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New England Journal of Medicine: R.I.P. Back and Neck Fusion Surgery

POSTED ON IN Latest News BY Chris Centeno

does back fusion surgery work

There has been an explosion in low back and neck fusion surgeries in the past two decades. However, I often tell my patients that “fusion is a dog with big fleas.” After they have a spinal fusion and are seen in the office and have more pain somewhere else, I tell them that they’re now getting bit by those fleas. Now a new high-level study published in the prestigious New England Journal of Medicine (NEJM) shows that fusions may be on the way out, as they failed to show any clinical value.

What Is a Spinal Fusion?

low back fusionThe spine was built to bend, and as such it has 24 segments or levels that each moves a little bit. A spinal fusion surgery means that one or more levels of the spine are bolted together, usually with screws, plates, or spacers in the disc. Bone is often used to literally grow the discs together.

Why Is a Spinal Fusion Performed?

As the spine degenerates, it gets sloppy and the segments move too much. The idea behind a spinal fusion is that by bolting the spine levels solid, they won’t be able to move. However, does this really solve the problem? Let’s explore that further.

Why Has the Frequency of the Surgery Exploded?

Twenty years ago, spinal fusion surgery was rare. Most patients who had a spinal problem, like a pinched nerve due to arthritis or a disc bulge, only had the bony area pinching nerves opened up surgically (a laminectomy) without a fusion of the operated levels. However, about 15 years ago, fusions became more and more common, and fast-forward to the past few years and most patients who get spinal surgery get offered a fusion. Why?

It’s certainly not because we have high-level research showing that a fusion adds a lot of improvement over the standard surgeries, like laminectomy. In fact, one of the drivers for this explosion has been that adding a fusion reimburses dramatically more from an insurance company than without. Add to that a huge industry that can sell a $5 screw made in China for several thousand dollars and it’s not hard to see why the practice has exploded.

What Are the Downsides?

Given that the spine was designed to be in motion and still needs to move no matter what we do to parts of it, it’s easy to see that locking down any one or more levels just overloads the adjacent levels. In fact, the breakdown of these adjacent segments is so common after spinal fusion that there’s actually now something called “adjacent segment disease” (ASD). This means that because of the fusion, the next level or two up or down degenerates more rapidly due to the lack of motion in the fused area.

Is There Any Evidence That Spinal Fusion Works?

Given the incredible invasiveness of bolting the spine together and the huge cost of these surgeries and the fact that we know that ASD is real, you would think there was incredible evidence that the surgery works. Nope. This week marked the publication of the world’s first randomized controlled trial of lumbar fusion.

In this new study, almost 300 patients with low back spinal stenosis (arthritis that’s putting pressure on nerves) were randomly assigned to undergo either a traditional laminectomy or that surgery plus a lumbar fusion. The result was not surprising—adding a fusion surgery didn’t improve outcomes at two or five years after surgery! 

Let’s think about that for a moment. We’re exposing patients to much higher surgical risk by adding a fusion and also placing them at risk for breaking down the adjacent sites of the spine. Without any positive effect of adding the fusion, why are we doing this surgery?

The upshot? Spinal fusion surgery doesn’t help patients; in fact I’ve seen more patients harmed than helped over the last two decades. Now it’s also official: the world’s most prestigious medical journal has now published a high-level study that shows that spinal fusion adds nothing to the average laminectomy surgery. RIP, spinal fusion!

    *DISCLAIMER: Like all medical procedures, Regenexx® Procedures have a success and failure rate. Patient reviews and testimonials on this site should not be interpreted as a statement on the effectiveness of our treatments for anyone else.
    Providers listed on the Regenexx website are for informational purposes only and are not a recommendation from Regenexx for a specific provider or a guarantee of the outcome of any treatment you receive.

    comments

    bruce says

    if your procedure is so successful why is it not covered by insurance. most people can't afford the cost, where back surgery is covered by insurance!

