If you are reading this, it’s probably unlikely that you have a fracture that is unstable since most people that have that condition usually present to an emergency room and are not going to be spending time searching around for whether or not they need a fusion.
In my experience, there are 3 good reasons to consider doing a spinal fusion.
- If you have a fracture or instability that is putting your spine at risk for injury
This is basically stabilizing the bones in the spine so that they’re not going to be putting the nerves of the spinal cord at risk.
- If you have an unstable spine
This is similar to a fracture, but you can develop instability of your spine when you have spine degeneration. This instability or slippage of the spine can cause the nerve to be pinched and it can also cause back pain.
This is called spondylolisthesis or spondy. If you don’t fix that slippage of the spine, then performing some sort of procedure to decompress it is going to make it worse so we have to prevent the bones from moving. This process can involve rods, screws or bone grafting and ultimately the fusion is where the bone grows across where the normal joint was and it no longer moves. If you have a spondylolisthesis this is a very valid reason to consider doing a fusion.
- If you have deformity of the spine
The word “deformity” in medicine is used to to describe any sort of angulation of the spine that is abnormal that has been created not just by a muscular or tendon laxity or muscle over construction on one side.
A true deformity of the spine may also be referred to as scoliosis. You can get scoliosis in the neck or in the low back. A classic type of neck deformity would be something where you’re looking down and you can’t pick your head up. We call that a chin to chest deformity and that is very severe. Some people will develop kyphotic in the lower back or angulation of the spine leaning forward and that can cause a lot of pain and it can cause other problems like even difficulty breathing or walking. We might see someone who has a bump or a hunch on their back and that type of deformity may cause a curve to the spine or real scoliosis.
Not every curve in the spine needs to be fixed. When the curve becomes problematic and prevents function, intractable pain or nerve impingement, then correcting and reconstructing the spine through a multi-level fusion procedure can be very helpful and there is a lot of good scientific data that says that this procedure is a good way to treat it, so not all fusion procedures are bad. If you were being recommended a fusion for one of those reasons, there is a good chance that your doctor is following good, evidence-based guidelines.
There is also a gray area where patients who have stenosis of the spine are also being recommended fusions. You might get an opinion from one doctor telling you that you need a 2/3 level fusion in your low back and then you could go to another doctor that is less aggressive on fusion and may only recommend a multi-level laminectomy or decompression. The difference between those two procedures is substantial.
Laminectomy or decompression alone could take a few hours and you can be out of the hospital or surgery center within a couple of hours. On the other hand, a multi-level fusion involves a lot more surgery and a substantially higher risk of infection, nerve injury, spinal fluid leak, time on the operating room table and a host of other risks including anesthesia and risk of pulmonary compromise. Recovery takes a lot longer. You will be recovering from the trauma that has occurred to the muscles in the low back or the part of the body that was accessed to perform the fusion, which could be the stomach or the side. Aside from the recovery of the tissue, the bones have to heal and grow new bone across where a normal joint was or in some cases, a degenerative joint. That can take at least 4-6 months, to 12 months. Most of the time we verify bone growth via CT scan unless the x-rays show it really well.
Some surgeons may recommend a fusion instead of a laminectomy because they might feel they may not get a good enough decompression or laminectomy done without removing too much of the normal anatomy or normal joint. The posterior facet joint in the spine can become arthritic and cause compression of the nerves. One of the jobs of a surgeon when treating someone who has stenosis is to shave that down and make room for the nerves. The surgeon may not be confident or comfortable of their capabilities in getting the nerves as decompressed as they need to be and they feel that they have to fuse the bones in order to make enough space for the nerves.
I personally would consider doing a laminectomy in place of a fusion because in my experience, the goals and outcomes from the surgery need to be geared towards the patient. I feel confident that in most of these cases, a laminectomy that can even be done in a minimally invasive fashion through a small incision can help you while the surgeon can achieve the desired result without a fusion.
If you’re recommended a multi-level fusion, ask your surgeon these two questions:
- Do I have slippage of my vertebrae?
- Do I have some sort of scoliosis? If not, ask why your surgeon is recommending a fusion and is there any way that your surgeon could fix your problem without performing a multi-level fusion?