diagnosis and treatment. With the combination of the proper diagnosis and properly applied spinal fusion most patients will have very good outcomes.