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Loose screws AND pseudoarthosis at the interbody fusion cage

FROGFFROG Posts: 393
edited 06/11/2012 - 8:48 AM in Back Surgery and Neck Surgery
I haven’t posted with any real news in quite some time. There really just hasn’t been any news to post. As most of you know this journey is a long one, filled with doctor appointment after doctor appointment, test after test, scan after scan and procedure after procedure. Eventually we figure out that not everyone gets a diagnosis and for the spine patient or the chronic pain patient, even a diagnosis doesn’t guarantee a cure. Along the way someone gets up the nerve to tell us we may have to work on ACCEPTANCE. Then we must decide can we do that? Should we do that? Have we really tried everything? Is acceptance really our only option left? Bite your tongue.

After a lost count of MRI’s, scans, procedures, surgical opinions, and getting my hopes up for naught I recently had a Bone Scan with spect and Hawkeye done. I just got the results. I won’t bore you with all the details and I’m certainly not asking you to interpret but I will share a couple highlights.

Among other things the report showed findings for pseudoarthrosis at the L4 L5 interbody fusion cage and L4 and L5 pedicle screw loosening, most pronounced along the right L5 screw. (It only took almost 2 years to figure this out!) Sarcasm intended!

For a refresher, my fusion was a TLIF with instrumentation in Jan of 08. Despite my repeated complaints of pain, a year after the fusion I was told I was fully fused and I could resume all activities. I tried to do just that. It wasn’t until about 15 month after the fusion I hit a brick wall. My symptoms became impossible to ignore, increased to other levels, and have only gotten worse. I have MRI’s and a Myleogram that show new problems above and below the fusion as well.

Has anyone else had these findings after a fusion? Something Similar? What was your surgeon’s advice? Some thing tells me it’s not going to be as easy as just removing those loose screws. Considering the area around the cage is showing non fusion I'm wondering if a revision will be necessary. My dream of getting rid of this Hardware is not looking so good is it?

Evidently the back is fused it’s just the area around the interbody cage showing lack of fusion.

I have read plenty on here about removal of hardware but nothing really about loose screws AND pseudoarthosis at the interbody fusion cage.

Needless to say I am quite interested in hearing all the advice/personal experience I can. (With the full understanding that I must consult with my own physician.)

If and when I’m going to let them back in I want to get it all done right, once, and for the last time! I went into the fusion with blind faith. Not asking enough questions. I don’t want to make that same mistake twice so I’ll take all the thoughts on this anyone is willing to hand out!

Thanks in advance,


  • So sorry you are going through this! I just underwent a PLIF a few weeks ago because of loose hardware and non-union at L4-L5...

    I too was intense pain. I knew something was wrong. I had the worse pressure in my back and legs. My right hip was very painful. Never new what position or turn would be so excruciating! My legs would give out.I basically had to sleep on ice each night along with pain meds.

    The Dr said when they went in for the revision he couldn't believe how loose all the hardware was. He said it was worse that what the scan said.

    I know what you are going through both emotionally and physically!

    Did the Dr recommend surgery? If so which way are they thinking?

    In 09" I had the 360 this time it was a PLIF and he had to make 2 6inch incisions one on each side of the back. If your Dr isn't listening to you find someone who will. A non union is very painful and you shouldn't have to live like this!!

    Please let me know who you make out.


    spondylolisthesis at L4-5; stenosis,
    Lumbar surgeries 1999 L4-L5
    Lumbar staph infection 1999-2000"
    Meningitis x5 in 1999-2001
    Brain shunt 2000"
    Brain shunt removed 20001"
    ALIF/PLIF fusion 8/5/09
    Failed fusion and Failed Hardware
    PLIF Fusion scheduled for 10/29/10
  • Matia,
    Thanks for your response. I'm sorry you had to go through it yourself but am thankful you can tell me a bit about your experience. I haven't actually spoke to the new surgeon yet that ordered the scan. I got the report back and spoke to my physiatrist about it. The surgeon is out of town until next week.

    Who would have thought it though? Honestly. My fusion was almost 3 years ago. This relentless pain in my hip and groin? Deep Deep pain in my leg? Those sudden jolts out of nowhere in my back that no doctor could explain. I was actually starting to buy into the, "it's all in your head" theory...Well not really, but If not for the constant cheering from a dear friend, I can say I was getting close to giving up! I am happy to finally be getting some answers. Now I just need to be prepared for how to handle them!
  • It's not in your head!! I have been told that by a Dr before and I actually had meningitis!If a Dr ever tells you that then I would suggest to move on!! We know our bodies. I'm not sure were you are from and I know we are not suppose to name the Dr on the sight. It you want to private message me I can tell you were I'm from and where I go. It's a great Orthopedic Hospital rated #1 in the country. I live on the east Coast.

