Spine fusion surgery: doctor responses to patient questions
The doctor is in!
The following explanations, insights and advice about spine fusion surgery are provided by Peter F. Ullrich, Jr., MD, an orthopedic spine surgeon and Medical Director for Spine-health.com.
Patients frequently e-mail us questions about spine fusion surgery. While we don’t provide individual responses, periodically, Dr. Ullrich will take time to respond to the more frequently asked questions and we publish the responses in this section of the site.
Please understand that the following responses to spinal fusion surgery questions represent the opinion of one physician, and are intended for informational purposes only and not as a substitute for professional medical help or advice.
Spine fusion questions and physician responses
More Spinal Fusion Info:
Question: My wife had neck surgery in July 2001 with (2) Sulzer BAK/C implants. She's been battling pain ever since. We received a 2nd opinion last week from a very well-known doctor, and he's confident that fusion is not taking place.
She smoked for about the first 6 months after surgery and she took Advil and Vioxx regularly. The surgeon gave her bags of samples of Vioxx and said that Advil would be OK for her to take. He never told her the effects of nicotine. She stopped smoking 6 months ago, but just quit the Vioxx and Advil this week, after meeting with this new doctor. The new doctor said that there's a chance that fusion will now take place now that she's quit Vioxx, Advil, and smoking. Is it too late or is he correct? What are our options?
Doctor's response: She may have what is known as a delayed union instead of a nonunion. The difference being that the delayed union may heal with time. Now that she is off the anti-inflammatory medications and nicotine, it very well may heal, although at one year out from surgery the chances are less than they would have been immediately after surgery.
There is no absolute test to see if a union has occurred but a thin cut CT scan with sagittal reconstruction is probably the best way to see if there is a fusion within the cages. Another technique that may help this fuse is to try an external bone stimulator. You can talk to your spine surgeon about this.
Question: I had an L5-S1 lumbar fusion in with the pedicle screws and rods. My surgery was successful and now my x-rays show complete fusion. I play competitive sports (ultimate Frisbee, which involves diving on the ground to catch the disc) and have resumed full activity for the past few years. I'm now 34. I pretty much can do anything, but have had a dull low back pain for the past 6 months, which I've recently felt in the sacrum. I also have some sciatica after running hard. I now want to get the hardware out. My doctor thinks I'm doing well and shouldn't bother getting them out. I really don't want them in and worry that the rigidity of the metal will cause problems in other parts of the spine later in life. I've also heard stories of the screws breaking or causing problems in the bones, but I don’t think I've experienced that yet (I probably would know). I don't hear many stories of young people getting their bolts out, so I don't know how common it is. Do you have any thoughts?
Doctor's response: It is not all that common to get the screws removed. At this far out from your surgery, they are not performing any structural function within your spine, so removing them is possible, but only about 50% of patients find it at all helpful for any ongoing lingering symptoms. The screws themselves are, however, not likely to cause any damage to the other tissues in the spine if you leave them in. I am not all that aggressive about recommending hardware removal, but the one time it probably can be of help is in those patients where they are placed at L5-S1. This seems to be a level where the screws can cause some soft tissue irritation. Sometimes if you have the area around the screws injected with Lidocaine, and the pain is relieved, this would give you more indication that removing the screws would be helpful.
Question: My back problems started at least 10 years ago and the pain is progressively getting worse. In December my PCP sent me for physical therapy - that really did not help, and it actually made it worse after most sessions. I went for and MRI, and it showed I have two herniated disks, L2/3 and L4/5.
I went back to my PCP, who put me on Medrol DosePak, Vioxx, Cyclobenzapr (Flexeril). These didn’t do anything. I talked to my PT and then went to a 4 week back stabilization class. That didn’t seem to make a difference for my problem, although I continue to do the exercises a few times a week. I went to another orthopedic spine surgeon. He said the herniated disks didn’t seem bad enough to be causing the pain. After all this info, he thinks a discectomy with a fusion and cage would be the best. He figures the slippage is what is causing the pain, since the pain is mainly in my back.
