Spinal Fusion – Indications, Contraindications

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Spinal fusion is used to strengthen the spine and prevent painful movements in people with degenerative disc disease or spondylolisthesis (following laminectomy). The spinal disc between two or more vertebrae is removed and the adjacent vertebrae are “fused” by bone grafts and/or metal devices secured by screws. Spinal fusion may result in some loss of flexibility in the spine and requires a long recovery period to allow the bone grafts to grow and fuse the vertebrae together. Spinal fusion has been associated with an acceleration of disc degeneration at adjacent levels of the spine.

Spinal fusion, also called spondylodesis or spondylosyndesis, is a neurosurgical or orthopedic surgical technique that joins two or more vertebrae. This procedure can be performed at any level in the spine (cervical, thoracic, or lumbar) and prevents any movement between the fused vertebrae. There are many types of spinal fusion and each technique involves using bone grafting—either from the patient (autograft), donor (allograft), or artificial bone substitutes—to help the bones heal together.[rx] Additional hardware (screws, plates, or cages) is often used to hold the bones in place while the graft fuses the two vertebrae together. The placement of hardware can be guided by fluoroscopy, navigation systems, or robotics.

Types of Spinal Fusion

The following list gives examples of common types of fusion techniques performed at each level of the spine:

Cervical spine

  • Anterior cervical discectomy and fusion (ACDF)[rx]
  • Anterior cervical corpectomy and fusion
  • Posterior cervical decompression and fusion

Thoracic spine

  • Anterior decompression and fusion[rx]
  • Posterior instrumentation and fusion – many different types of hardware can be used to help fuse the thoracic spine including sublaminar wiring, pedicle and transverse process hooks, pedicle screw-rod systems, vertebral body plate systems.[rx]

Lumbar spine

  • Posterolateral fusion is a bone graft between the transverse processes in the back of the spine. These vertebrae are then fixed in place with screws or wire through the pedicles of each vertebra, attaching to a metal rod on each side of the vertebrae.
  • Interbody Fusion is a graft where the entire intervertebral disc between vertebrae is removed and a bone graft is placed in the space between the vertebra. A plastic or titanium device may be placed between the vertebra to maintain spine alignment and disc height. The types of interbody fusion are:
    • Anterior lumbar interbody fusion (ALIF) – the disc is accessed from an anterior abdominal incision
    • Posterior lumbar interbody fusion (PLIF) – the disc is accessed from a posterior incision
    • Transforaminal lumbar interbody fusion (TLIF) – the disc is accessed from a posterior incision on one side of the spine
    • Transposons interbody fusion (DLIF or XLIF) – the disc is accessed from an incision through the psoas muscle on one side of the spine
    • Oblique lateral lumbar interbody fusion (OLLIF) – the disc is accessed from an incision through the psoas muscle obliquely

The common surgical approaches for lumbar interbody fusion include posterior lumbar interbody fusion (PLIF), transforaminal lumbar interbody fusion (TLIF), lateral lumbar interbody fusion (LLIF), oblique lumbar interbody fusion/anterior to psoas (OLIF/ATP), and anterior lumbar interbody fusion (ALIF) [,. The anterior and lateral approaches grant surgeons with a direct midline or lateral view of the disc space, which ultimately allows for a more thorough endplate preparation and maximization of implant size

Indications of Spinal Fusion 

A herniated disc pressing on spinal nerves. Spinal fusion can be used to treat a variety of conditions affecting any level of the spine—lumbar, cervical, and thoracic. In general, spinal fusion is performed to decompress and stabilize the spine.[rx] The greatest benefit appears to be in spondylolisthesis, while evidence is less good for spinal stenosis.[rx]

Lumbar and cervical spinal fusions are more commonly performed than thoracic fusions.[rx] Degeneration happens more frequently at these levels due to increased motion and stress.[rx] The thoracic spine is more immobile, so most fusions are performed due to trauma or deformities like scoliosis, kyphosis, and lordosis.[rx]

Conditions, where spinal fusion may be considered, include the following:

  • Degenerative disc disease
  • Spinal disc herniation
  • Discogenic pain
  • Spinal tumor
  • Vertebral fracture
  • Scoliosis
  • Kyphosis (e. g., Scheuermann’s disease)
  • Lordosis
  • Spondylolisthesis
  • Spondylosis
  • Posterior rami syndrome
  • Other degenerative spinal conditions[rx]
  • Any condition that causes instability of the spine[rx]

Contraindications of Spinal Fusion 

Bone morphogenetic protein (rhBMP) should not be routinely used in any type of anterior cervical spine fusion, such as with anterior cervical discectomy and fusion.[rx] There are reports of this therapy causing soft tissue swelling, which in turn can cause life-threatening complications due to difficulty swallowing and pressure on the respiratory tract.[rx]

What happens before surgery?

