The evidence against spinal fusion surgery
We do not like spinal fusion surgery. We don’t like it because it does not correct the underlying problems of spinal instability as many people would think it would. In fact, spinal fusion surgery may increase spinal instability and degeneration. Now I have said a lot in these opening sentences but what I said is shown in the independent research below offered by leading medical hospitals and universities.
Let’s get to your problem.
If you are seeking alternatives to spinal fusion you probably have years of medical care behind you. Your case has become “complicated,” “difficult to treat,” your medication consumption may have increased dramatically as your situation degenerates rapidly. You have spent a lot of time online looking for answers including the time you spend here with me reading this article.
- You are considering fusion because you may have a lot of pain in L5/S1 or L3/L4 for example, (For cervical neck problems please see my article Anterior Cervical Discectomy and Fusion | Does this surgery cause more cervical spine instability and deformity?)
- You have a diagnosis of stenosis on multiple levels, your MRI is showing “snake eyes.”
- The pain in getting unmanageable, you are on medications, you have tried physical therapy. You have decided that something needs to be done now and that something that gives you the best chance for fast relief is surgery.
- But, you would not be here on this page if you were completely sold on the fusion.
Research suggests that if you knew what spinal fusion surgery was and the realistic post-surgery success and complication possibilities, you would likely not have it
In September 2017, doctors at the Neuroscience Institute, Virginia Mason Medical Center in Seattle, published a paper in the medical journal Spine.(1) Joined by researchers from Massachusetts General Hospital and the University of Washington, they suggested that:
- Patients who have a case review by a team of spinal pain specialists, including physiatrists, anesthesiologists, pain specialists, neurosurgeons, orthopaedic spine surgeons, physical therapists, and nursing staff, and are counseled in the findings of that review, will likely decline to have the surgery.
This is a very interesting study for the patient with concerns and fears of what spinal fusion surgery can offer them. So let’s break it down a little bit.
The paper sought to establish a comparison between getting guidance from a multi-discipline and diverse group of health care professionals as opposed to only getting guidance from a surgeon in whether or not they should proceed with spinal fusion.
- What is highlighted is the fact that the patients in this study had ALREADY suffered from a complex spinal history of PRIOR spinal surgery.
In their review and counseling, patients’ were involved in discussions about deciding on surgery, the type of surgery, and to see if they were good candidates for that particular surgery.
Highlights from the study:
- A total of 137 consecutive patients were reviewed
- Of these, 100 patients had been recommended for lumbar spine fusion by a surgeon.
- The consensus opinion of the multidisciplinary group suggested to the patient:
- Nonoperative management in 58 patients (58%) who had been previously recommended for spinal fusion at another institution.
- A different surgery was recommended: The surgical treatment plan was revised as a product of the conference in 16 patients (28%)
Isolated surgical decision making (relying solely on one opinion and that of a surgeon) may result in suboptimal treatment recommendations. Or saying it like it is “Failed Back Surgery”
The research concludes:
- Isolated surgical decision making (relying solely on one opinion and that of a surgeon) may result in suboptimal treatment recommendations. Multidisciplinary conferences can reduce the utilization of lumbar spinal fusion, possibly resulting in the more appropriate use of surgical interventions with better candidate selection while providing patients with more diverse non-operative treatment options.”
Research is addressing the problem that patients DO NOT understand what is causing their back pain and rely too much on the surgical interpretation of MRI to give the go-ahead to fusion surgery.
If patients have information, they are more likely NOT to have spinal fusion surgery.
In October of 2018, another study confirmed the findings we shared above. In this new research, doctors at the VA Maryland Health Care System and the University of Maryland School of Medicine offered these observations after they established a “multidisciplinary spine board” to review candidates selected for elective lumbar spine surgery.
The board comprised representatives from orthopedic spine surgery, neurosurgery, psychology, physical therapy, radiology, pharmacy, primary care, pain management, anesthesiology, and veteran advocacy.
The multidisciplinary spine board reduces spinal fusion recommendations offered to patients
- Between March 1, 2016 and December 30, 2016, the spine board itself discussed 11 patients.
- All patients underwent clinical examinations and radiological assessments findings that warranted elective lumbar surgery.
- The board recommended non-surgical interventions before proceeding with the planned surgeries in all cases.
