Alternatives to spinal fusion surgery and revision spinal fusion surgery

Ross Hauser, MD

Spinal fusion surgery complications and treatment options

If you are seeking alternatives to spinal fusion or a revision spinal fusion surgery, you probably have years of medical care behind you. Your case has become “complicated,” “difficult to treat,” and 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 us reading this article.

We are going to present a lot of information in this article. This information comes from 29+ years of experience in helping people avoid spinal fusion surgery, our own published research in medical journals, and the research from surgeons at leading medical universities and hospitals. We hope this information will help you in your journey to finding pain relief and the ability to enhance and increase your quality of life.

Many people do very well with spinal fusion. The surgery can be very successful. These are not the people we see in our clinic. We see the people for whom fusion surgery may not be the best option or the patients with problems after the surgery.

Article Summary:

You live in a world of pain. Your entire day is spent managing your back pain and worrying about it.

In the image below the caption reads: Almost all chronic pain in the lower back occurs in a six-by-four-inch area. Pain in the lower back occurs in the area where the lumbar vertebrae join the sacrum and the iliac crest.

Pain the the lower back occurs in the area where the lumbar vertebrae join the sacrum and the iliac crest.

You do not want a “significant and major spinal surgery.” In fact, you would not be here on this page if you were completely sold on your doctor’s recommendation for lumbar discectomy or spinal fusion. You do know that people do get benefit from major spinal surgery and are able to rebuild their lives, you have also done a lot of research that shows you that spinal fusion or discectomy can make things a lot worse. These surgeries come with significant risks.

Spinal Instability and your pain issues

We do not like to recommend spinal fusion surgery unless it is clear that the patient’s situation offers no other choice. We don’t like to recommend spinal fusion because it does not, in many cases, correct the underlying problems of lumbar spinal instability as many people would think it would. In fact, spinal fusion surgery may increase spinal instability and degeneration. How can this be?  Because the surgery was performed with the idea that it was the discs that were causing the person’s problems. The surgery failed because it was not the discs by themselves, but spinal instability caused by weakened degenerated ligaments. For many people we see, the missing diagnosis, the missing treatment was the one that addressed your damaged spinal ligaments.

In a way, you can think of strengthened bands of connective tissue, the ligaments, degenerating and weakening to the point where they have to be replaced by steel rods and screws.

What are we seeing in this image?

Progression of Degeneration of Lower Back. An initial injury to the spinal ligaments causes the progression of spinal instability that can lead to spinal fusion.

Progression of Degeneration of Lower Back. An initial injury to the spinal ligaments causes the progression of spinal instability that can lead to spinal fusion.

A teaching point of this article: Understanding what degenerative spinal instability is and how surgery may not be the best option.

Throughout this article, we are going to present research from leading medical centers and universities. We do this so that you will see the contents of this article are not just our opinion. Our opinions are shared by others in the medical community.

Doctors teaching radiologists what a degenerative spine is:

In the April 2018 edition of the medical journal Insights Imaging (1) doctors from Mercy Catholic Medical Center published a paper entitled “ABCs of the Degenerative Spine.” This paper was written for the benefit of radiology residents.

We like to call these “insults” or injuries, the excessive load and destructive joint forces caused by damaged, weakened spinal ligaments. This 2018 paper is copied in later research we will discuss below.

When you are being sent for an MRI you are being sent for a confirmation that you must have lumbar spine surgery.

In some cases, an MRI like the one shown in the image below can send you to a surgical consultation. The image caption reads Lumbar disc herniation at L5-S1 compressing the lower lumbar nerve roots (arrow).

Lumbar disc herniation at L5-S1 compressing the lower lumbar nerve roots

When radiographs are taken of patients with low back pain, they often show one or more of the following findings that may be indicative of a recommendation for spinal fusion

While these findings may be diagnostic by x-ray, CT scan, or MRI standards, they are not the true diagnosis since they are not what is actually causing a person’s symptoms: the likely diagnosis, instead, is spinal instability. For more discussion on this topic please see our article MRIs Cause Failed Back Surgery,

The degenerative cascade associated with back pain begins long before the above-mentioned symptoms become evident, and appears to evolve in stages. The traditional thinking regarding the spinal degenerative cascade was that the intervertebral discs were thought to undergo three phases of degeneration:

Disc degeneration Phase 1: Dehydration, loss of disc height, heightened pain

The first phase of degeneration is the Dysfunctional Phase – whereby circumferential painful tears of the annulus occur in association with endplate separation. This leads to further radial tears that are more susceptible to protrusion and to the loss of the disc’s ability to maintain water, which causes dehydration in the disc and a reduction in disc height. Vascular tissue and nerve endings may also encroach upon fissures produced in the degenerating disc, increasing innervation and the disc’s capacity for pain signal transmission.