Health exam

You will need to have a physical exam from your primary care physician before surgery to be sure your heart and lungs are healthy. A blood test, electrocardiogram (EKG), and chest X-ray may be performed. Discuss all medications (prescription, over-the-counter, and herbal supplements) you are taking with your health care provider. Some medications need to be continued or stopped the day of surgery. Medications that thin the blood should be stopped 7-10 days prior to surgery. Drugs that thin the blood include:

  • Aspirin
  • Ibuprofen (Advil, Motrin, Nuprin)
  • Anti-inflammatories (Aleve, Naprosyn)
  • Fish oil
  • Vitamin E
  • Herbals (gingko, glucosamine)
  • Blood thinners (Coumadin, Heparin)
  • Antiplatelets (Plavix, Ticlid, Fragmin, Orgaran, Lovenox, Innohep)
  • Wintergreen snuff

Do not drink alcohol 1 week before and 2 weeks after surgery to avoid bleeding problems.

The hospital will call you several days before your surgery and ask questions about your health (allergies, bleeding history, anesthesia reactions, previous surgeries). They will also ask for a complete list of medications including prescriptions, over-the-counter, and herbal supplements.

Smoking

The most important way to achieve a successful spinal fusion surgery is to quit smoking. Stop all tobacco use: cigarettes, e-cigarettes, cigars, pipes, chewing tobacco, and smokeless tobacco (snuff, dip). Nicotine prevents bone growth and decreases successful fusion. Fusions fail in 40% of smokers, compared with 8% of non-smokers [1]. Smoking also decreases blood circulation, resulting in slower wound healing and an increased risk of infection.

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Talk with your doctor about nicotine replacements, pills without nicotine (Wellbutrin, Chantix), and tobacco counseling programs.

Home preparation

It’s a good idea to get your home ready before surgery. Move things that you use often to a level between your shoulders and hips, so you do not have to bend or reach. Tie up phone cords and remove throw rugs so you don’t trip. Prepare and freeze meals. Put non-slip strips in the shower/tub. You may need grab bars in the tub or toilet area. If your toilet is low, get a raised toilet seat. Identify a chair with a firm cushion, armrests and a seat at knee level that is easy to get out of.

Many patients have trouble with constipation after surgery caused by pain medication and anesthesia. The week before surgery eat foods high in fiber including fruits, vegetables, beans and whole-grain cereals and bread. Drink water; 8 to 10 glasses of fluid every day. Walking also helps the intestines move more rapidly and regularly. Over-the-counter fiber supplements such as Metamucil, Fibercon and Citrucel can help keep stools soft and regular. Don’t rely on laxatives, such as Correctol or Dulcolax, which cause muscle contractions in the intestines.

Who will stay with me?

Most patients go home 2 to 3 days after surgery. Identify someone who can be with you for the first couple days and help you move around, take care of pets, housework, cooking, and shopping.

What to bring to the hospital
  • Your medication list (prescriptions, over-the-counter, and herbal supplements) with dosages and the times of day usually taken.
  • Bring a list of allergies to medications or foods.
  • Bathroom items
  • CPAP machine (if you use one at home)
  • Brace (if you’ve been given one)
  • Personal items (book, music) to help you relax
  • Wear loose fitting clothes and flat-heeled shoes with closed backs
  • Leave all valuables and jewelry at home (including wedding bands)
Night before surgery
  • Do not drink any alcoholic beverages.
  • No food or drink is permitted past midnight.
  • If you have a cold, fever, flu or some other illness the day before surgery, call your surgeon’s office.
  • Shower with antibacterial soap (Dial, Hibiclens) and wear freshly washed clothing.
  • Confirm your transportation home because you will not be able to drive yourself.

What happens during surgery?

Morning of surgery
  • Shower again using antibacterial soap and dress in freshly washed clothing.
  • You may brush your teeth. Do not eat or drink.
  • If you have instructions to take regular medication the morning of surgery, do so with small sips of water.
  • Remove make-up, body piercings and nail polish.
  • Arrive at the hospital 2 hours before (surgery center 1 hour before) your scheduled surgery time to complete the necessary paperwork and pre-procedure work-ups.

At the hospital

The nurse will check you in and show you to a room. You will be asked to remove your clothing (including underwear and socks) and put on a surgical gown. In addition, you should remove any contact lenses, dentures, wigs, hairpins, jewelry or artificial limbs. Please give these and other personal belongings to your visitors to hold while you are in surgery and until you are in your assigned room.

