What Is Lumbar Fusion Surgery?
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Lumbar Fusion Surgery Overview
Spinal fusions have been performed for decades and this procedure is undertaken for a variety of conditions. These conditions include spondylolisthesis which involves one, two or more vertebrae slipping forward, relative to the vertebrae below it, spinal deformity, scoliosis, kyphosis, flatback syndrome, stenosis, and in patients with previous spine surgery that continue to remain problematic.
Broadly speaking, fusion surgery is required when there is spinal instability, a deformity, or when spinal stenosis is very severe.
Spinal fusion can be performed on any region of the spine which consists of three segments. When the spinal column is viewed from the side, these segments form three natural curves. The “c-shaped” curves of the neck (cervical spine) and lower back (lumbar spine) are called lordosis. The “reverse c-shaped” curve of the chest (thoracic spine) is called kyphosis.
Lumbar fusion surgery involves fusing two or more lumbar vertebrae with the goal of creating a solid, stable bone structure.
Table of Contents
Treats
Diagnosing
Recovery
Surgical Approaches to Lumbar Fusion
Lumbar fusion surgery is performed using one of the following two approaches:
Minimally Invasive Spine Surgery
This type of fusion involves inserting highly specialized instruments through small incisions in the back. An arthroscope is a thin, lighted instrument with a small camera transmitting pictures of the inside of the body to a screen viewed by the doctor performing the surgery.
Minimally invasive spinal fusion surgery normally involves faster recovery and less severe pain afterwards than open surgery because it causes less damage to surrounding tissue. Spine surgeons will make smaller incisions and use surgical tools that are maneuvered around muscle and tissue instead of cutting through or displacing them as in open surgery.
Open surgery
This involves making a large incision in the back (posterior approach), abdomen (anterior approach), or side (lateral approach). Open surgery lets the surgeon directly view and access the surgical area. Open surgery generally involves a longer recovery and a greater degree of pain than minimally invasive spinal fusion surgery because it requires cutting and displacement of muscle and other tissues. Even so, open surgery may be a safer or more effective method for certain patients.
Interbody Fusion
Interbody fusion is a type of spinal fusion that involves removing the intervertebral disk from the disk space. Interbody fusion can be performed using a variety of different approaches. These include ALIF, PLF, AxiaLIF, and XLIF.
Patients Ask:
What is ALIF?
Texas Back Institute Responds: Anterior lumbar interbody fusion (ALIF) is a surgical procedure in which part of the lumbar spine is fused from the front. The surgeon makes an incision in the abdomen and gently retracts the abdominal contents to visualize the front part of the spine. Disc material is removed, and a fusion graft is placed into the disc space. The graft is usually bone, or a cage combined with bone.
Patients Ask:
What is PLF?
Texas Back Institute Responds: Posterior Lumbar Fusion (PLF) surgery is a surgical procedure in which the back part of the lumbar spine is fused from the back. This procedure is called a “posterior” lumbar spine fusion because the surgery is performed from the back (or “posterior” aspect) of the body as opposed to surgeries performed from the front or side of the body.
The surgeon makes an incision in the lower back, through the muscles. It is common to perform decompression surgery combined with the PLF. A bone graft is placed along the edges of the back part of the spine. Often, pedicle screws, which are placed above and below the vertebrae that are being fused. A rod is used to connect the screws which prevents movement and allows the bone and graft site to heal. are placed into the vertebral bodies and connected with rods. This helps to stabilize the spine.
Patients Ask:
What is AxiaLIF?
Texas Back Institute Responds: This is a Trans-sacral Interbody Fusion (AxiaLIF), a surgical procedure in which the front part of the lumbar spine is fused from below. The surgeon makes an incision just above the tailbone. Trans-sacral fusion surgery applies only to the lower-most disc(s). Instruments are passed through a tube into the disc space. Disc material is removed, and a fusion implant or bone graft, is placed into the disc space. The graft is usually a screw-like cage combined with bone. Trans-sacral fusion is most performed for the treatment of painful disc degeneration or spondylolisthesis.