Disc degeneration Phase 2: Subluxation and instability

The second phase of degeneration is the Instability Phase, whereby progressive changes in disc resorption, internal disruption, and continuing annular tearing cause a loss in the mechanical integrity of the disc. This catastrophic event occurs in combination with facet degeneration, which can lead to subluxation and instability.

Disc degeneration Phase 3: Bone spurs and sclerosis

The third phase of degeneration is the Stabilization Phase, whereby continued disc space narrowing and fibrosis take place, along with the formation of osteophytes and transdiscal bridging.

Is it the discs then causing the pain?

In the caption of the image below: MRI showing lumbar spondylosis. Joint instability is the best explanation of the MRI and X-ray findings of degeneration including endplate sclerosis, disc space narrowing, and osteophytes or bone spurring.

MRI showing lumbar spondylosis

The main problem with thinking in terms of the traditional spinal degenerative cascade is the emphasis on the disc as the primary source responsible for causing chronic pain. The intervertebral disc is the largest avascular (no blood supply) structure in the body and has very few nerve endings. Like cartilage, which is also avascular and has no nerve endings, the disc does not normally cause pain, simply because pain cannot be transmitted without nerves.

Therefore, the pain being felt must be the result of something that does cause pain: spinal ligament laxity and injury. If a disc herniates and free disc material (not contained within the disc) is lying on top of a nerve, then, of course, it would cause pain. However, a degenerative disc typically causes very little pain itself.

Later in this article, we will discuss the role of spinal ligaments in maintaining spinal strength and pain-free movement. It is very likely that if you are reading this article and are contemplating spinal surgery, the role, function, and repair of spinal ligaments HAVE NOT been discussed with you at all. Let’s talk surgery first.

Patients are asking for lumbar surgery that their health providers do not want to offer them. When educated, patients move to decline the surgery.

In September 2017, doctors at the Neuroscience Institute, Virginia Mason Medical Center in Seattle, published a paper in the medical journal, Spine. (2Joined researchers from Massachusetts General Hospital and the University of Washington, suggested that patients were more likely to want surgery than their healthcare providers were willing to offer. In this paper, the suggestion is for 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 patients with concerns and fears about 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.

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:

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:

Spinal fusion surgery complications and treatment options before the surgery. In this x-ray image, narrowing of the intervertebral foramina at the L3 and L4 levels are seen in the x-ray extension view, but they are seen as open in the flexion view. This is a problem of adjacent segment disease and the cause of lumbar radiculopathy. Restoring spinal stability by treating the spinal ligaments with Prolotherapy can be seen as a viable and simple option to this problem.

Spinal fusion surgery complications and treatment options before the surgery. In this x-ray image, narrowing of the intervertebral foramina at the L3 and L4 levels is seen in the x-ray extension view, but they are seen as open in the flexion view. This is a problem of adjacent segment disease and the cause of lumbar radiculopathy. Restoring spinal stability by treating the spinal ligaments with Prolotherapy can be seen as a viable and simple option for this problem.

The question is, how long can these educated patients decline having the surgery?

The question is, how long can these educated patients decline having the surgery? Following up on this 2017 paper was a 2022 study published in the journal BioMed Central Health Services (3) which wrote: “Second opinions might be particularly useful for people recommended surgery for their back pain as surgery has at best a limited role in the management of back pain. . . second opinion services typically recommend less surgical treatments compared to first opinions and may reduce surgery rates in the short-term, but it is unclear whether these reductions are sustained in the long-term or if patients only delay surgery.”

As 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

What are we seeing in this image? A patient with a long history of back pain and surgical intervention. This patient had many surgeries, this is evident from this pelvic x-ray showing the seven spinal fusion screws. Following the spinal fusion, we see evidence that the patient had continued pain by the fact that the patient has a spinal cord stimulator. This is an x-ray of a patient who then went on to have Prolotherapy injections that helped her. Prolotherapy is explained below.

What are we seeing in this image? A patient with a long history of back pain and surgical intervention. This patient had many surgeries, this is evident from this pelvic x-ray showing the seven spinal fusion screws. Following the spinal fusion we see evidence that the patient had continued pain by the fact that the patient has a spinal cord stimulator.