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    Regenexx Team says

    Bruce,
    it takes a long while for the Insurance Industry to cover something new. It took time before they decided to cover Interventional Cardiology in which things that used to be treated with open heart surgery are now treated through a catheter, and it will take time before they cover Interventional Orthopedics, in which what was treated with Orthopedic Surgery, can now be treated with injections of your own stem cells. At the moment they're only choosing to cover the surgeries for which there is ever mounting evidence, don't work and /or cause other problems: http://www.regenexx.com/the-orthopedic-structural-paradigm-is-dead/ http://www.regenexx.com/the-regenexx-procedures/back-surgery-alternative/

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    1nbracken says

    So until the Insurance Industry finally decides to cover something new what is a patient with failed spinal fusion to do, take it to the lord in prayer?

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    Chris Centeno says

    1nbracken,

    The healthcare system is likely going to be changing soon, and better for the patient, less expensive options, might be looked at differently when that system is rejigged. If not, avoid steroid shots as they will make the situation worse, and get examined so you at least know what your options are. Here's a list of Doctors who can do that type of exam, which is covered by insurance if you're in network. http://www.regenexx.com/find-a-physician/

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    karen says

    Having had 5 spinal surgeries, including fusion, each one was easily $5k out of pocket and I KNEW I was being set up for additional future surgeries(I have an Aunt t that has have nearly EVERY vertebrae fused since 1970) and the problem with my connective tissues were not being solved. I actually have another fusion scheduled in June...I do like walking and there is no disc left being bone on bone with 60% step off into my spinal cord that is excruciating. I would gladly pay that same $5k for injection into my L2/3 to protect and preserve it for as long as possible.
    I have grade 4OA knee that is inoperable, due to my "young" age for knee replacement...the last thing that I want! I hope to get Into Vegas or San Rafael clinic to get a knee injection just before surgery so both back and knee can be on the mend this summer and I can have my life back... and the IRS can kiss my butt when I claim o error 20k in medical and audit me again.

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    Regenexx Team says

    Karen,
    The Las Vegas location won't be up and running till June, so you may consider getting both your back and knee treated at San Rafael. http://www.regenexx.com/the-regenexx-procedures/back-surgery-alternative/ http://www.regenexx.com/the-regenexx-procedures/knee-surgery-alternative/

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    Patrick Millen says

    There has been success in using the membrane/discs from donars, and replacing the damaged ones with the donar.

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    Regenexx Team says

    Patrick,
    If that were being done, that would still require the surgical the removal of yours... The point is simply that the problem is often treatable with much less invasive measures like injections of your own platelets or stem cells

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    Regenexx Team says

    Patrick,
    While bone allografts are used instead of harvesting bone from the patient's hip in some fusions, donor discs and donor disc membranes would be a very different thing. Injections of your own stem cells and platelets would certainly be less risky! http://www.regenexx.com/the-regenexx-procedures/back-surgery-alternative/

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    Ailsa giles says

    With a left hip arthrodesis as a child, my L4/5 disc didn't stand a chance....however, fab surgeon replaced it 7 years ago and am now managing my back pain with lots of hemp oil and turmeric tablets. Would dearly love a hip replacement to eleviate the constant stress on my back that the arthrodesis has caused throughout my 54 years but have been advised against it.

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    Regenexx Team says

    Ailsa,
    Before you consider a hip replacement, your hip should be ruled in or out as the source of the problem, by someone qualified to do that. We'd be glad to take a look. Please fill out the Candidate form: http://www.regenexx.com/knee-replacement-questions/ http://www.regenexx.com/the-orthopedic-structural-paradigm-is-dead/

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    Truth Hurts says

    A procedure that doesn't work is covered; so, therefore it must be valid ... Insurance companies are happy to pay for spinal surgery because they often end up in patients filling for disability which means they become the problem of the government and Medicare ...

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    cindy Cox says

    I had L2L3 sinal fusion with spacer, flexi rods and spurs cleaned up I know have. 6-8 in scar on my back still on pain meds trying cbd oil could cry, 4 screws and still have pain.*now , I will NEVER HAVE BACK SURGERY EVER AGAIN. I feel the screws pain has moved down my back and up above fusion ????