Patients Ask:
What is XLIF?
Texas Back Institute Responds: This acronym refers to Extreme lateral interbody fusion (XLIF), a minimally invasive spinal fusion procedure performed through the side of the body to treat spinal disorders and reduce long-term back or leg pain that has not responded to other treatments, such as steroid injections, physical therapy and pain medication. Texas Back Institute surgeons have pioneered minimally invasive surgical procedures because they are completed with very small incisions, resulting in less tissue damage, quicker healing for patients and fewer surgical complications such as infections.
Transforaminal Lumbar Interbody Fusion
This procedure is a variation of the posterior lumbar fusion. In transforaminal lumbar interbody fusion (TLIF), the surgeon approaches the disk space slightly more from the side. The advantage of this approach is that it requires less movement of the nerve roots which decreases the chance of nerve injury.
According to the American Academy of Orthopaedic Surgeons, each surgical approach, whether from the front, back, or side, has advantages and disadvantages.
The advantage of a posterior/transforaminal lumbar spinal fusion include:
- Direct access to the bone putting pressure on the nerves
- When performing a revision surgery, it allows the surgeon to remove previous hardware
- There is Improved alignment of the spinal bones
- It may be performed with a less invasive technique, resulting in reduced muscle and tissue injury
Patients Ask:
What are the possible complications with TLIF?
Texas Back Institute Responds: The complication rate for the posterior/transforaminal procedure is like that of traditional spinal surgery. Possible disadvantages include nerve damage, which can result in weakness in the leg, potential for the cage to move and add pressure on the nerve, and hematoma, or bleeding into the muscle which puts pressure on the spinal nerves, and causes weakness. The spine specialists at Texas Back Institute will discuss in detail all your available options and assist you in choosing the approach that will best meet your health needs.
Lumbar Fusion Protocol
With any surgical procedure and regardless of the number of times this procedure has been successfully completed, patients are often nervous about what to expect before, during and after the surgery. This is understandable. However, having a “snapshot” of what’s involved in each phase of this surgical process can (hopefully) lead to less anxiety.
Before Lumbar Fusion surgery
(insert photo of TBI physician consulting with patient or looking at x-rays)
The spine specialists at Texas Back Institute list the following activities, once the decision to have the spinal fusion surgery is made:
- A medical examination, chest X-ray, EKG, and blood work will be completed.
- The patient may be asked to have a neurological or psychological examination.
- If taking aspirin or anti-inflammatory medications daily, the patient should stop these medications at least one week before cervical fusion surgery.
- If taking prescription medications or other drugs, including herbals, ask your doctor how soon before cervical fusion surgery you should stop taking these.
- Patients should refrain from eating or drinking for 6 to 8 hours before surgery.
- Patients will check into the hospital the morning of surgery.
- Prior to surgery, patients will be asked to sign permits for surgery, anesthesia, blood, and blood products.
During the procedure
- An intravenous (IV) line will be initiated. An indwelling catheter may also be ordered by your physician to drain urine.
- The procedure is done under general anesthesia. This means the patient will be asleep for the entire duration of the procedure. A tube to aid your breathing may be inserted through the mouth to help patients breathe during the operation.
- If your surgeon is using your own bone for the spinal fusion, he or she will first make an incision on your hip area and gather a ‘bone graft’. If the bone graft is from another person, it will be harvested before your procedure.
- If the decision is made to use the open procedure, the patient will be placed in the proper position. The surgeon will then create an incision over the region of the affected vertebrae.
- In some cases, spinal fusion may be performed via laparoscopic technique which is a less invasive procedure. This technique necessitates several tiny keyhole incisions (rather than one or two large incisions if open surgery), through which the laparoscope and other special surgical instruments are inserted.
