To Fuse or Not to Fuse: The Spinal Question
By Dr. Jeffrey R. Carlson

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.

About the Author: Dr. Jeffrey R. Carlson is doctor at the
Orthopaedic and Spine Center, a leading provider of
http://www.osc-ortho.com Hampton Roads orthopedics services such
as http://www.osc-ortho.com/services/spine.html Newport News
spine surgery, http://www.osc-ortho.com/services/knee.html
Newport News custom fit knee replacement, and many other
services. The Orthopaedic and Spine Center can be found online
at: OSC-Ortho.com .

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