    Just so you know all the symptoms you mentioned is what I was experiencing...I really hope you find answers soon!!

  • First off, *HUGZ* So sorry this is happening. I am glad you stuck to your guns and am finding out what is going on! As you know, my surgeries have been cervical and arm/hand. My fusion isn't working, still have a cracked vertebra, and looking at more surgery plus two more levels total (for now grr).

    When I see things like this, my heart goes sooo out to you. I can't give you much advice for the back, as mine are cervical...but to say stick with it, and find the best surgeon and team you can get! I will keep you in my thoughts, and send you positive energy to face the as yet unknown answers to come! *HUGZ*

    PCTF C4 - T2, Laminectomies C5, C6 & C7. Severe Palsy left arm/hand.
  • Hi Frog,
    Sorry to hear from your problems, but remember your not the only one.
    I have also pseudo-arthosis (non-fusion) at L4L5. L5S1 is also fused and this level there is a steady fusion developed, luckely. So it not my body. Do you have fusion at L5S1 alwell. The reason of mine non-fusion at L4L5 is the surgeon have used a to big cage/block between the vertebrae's so gap to create the bone bridge is to big. And a another problem is also that when L5S1 is also fused there will be more bending at the level L4L5, so there will be always micromovement there till the bone bridge is created. My symtoms are: when I have pain, its a deep pain, sort of painfull pressure in the middle of my spine at L4L5; I can point the spot. There are days or hours of no hardly pain, but when I move to much, more then laying on my back, its creates a pain breakthrough (level 8 to 10). I have also radical pain, tintling, arching, to my left butt, backside upperleg, outerside underleg and foot. But the hardest to handle is the deep painly pressure in the middle of the spine. Especially sitting (max 3 min.)will often create this pain. I have already had a revision; 2 screws were loose and between the cage/block and the vetrebrae bone was a cap of mm's. Also the bone which was laid on the facetjoints was totally degenerated and loose. The surgeon has replaced the screws by thicker ones and laid new bone to facetjoint to create a bone bridge.
    But now one year later I have still the same problem, probably because the cage/block is not yet grown fix (non-fusion). But the surgeon could not fix this because there was no space enough to do something there. Now I have to wait and hope. But it is very hard to handle.
    Are your symtoms simular which I have describled? When you see your doctor ask him to only to revise the posterior hardware, but also what I is planning to do with the cage between the vertebrae's. This is the most important.
    Take care. Renos
  • Brenda,

    Thanks for the kind words and the HUGZ! Right back at ya! It helps you know. It really does! We’ll see where it goes from here. All I can do is pray that God leads me to the best Surgeon and that he has given him the talents he needs to handle the task at hand. Now there is a tough one for me!

    I know you said you couldn’t give much advice….Lumbar or Cervical? Yeah there are some technical differences but in the end don’t you think it’s a “Been there done that?” It’s all just a mess. We just start crumbling. At least that is the way I feel. LOL!

    Seriously, you keep your chin up too! (You do realize that’s a figure of speech cause with neck problems like yours you have no choice.) Thanks for the support!


    Thanks for the advice. I did not have a fusion at L5-S1. According to the report, all 4 screws are loose as well as the non union area around the cage. It does say the posterolateral area is fused.

    The back pain I experience is mostly just sharp pain usually for no apparent reason. A sudden movement or bending will bring on sharp intense or stabbing pains that I can exactly put my finger on. I can hear a “thunk” in there. Sounds silly I know. The doctors always dismiss it when I bring it up or tell me the thunks are normal. Pops and cracks may be normal, thunks to me, are not. Of course, these are the pains that wake you each time you move in the middle of the night.

    The deep pain is felt in my right leg in my hip, groin saddle area and down the leg into the foot and occasionally on the left leg. It is usually brought on by movement and activity. I can get some relief by lying down and using ice or heat but once it gets flared up… I have a hard time distinguishing between the deep pain and nerve pain. Sometimes I can tell them apart. Sometimes I just can’t. As I said before, I am not convinced how much is related to the loose hardware and non union by the cage and how much is related to problems now at other levels.