An anesthesiologist will talk with you and explain the effects of anesthesia and its risks. An intravenous (IV) line will be placed in your arm. You will be given antibiotics to decrease the risk of infection.

You will be transported to the operating room on a stretcher. At that time, the nurse will direct your visitors to the Surgery Waiting Area. When surgery is over, your doctor will talk with your visitors there.

Once in the OR, you will be given anesthesia. Your surgery will take several hours. This time frame includes the skin preparation, positioning, and anesthesia time.

What happens after surgery?

You will wake up in the recovery area called the post-anesthesia care unit (PACU). You may have a sore throat from the tube used during surgery to assist your breathing. You may feel tired, thirsty, cold, or have a dry mouth. Once awake you will be moved to a regular room.

Pain

Pain and anti-nausea medication will be given as needed. Everyone feels pain differently. Only you know how to describe your pain. Your healthcare team may ask you to rate your pain on a scale of 1 to 10. 1 = mild pain and 10 = worst possible pain.

Nursing care

Your blood pressure, pulse, temperature and breathing will be checked at intervals. The nurse will also examine your incision, change the dressing and check your circulation. You will be given antibiotics through your IV after surgery. Good nutrition and keeping your incision clean and dry helps prevent infection.

You will not be able to eat or drink right away. An IV will give you fluids for hydration. You may have ice chips to wet your mouth. The nurse will increase your diet once you are passing gas and there is movement in your stomach.

You may have a catheter to drain your bladder. It is usually removed after surgery.

Respiratory therapy will monitor your breathing. You will be shown how to use a breathing aid (incentive spirometer) to help keep your lungs healthy after anesthesia. Breathing deeply and coughing helps clear air passages and reduces the risk of pneumonia.

Mobility

Being out of bed and walking several times a day is very important to your recovery. At first, you may need help, but gradually you’ll increase your activity level (sitting in a chair, walking). A therapist will also show you how to use the toilet and shower, get in and out of bed.

In some cases, the surgeon may order a brace for extra support. If required, you will be shown how to put on the brace and how it is to be worn.

Preventing blood clots

Deep vein thrombosis (DVT) is a potentially serious complication of surgery in which blood clots form inside the veins of your legs. The clots may break free and travel to your lungs, causing collapse or even death. Being less active slows blood flow to the legs. If your blood is moving it is less likely to clot, so an effective treatment is getting you out of bed as soon as possible.

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There are several ways to treat or prevent blood clots. You will wear tight-fitting elastic socks called TEDS. Compression boots sequentially squeeze and release the legs to keep the blood from pooling in the veins.

Going home

Depending on the type of fusion, some patients go home the same day while others may go home in 2 to 4 days. In some cases, a home healthcare provider may need to be hired to help for a period of time. For those who need advanced help, transfer to transitional care or short-term rehabilitation facility may be arranged.

When you are ready to go home, you will be given discharge instructions:

Pain medication
  • Take pain medication as directed by your surgeon. Narcotics can be addictive and are used for a limited period of time.
  • Narcotics can also cause constipation. Drink lots of water and eat high-fiber foods. Laxatives and stool softeners such as Dulcolax, Senokot, Colace, and Milk of Magnesia are available without a prescription.
  • Do not use non-steroidal anti-inflammatory drugs (NSAIDs) (aspirin, ibuprofen, Advil, Motrin, Nuprin, naproxen, Aleve) without surgeon’s approval. They prevent new bone growth and may cause your fusion to fail. You may use acetaminophen (Tylenol).
Restrictions
  • Avoid bending, lifting or twisting your back for the next 2 weeks.
  • Do not lift anything heavier than 5 pounds for 2 weeks after surgery.
  • No strenuous activity for the next 2 weeks, including yard work, housework and sex.
  • DO NOT SMOKE, vape, dip, chew or use nicotine products. It prevents new bone growth and may cause your fusion to fail.
  • Do not drive until after your follow-up appointment. You may ride in the car for short distances of 45 minutes or less if necessary.
  • Do not drink alcohol for 2 weeks after surgery or while you are taking narcotic medication.
Incision Care
  • Wash your hands thoroughly before and after cleaning your incision to prevent infection.
  • If you have Dermabond (skin glue) covering your incision, you may shower the day after surgery. Gently wash the area daily with soap and water. Pat dry.
  • If you have staples, steri-strips, or stitches, you may shower 2 days after surgery. Remove the gauze dressing and gently wash the area with soap and water. Replace the dressing or completely remove it if no drainage. Inspect and wash the incision daily.
  • Do not submerge or soak the incision in water (bath, pool or tub).
  • Do not apply any lotions or ointments over the incision.
  • Some drainage from the incision is normal. A large amount of drainage, foul smelling drainage, or drainage that is yellow or green should be reported to your surgeon’s office immediately.
Activity
  • Get up and walk 5-10 minutes every 3-4 hours. Gradually increase your walking time, as you are able. Avoid sitting for long periods of time.
  • Log roll in and out of bed as you did in the hospital. Lie on your back with a pillow under your knees. Lie on your side with a pillow between your knees.
Icing
  • Ice your incision 3-4 times per day for 15-20 minutes to reduce pain and swelling.
Bracing
  • If you were given a brace, wear it at all times unless you are sleeping or showering.

