What is spinal fusion and why might I need this surgery?
One of the main goals of any surgical procedure on the skeletal system is to stop the pain caused by joints that have worn out over time. One of the more reliable ways to reduce pain from degeneration is to fuse the joint together. A fusion is an operation where two bones, usually separated by a joint, are allowed to grow together into one bone.
Back pain is common and affects about 80% of Americans at some time in life. It is usually caused by overuse, muscle strains, poor body mechanics or injury. Degenerative disc disease (DDD) affects up to 40% of all patients with low back pain and is generally caused by the conditions mentioned above and is related to aging and wear and tear on the back.
Your back is made up of bone vertebrae and cushioning discs and those discs can wear out, tear or rupture. When damage occurs, and the cushioning effect is lost, pressure is exerted on nerve roots. This can lead to nerve impingement, a cause of the inflammation and debilitating pain that is often associated with disc disease and may be the reason your Doctor recommended lumbar fusion. (See the animated lumbar spine illustration to the right.)
Initially, your doctor will recommend a conservative treatment approach. If a physician suspects a disc problem, a MRI or CT scan can be performed to evaluate disc damage. Pain medication, anti-inflammatory drugs, physical therapy and lifestyle changes usually are the first line of treatment. Once patients get past the immediate acute pain, they are expected to work on a long-term program of back exercises, stretching, and, in some cases, modification of their work environment to decrease back stress.
After more conservative options have been attempted without success, physicians may suggest surgical options. Back surgery carries a certain degree of risk because of the proximity to the spinal cord. And there’s always the possibility a surgical procedure, even one performed successfully, might not bring pain relief.
Lumbar spinal fusion is the most frequently performed of all spinal fusion operations. For many years the gold standard surgical treatment for degenerative disc disease has been spinal fusion. In a healthy spine, the cushioning disc allows motion to occur between each vertebra. Removing a degenerated disc and allowing the two vertebrae to fuse together can stabilize the area, restoring the spine to it's proper height, and reducing pain because the nerves are no longer pinched.
Only when all other conservative treatments have failed will your doctor suggest fusion surgery. Over the past 40 years, lumbar spinal fusion has become the standard of care in the management of several pathologic conditions. The following conditions may require a spinal fusion:
- degenerative disc disease
- spinal instability
- spine curvature
- spondylolysis and spondylolisthesis
- facet joint problems
- spinal trauma
A number of advances in technology have improved the success of spinal fusion, giving surgeons better materials and procedures to work with.
My Doctor has recommended lumbar spinal fusion. Why should I ask my doctor if I am a candidate for the XLIF® procedure?
Due to advances in medical technology, patients suffering from pain due to degenerative conditions now have more options than ever before. Each option has its own set of risks and benefits. Generally speaking, each procedure is defined by the "approach", or the way in which the surgeon accesses the spine. There are several fusion treatment approaches, including traditional approaches such as anterior, posterior and posterolateral, a combination of anterior and posterior, and the latest approach is lateral. Please note that not everyone is a candidate for the XLIF® surgery, once conservative (non-operative) treatments have failed, you should consult a surgeon to see if you are an appropriate candidate.
Because the incision is so much smaller and less trauma is done to other tissues in the body during surgery, blood loss is minimal and most XLIF® patients are able to return home from the hospital within one to three days.
Benefits to patients:
- Less-invasive procedure allows for less tissue disruption
- Procedure provides relief to patients who have lived with back or leg pain through years of various failed treatments, including steroid injections, physical therapy, and pain medication
- Patients are typically walking the same day after surgery and require only an overnight stay in the hospital, compared to several days of immobility and hospitalization typical of traditional open approaches
- Rapid return to normal activity, typically weeks, compared to months
How is the surgery performed?
XLIF uses minimally invasive techniques which means the surgery is performed through small incisions, usually with the aid of microscopes or endoscopic visualization (very small devices or cameras designed for viewing internal portions of the body). The "inside" view of the patient's body is projected onto television screens in the operating room.
Minimally invasive spine surgery was developed from the desire to effectively treat disorders of the spinal discs with minimal muscle-related injury and with rapid recovery. Minimally invasive techniques offer several advantages including tiny scars instead of one large scar, minimal muscle-related injury, a shorter hospital stay (two to three days versus five to six), reduced post-operative pain, a shorter recovery period and the ability to return to work and daily activities much sooner.
During the XLIF procedure the lumbar spine is approached from the your side (laterally), your surgeon will use an X-ray to precisely position and locate the operative space. Next, your skin will be marked at the site where the two small incisions will be made. Your surgeon will use the latest instrumentation to access the spine in a minimally disruptive manner. The surgery is performed through a muscle that lies next to the lumbar spine known as the psoas muscle. Disc preparation is the next step. This is done by removing the disc tissue which will allow the bones to be fused together. Several X-rays will be taken during this stage to ensure the preparation is correct. Once the disc has been prepared, the surgeon will then place a stabilizing implant (an artificial graft) into the space to restore the disc height and enable the bones to fuse together. Once in position, a final X-ray will be taken to confirm correct implant placement. In the event that further stabilization is necessary, the surgeon may choose to insert additional screws, rods, or plates into the vertebrae.