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    Chris Centeno says

    Cindy Cox,
    So sorry to hear about yoour situation, but wish we could say it is unusual. This is called adjacent segment disease and eventually happens in most fusions. While the fusion is irreversible because the discs have been removed, the ASD is treatable and we can ususally help. Please see: https://www.regenexx.com/pain-after-back-fusion-adjacent-segment-disease/

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    Jennifer Palma says

    I have had two spinal fusions and got much worse after the second one and am now permanently disabled. I once had a surgeon who didn't believe in fusions, but he did disc replacement, day "friends don't let friends get fused" I have remembered that. I will never have another fusion again. I had my first one at 27 hearts old because the surgeon seemed to care and said it would help me be OK again... I had arthritis in less than 12 months post-op and then found out after years of increased leg and back pain that I sustained permanent nerve damage from that fusion. I have a signal cord simulator to combat the nerve damage pain and along with many other conditions I have chronic pain syndrome. I don't ever recommend fusion to anyone unless they are absolutely beside themselves in pain and losing bladder/or bowl control.. It just doesn't fix everything.. It actually caused additional problems.

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    Mike says

    Friends don't let friends get fused? Sounds like Dr. Pettine.... am I right?

    Same unfortunate results here ...

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    Chelsea says

    What are some successful treatments for degenerative discs?

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    Chris Centeno says

    Chelsea, we use many different treatments for degenerative discs, see http://www.regenexx.com/the-regenexx-procedures/back-surgery-alternative/

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    Robert Hawkins says

    I have had 4 spinal surgeries and am fused from L4-S1 and still have radiating pain down my right leg. Decreases flexibility and now pain management is my life! My son in law just had a new coil done instead of fusion and he is doing great! I was five years to early

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    Regenexx Team says

    Robert,
    Timing is everything! http://www.regenexx.com/the-regenexx-procedures/back-surgery-alternative/

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    BC says

    It depends on the surgeon. Some conditions do not respond to anything other than fusion. I had a scoliosis which was corrected with a Harrington's at 22 and then a further fusion at l5-6 to correct a spondylolythesis at the age of 48. I now have virtually no back pain. During the period after the first fusion I played cricket at a reasonably high level, squash and golf to a 1 handicap. After the second surgery, I played golf at the same level. Age has caught up with me, but I don't have any real back pain other than occasional stikkness in the neck area. It stands to reason that the adjacent vertebrae will suffer more wear and tear, but id would be in a very bad place if it were not for Dr Guillaume du Toit who performed both surgeries. He was simply a genius.

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    Chris Centeno says

    BC, the post focuses on elective fusions routinely added to a laminectomy surgery (and/or the common fusions performed for pain). This last several years, many insurers have begun to deny coverage for fusions that are not performed to correct deformity (the more common type). Yours was obviously done to correct deformity, which is a different surgery that the one this post discusses.

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    BC says

    That should be "stiffness".

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    L P says

    Do you treat knee issues? My daughter has had 3 surgeries (she's 26) and now one of her anchors has moved. She's in chronic pain. We actually live in Las Vegas. Please send info if you have any.

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    Regenexx Team says

    LP,
    Yes, definitely. Here is how we treat knees, see: http://www.regenexx.com/the-regenexx-procedures/knee-surgery-alternative/ Filling out the Candidate form on that page will allow her to upload her MRI's and set up a call with one of our Physicians to talk about her case specifically.

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    Liz says

    I had a L5 S1 fusion surgery. I had starting getting pain I my lower back prior to my pregnancy in 11, after about my 6th month I would turn corners, twisting my back in the process, and be on knees in pain. After I had my son in December 2011, it seemed to be less painful. But, slowly it came back. I had an xray which showed my L5-S1 disc was decompressed and I was bone on bone. I went to my family doc, had an MRI and started medication and physical therapy. When that didn't help I went to a spine specialist, reveiwwd my MRI and sent me to a pain doc to try injections. I had 2 rounds of 3 injections each of epidurals and nerve facet blocks. No help or little relief. I went back to the spinal doctor and scheduled my fusion. About 3 more than after I was experiencing pain in my lower back. I had a CT Myelogram and a full body scan, found out I had bad SI joints. So, back to the pain doc. Had more rounds of epidurals and nerve facet blocks, only lower in levels to try to help with the pain. All the while I was placed on a pain patch to help with the pain between injections. I ended up with a spinal cord stimulator that only worked for a short while. Now onto injections in my SI joints with only little help. What next!?!?