- The board stopped or delayed 11 or 11 surgeries.
The presence of team “spine board,” alone in a medical hospital caused the number of spinal fusions to be reduced by half
- The doctors noted that before they had a “Spine Board,” a total of 101 elective lumbar spine surgeries were performed.
- After the establishment of a spine board, a total of 51 elective lumbar spine surgeries were performed.
- The surgical plan for elective lumbar spine surgery in the post-implementation period was not directly influenced by the review of spine board because none of the cases were discussed in the conferences; however, the care occurred at a hospital where the spine board was implemented. (2)
As we discussed in the research above, if patients have information, they are more likely NOT to have spinal fusion surgery. But what if they were given a piece of information that, by itself, suggested a fusion may be necessary? What if that information was not corroborated? Then you have symptom-free patients heading for surgery.
Spondylolisthesis (Slipped disc), Spondylolysis ( stress fractures from wear and tear), Spondylosis (arthritis wear and tear of the discs). These are sometimes confusing terms that act as a catch all phrase or umbrella term to describe neurological or degenerative or inflammatory disorders caused by spinal defects which can occur in the cervical, thoracic, and lumbar regions.
The terms can also be linked to degrees of severity such as mild or moderate or advanced spondylosis or severe spondylosis that can cause local or diffuse pain. Sometimes everything is just thrown into one term spondylotic. It is sometimes difficult for them to understand all these definitions.
When patients do not understand the options they opt for surgery.
In a recent study from doctors at Wayne State University School of Medicine appearing in the Journal of Neurosurgery, patients referred to a neurosurgery clinic for degenerative spinal disorders were surveyed to determine their understanding of lumbar spondylosis diagnosis and treatment.(3)
The survey consisted of questions designed to assess patient understanding of the role of radiological imaging (MRI for low back pain) in the diagnosis and treatment of low-back and leg pain, and patient perception of the indications for surgical compared with conservative management.
- A total of 121 surveys were included in the analysis.
- More than 50% of the patients indicated that they would undergo spine surgery based on abnormalities found on MRI, even without symptoms;
- more than 40% of patients indicated the same for plain radiographs.
- Similarly, a large proportion of patients (33%) believed that back surgery was more effective than physical therapy in the treatment of back pain without leg pain.
- Nearly one-fifth of the survey group (17%) also believed that back injections were riskier than back surgery.
These results show that a surprisingly high percentage of patients have misconceptions regarding the diagnosis and treatment of lumbar spondylosis, and that these misconceptions persist in patients with a history of spinal surgery.
- Specifically, patients overemphasize the value of radiological studies and have mixed perceptions of the relative risk and effectiveness of surgical intervention compared with more conservative management.
These misconceptions have the potential to alter patient expectations and decrease satisfaction, which could negatively impact patient outcomes and subjective valuations of physician performance. While these results are preliminary, they highlight a need for improved communication and patient education during surgical consultation for degenerative lumbar spondylosis.
Are you a good candidate for spinal fusion?
The two studies cited above suggest that you are a good candidate if you sought many medical options about your spinal fusion, especially if you already have complicated back issues from previous spinal surgery. They also suggest that you are a good candidate if you do not believe everything the MRI is showing you. However, are there more considerations to take into account if you are exploring spinal fusion surgery?
As recent research published by the Japan Neurosurgical Society points out “despite the fact that an absolute indication for this surgery is still unclear, decisions about performing lumbar fusion for degenerative Spondylolisthesis should be undertaken by considering not only the patient’s condition but also the social circumstances, medical insurance system, economic effects, and the surgeon’s preference and experience. “(4)
So are you a good candidate for spinal fusion? Yes if . . .
- You have good insurance,
- Can take a lot of time off from work,
- You do not need to provide for you or your family,
- and have been prepared for a long rehabilitation period with a compromised quality of life . . . then you are a good candidate for a surgery recommendation that is unclear and imprecise.
Spinal Fusion Surgery – the Failure of Treatment
A news story in the New York Times dated August 3, 2016 had this to say about the effectiveness of spinal fusion surgery:
“(Spinal fusion is an) operation that welds together adjacent vertebrae to relieve back pain from worn-out discs. Unlike most operations, it actually was tested in four clinical trials. The conclusion: Surgery was no better than alternative nonsurgical treatments, like supervised exercise and therapy to help patients deal with their fear of back pain. In both groups, the pain usually diminished or went away.