For a single level XLIF procedure, the surgery can be usually be performed in about an hour. Most patients stay in the hospital for 24 hours following the procedure, and do not require a brace. Occasionally, weakness may be noticed while lifting your leg after surgery. This psoas muscle weakness should return to normal fairly soon after surgery. (Watch a new clip on a XLIF patient - with an animation of the procedure.)
Is an MRI the only test used to determine if and what nerves are being compressed?
An MRI scan is definitely the best test, but there are other alternatives. A CT scan with myelography is just as effective as an MRI but is more painful because it involves a spinal injection. An EMG study of the leg (electromyography) can explore whether a muscle group is affected; but this is a non-specific test and does not find a lot of disc herniations.
When is spine surgery usually necessary?
Surgery is recommended for spinal problems only after all appropriate conservative measures have been applied. If symptoms are not controlled effectively with medications, physical therapy and injections, then surgery can be considered, depending on the specific situation.
Do I need a fusion?
Although our physicians are trained and experienced in these techniques, a fusion is not a procedure to be taken lightly.
Instability is the commonly accepted indication for fusion; in patients that meet the strict criteria for instability in the lumbar spine, a procedure with or without instrumentation will be discussed.
An inordinate number of lumbar spinal fusions are currently being done in this country, with little agreement on indications and requirements for this procedure. What is known, is that the complication rates and failures in patients chosen with liberal criteria are quite high. These considerations are weighed very seriously before lumbar and cervical fusion is considered for treatment.
Can I bend over if I have a fusion?
Yes. Most of the motion, when you bend at your waist, occurs in yours hips. Most likely, you’ll only have 1 or 2 levels of your spine fused. Sacrificing some motion may occur – but the alternative is less back pain, allowing you to have better motion than before. Generally, there is very little change in motion from this operation.
What are the alternatives to spinal fusion?
There are alternatives to spine fusion surgery that may be considered for patients with low back pain from lumbar degenerative disc disease. Currently, the main fusion alternatives include:
Intradiscal electrothermal coagulation (IDET): IDET is a minimally invasive procedure, which uses a needle to pass a heated catheter into the lumbar disc space, heating up the annulus (the outer core of the disc space) in an attempt to stabilize a painful disc and disable the associated nerve. It is theorized that the heat contracts and thickens collagen fibers in the disc wall, which in turn seals up painful tears and cracks and reduces pain. This procedure will likely become obsolete in the near future after further independent studies are completed. Not all patients benefit from IDET, and the treatment is more likely to help people with less severe degenerative disc disease that people with significant disc degeneration.
Artificial discs: Disc replacement surgery involves replacing the painful disc in the spine with an artificial disc. The FDA has approved at least two brands of lumbar artificial discs: the Charite lumbar artificial disc and the PRODISC-L lumbar artificial disc. A number of other artificial disc brands are in the clinical trial testing phase. The goal of artificial disc replacement surgery is to preserve the normal motion of the spine. Artificial disc surgery has two primary theoretical advantages over spinal fusion; 1) it is thought that preserving spinal motion reduces the risk that other segments of the lumbar spine will wear down prematurely; 2) it is believed that artificial disc surgery may achieve better pain reduction than fusion. Not all patients are candidates for this procedure and the long term safety and effectiveness of the artificial disc has yet to be proven.
Posterior dynamic stabilization: This treatment is different from fusion in that posterior dynamic stabilization seeks to preserve motion in the spine while also taking pressure off the diseased vertebral disc. The theory is that removing pressure from the painful disc will create a favorable healing environment and reduce pain. The devices used in the surgery are designed to unload pressure from the vertebral disc in the same way a dynamic (moveable) brace unloads pressure from an injured knee or ankle to allow it to heal. Various forms of posterior dynamic stabilization devices are still in the investigative or testing phase or early in use, and their safety and effectiveness has yet to be proven.
Disc regeneration: Researchers in cellular and molecular biology are exploring ways to use gene therapy to stimulate regeneration of the vertebral disc and/or to slow or prevent degeneration of the disc. The hope is that this therapy could prevent the need for surgery. For example, in animal studies, the BMP-12 gene (bone morphogenetic protein) has dramatically increased the generation of cells in both the nucleus and the annulus of the vertebral disc. BMP-12 is a molecule that, among other duties, promotes formation of embryonic joints. Research is also being performed on gene therapy that could inhibit the degeneration process. Gene therapy for treatment of the intervertebral disc is still in the early stages of research.
Percutaneous Arthroscopic Discectomy with Laser Thermodiscoplasty: This is a new procedure to shrink and remove a herniated disc. Using brief general (cervical) or local (lumbar) anesthesia and the help of x-rays for guidance, specially designed micro-instruments, the discectome and a laser probe are inserted into the herniated disk space, and a portion of the offending disk is removed with suction and then vaporization with a laser to shrink the disc further, instead of open surgery. This minimally invasive procedure can remove the portion of the disc that has herniated without removing the entire disc. These procedures alleviate all pain and symptoms associated with the herniation while leaving the healthy portion of the disc intact. Not all patients are candidates for this procedure.
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