Well, I then went for a second opinion to a neurosurgeon that was highly recommended by my PT. After he looked at the MRI, he told me that what he saw on the MRI didn’t need surgery. I had kind of figured the orthopedic surgeon was going to tell me a discectomy was what I needed, so when he said fusion that blew me away. Well, then, I had resigned myself to the fact that having the fusion would be best to get rid of the pain and that when I went to the neurosurgeon he would be setting that up; then the neurosurgeon said no to surgery.
So after all this I don’t know what to do next. I don’t know who to talk to. I just want to resolve this one way or another and get on with my life. Do you have any suggestions?
Doctor's response: How you would respond to a spine fusion largely depends on what the disc looks like on MRI. If it is very collapsed and degenerated, and the cartilaginous endplates have eroded, then an anterior fusion has a high success rate, especially if all the other discs are relatively normal.
If there is just some decreased signal intensity (black disc), then a spine fusion is unlikely to work. There has to be substantial disc space collapse. In order for a discectomy to be successful, there has to be nerve root pinching from the disc bulge/herniation. Sometimes this has as much to do with how big your spinal canal is as opposed to how big a disc is. If there is any doubt, a CT myelogram is a more sensitive test for nerve root pinching than a MRI scan. If the scans are otherwise negative, there is a chance that this is not from your back but from something else, such as nerve impingement from piriformis syndrome.
An accurate diagnosis as to the cause of your pain is the most important factor in determining whether or not any surgical procedure will be of benefit.
Question: I have seen an orthopedic surgeon. He wants to do a discectomy for numbness and pain in my left leg, but said that would not help my lower back and buttocks pain because of disc problems at L4-5. I think I'm saying this correctly. I have scheduled a discogram at his suggestion. I see a possible recommendation for a spinal fusion coming, which I don't want.
No one has suggested IDET or LED. Advice?
Doctor’s response: It really all depends on your predominant problem. If chronic low back pain is more your problem, then it is reasonable to at least consider a fusion procedure. If you have had acute low back pain that is associated with the disc herniation and the leg pain, then it would be more reasonable to just treat the disc herniation with a microdiscectomy and then proceed with rehabilitation (physical therapy) for the low back pain. In most cases of acute low back pain, even if there are some degenerative changes on the MRI scan in the disc spaces, microdiscectomy leads to a good to excellent result and a spine fusion is not necessary. Also, a spine fusion surgery can always be done at a later date if rehabilitation fails after the disc surgery.
If you have two degenerated discs they are probably looking at a two level fusion. A two level spine fusion changes the mechanics in the back quite a bit because the L4-L5 level is a major motion segment in the lumbar spine, and fusing it transfers stress to the L3-L4 level.
A microdiscectomy does not change the mechanics in the back, and is designed to alleviate compression on the nerve root and allow it to heal.
The two principal factors you need to consider are whether or not your leg pain is worse than your back pain and if the pain is fairly acute (3-6 months). If both of these are the case, then microdiscectomy is probably more reasonable. If you have more back pain and have had it for years, then spine fusion surgery is possibly a better way to go. IDET will not address the leg pain and would probably be contraindicated if you have any degree of nerve pinching
Question: I have 2 ruptured and degenerated discs (L4-L5 and L5-S1) with recurrent low back pain (debilitating) at least once a year, and more recently every six months. I have researched some alternatives to surgery, and have found the VAX-D therapy to be the most comprehensive. I am 35 years old and fairly active (when able). The VAX-D therapy consists of 30 sessions at 200 dollars each, and insurance will not cover it. Am I better off opting for implant surgery (which would be my preference to fusion), or should I try the VAX-D therapy? What is your opinion of VAX-D, and is the PRODISC (or any comparable artificial disc) implant an available alternative yet?
Doctor’s response: My understanding is that there basically is no scientific evidence that VAX-D changes the natural history of low back pain. It is expensive and not covered by insurance because it is unproven. That is not to say that it does not work on some people, but it can be a lot of money for little benefit.
The PRODISC artificial disc is not commercially available as of yet, and the Charité artificial disc, which is FDA-approved for use in the U.S., is not approved for two-level artificial disc replacement surgeries.
A two-level fusion procedure in a young healthy adult is a big undertaking and should only be considered as a salvage procedure if you cannot function well. The best alternative is to try to manage the pain with an active exercise program focused on stretching, strengthening, and conditioning. If your pain is only intermittent, any type of surgical intervention (either artificial disc or fusion surgery) is probably a bit aggressive. It is probably better to manage your bouts of pain rather than shoot for a "cure."