When to Call Your Doctor

  • Fever over 101.5° F (unrelieved by Tylenol).
  • Incision begins to separate or show signs of infection, such as redness, swelling, pain, or drainage.
  • Rash or itching at the incision (allergic reaction to Dermabond skin glue)
  • Swelling and tenderness in the calf of one leg.
  • New onset of tingling or numbness in the arms or legs.

Prevention

You will need to set up an appointment for a follow-up visit with your doctor two weeks after surgery. You may be given light stretching exercises to do on your own. Your level of commitment to exercise will determine how fast and how well you recover.

About six weeks later, routine visits should start with physical therapy to begin your rehabilitation. A physical therapy program will likely include exercises to strengthen your back and low-impact aerobics, such as walking or swimming.

Your physical therapist will show you how to make modifications to your daily standing, sitting, and sleeping habits-for example, learning how to lift properly or sitting for shorter periods of time. Regular back exercises strengthen muscles that support your spine, easing pain and preventing further injury.

Recurrences of back pain are common. The key to avoiding recurrence is prevention:

  • Proper lifting techniques
  • Good posture during sitting, standing, moving, and sleeping
  • Appropriate exercise program
  • An ergonomic work area
  • Healthy weight and lean body mass
  • A positive attitude and relaxation techniques (e.g., stress management)
  • No smoking

Most people who have spinal fusion surgery are off work for several weeks depending on the type of work you do and the surgical procedure. You may or may not need to return to work with restrictions based upon your job. If you have a physically demanding position, you may need to be on restrictions when you return.

Risks

Spinal fusion is a high-risk surgery and complications can be serious, including death. In general, there is a higher risk of complications in older people with elevated body mass index (BMI), other medical problems, poor nutrition and nerve symptoms (numbness, weakness, bowel/bladder issues) before surgery. Complications also depend on the type/extent of spinal fusion surgery performed. There are three main time periods where complications typically occur:

During surgery

  • Patient positioning on the operating table 
  • Blood loss
  • Damage to nerves and surrounding structures during the procedure
  • Insertion of spinal hardware
  • Harvesting of bone graft (if autograft is used) [rx]

Within a few days

  • Moderate to severe postoperative pain
  • Wound infections – risk factors include old age, obesity, diabetes, smoking, prior surgery
  • Deep vein thrombosis (DVT) 
  • Pulmonary embolism (PE) 
  • Urinary retention 
  • Malnutrition[rx]
  • Neurologic deficit [rx]

Weeks to years following surgery

  • Infection – sources of bacterial bioburden that infiltrates the wound site are several, but latest research work is highlighting repeated reprocessing of implants before surgery and exposure of implants (such as pedicle screws) to bacterial contaminants in the “sterile-field” during surgery as a major risk factor.
  • Deformity – loss of height, alignment, and failure of fusion 
  • Pseudarthrosis – nonunion between fused bone segments. Risk factors include tobacco use, nonsteroidal anti-inflammatory drug use, osteoporosis, revision procedures, decreased immune system.[rx]
  • Adjacent segment disease – degeneration of vertebrae above/below the fused segments due to increased stress and motion.[rx]
  • Epidural fibrosis – scarring of the tissue that surrounds the spinal cord[rx]
  • Arachnoiditis – inflammation of the thin membrane surrounding the spinal cord, usually caused by infection or contrast dye.[rx]
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Recovery

Recovery following spinal fusion is extremely variable, depending on the individual surgeon’s preference and the type of procedure performed.[rx] The average length of hospital stay for spinal fusions is 3.7 days. Some patients can go home the same day if they undergo a simple cervical spinal fusion at an outpatient surgery center.[rx] Minimally invasive surgeries are also significantly reducing the amount of time spent in the hospital.[rx] Recovery typically involves both restriction of certain activities and rehabilitation training.[rx] Restrictions following surgery largely depend on surgeon preference. A typical timeline for common restrictions after a lumbar fusion surgery are listed below:

  • Walking – most people are out of bed and walking the day after surgery
  • Sitting – can begin at 1–6 weeks following surgery
  • Lifting – it is generally recommended to avoid lifting until 12 weeks
  • Driving – usually can begin at 3–6 weeks
  • Return to sedentary work – usually between 3–6 weeks
  • Return to manual work – between 7–12 weeks[rx]

Rehabilitation after spinal fusion is not mandatory. There is some evidence that it improves functional status and low back pain so some surgeons may recommend it.