The studies were completed by the early 2000s and should have been enough to greatly limit or stop the surgery, says Dr. Richard Deyo, professor of evidence-based medicine at the Oregon Health and Sciences University. But that did not happen, according to a recent report. Instead, spinal fusion rates increased — the clinical trials had little effect.”
It is unclear if a decade of clinical trials saying spinal fusion is no better than conservative treatments and one New York Times article will change anything, spinal fusion surgery will still be done. Why? Because the MRI will always show clear evidence of the need for medical intervention.
Spinal fusion does work for some people, but why would researchers say that the success of spinal fusion surgery is “a matter of chance.”
Leading neurologists and spinal surgeons in Norway and Sweden published their research in the Scandinavian journal of pain (published in the United States) in July 2017. The paper entitled: Symptoms and signs possibly indicating segmental, discogenic pain. A fusion study with 18 years of follow-up, followed patients who had spinal fusion over an 18 year period.
Let’s see what they had to say:
- There are only five studies that compare conservative care (exercise, cognitive intervention – the way people think about their back pain, physical therapy, etc.)
- Only two of these five existing randomized studies have reported better results from fusion surgery for chronic low back pain compared to conservative treatment.
- In these studies, the back symptoms of the patients were described simply as “chronic low back pain.” One possible reason for the modest results of surgery is the lack of a description of specified symptoms that might be related to a painful segment/disc, and patient selection may, therefore, be more or less a matter of chance.
- Previous prospective studies including facet joint injections and discography and eventually MRI have failed to identify patients with a painful segment/disc that will benefit from fusion surgery.(6)
What we have in the introduction of this paper is the spinal surgeons found that:
- Conservative care treatments provided better results than spinal fusion.
- Remarkably, pre-screening presently offered did not help predict who would benefit from surgery and who would not.
- Incredibly, that the surgery would be successful or not was “ a matter of chance.”
The purpose of this paper was to help identify which patients spinal fusion may help. In its conclusion, the researchers found patients with midline back pain and acute pain on sudden movement may benefit most. Results were not conclusive.
A remarkable research finding “Results following fusion for chronic low back pain are unpredictable and generally not very satisfying
I want to point out that this research was led by renowned spinal surgery researchers Bo Nystrom of the Clinic of Spinal Surgery in Sweden. Among his many studies, Nystrom led a team of researchers that writing in The Open Orthopaedics journal suggested that if MRI showed what was really causing back pain, lumbar fusion would have worked. Here is a remarkable finding from that research on lumbar fusion success or non-success.
- “Results following fusion for chronic low back pain are unpredictable and generally not very satisfying. The major reason is the absence of a detailed description of the symptoms of patients with pain, if present, in a motion segment of the spine.
- Various radiological findings have been attributed to discogenic pain, but if these radiological signs were really true signs of such pain, fusion would have been very successful.
- If discogenic pain exists, it should be possible to select these patients from all others within the chronic low back pain population. Even if this selection were 100% perfect, however, identification of the painful segment would remain, and at present, there is no reliable test for doing so.” (7)
Your life on painkillers after surgery. Why these painkillers cause the need for more surgery
The three studies cited above suggest to patients the many complexities of spinal fusion surgery. All of them discuss the quality of life in patients for whom there were complications causing post-surgical pain. Now here is a fourth study that brings in a more detailed analysis of the need for painkillers after the spinal fusion.
In research from the medical journal Spine, doctors looked at Worker’s Compensation patients who were given Lumbar Fusion Surgery for Degenerative Disc Disease. What they wanted to measure was how much painkiller medication they were on, if any, and what was the effect.
One thousand and two patients participated who had a lumbar fusion from 1993-2013.
- Postoperative use of chronic opioid therapy (chronic use of painkillers) was defined as being prescribed the medications for more than one year after the 6 week acute period following fusion. Of the 1002 patients (57%) or 575 patients took the pain medications for more than one year following surgery.