    replies

    Regenexx Team says

    Liz,
    I wish I could say that your horrible saga was not a predictable course of events in the orthopedic structural paradigm, but sadly I can't: http://www.regenexx.com/the-orthopedic-structural-paradigm-is-dead/ lmportantly, steroid injections (epidural or otherwise) are lethal to stem cells, so whatever they're being injected into is likely to get worse quickly. http://www.regenexx.com/new-research-steroids-hammer-stem-cells/http://www.regenexx.com/the-regenexx-procedures/back-surgery-alternative/ Please fill out the Candidate Form so we can take a look at your recent films and you can chat with one of our Physicians about your case.

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    Jerry says

    I'm fused from C4-L4 as a result of extreme scoliosis, lordosis, kyphosis. How could have this helped me?

    replies

    Regenexx Team says

    Jerry,
    Without having examined you pre-surgery we can't answer that question, however the type of fusion discussed in the blog and fusions to correct deformities are different surgeries. How are C0-C3 and L5 doing?

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    Michael Terrell says

    All of the comments have been backs and knees. I have had 2 cervical spinal fusions with 2 metal plates, some of my hip bone and some cadaver bone. Almost constant but tolerable pain that flairs up big time with a bit of activity. It started with degenerative disk disease, then a broken fusion from a bad fall. Any options at this point?

    replies

    Regenexx Team says

    Michael,
    Yes. See: http://www.regenexx.com/neck-epidural-failed/ http://www.regenexx.com/new-treatment-for-neck-pain/ http://www.regenexx.com/alar-ligament-treatment/ http://www.regenexx.com/hands-numb-while-sleeping/ http://www.regenexx.com/the-regenexx-procedures/back-surgery-alternative/

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    Stacy says

    My spine was fused in 1978 due to an increasing (82 degree) curve (no Herrington rod, due to previous surgery and scar tissue). Now I'm having a LOT of shoulder and neck pain (approaching 50 yo). Once there has been a fusion, is there anything else that can be done?

    replies

    Regenexx Team says

    Stacy,
    Generally yes. It of course depends on many factors. Please see: http://www.regenexx.com/back-of-shoulder-pain/ and : http://www.regenexx.com/neck-epidural-failed/ If you'd like to see if your a good candidate for a Regenexx procedure, please fill out the Candidate form.

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    Donna says

    I'm fused C2 thru C7 and now live with daily pain meds due to constant pain. I can no longer turn my head to the right more than 5 degrees... My life as a nurse is over! I have cadaver bone and plates and screws due to fracturing my 1st fusion of only cadaver bone. Now they tell me there is nothing else they can do for me except manage my daily pain through a pain clinic I used to be an addictions nurse now I am attending a pain clinic wish I had never had the surgery

    replies

    Regenexx Team says

    Donna,
    Really wish we had the chance to get this all working before the fusions! That said, we'd be glad to take a look, and see what we can do, as living on pain meds is not a good thing. This needs to approached like a detective: http://www.regenexx.com/can-your-neck-cause-hip-pain/ http://www.regenexx.com/neck-epidural-failed/ Please fill out the Candidate form.

    replies

    Sarah says

    I have a bulge on my spine I am awaiting a spinal unit appointment I also have sacroiliac joint distinction and Rheumatoid Arthritis my doctors think due to the bulge on my spine this is why my legs don't work anymore spinal fusion I think may have been on the cards but after reading this I'm not so sure I'd want it!!!!!! I'm in the UK.

    replies

    Regenexx Team says

    Sarah,
    We don't have any Regenexx providers in the UK, but we can take a look remotely if you fill out the Candidate form here: http://www.regenexx.com/the-regenexx-procedures/back-surgery-alternative/ This would allow you to upload your films and discuss your case by phone with one of our Physicians.