- The procedure also involves the insertion of the bone graft between the spaces of two vertebrae. The surgeon may place a plate and screws over the graft to join and hold the vertebral body together until they ‘fuse’ into one bone.
- To complete the procedure, the surgeon will close the incision with stitches.
After Lumbar Fusion surgery
- The surgeon will contact your family while you are in recovery.
- After going to a hospital room, the patient will be able to use a PCA pump to get medication for pain control. This machine controls the amount of medication that can be received.
- In most cases, the Texas Back Institute staff will get the patient out of bed shortly after surgery.
- The hospital stay is usually 1-2 days.
- A brace may be prescribed to restrict bending and promote healing of the fused area.
- Most patients will have some difficulty with swallowing after surgery. This improves with time.
- Patients will be given any needed prescriptions and discharge instructions.
- A set of exercises to do at home will be provided.
- Patients will be able to ride in a car or plane upon leaving the hospital.
- After going home, patients should contact the physician if they exhibit signs of infection, such as:
- Redness, tenderness or swelling
- Wound drainage
- Shaking chills
- Fever higher than 100.4 F (38 C)
Physical therapy is usually initiated after the first office visit with your doctor following cervical fusion surgery. Recovery from Fusion Surgery varies greatly among patients and is dependent on the extent of the surgery as well as the age and health of the individual.
Three Stages Bone Healing After Lumbar Spinal Fusion
After surgery, the bone healing process follows three stages.
• Stage One
This is the Inflammatory phase which lasts for about five days. A blood clot forms at the site of the surgery and provides a protective barrier for the treated area. This helps promote healing through the infiltration of proteins and enzymes that stimulate the growth of new bone.
• Stage Two
The repair phase continues for about a month. New bone tissue is produced through a process called osteogenesis. Specialized cells construct new bone and cartilage and fuse with the surrounding bone tissue. The bone graft used in the surgery functions as a frame for new bone growth.
• Stage Three
Bone remodeling lasts anywhere from the 18th day of surgery to months or years after the surgery. In this stage, the new bone tissue is reshaped and strengthened, while responding to the biomechanics of spinal movement and physiologic loads.
As always, it’s important to follow the doctor’s instructions for post-surgical care, including physical therapy and activity modification to ensure bone healing and to avoid complications.
What Are the Permanent Restrictions After Spinal Fusion Surgery?
About 8 to12 months after surgery, most patients fully recover and can regain the ability to participate in normal activities. However, spinal fusion patients will never regain the ability to bend, twist, or flex the fused segment. This is because spinal fusion eradicates all motion at the fused segment. This limited mobility is the primary “downside” to having this procedure.
Plus, even when spinal fusion relieves symptoms, it doesn’t prevent future back pain. Most back pain is caused by arthritis and surgery does not cure arthritis.
Other back problems can occur after spinal fusion, and they must be resolved with revision surgery. These include:
- Pseudoarthrosis – This is when the bone graft fails to fuse the vertebrae after spinal fusion. This condition may cause lower back pain but requires imaging tests for diagnosis.
- Recurrent Back Pain After the Procedure – Spinal fusion does not always eliminate back pain. Some patients experience recurrent back pain after this procedure and require additional surgeries.
- Adjacent Segment Disease – Adjacent segment disease, or ASD, is another complication after spinal fusion. It involves the degeneration of the spinal segments neighboring the fused vertebrae. This occurs because the adjacent segments must bear additional impact than usual to accommodate the lack of motion in the fused segment.
- Neurological symptoms – This can include tingling, weakness, numbness, and radiating pain.
- Muscle Atrophy – Muscle atrophy can affect the back muscles around lumbar spinal fusion. This issue commonly affects patients who experience continued pain after spinal fusion. Unfortunately, muscle atrophy can diminish support for the spine.
Having a part of the spine that is less mobile or doesn’t move at all puts more strain on the areas around the fused part. As a result, those areas of the spine might break down faster. This can result in the spine requiring more surgery in the future. It is a good idea to discuss these mobility issues with the experts at Texas Back Institute.