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 research, doctors at the VA Maryland Health Care System and the University of Maryland School of Medicine (4) 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 multi-disciplinary spine board reduces spinal fusion recommendations offered to patients

The presence of a team “spine board,” alone in a medical hospital caused the number of spinal fusions to be reduced by half

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 degenerative or inflammatory disorders caused by spinal defects that can occur in the cervical, thoracic, and lumbar regions.

The terms can also be linked to degrees of severity such as mild to 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.

Five years later in July 2023 in the journal Spinal Deformity (5) researchers noted that the multi-disciplinary spine board does make a significant impact in preventing surgeries at high risk for failure. The researchers from NYU Langone Health Department of Orthopedic Surgery noted: “Following implementation of a multidisciplinary high-risk case conference, 30- and 90-day reoperation and readmission rates, intraoperative complications, and postoperative deep (Spinal Cord Stimulator implantation) decreased. . . .These associations suggest a multidisciplinary conference may help improve quality and safety for high-risk spine patients. Particularly through minimizing complications and optimizing outcomes in complex spine surgery.”

When patients do not understand the options they opt for surgery.

In a recent study by doctors at Wayne State University School of Medicine appearing in the Journal of Neurosurgery(6) patients referred to a neurosurgery clinic for degenerative spinal disorders were surveyed to determine their understanding of lumbar spondylosis diagnosis and treatment.

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.

In March 2022, a paper published in the journal Quantitative Imaging in Medicine and Surgery (7) suggested that an examination and patient history provided good prognostic value to determine whether low back pain patients with or without radiculopathy required surgical treatment. The addition of MRI findings yielded no significantly incremental prognostic value.

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. 

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.

The decision for spinal fusion may be made because patients are being steered towards spinal fusion “superficially’ What does this mean?

A November 2018 paper in the Public Library of Science One (Plus One) explains:(8)

“Across many different patient populations with data obtained from a variety of study designs, common themes emerged (among patient opinions) which highlighted areas of patient dissatisfaction with the medical management of low back pain, in particular, the superficial approach to care perceived by patients and concerns regarding pharmacotherapy.

Patients perceive unmet needs from medical services, including the need to obtain a diagnosis, the desire for pain control, and the preference for spinal imaging. These issues need to be considered in developing approaches for the management of low back pain in order to improve patient outcomes.”

It can be easy to see how patients want surgery because nothing else has helped them up until this point and patients find it difficult to get pain management otherwise.

Are you a good candidate for spinal fusion?

The studies cited above suggest that you are a good candidate if you sought many medical options for 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 (9) 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. ”

So are you a good candidate for spinal fusion? Yes, if . . .

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: It caused an uproar then, and its repercussions are still felt today in 2023.

“(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.

That of course is a 2016 article, about eight years old. With new technology, things must have changed. For the most part no.

The problems following spinal fusion – a class in understanding for the radiologist.

In June 2021 radiologists at Yale Radiology and Biomedical Imaging, Yale University published a paper in the journal Skeletal Radiology (10) which gave this assessment of the problems radiologists may encounter as they look at scans of patients who had a previous posterior motion preservation spinal fusion procedures. The key here is the surgery was designed to preserve a more natural spinal motion.

“Spinal fusion is performed to eliminate motion at a degenerated or unstable segment. However, this is associated with loss of motion at the fused levels and increased stress on adjacent levels. Motion-preserving implants have been designed in an effort to mitigate the limitations of fusion. . . In the lumbar spine, motion-sparing systems include interspinous process devices (also referred to as interspinous process spacers or distraction devices), posterior dynamic stabilization devices (also referred to as pedicle screw/rod fixation-based systems), and posterior element replacement systems (also referred to as total facet replacement devices). Knowledge of the intended physiologic purpose, hardware utilized, and complications are important in the assessment of imaging in those who have undergone posterior motion preservation procedures.”

Clearly, this is still an ongoing problem.

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. (11) 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:

What we have in the introduction of this paper is the spinal surgeons found that:

The purpose of this paper was to help identify which patient’s spinal fusion may help. In its conclusion, the researchers found patients with midline back pain and acute pain on sudden movement may benefit most. The results were not conclusive.

A remarkable research finding “Results following fusion for chronic low back pain are unpredictable and generally not very satisfying

We want to point out that this research was led by renowned spinal surgery researcher Bo Nystrom of the Clinic of Spinal Surgery in Sweden. Among his many studies, Nystrom led a team of researchers that wrote in The Open Orthopaedics Journal  (12) suggesting 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.