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    Debbie says

    I am 56 years old and had my first spinal surgery at 30 years old. I had been rear-ended in an automobile accident, and it caused my vertebrae to collapse when I would bend over. So, my orthopedic surgeon suggested a fusion of L4, L5, S1. Trusting him, I had it done. Well, my surgeries started back up again 10 years later, and continued for the next 4 years.
    I wish I had never had any fusion done, ever! I'm now on disability, receiving Medicare. I can't afford any other treatment that isn't covered by my insurance.
    My life has completely changed. I used to be very active, involved in extra curricular activities.
    Now I can't even clean my house.
    Yes, fusion will change your life. It will ruin it.

    replies

    Regenexx Team says

    Debbie,
    So sorry to hear that. It has, not unexpectedly, become a very disturbing recurrent theme in people who have had fusions. Which brings up the question...why are they being performed? http://www.regenexx.com/the-orthopedic-structural-paradigm-is-dead/

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    Rodney says

    Ive always wondered why, instead of a solid rod disc fusion, a telescoping rod or "shock absorber" isn't used to allow for flexibility but still bump stop before disc bulging.

    replies

    Regenexx Team says

    Rodney,
    Good thought. While treating the cause of the instability is definitely the better plan, for the small parentage of cases where surgery is necessary, something more like an internal brace rather than a fixator does sound like a better plan.

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    Jody says

    I had a spinal fusion in 2001 due to severe scoliosis.. i have been pain free since... before my fusion i could stand for more than a few hours at my job without pain... i have no restrictions and no pain. If I didnt have that surgery I would be disabled now and in a wheelchair.

    replies

    Regenexx Team says

    Jody,
    That's great news. Surgery will always be needed in some cases. The problem is when fusions are routinely included in laminectomy to the detriment rather than the benefit of the patient.

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    bb says

    Do you treat Thoracic Outlet Syndrome? Backstory: after a MVA in '09 I had a artificial disc (pro disc c) placed at c5/6. I was still having neck arm and shoulder pain a year later so I pursued a second opinion and was diagnosed with thoracic outlet syndrome. I avoided surgery for years and finally pursued an operation clear across the country with a top TOS surgeon in Boston. My pain is now treatable where as hardly anything gave me relief before. However I'm still concerned about potential for the artificial disc still causing problems and the extreme likelihood that the scar tissue in my brachial plexus will just get bad again. I'm also suffering from pec minor symptoms as I only had a scalenectomy and first rib removal during my operation in Boston. Wondering if this treatment helps with scar tissue formation and what if anything I should do to check if my ADR is causing issues?

    replies

    Chris Centeno says

    Yes, we treat quite a bit of TOS in Colorado. After a surgery has removed parts and pieces, that may be a bit more challenging. We can treat scar tissue around the brachial plexus with precise ultrasound guided procedures. Best test for your ADR may be flexion-extension x-rays.

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    Leonardo Martinez says

    I have an L4/L5 fusion , it was done in 2000 ever since the minute I tried getting out of the bed at the hospital after surgery I have serious life altering pain . my legs right leg radiates all the way to my foot , and the burning feels like I'm on fire .I went,on disability and cannot raise my son with that kinda money. Anyway to end my Dad story , PLEASE DONT HAVE. A FUSION

    replies

    Regenexx Team says

    Leonardo,
    So sorry to hear about how the fusion has impacted your life. If you read through the comments you'll see you are in very good company. The hope is that articles like this will both show people that surgery can often be avoided by treating the cause of the instability, and inform them enough to ask questions of their surgeon and make sure Fusion isn't being added to surgery just because they're already in there! http://www.regenexx.com/the-regenexx-procedures/back-surgery-alternative/

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    Sharon says

    I have a 16 year old son with nonunion fracture at L3. Could have happen last summer as there was back pain at that time. The injury was not discovered until Mar 2016 from MRI and CT scan. There is currently no slippage but I would like the fracture to heal so that he is safe to resume athletics. He is very active. Do you currently show success with this type of injury.

