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Spinal Fusion Is It Worth It? More Research Says No…

POSTED ON IN Back/lumbar Latest News Neck/Cervical BY Chris Centeno

spinal fusion is it worth it

A spinal fusion is a surgery that uses hardware and screws to “fix” together two or more vertebrae to make a damaged section of spine immovable. Given that this is a big surgery with many known serious side effects, a patient the other day posed this question: “Spinal fusion is it worth it?” My answer, based on what I already knew, was a strong no, but when I dug deeper into the research, my resolve deepened.

So what is spinal fusion? One of the more common types of fusions is called a 360 degree fusion (360 fusion) because it fuses together the vertebrae from both the front and back sides of the spinal column. Fusion surgery is commonly done when a patient has some type of degenerative disc disease, herniated discs, stenosis, or other spinal injuries that cause pain or spinal instability. These surgeries are lengthy, risky, and painful, and besides the fact that the term “fusing” seems more suited a welder’s trade than a surgeon’s—or perhaps because of it—the truth is, long-term 360 degree fusion outcomes are awful!

To address why spinal fusions are such a bad idea, we’ll first explain the structures of the back, and then we’ll jump into the latest of many studies showing the ineffectiveness of spinal fusion surgery.

The Structures of the Spinal Column

The spine is like a series of blocks stacked one upon the other, creating structure and containing and protecting the spinal cord. The “blocks” are our vertebrae, or the bones in our spinal column, and there are discs between each vertebra for absorbing shock.

Some other structures along our spine include facet joints, which control the motion between each vertebra. Our spinal column also protects our spinal cord, which is like a bundle of wire containing all of our nerves and nerve roots that, along with the brain, make up our central nervous system. These nerves transmit feeling and tell our muscles what to do. It’s all held together by ligaments and kept stable by a series of muscles called multifidus, and the column has natural opposing curves to distribute our weight and provide stability. A more in-depth description of the spine can be viewed in my video below.

Damage (degenerative or an injury) to the discs, vertebrae, ligaments and other structures can cause instability. Fusion surgery is done when vertebrae become so unstable that movement affects the nerves or causes pain. But the problem from a structural standpoint is that making two or more vertebrae “fixed” and immovable simply puts more stress and load on the vertebrae above and below the fusion, which causes degenerative arthritis and can lead to adjacent segment degeneration (ASD) as you’ll see in the study highlighted next.

Study Shows Serious Issues with 360 Degree Lumbar Fusions

A new study looked at circumferential lumbar fusions (360 degree lumbar fusions) in 73 patients at 2, 5, 10, and 15 years postop. While the fusions show good short-term results, this is deceiving; there is actually a progressive worsening of the patients’ conditions throughout the duration of the study. Take a look at these statistics below showing the number of patients who underwent revision surgeries because of adjacent segment degeneration (ASD), or degeneration in the disc levels adjacent to, or above and below, the fusion:

  • By 5 years postop, 7 patients required revision.
  • By 10 years postop, 18 patients required revision.
  • By 15 years postop, 24 patients required revision.

Are you seeing a pattern? Is the answer to Spinal Fusion is it worth it getting clearer?  Even more stunning is the fact that by 10 years, 37 (51%) of the 73 patients showed ASD on radiology exams. The study concludes, “The high rate of ASD occurrence and reintervention questions the reliability of this technique for lumbar fusion.”

Between 10 and 15 years postop, the average ODI scores (which measure the degree of disability) for the patients in this study had returned to the levels they were at before the 360 fusion. What’s amazing about this study is that it’s one of the few that seems to match what we see in the clinic every day, even with fusions that only install hardware on the back part of the spine. While other studies show that adjacent levels break down due to the fusion, they always seem to minimize the phenomenon and somehow blame it on the patient. For example, some are now claiming that it’s bad genetics that are responsible for these poor sad sacks who have rapid deterioration of the levels next to the fusion. Huh? These levels would have been fine without the fusion, even with the patient’s genes.

There are many different types of spinal fusion surgeries out there, and each carry significant risks with them. One of the most common is posterolateral gutter fusion, which places bone graft in the region that lies right outside the spine. Posterior lumbar interbody fusion is done from the back and involves the removal of the disk found between the affected vertebrae. Anterior lumbar interbody fusion is a type of surgery approached from the front instead of the back, like the PLIF version. Extreme lateral interbody fusion is similar to the others but done from the side.