L5-S1 adjacent segment degeneration

A July 2022 study (13) from Japan’s leading universities’ Departments of Orthopaedic Surgery evaluated the incidence, characteristics, and risk factors for clinical L5-S1 adjacent segment degeneration (ASD) after L5 floating (disc was removed) lumbar fusion. The researchers write: “Adjacent segment degeneration is known to occur after lumbar spine fusion at a certain frequency. Several studies on radiological L5- S1 Adjacent segment degeneration have been reported. However, there are only a few studies on L5-S1 Adjacent segment degeneration with clinical symptoms, including back pain and/or radiculopathy.

The topping-off method to reduce spinal fusion complications and adjacent segment disease

Let’s review the suggestions of a 2017 study (14)  in describing the “topping off” or hybrid fusion technique to help prevent adjacent segment disease.

This “topping-off” technique refers to the application of a hybrid dynamic pedicle screw construct or interspinous process device above the fused segments. This technique provides a transitional zone between caudal rigid fused construct and cephalad (upwards towards the head) mobile/unfused segments, which may decrease the incidence of adjacent segment disease. The rationale of this technique is that the semirigid zone provides a gradual transition from the rigid to mobile segments to lessen stress concentration at the adjacent level.

Does this new transition from a rigid spine to a flexible spine help prevent adjacent segment disease?

Again from the 2017 study: “Although the evidence is weak, the “topping-off” technique with hybrid stabilization device or interspinous process devices might decrease the incidence of proximal adjacent segment disease both radiographically and symptomatically as compared to the fusion group.  . . In conclusion, the “topping-off” technique might be considered as a possible solution for postfusion adjacent segment disease, but further research is needed prior to wide application.”

An August 2023 paper (15) found possible problems at the sacroiliac joint. In this study, researchers investigated the biomechanical effects of topping-off instrumentation on the sacroiliac joint after lumbosacral fusion. They found: “Motion, stress, and ligament strain at the sacroiliac joint increase when supplementing lumbosacral fusion with topping-off devices, suggesting that topping-off surgery may be associated with higher risks of sacroiliac joint degeneration and pain than fusion alone.”

In this video, Ross Hauser, MD, discusses the difference between Dynamic Spinal Stenosis and Static Spinal Stenosis and who should get surgery, and who can get the benefit without surgery

These are some learning points from the video:

How do we determine in the office who needs surgery and who doesn’t?

“an alternative to opioids, unwarranted diagnostic tests, and unnecessary surgery.”

Doctors at Duke University’s Department of Orthopaedic Surgery, Duke Clinical Research Institute, wrote in December 2020 in the medical journal Pain Transforming (16) about low back pain care delivery in the United States.

“Low back pain continues to be a challenging condition to manage effectively. Recent guideline recommendations stress providing non-pharmacological care early, limiting diagnostic testing, and reducing exposure to opioid pain medications. However, there has been little uptake of these guideline recommendations by providers, patients, or health systems, resulting in care that is neither effective nor safe.

There is an urgent need to transform low back pain care by optimizing clinical care pathways focused on multiple opportunities for non-pharmacological treatments, carefully considering the escalation of care, and facilitating self-management. Such approaches have the potential to increase patient access to guideline adherent LBP care as an alternative to opioids, unwarranted diagnostic tests, and unnecessary surgery.”

In these next sections, we will discuss possible options for opioids, unwarranted diagnostic tests, and unnecessary surgery.

Your life on painkillers after surgery. Why painkillers cause the need for more surgery

The 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 a spinal fusion.

In research from the medical journal Spine, (17) 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.

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

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.

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.

Please refer to our articles on How narcotic pain medications can increase chronic pain and why chronic non-steroidal anti-inflammatory drug (NSAIDs) usage can make the pain worse.

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. (18)

We see many failed back surgery patients, so 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 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).”

Building on the above research was a July 2020 paper (19) from doctors at the Texas Back Institute and Department of Orthopedic Surgery, Rush University Medical Center. This review paper showed that persistent pseudarthrosis (failure of the fusion) after revision posterolateral fusion (the surgery is performed from the back) occurs at rates of 35 to 51%.

Summary and contact us. Can we help you?

Lumbar spinal fusion operations fuse together several segments of the vertebrae. Such an operation is commonly performed for spondylolisthesis, a condition where one vertebral segment slips forward on another. This causes back pain, especially when bending. By definition, spinal fusion causes permanent bonding or fusing of several vertebral segments. Mobility is decreased, causing increased stress on the areas above and below the fused segment. While fusion is sometimes a necessary surgery, the long-term consequences should be known and all conservative efforts tried, including Prolotherapy.

We hope you found this article informative and it helped answer many of the questions you may have surrounding issues with your back pain.  If you would like to get more information specific to your challenges please email us: Get help and information from our Caring Medical staff

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