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    T.Y. says

    Well really, their just now figuring this out now!!!
    At the age of 11 I was forced to have spinal fusion from T7 to L3. It was a horrific surgery! Now 29 years later, I have to deal with the aftermath on a daily basis! Spinal stenosis above and below the fusion, pinched nerve, Great trouble sleeping comfortably, sciatic nerve issues, weakness on my right leg that causes me to trip & fall at times! I refuse to be put on painkillers Or narcotics and be just another statistic, another zombie drug addict the drug companies create in this country!! I've been told by numerous doctors I need more fusion to deal with the spinal stenosis. if that's the case hell I will not be able to bend over and put on my pants are tie my damn tennis shoes now!!!!!!! Thank you very much "Charlotte orthopedic clinic", Charlotte North Carolina!

    replies

    Chris Centeno says

    T.Y.,
    Not an unusual story for fusion, but so sorry to hear you went through that at 11 years old!

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    Linda says

    What about spondylolisthesis? I've had sciatica and bit slower reaction time with my left leg. CT can and MRI show the slip of my spine is putting pressure on my nerves. The severity comes and goes though. But there doesn't seem to be anything to help this but a fusion. I am still holding out though after 10 years of on and off pain.

    replies

    Chris Centeno says

    Linda,
    Thankfully, given the lifelong effects of fusion, Spondylolysis can often be treated with precise image guided injections of your own platelets and or stem cells. Please see: http://www.regenexx.com/spondylolysis-treatment-options/ and http://www.regenexx.com/a-hip-stem-cell-treatment-in-an-akido-master/ As always it's about tracking down what's causing what. If you'd like to see if you're a good Candidate for a Regenexx procedure, please submit the Candidate form.

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    th says

    I had a laminectomy which only caused my spine to further collapse. The pain from the pressure on the nerve was unbearable and I could not stand for more than five minutes without pain. Subsequently, I had a 7 level fusion. Two years later I am walking 3-5 miles a day and hiking. I know fusions don't work for everyone, but it my case it was highly successful.

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    Chris Centeno says

    th,

    The stats on fusions are not good, especially long term as the vertebrae above and below the fusion eventually get overloaded; it's just physics. That said, really glad it's given you relief and gotten you back out there!

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    ken says

    The problem is not the surgery. It is the surgeon. With the correct diagnosis coupled with an appropriate psycho-social patient profile it is hugely successful. Those who are good candidates are often put off for long periods or done as salvage surgery for past blunders. Cure is not expected. Control with the ability to resume a more normal life is. Now there is no question that ASD is real but I don't know of any good studies that support that observation. But there are plenty that show DDD is common, more often asymptomatic and can be managed with Physical Therapy manual procedures and exercise. So who cares if you get ASD if the offending abnormal movement segment(s) is/are stabilized?

    replies

    Chris Centeno says

    Ken, I'll have you talk to the hundreds of ASD patients I have treated who have been made miserable by fusion and whose lives are wrecked. I would expect that they would argue to the point of "who cares if you get ASD"...

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    Lrae Wintercorn says

    I have a spinal fusion at C4 to C6 from 1998. I currently am scheduled for a MRI next week to check update for a large bone spur and a herniated disk at C3. it has collapsed. C2 moves out of place all the time which causes headaches. I have very little room between the plate, which causes swallowing issues. Since Jan. having the flu and coughing has made it worse. I developed SVT, all cardiac and pulmonary tests are normal. I believe the bone spur on the spinal cord is causing this problem. The docs don't believe so. They want to do another fusion and somehow connect the two. I'm not going to lie, I'm scared. I don't have the out of pocket expenses, but I don't want another fusion. help?

    replies

    Chris Centeno says

    Lrae,
    Unfortunately, because fusion "fuses" the vertebrae together and prevents movement, the vertebrae above and below the fusion get overloaded. This is called Adjacent Segment Disease, or ASD, which left unchecked can cause these types of severe issues. Please see: https://www.regenexx.com/pain-after-neck-fusion-2/ If you have a recent MRI we could take a look through the Candidacy process to see if we can help. The exam is usually covered by insurance if the Provider you see is in network.

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    About the Author

    Chris Centeno

    Christopher J. Centeno, M.D. is an international expert and specialist in regenerative medicine and the clinical use of mesenchymal stem cells in orthopedics. He is board certified in physical medicine as well as rehabilitation and in pain management through The American Board of Physical Medicine and Rehabilitation.…

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