    Thanks again for the responses! Now I wouldn’t wish my problems on anyone but confirmation helps and it has helped to read that I am not the only one that has had a problem getting surgeons to admit there is an issue. I have received a few PM’s as well I thank those who chose to reply that way!

  • FROG,

    I have lumbar issues, but no surgery down there (yet) hence the "no advice." I do know that the pain can be something else! (Yeah, I've been bad - overdid..paying the Piper!) Crumbling, grrr.... Nodding, been there, done that...whoops, still doing that! It is a slippery road FROG, but I will keep my fingers crossed for you that all will turn out well! Yeah I know, I'm an optimist!! Warm and supportive *HUGZ* as always!!! :)

    PCTF C4 - T2, Laminectomies C5, C6 & C7. Severe Palsy left arm/hand.
  • just some thoughts... im wondering what causes the screws to loosen

    my understanding is the surgeon should use the appropriate width/length for the individuals anatomy/vertebra/problem

    and correct placement

    why do they become loose? think ill add this to my questions for my NS

    Frog im so sorry you are going through this

    i hope you get some good info from your surgeon
    and that your surgeon can help you 'handle" to process it all
    coming to terms with this stuff is difficult

    take care and good luck and hugs
  • What causes them to loosen indeed!

    Maybe the lack of fusion? You know I really don't know.

    What happens to the rods when the screws are loosening?

    If I could reach maybe I could just reach back there with a screwdriver and tighten those bad boys up!

    Thanks Flower,
    If I find out anything first I'll let you know.

  • Explanation why screws loose. The screws are temporary, just to keep it with each other. Its like broken leg, you can have a gypsum brace or a construction with screws and rods. For torso its a bit difficult to fix it with gypsum, but this is done in the past at fusions of the spine. So when the fusion is ocurred, and the vertebrae's are grown together, there is no micro-movement anymore at the screws and have no function anymore. There is also no force on the screws which can loose them. Its like a screw in plasterboard; when there is a variable load on, it will make the hole of the screw wear out. So the problem is that the vertebra's will not fuse. This can be cause by to much (micro) movement so its hard to create a bonebridge. And by nature there is always bending on the spine due to sitting and bending the torso. If the spine is already a bit stiff, the movement of the bending will also occur at the fixed level which not fused already. My Neurosurgeon have for that adviced my not bending, not rotating, not sitting. Only laying and walking. But whem sitting is inevitable, your butt have to be higher then your knees, so the angle of the torso and the upperlegs is as big as possible.
  • :) you can see the funny side frog, you gave me a laugh
    if only it really was that simple , hey.

    renos64, thanks for your explanation, yes i understand how a fusion works, but i couldnt really get why a few pple have loose screw probs.
    i also thought the same , that movement of the area could stress the screws in vertebra to loosen, are there any other variables? how much is too much movement? yes , there is no BLT, but yes , there is still some movement.
    thats interesting what your NS said re your butt has to be higher than knees when sitting

    so yikes ! that means no reclining (dont like that idea, lol)

  • Hi Flower,
    I mean by that your butt have to higher then your knees at sitting, that the angle of the torso and the upperlegs have to be bigger then 90 degrees. So no scharp angle. Sorry for my english, could sound funny, but I am from Europe, Holland, so my english is a bit poor.

  • factors which cause non-fusion which result in loose screws:
    1. age
    2. multi-level fusion; the more fused the more bending on the outside level.
    3. the bigger the bone bridge (gap between vertebrae's the higher chance on non-fusion.
    4. Smoking
    5. healty life style, food, alcohol, nutritions
    6. exercising or not.
    7. to fast perform some movements after surgery, like bending, rotating, sitting, so the spot have no chance to form bone.
    8. genetic
    9. medications; NSAID's (Inbuprofen, Diclofenac, etc.) cause less bone growth due to anti inflammation. This is necessary for tissue healing.
    10. Vitamine D; necessary to have bone growth.
    And probably much more effects.
  • renos, your english is good, i can understand what your saying extremly well
  • First off let me just applaud your excellent use of the written English language Reno. Especially considering it is not your home lanqguage. I think you are doing AWESOME!

    Thanks so much for the explanation. It really does make a bit more sense now. If I am understanding this correctly, had the entire area fully fused movement would not have caused the hardware to loosen. (It just would have hung around in there minding it's own business causing no harm.)

    For those of you that did have this problem, once you were discovered to have this loose hardware and non fusion how long before you were back in for a revision? Did you have to follow the no BLT etc. rules inbetween. Cause I have to tell you, for 2 years I have been searching for answers for my pain and every doctor has encouraged me to get out there excercise, swim, etc. Even all my PT has involved Bending and twisting and my symptoms have only increased.