Yes, there are many spinal fusion surgeries, but let’s take a look at the risks involved. For most kinds of spinal fusion, there’s a chance that surgeons are unable to solidly fuse the vertebrae, which would require another surgery in the future. In cases where the fuse is solid, patients may also experience what is referred as adjacent segment disease or ASD. This is what happens when a segment adjacent to the fused area begins to break down thanks to an increase in stress. Some types of spinal fusion surgery, like anterior lumbar interbody fusion surgery, carry added risks. Due to the nature of the surgery, the procedure comes close to large blood vessels. Any damage done to those blood vessels could lead to a great deal of blood loss.

Other complications may arise in a major surgery such as this one. Patients may experience blood clots, infection, bleeding, pain, and the risks that come from using anesthesia. But that’s not the end of potential problems. A surgery dealing so closely with the spine may end up causing a nerve injury. Mild conditions of this may result in sensations of tingling or even numbness in the leg. A more serious complication would be losing movement in a limb. Outside of nerve injuries, patients may also have to deal with donor bone graft issues, the most common being tissue rejection and infection.

For some, the potential issues and complications are risks they’re willing to take for pain relief. However, even in cases where spinal fusion is successful, there’s always a risk that the patient’s pain doesn’t completely go away. It might even get worse. Think about that for a moment. Getting rid of pain is the very reason someone undertakes such a drastic surgery, and there’s a notable chance that they won’t get the outcome they wanted.

The other thing to consider is the spinal fusion surgery recovery process. A surgery of this scope will require a hospital stay of around four days, possibly more. The patient will need to be hooked up to medical devices, from a heart monitor to an IV and catheter. Even when the patient is out of the hospital, they’ll need follow-up appointments for months and even years afterwards. And that doesn’t count the physical therapy they’ll need before they’re back to where they want to be.

Other Poor Outcomes Due to Spinal Fusions

While I have seen a few patients who have a severe instability that can only benefit from a fusion, these patients are rare. More often than not, post-fusion patients require revision surgeries; need ongoing narcotics following surgery; experience complications due to their surgery, such as irrevocable damage to the multifidus muscle; and spend a lot of money on a serious surgery providing very little to no long-term returns. With results this poor and so much research showing reasons not to, why would you want a fusion?

Even more concerning is the fact that we don’t have any high-level evidence that spinal fusions are effective. There are low-level studies published by spine surgeons and fusion-device manufacturers that seem to show that fusion works. However, this doesn’t fit with the clinical experience of anyone who sees a lot of post-fusion patients who are still in pain. And it certainly doesn’t mesh with high-level studies such as the one above showing glaringly poor 360 fusion outcomes.

In addition, in the case of spinal stenosis, for example, spinal fusions are far more dangerous due to their complication rates than the decompression surgery they’ve gradually replaced over the last 10–20 years.

The upshot? So spinal fusion is it worth it? Just because a 360 degree fusion is the popular option doesn’t mean it’s the safest or most effective option. The spine is not meant to be a stationary structure, so leave the fusing to the welders, and look into other options to address your pain and spinal instability that will allow you to maintain the natural movement and curve of your spine.

    *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

    Kathy carroll says

    I did not know about Regrnexx prior to my 4 level fusion. A plate was placed on the back side if my spine. 5 months out I was still in severe pain. I am currently working with Dr Patel in Los Angeles to eliminate the pain. He did platelet lysate and PRP. He was very pleased as the hardware did not interfere with the procedure. I am 2 weeks out and start p/t Monday. No definitive relief yet but I am still positive. Would actual stem cells be helpful when someone has had fusion?

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    Regenexx Team says

    Kathy,
    Do stay positive as 2 weeks is very early! All Regenexx treatments are customized to the patient and the situation, and yes, Stem cells can be used in the most severe cases of spine treatment. Dr. Patel would be the one to determine if stem cells were to be needed at some point, so please keep him updated about your progress. http://www.regenexx.com/neck-epidural-failed/

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    chris says

    Add it to your growing list of orthopedic surgeries that have no research showing benefits. Still, it doesn't unseat the reigning champion, scoliosis surgery. Research and results truly horrifying.

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    Regenexx Team says

    Chris,
    What a competiton to win! http://www.regenexx.com/the-orthopedic-structural-paradigm-is-dead/

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    stef says

    I don't understand what the word science is doing in all of this ??? Is it not science factual based ? Why are so many "scientists" (doctor are doing science ?) doing what does not work ?