Here are the summary points for people who had surgery and their primary treatment after three years became chronic opioid therapy:
People on chronic opioid therapy were more likely to
- suffer failed back syndrome 85.0%
- additional surgery 76.4%
- clinically diagnosed depression 77.1%
- had extended work loss before fusion 61.3%.
Within 3 years after fusion, the chronic opioid therapy group was supplied with an average of 1083.4 days of opioids and 49.0 opioid prescriptions, 86.2% of which were Schedule II.(6)
Examples of Schedule II narcotics include hydromorphone (Dilaudid®), methadone (Dolophine®), meperidine (Demerol®), oxycodone (OxyContin®, Percocet®), and fentanyl (Sublimaze®, Duragesic®). Other Schedule II narcotics include morphine, opium, codeine, and hydrocodone.
Why you may need more surgery after the spinal fusion – You may not fuse, You may fuse too much
In the research above, studies centered on patients who already had spinal surgery that resulted in a “complex history of prior spinal surgery.” The causes of failure are many and complex. What the studies above point out is the need to try not to go back to another surgery.
A study in the Global Spine Journal examined Pseudarthrosis (the non-union or non-healing of bones) following spinal fusion.
To a doctor like myself, who sees many failed back surgery patients, it is not surprising that the researchers said the non-union or non-healing of bones remains a substantial problem. Current data shows that patients who develop a pseudarthrosis have suboptimal outcomes. (Some would call suboptimal, failure, or catastrophic failure of the spinal fusion).
The somber news for patients with a non-healing spinal fusion is that these researchers concluded after an evaluation of the surgical approaches to revision surgery to fix this problem: “All surgical approaches examined for the treatment of lumbar pseudarthrosis resulted in only poor to modest improvement in (disability improvement scoring).”(8)
Special notice for patients over 80
In the January 2018 edition of the medical journal Acta Neurochirurgica, doctors put out a special warning for patients over the age of 80 who were being recommended to spinal fusion surgery. Here is what the conclusion of this research reported:
- The incidence of perioperative (the phase of preparation before surgery) medical complications and mortality rates in octogenarians undergoing elective spinal surgeries are quite high.
- The benefits of having surgery must be weighed against the risks of not only surgical but also adverse medical events.
- An informed decision-making process should include a discussion of potential postoperative morbidity (complications) specific to this patient population in order to guide a patient’s acceptance of higher risks and expectations postoperatively.
- It is also important to identify potential complications and adopt preventive measures in order to help minimize them in this patient population.(9)
Higher risk of hip replacement complications in patients who had a previous spinal fusion
Doctors at New York University publishing in the Spine Journal write that lumbar fusion reduces the variation in pelvic tilt between standing and sitting. What does this mean? It means while a flexible lumbo-pelvic unit increases the stability of total hip arthroplasty in the seated position, preventing impingement of the prosthesis. A previous lumbar fusion may eliminate this flexible and protective pelvic movement, according to the NYU researchers and puts these patients at increased risk for hip prosthesis dislocation.(10)
National University of Singapore researchers have found the same phenomena. Publishing in the Journal of Arthroplasty, their study strongly demonstrates that patients with prior spinal fusion had worse outcomes after hip replacement than patients without prior spinal fusion. This has clinical significance in counseling patients with previous spinal fusion considering a total hip replacement.(11)
Also writing in the Journal of Arthroplasty, doctors at the University of California, San Francisco found more troubling problems:
- Patients with previous spinal fusion had in addition to greater risk for prosthesis dislocation, higher risks for infections, hospital readmissions, and challenges with postoperative walking distance.
- Patients who had more than three segments fused had increased cumulative postoperative narcotic consumption.(12)
What are our treatment options for back pain other than fusion?
This is not an answer that can be given in a few sentences. If you are seeking alternatives to spinal fusion you probably have years of medical care behind you. Your case has become “complicated,” “difficult to treat,” your medication consumption may have increased dramatically as your situation degenerates rapidly.
These pages on our website will get you to information specific to your problem.
- Non-surgical option: Prolotherapy non-surgical treatment of a bulging or herniated disc
- Aggressive Non-surgical treatment options for lumbar spinal stenosis
- Prolotherapy and stem cells as an alternative to degenerative disc disease surgery
If you have questions about Spinal fusion surgery complications, Get help and information from our Caring Medical staff
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