Complications

As with any surgery, there are risks associated with spinal fusion. Your doctor will discuss each of the risks with you before your procedure and will take specific measures to help avoid potential complications. Potential risks and complication of spinal fusion include:

  • Infection – Antibiotics are regularly given to the patient before, during, and often after the surgery to lessen the risk of infections.
  • Bleeding – A certain amount of bleeding is expected, but this is not typically significant. It is not usually necessary to donate blood before spinal fusion.
  • Pain at the graft site – A small percentage of patients will experience persistent pain at the bone graft site.
  • Recurring symptoms – Some patients may experience a recurrence of their original symptoms. There are various causes for this. If your original symptoms recur, inform your doctor so that he or she can determine what is causing your symptoms.
  • Pseudarthrosis – This is a condition in which there is not enough bone formation. Patients who smoke are more likely to develop pseudarthrosis. Other causes include diabetes and older age. Moving too soon—before the bone is able to start fusing—may also result in pseudarthrosis. If this occurs, a second surgery may be needed in order to obtain a solid fusion.
  • Nerve damage – It is possible that nerves or blood vessels may be injured during these operations. These complications are very rare.
  • Blood clots – Another uncommon complication is the formation of blood clots in the legs. These pose significant danger if they break off and travel to the lungs.
  • Fail to benefit symptoms or to prevent deterioration
  • Worsening of pain/weakness/numbness
  • A blood clot in wound requiring urgent surgery to relieve pressure
  • Cerebrospinal fluid (CSF) leak
  • Surgery at the incorrect level (this is rare, as X-rays are used during surgery to confirm the level)
  • Blood transfusion
  • Implant failure, movement, or malposition (when a fusion is also done)
  • Recurrent disc prolapse or nerve compression
  • Nerve damage (weakness, numbness, pain) occurs in less than 1%
  • Quadriplegia (paralyzed arms and legs)
  • Incontinence (loss of bowel/bladder control)
  • Impotence (loss of erections)
  • Chronic pain
  • Instability or forward collapse of the neck (kyphosis) (may require further surgery)
  • Stroke (loss of movement, speech etc)

Next steps

Before you agree to the test or the procedure make sure you know

  • The name of the test or procedure
  • The reason you are having the test or procedure
  • What results to expect and what they mean
  • The risks and benefits of the test or procedure
  • What the possible side effects or complications are
  • When and where you are to have the test or procedure
  • Who will do the test or procedure and what that person’s qualifications are
  • What would happen if you did not have the test or procedure
  • Any alternative tests or procedures to think about
  • When and how will you get the results
  • Who to call after the test or procedure if you have questions or problems
  • How much will you have to pay for the test or procedure

Glossary

  • allograft – a portion of living tissue taken from one person (the donor) and implanted in another (the recipient) for the purpose of fusing two tissues together.
  • annulus (annulus fibrosis) – the tough fibrous outer wall of an intervertebral disc.
  • autograft (autologous) – a portion of living tissue taken from a part of one’s own body and transferred to another for the purpose of fusing two tissues together.
  • bone graft – bone harvested from one’s self (autograft) or from another (allograft) for the purpose of fusing or repairing a defect.
  • bone spurs – bony overgrowths that occur from stresses on bone, also called osteophytes.
  • cancellous bone – (sometimes called trabecular bone) the spongy bone found beneath the hard outer bone that is rich with bone-growing proteins.
  • cortical bone – the outer layer of dense, compact bone.
  • facet joints – joints located on the top and bottom of each vertebra that connects the vertebrae to each other and permits back motion.
  • fusion – to join together two separate bones into one to provide stability.
  • instrumentation – titanium, stainless steel, or non-metallic devices implanted in the spine to increase stability. Includes hooks, rods, plates, screws, and interbody cages.
  • osteoblasts – the bone-building cells in bone.
  • osteoclasts – the bone-removing, or resorption, cells in bone.
  • osteophytes – bony overgrowths that occur from stresses on bone, also called bone spurs.

References

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