Warning: Proceed with Caution Before Fusion Surgery

Spinal fusion surgery for low back pain has gotten quite a bad reputation for delivering poor results.

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ALIF (Anterior Lumbar Interbody Fusion) Video Education is key before deciding for a fusion. Watch: ALIF (Anterior Lumbar Interbody Fusion) Video

Because it is a painful, dangerous, and costly surgery, surgeons should only recommend spinal fusion surgery for the most severe symptoms and—I can't stress this enough—only when there is a clearly defined anatomical problem that will be addressed with fusion. Sadly, this is not always the case.

An unbelievable first opinion

In my practice, I saw as a second opinion a young man who had been offered a 3 level fusion by another surgeon—a prominent academic surgeon at a medical school. This 19-year-old male was debilitated with low back pain and bilateral leg pain that was made worse with activity. The young man was taking large doses of oral narcotics to control his pain and had already maximized his non-surgical treatments, including 3 epidural injections.

The only abnormalities that his MRI scan revealed were congenital stenosis of his lumbar spine, made somewhat worse at L4-L5 by a slightly bulging disc. The surgeon recommended and booked this young man for a 3-level decompression, instrumentation, and fusion, and told him that, "additional levels of the spine may need to be fused once they see what is going on during surgery."

See Multilevel Spinal Fusion for Low Back Pain

This is truly an unbelievable opinion. The chance that a 3-level fusion would relieve the patient's pain is only about 50%. Moreover, there is a 50% chance that the surgery would actually make his pain worse. Unfortunately, fusion surgery is a one-way operation, and if the surgery does not work or makes the pain worse it cannot be undone. However, there is an underlying fear by many physicians that if they do not offer a patient a definitive fusion procedure, someone else will and they will lose the patient and the surgery. This is not a sound justification for doing a large, destructive surgery.

See How to Select a Spine Surgeon

Even if the fusion did provide pain relief, it would only be temporary until the next level of the spine wore out and started causing pain. The spine is meant to move, and fusing 3 levels, especially in a 19 year old, completely alters the biomechanics of the spine. In the spine surgery world, the term "fusion disease" is used to describe the ongoing or worsening pain that follows a multilevel fusion.

See Failed Back Surgery Syndrome (FBSS): What It Is and How to Avoid Pain after Surgery

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Get an accurate preoperative diagnosis

This young man's scan and X-rays did not show any pathology that would warrant a fusion.

The number one determining factor whether or not a fusion surgery will deliver the desired reduction in pain is an accurate preoperative diagnosis, meaning a diagnosis that clearly identifies the underlying cause of the patient's pain.

See When to See a Surgeon for Low Back Pain

Identifying degeneration of other changes in the spine is not sufficient—the diagnosis needs to identify that those changes in the spine are actually causing the patient's pain. Many people have a bulging disc, herniated disc, stenosis, and other issues with their spine, but no pain.

I can't stress this point enough.

Lumbar fusion does work very well for certain conditions. Severe degenerative disc disease of one (or maybe 2) level(s), spondylolisthesis, tumor, fracture, or infection all can be successfully treated with a fusion that removes the motion at a painful motion segment. But this young man did not have any of these problems, so a fusion would be unlikely to help him.

See What Is Degenerative Disc Disease?

Given this young man's diagnosis, the only possible surgery that should have been considered is a one- or two-level lumbar laminectomy to treat the spinal stenosis, but not a multilevel fusion.

Unfortunately, I do not know if he went through with the fusion or not. It is not uncommon, however, to see patients like this who continue to struggle after a large fusion procedure, and as a matter of fact, many insurance companies will no longer approve a fusion procedure unless there is discrete pathology.

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Patients need to question the need for a fusion

There is no way to justify a reckless use of fusion surgery such as the recommendation that this man received, and it typifies what is wrong with fusion surgery today.

Having a 3-level fusion at age 19 would have severely damaged this patient's life forever. Using a newer fusion technique does not improve the final outcome. Getting pain relief from a spine fusion is still dependent on an accurate preoperative diagnosis.

Get educated

It is in the patient's own interest to get educated about the options and understand exactly why the surgeon is doing the surgery, the risks and benefits, and any other options, before deciding on fusion surgery. A good surgeon will not be offended by these questions, and will not be offended if you say you are going to get a second opinion before deciding about the surgery.

It is your back and your decision whether or not to have surgery. A good surgeon will commend you for carefully considering your options.

Learn more:

Elements of a Spine Fusion

Postoperative Care for Spinal Fusion Surgery