Future Directions
Continuing advancements in lumbar fusion surgery are substantially improving the precision, safety, and effectiveness of the procedure. At the forefront of these surgical advancements are robotic assistance, advanced imaging, and innovative implants.
Newer technology has led to the development of more minimally invasive techniques, including tubular retractors that can be used in spinal decompression and lumbar fusion. Innovations in surgical materials are becoming even more refined. For example, the latest generation of artificial disc implants have pliable cores that mimic the movement of natural discs.
Research and technology will continue to move into the future and so will spinal fusion surgery, offering better solutions for those suffering from debilitating pain. Scientists are exploring stem cell therapy (link to TBI blog on this topic) enhancements extracted from the patient’s bone marrow to facilitate bone regeneration and fusion.
Improved patient care and leading-edge innovations continue to ensure that spinal fusion procedures are safe, efficient, and successful. Most people who have lumbar fusion surgery are happy with the outcome. Spinal fusion surgery can improve a patient’s quality of life, giving them freedom from chronic pain and the ability to spend more time doing the things that they enjoy.
Do You Have Concerns About Back Pain?
The spine surgeons and staff at Texas Back Institute are highly trained and world-class physicians. They also employ the best technologies, and in many cases, minimally invasive spinal fusion. If pain from injuries or disease are robbing you of your quality of life, there is no longer any need to wait. Contact us and set an appointment today.
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Frequently Asked Questions
Anterior lumbar interbody fusion (ALIF) is a surgical procedure in which part of the lumbar spine is fused from the front. The surgeon makes an incision in the abdomen and gently retracts the abdominal contents to visualize the front part of the spine. Disc material is removed, and a fusion graft is placed into the disc space. The graft is usually bone, or a cage combined with bone.
Posterior Lumbar Fusion (PLF) surgery is a surgical procedure in which the back part of the lumbar spine is fused from the back. This procedure is called a “posterior” lumbar spine fusion because the surgery is performed from the back (or “posterior” aspect) of the body as opposed to surgeries performed from the front or side of the body.
The surgeon makes an incision in the lower back, through the muscles. It is common to perform decompression surgery combined with the PLF. A bone graft is placed along the edges of the back part of the spine. Often, pedicle screws, which are placed above and below the vertebrae that are being fused. A rod is used to connect the screws which prevents movement and allows the bone and graft site to heal. are placed into the vertebral bodies and connected with rods. This helps to stabilize the spine.
This is a Trans-sacral Interbody Fusion (AxiaLIF), a surgical procedure in which the front part of the lumbar spine is fused from below. The surgeon makes an incision just above the tailbone. Trans-sacral fusion surgery applies only to the lower-most disc(s). Instruments are passed through a tube into the disc space. Disc material is removed, and a fusion implant or bone graft, is placed into the disc space. The graft is usually a screw-like cage combined with bone. Trans-sacral fusion is most performed for the treatment of painful disc degeneration or spondylolisthesis.
This acronym refers to Extreme lateral interbody fusion (XLIF), a minimally invasive spinal fusion procedure performed through the side of the body to treat spinal disorders and reduce long-term back or leg pain that has not responded to other treatments, such as steroid injections, physical therapy and pain medication. Texas Back Institute surgeons have pioneered minimally invasive surgical procedures because they are completed with very small incisions, resulting in less tissue damage, quicker healing for patients and fewer surgical complications such as infections.
The complication rate for the posterior/transforaminal procedure is like that of traditional spinal surgery. Possible disadvantages include nerve damage, which can result in weakness in the leg, potential for the cage to move and add pressure on the nerve, and hematoma, or bleeding into the muscle which puts pressure on the spinal nerves, and causes weakness. The spine specialists at Texas Back Institute will discuss in detail all your available options and assist you in choosing the approach that will best meet your health needs.
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