A lumbar fusion is an operation usually done for lumbago (back pain as opposed to sciatica or leg pain). A lumbar fusion is a type of lumbar disc replacement surgery. The disc is replaced with bone. The new bone eventually heals in place. Two or more vertebral bones become one solid unit. To do a lumbar fusion, the surgeon removes a disc, replaces the disc with bone, and inserts screws or rods to hold the bones in place as they heal.
Lumbar fusions have been done for about forty years. The science is constantly advancing. The fusions done today look almost nothing like those done forty years ago. Once very major and extremely painful surgeries, they can now be done with minimally invasive techniques. Even ten years ago, almost half of fusions failed. Because of the large incisions, the pain and the high failure rates, people told “horror stories” about their lumbar fusions. The changes which have made fusions safer, less painful, and more often successful have to do with several recent “high tech” advances. New instruments allow us to use smaller and less painful incisions. The newly titanium spine hardware is easier to install and rarely needs to be removed. Perhaps the greatest advance has been the development of a bone growth hormone called “bone morphogenic protein” or “BMP.” This hormone makes bones heal together quickly and reliably. The hormone means that a hip graft is no longer needed. The hip graft was once the most painful part of the operation.
Because of the new techniques, hospital stays are now shorter, the amount of time off work is less, and patients can return to a normal activity level in a few weeks in many cases.
Lumbar fusions can be done using any of several approaches. The approaches are named by the place where the fusion bone is placed. A “posterolateral fusion” is done by adding new bone and growth hormone along the back (the posterior) and sides (the lateral areas) of the vertebral bones. “Interbody fusions” involve the placement of bone and bone morphogenic protein in the disc space (interbody means between the bone bodies). “Facet joint fusions” are done by replacing the small joints in the back with solid bone. Combinations of two or more of the above techniques are common.
How do you decide that you need a fusion?
The most common indications for fusion include:
- Mechanical back pain (often from disc disease)
- Spondylolysis (a congenital deformity which occurs in 6% of the population)
- The failed back syndrome
- Spinal stenosis (when there is also instability)
- Scoliosis (deformity)
Why do so many people have back surgery?
Eighty percent of adults will develop low back pain at some time in their life. The painful symptoms are most often brief and need little or no medical treatment. A small percentage of people who do not get better with conservative care, may need an operation.
Are there any tests that predict whether a fusion will work?
A discogram is a study that can be very helpful. Before considering a lumber fusion, most doctors recommend this study. The discogram study involves inserting a needle into the disc and injecting a small amount of dye. If this injection causes the patient's usual pain, it is presumed that the painful disc is the cause of the pain. Other studies may be needed such as an electromyography (EMG). This study involves tiny needles in the legs to determine whether the nerves are working properly. A selective nerve root block (SNRB) can be quite helpful, to identify the damaged nerve. This is also used for treatment.
What are the risks of a lumbar fusion?
Potential risks and complications of a spine fusion surgery are the same as with any major surgical operation. Basically they including four types of problems:
- damage to the tissue where we work and,
- medical problems usually associated with the anesthesia
- Bleeding is now uncommon. Only about three or four shot glasses of blood are lost in most fusions. Transfusion is rarely needed and can almost always be avoided. If a person wants, they may set aside some of their own blood in advance.
- Infection occurs about one percent of the time. It is a very serious problem when it does occur. It can take months to treat. Ask your surgeon about his infection rate. If it is more than two or three percent, go elsewhere. Note that infection can occur any time the skin is opened. It is one of the risks common to all surgical operations.
- Damage to the structures worked on is the most common risk of any of the spine fusion surgery. There are several types of possible damage:
- Pain symptoms following is the commonest risk. This occurs in about five to twenty percent of spine fusion patients. It is most common with fusions of three or more levels.
- The fusion may not heal solidly. People who smoke, those who are overweight, those with other medical problems and those who have had a prior failed fusion are at the greatest risk.
- The graft or the pedicle screws may cause problems such as pain. The pain is usually easy to treat but may not be possible to cure.
- Nerve damage occurs in a small percentage of all patients with fusion. It can cause pain, numbness, or weakness. In men who have an anterior fusion, there is a one percent risk of problems with ejaculation (but not with sex or impotence). This usually resolves over six to twelve months.
Medical complications are usually related to the anesthesia and include heart problems, lung problems, pneumonia, stoke and even death. The chance of a serious or permanent complication is less than one in a thousand. To decrease this risk, our practice has all patients seen by an internist before surgery.
What will happen to me on the day of surgery?
The staff will have you report to the hospital a few hours to a day before the surgery. Once there, the nurses will ask you a number of questions, examine you, and get you ready for surgery. You will probably have to answer the same questions many times. This is done for your safety.
The anesthesia specialist will either talk to you the night before surgery or shortly before the operation. Occasionally an anesthesia consultation before surgery is needed. Under most cases, general anesthesia (with the patient asleep) is required for this operation.
RECOVERY ROOM —
When you wake up, you will notice the dressing on your back, the I.V. in your arm, the catheter in your bladder, and the squeezing boots on your legs. You will notice plastic drains in your back. The nurse may give you some pain medications or may give you back some of your own blood. Your relatives probably will not be able to visit you until you have left the recovery room. The recovery room tends to be very crowded and very busy.
AFTER SURGERY —
After surgery, it is normal to be a little “fuzzy.” Family and friends can visit. You may not want to have them visit for long periods, however.
PAIN CONTROL —
After your surgery, you will be given pain medications by way of a “PCA” pump. This machine will deliver a dose of pain medication every time you push a small button. As your pain improves, the pain medication will be changed to pills. You will be on pills before you go home.
GETTING UP —
You should be able to get up with the assistance of the physical therapist, either the day of the surgery or the day after the surgery. The first time that you stand up you may be a little unsteady. Do not worry. This is normal. You may also require a walker or a cane for the first few days. This is also normal.
BREATHING AND CIRCULATION EXERCISES —
-- For the first few days after the surgery you will not be moving around much. It is important to avoid complications by taking deep breaths and by doing gentle exercise. The breathing exercise will decrease the risk of lung problems. The exercise will reduce the chance of blood clots.
BATHING AND INCISION CARE —
You may shower on the second or third day after the surgery. You may want to take a bath until at least a day or two after the sutures have been removed. Sutures are usually removed after the first postoperative visit following the discharge.
RECOVERY PRECAUTIONS —
The most frequent adverse effect is a flare-up of pain. The surgery may cause a transient increase in pain. Walk slowly and be careful. Do not do too much. Do not do any bending, stooping, or lifting.
INSTRUCTIONS FOR DISCHARGE —
Before you come in the hospital, you will generally receive discharge instructions. You will need to follow the instructions carefully. You will need to make each of your appointments. If you do not come to the appointments, we will not be able to provide good care.
What alternatives are available?
Spinal fusion is not the only treatment for back problems. One may opt to do nothing. One may opt to do a lesser surgical treatment (such as a discectomy). One may avoid surgery entirely and treat pain with medications and exercise. If one does a fusion, there are a variety of different fusion devices. You should talk to your spine surgeon before undergoing spine surgery to make sure that you understand all of the available options. Generally choose the safest, least invasive, and most effective procedure.
Will I go back to work and normal activities after surgery?
The best answer to this question is “maybe.” Most patients go back to their old job but few can do very heavy work. Most go back to their old hobbies but, again, very strenuous hobbies may not be possible. For example, following this operation, one should not go jogging.
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