Patients who are in pain are often highly motivated to resolve their situation, even if it means having a major surgery such as a lumbar spine fusion.
Unfortunately, identifying the reason for the pain a patient is feeling is not always simple. Some diagnoses are easier than others to predict how well a spine fusion will work.
Reasons for spine surgery
Spine surgery can do only two things to repair an anatomical cause of pain:
- stabilize an unstable spinal segment
- decompress a nerve root
Conditions that exhibit both of these symptoms do the best with surgery. Where there is both a spondylolisthesis (slipped vertebral body), along with spinal stenosis, you can expect good resolution of pain with fusion surgery. Where neither condition exists (i.e. degenerative disc disease), postoperative results vary.
Most spine surgeons agree that the most reliable symptom that a fusion surgery can relieve is leg pain generated by compression on a nerve root (radiculopathy). Patients with back pain alone can expect that this surgery will not be quite as reliable for them in relieving the pain as for a patient with mostly leg pain.
Degenerative disc disease and fusions
A situation concerning degenerative disc disease that lends itself well to fusion surgery is when 1, or possibly 2, discs are very degenerated and collapsed.
A lot of times only air (“vacuum disc”) is left within the disc space. If all the other discs are healthy, it is a pretty good bet that the really diseased disc is the pain generator. I personally did not offer fusion surgery to patients if there were not extensive degenerative changes, and I was not a big believer in discograms as a reliable test to determine if a certain disc space was painful.
Also, patients who progressively experienced back pain over the course of years did far better than those who had an event that started the course of low back pain fairly rapidly.
Pain and disability levels before surgery
The patient’s pain also needs to match the disease process. Highly disabled patients with high need for chronic opioid medications to control their symptoms have a far more unpredictable outcome with spinal fusion surgery than those that can control their symptoms with intermittent medications and activity modifications. Patients who have minimal anatomic changes but a lot of pain cannot realistically expect good results with spinal fusion surgery.
Patients who have a very identifiable pain generator based on their anatomic pathology, and who are otherwise healthy and active can expect good functional restoration after a lumbar spine fusion. All others would be well advised to seriously reconsider whether or not a spine fusion will be all that helpful. To paraphrase an old timer and pioneer in spine fusion surgery, Dr. Dan Spengler, “It is perfectly reasonable to not do a spine fusion in patients that cannot reasonably expect a good result.”