Patients unable to function because of the pain or who are frustrated with their activity limitations may consider lumbar spinal fusion surgery for symptomatic lumbar degenerative disc disease.
Lumbar Spinal Fusion Surgery
Lumbar fusion surgery is designed to reduce the pain because it stops the motion at a painful motion segment.
Depending on which level of the spine is affected, the fusion will be somewhat different:
- A one-level fusion at the L5-S1 segment and is the most common form of fusion, as the L5-S1 segment is the most likely level to break down for degenerative disc disease. A fusion at this level of the spine does not significantly change the mechanics in the back.
- Fusion of the L4-L5 level does remove some of the normal motion of the spine as this is a major motion segment in the lower back (as opposed to L5-S1, which has limited motion).
Multi-level fusions for treatment of lumbar DDD are more problematic than a single-level fusion.
- A 2-level fusion may be considered for patients with severe, disabling pain
- 3-level fusions are not generally recommended because back movement is too diminished and altering the muscle composition can in and of itself cause pain (this has been termed fusion disease).
While a single-level fusion is in and of itself a major surgery, a multi-level fusion has significantly more potential risks and complications associated with it and should be considered only in rare instances.
While it is a major surgery, fusion surgery can be an effective option for patients to enhance their activity level and overall quality of life. This potential positive outcome is particularly true now that less invasive surgical techniques are available to decrease post-operative discomfort, preserve more of the normal anatomy of the low back, and result in higher rates of fusion than previous techniques.
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Lumbar Artificial Disc Replacement Surgery
A newer surgery to treat pain and disability from lumbar degenerative disc disease is artificial disc replacement. The theory is that replacing the disc, instead of fusing the disc space together, maintains more of the normal motion in the lumbar spine, thereby reducing the chance that adjacent levels of the spine will break down due to increased stress. This procedure is still a new procedure in the US, so long-term efficacy, and potential risks and complications are still relatively unknown.
The major worry with artificial disc replacement is that anything that moves can wear out with time. Many patients getting surgery for DDD are younger than patients that are receiving artificial joints for hips and knees, and although there is less wear and tear on a spinal joint that a major joint like a hip or knee, over the course of a lifetime, there may be considerable risk that these artificial discs will need to be replaced in the future.
Artificial discs are placed through an anterior approach to the spine under the great vessels (aorta and vena cava). After the procedure, these vessels become scarred down onto the spine, making revisions problematic.