Question: I have been diagnosed with a C5-C6 cervical herniated disc that is compressing the spinal cord. Anterior cervical fusion surgery has been recommended with urgency. However, I am concerned that the discs adjacent to the fusion site may become vulnerable and that the fusion may not be successful. What less invasive procedures can treat a cervical herniated disc affecting the spinal cord?
Doctor’s response: There aren’t really any more effective options for a large cervical herniated disc with spinal cord impingement than anterior cervical fusion surgery. That is the bad news. The good news is that it’s a reliable surgery that usually leads to good results.
Spine fusion in the neck is not usually as bad as it is thought to be. Since there are many motion segments in the cervical spine, fusing one segment does not excessively limit the motion in the neck.Most patients with a one level fusion do not notice any difference in their cervical range of motion. Likewise, a one-level fusion in the neck does not place considerably more stress on adjacent levels of the spine (which is thought to be the cause of the adjacent disc problems). In my own practice, I have done many one-level cervical fusions and only had a few patients come back after the surgery with a herniation at an adjacent level.
Part of what is hurting your spinal cord is the motion at the segment with the disc herniation. Without stopping the motion by fusing the spine, it can continue to move and injure the cord. A cervical discectomy with a fusion is generally a reliable procedure with an excellent track record. It is generally considered the gold standard in surgical care for a cervical herniated disc that is impinging the spinal cord.
Although cervical artificial disc technology has come a long way in possibly replacing cervical fusion, as of the publishing of these responses, there are currently no FDA approved cervical artificial disc devices available on the market. However, there currently are at least four FDA-approved trials testing artificial disc technology.
Question: I've suffered for several years with chronic low back pain. After some chiropractic sessions, I started to suffer pain along my right leg, and now it’s difficult to stand and walk for a long period of time. The leg pain is worse than the low back pain. An MRI uncovered a lumbar herniated disc at L5-S1. I’ve since tried cortisone injections, epidural injections and acupuncture with no pain relief.
One neurosurgeon recommended surgery, a fusion with titanium cages to eliminate the herniated portion of the disc. Another neurosurgeon said that my disc herniation can be treated with a microdiscectomy, but surgery is not urgent. I decided to postpone surgery and try chiropractic treatment for 2 more weeks.
Do you think I have undergone a sufficient amount of conservative treatment to avoid surgery to treat the lumbar herniated disc? If surgery is most likely the next step, is fusion the best option, or is a microdiscectomy enough? What are the potential advantages of a fusion for a low back herniated disc (versus other surgical procedures)?
Doctor’s response: It does sound as if you have pretty much maximized your conservative treatment and your symptoms are severe. Usually, if the leg pain from a large disc herniation is severe and has not gone away after about six to twelve weeks of non-surgical treatments, surgery is the best way to get better the quickest.
If you have mainly leg pain from a large herniated disc, a microdiscectomy would usually be all that is needed. Although a fusion surgery may be necessary in the future, there probably is about a 90-95% chance that it would never be needed. In my own practice, I usually will only do the microdiscectomy and the vast majority of patients do well. It is also far easier to recover from a minimally invasive microdiscectomy than a much more invasive fusion surgery. Since a fusion surgery will forever change the mechanics in the back, in my opinion it should only be done in the rare cases where patients still have low back pain after a discectomy.
What next?
If you have questions about spine fusion surgery or other back treatments, please use this site to find peer-reviewed health information about spinal conditions, diagnosis and treatment options. The quickest way to locate information on the site is to use the “keyword search” box located in the upper left hand corner of each page. Also, if you want to talk online with others who may be in a similar situation or exchange information with other patients who have had or are considering spine fusion surgery, please go to the Spine Forum Message Boards.
Additional disclaimer: Spine-health.com does not offer medical advice or treatment. This information does not replace the physician-patient relationship, and the information is not medical advice or treatment. It should only be considered as one physician's opinion based on an extremely limited amount of information. Patients should always seek the advice of a trained health professional for back pain or any health condition. Please note that the contents of this section have not been peer reviewed by Spine-health.com’s Medical Advisory Board.