    Thanks again everyone for your input!
  • It took me 2 years since I had my revision. I have had even a 20 weeks inhome rehab in a rehabilitation centre, where I have to do all kind of exercise like bending etc. It made me worse. When I have my initial fusion surgery, I had always a bad feeling that is was not fixed, but no doctor believed me, and no scans or photos it was clear. Pseudoarthrosis is hard to diagnose. See:
    URL Removed

    So the only possiblity was a open testing and if if it was not fused, a revision was carried out. And so it happened. I was so glad that I was all the time right end.
    FROG, what means BLT?


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  • Renos,

    Thanks for the Link and for sharing more of your story.

    Sorry, BLT is Bending lifting and Twisting.

    I should never assume people can read my mind. Shame on me!

    Thanks again.

  • It sounds like me sitting on the small chairs at the school where I work is not a good idea!!

    I do have a special chair, which is comfortable and suits me well, but sometimes I am in another room and the only chair available to sit on is a small child's chair. Hhhmmmmm! I am nearly 8 months post surgery, so I hope that I will be ok. My x-rays taken at 2 months, showed no sign of fusion, but that was early days.

    What do you guys think? :?
  • Hey Jelly,

    I have often heard you say you have to wait the full year with no x-rays inbetween and I shudder.

    I had x-rays every 3 months and each time saw some improvement. I looked forward to those appointments. (Look where that got me.)

    Is sitting in those little chairs painful? Would it be easier for you to stand than sit in those chairs. I'm thinking as long as you keep your spine straight and don't hunch over...

    Keep in mind you are still fusing between 8 months-year. I've read some research that says the bone continues to evolve over the next couple of years and have been told by people that they actually put down more bone in their second year.

    I've also heard that the NO BLT was just for the first 3 months until the initial bone was put down. After that the movement is actually GOOD for the bone growth process, helping it to become stronger.

    As you can see I am now very very very confused. I was certainly not told not to bend twist or lift for a year. Only the first 3 months. Of course, I wasn't put in a brace either and the whole reason for this thread is the fact that I have an area of non fusion...
  • Hi Frog,
    You wrote that you red a study about bone growth post surgery. I am very interested in this study. Especially that bone growth is beter in the second year. Do you have ot available or can you give a link to this article?

    Further I wander, if you can sit without causing problems? Its mine biggest problem at the moment.

    Further my Neurosurg is again BLTS (and sitting) before the sign of fusion is determined. If there is no fusion and you create to much movement at the spot where the fusion have to be, by BLTS, the chance of fusion will be less.
    Sitting is according to him the heaviest load on the fusion area due to the bending. Only under special conditions you are allowed to sit. I wrote that in earlier comments.

    Have you even consider to use a bone growth stimulator?

  • Hey Renos,
    If I recall It didn't say you were necessarily putting down MORE bone but could STILL be putting down bone growth in the second year. Let me see if I can find it again and I will send you the link via PM. Give me some time.

    Sitting is most difficult for me. The most uncomfortable position I could possibly be in. Sitting through a meal is nearly impossible.

    I do understand and agree with your NS about the no BLT and sitting before the signs of bone growth.

    However I am under the understanding that once bone growth is in place that movement or stressing the new bone growth actually makes it grow stonger. I definitely can see how it would be a problem before the fusion begins to take place.

    I never used a bone growth stimulator and was never offered one. I am 3 years out from my fusion so I'm thinking I'm a day late a few dollars short.

  • If you manage to find that study about bone growth, I'd be very interested to read it too. :-)

    I wouldn't call sitting on the little chairs painful, but it isn't comfortable either.
    When I try to stand up, I feel very stiff and rather sore!

    I have had some pain in my lower back over the last day or so, and have sat on small chairs on three days this week. When in the classroom, I can easily stand if I need to but twice this week was during assembly time, and then I would feel rather conspicuous if I stood up. :S In the class, I often 'perch' on a table, which keeps my back straight.

    My surgeon didn't give me any restrictions and seemed very keen for me to get moving and back to usual activities as soon as possible. He doesn't give his patients a brace either, as he thinks that they make the muscles weak. He has very good faith in his handiwork, and says that the screws and rods will hold things together until fusion takes place. He didn't seem to worry about my disc above and below my fusion either, which were already degenerated. (I had been told by another doctor who read my MRI that I might need to have 2 or even 3 levels fused. I hope he is right!!! :SS

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