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When Is Lumbar Fusion Necessary?

When talking to my patients, I’ve found that there is often concern about the prospect of having lumbar fusion surgery. Although I always encourage them to carefully consider their surgical options, I also think it’s important they realize that in some cases, lumbar fusion is the best and most appropriate way to treat their lower back pain. Here, I’ll explain how we determine who is a good candidate for lumbar fusion and clear up some common misconceptions about this procedure.

Lumbar Fusion Stops Painful Movement and Provides Stability to the Affected Area of the Spine.

Lumbar fusion surgery is designed to “weld” adjacent vertebrae into one solid bone, eliminating motion and providing stability in the part of the spine that’s causing pain. Some patients who should consider spinal fusion include:

  • Patients with spondylolisthesis. This is a condition in which one bone of the spine slips over another, out of its proper place. It can lead to symptoms such as back pain and leg pain or weakness. A fusion can help correct that abnormal movement.
  • Patients with degenerative disc disease. The shock-absorbing discs in between the vertebrae can wear down over time, causing them to collapse and pinch nerves as they exit the spine. A fusion can restore the proper spacing and relieve the pressure on the nerve.
  • Patients who’ve undergone multiple microdiscectomies or decompression surgeries. If a patient has had repeated procedures of this nature and requires another, there may not be enough bone stability left in the spine to carry it out. A fusion would be more appropriate in this case.

Artificial Disc Replacement Is Great for the Neck, but Lumbar Fusion Is a Better Solution.

We’ve come a long way with artificial disc replacement, which has allowed us to perform fewer spinal fusions. However, artificial disc replacement isn’t appropriate for everyone. It really depends on the part of the vertebrae that’s affected, as well as the underlying pathology.

For example, when there is documented instability of the spine, as with spondylolisthesis, artificial disc replacement would not be advised. Also, patients who have arthritis in the facet joints of the spine are not great candidates for artificial disc replacement.

Artificial disc replacement is often very successful for treating degenerative disc disease in the neck or cervical spine. But when we are dealing with issues of the lower back, or lumbar spine, a lumbar fusion is the preferred method.

Some Professional Athletes Continue Their Sport After Spinal Fusion.

The number of levels of the spine that are fused and the location of the fusion have an effect on recovery. However, the vast majority of patients that have a one-level fusion do not experience a real change or reduction in their motion. Most patients get back to life with minimal discomfort, and the pain that they came in with can be eliminated. In fact, top athletes such as Peyton Manning, who had a neck fusion, and Tiger Woods, who had a lumbar fusion, were able to play professionally after their procedures. I think knowing this helps reassure patients that their lives don’t have to be dramatically altered if they have a lumbar fusion.

It’s Important to Consider the Patient’s Long-Term Outlook.

One of my patients’ biggest worries after lumbar fusion is that they might develop something known as adjacent segment disease. We know when you fuse a segment of the spine, the stress from that segment is imparted onto the next level of the spine above or below it. Adjacent segment disease implies that a segment next to the one that was fused is more likely to degenerate as a result.

There are a few different ways of looking at this. Is the next spinal segment bound to degenerate faster as a result of the fusion? Or is a patient’s spine just preprogrammed to have this kind of thing happen, meaning the same process that caused the first one to degenerate can also cause the next level to degenerate? Or is it a combination of these two?

In my opinion, I think it’s usually the patient’s natural history. Whatever caused my patient to need surgery at one level of the spine is likely the same thing that happened at the next level. I tell my patients to think of it like a cavity—just because you fix a cavity in one tooth doesn’t mean the tooth next to it can’t get one.

For this reason, when discussing surgical options, a reputable spine surgeon should address the patient’s present situation as well as future outlook when determining the best treatment plan. This is always the approach I take.

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Rojeh Melikian, M.D.

About the author

Rojeh Melikian, M.D. Dr. Rojeh Melikian is a Harvard and Emory University-trained orthopaedic spine surgeon. He was subsequently accepted into the prestigious Harvard Combined Orthopaedic Surgery Residency Program, where he excelled and was appointed as Chief Resident at the Massachusetts General Hospital. He received extensive training in complex spinal surgery, scoliosis, as well as primary and metastatic spine tumors. Upon graduation, Dr. Melikian was awarded the prestigious Harvard Orthopaedic Surgery Thesis Day Award for best clinical presentation for his work on spinal infections. Dr. Melikian has authored numerous presentations, posters and journal articles on spine surgery. Read more articles by Rojeh Melikian, M.D..

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