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    Regenexx Team says

    Stef,
    It's really a paradigm issue. http://www.regenexx.com/the-orthopedic-structural-paradigm-is-dead/ http://www.regenexx.com/bmj-chimes-scandalously-poor-evidence-for-orthopedic-surgery/ http://www.regenexx.com/the-future-of-orthopedics/

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    Sue Anne says

    Excuse me, but I could no longer walk before my 8 fusions. I was destined for a wheelchair for the rest of my life. While I have some muscle soreness in my spine, I can walk! My spine was collapsing.please don't make me feel stupid for deciding on a fixed spine. It's not perfect but it's better than a wheelchair!

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    Regenexx Team says

    Sue Ann,
    Surgery will always be needed in some cases. The problem is when surgery is done in cases where less invasive treatment can fix the problem without creating other ones. Very happy to hear yours worked out for you!

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    Bob says

    Has stem cell therapy helped strengthen atrophying multifidus muscles?

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    Regenexx Team says

    Bob,
    In our clinical experience, damage and pain related to the multifidus can often be reversed through regenerative injection treatments and special exercises, without resorting to surgery (which generally destroys the muscle). Regenexx Advanced Platelet Lysate and Super Concentrated Platelet Rich Plasma for Spine utilize the growth factors from your own blood platelets to reduce the causative nerve irritation and help clean up the disc herniation that caused it. Combining that with special exercises should get the multifidus back on track. Stem cells can be used in special circumstances.http://www.regenexx.com/multifidis-pain/ http://www.regenexx.com/the-regenexx-procedures/back-surgery-alternative/

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    Sharon Brown says

    What is your opinion on fusing neck vertebrae because of narrowing of the vertebrae? I have had PRP done on my neck and it has helped a lot. My right hand/arm was numb some. The little finger is still numb. I am 3 months out from the PRP. Hoping for more relief.
    Stem cells worked on my left knee in 2010. I know it takes time.

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    Regenexx Team says

    Sharon,
    Tackling the instability that is causative in the stenosis is a better plan than surgical options like fusion and laminectomy because neither of those options address the root cause of that instability, but do create additional problems: http://www.regenexx.com/spinal-stenosis-surgery-questions/ It does take time but it's also very important to keep the treating doctor informed of your progress as they know what would be expected at what point in your particular case and whether anything needs to be tweaked.

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    JM says

    Here are the findings from my last x-ray
    5 images obtained

    Vertebral:
    5 lumbar type vertebral bodies are present. No compression deformity. L5
    spondylolysis with grade 2 spondylolisthesis at L5/S1 measuring about 18 mm.
    No significant change on flexion or extension is identified. Remaining
    vertebral bodies are normal in height and alignment.

    Disc:
    Mild disc height loss at L5/S1 is present. Remaining disc spaces are
    preserved.

    Joint:
    Facet joints appear anatomically aligned.

    Can you help me or am I destined for a fusion? The spondylolisthesis at L5/S1 was grade 1 eight months ago.

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    Chris Centeno says

    JM,
    Spondylolysis and Spondylolisthesis are issues we treat regularly. Please see: https://www.regenexx.com/the-regenexx-procedures/back-surgery-alternative/ https://www.regenexx.com/a-hip-stem-cell-treatment-in-an-akido-master/ and https://www.regenexx.com/spondylolysis-recovery-time-avoiding-knife/ If you'd like to see if you'd be a Candidate, please submit the Candidate form.

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    Penny says

    Interesting, I had an L5 S1 fusion in 2009. I had only back pain off and on but more sciatic problems. Partial numbing in the leg and foot I was looking forward to being rid of that. Not the case 8 years later, the numbness is still there and when I went to my surgeon a few years ago, he said grin and bear it.
    I am now having problems with my neck with the pain radiating downwards and not sure whether this is related, noticing lately where I had my fusion is now flat when it never was. If anyone could be of help or recommend something or even suffering similar symptoms. I live in New Zealand and pretty sure we're a little behind in terms of back treatment.

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    Chris Centeno says

    Penny,
    We'd need to be able to examine you to diagnose what's going on. If you're able t travel for treatment and you'd like us to weigh in on your particular case, please submit the Candidate form to the right of the blog. Please see: https://www.regenexx.com/find-a-physician/ and https://www.regenexx.com/the-regenexx-procedures/back-surgery-alternative/

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    RUSSELL M says

    For most people, I agree. A spinal fusion is the last thing to to. My back surgeon told me he hoped my fusion would help with the pain, but said he couldn't promise that. The only thing it would help with for sure was the instability. My instability was getting worse quickly. My L5-S1 disc was gone. Those 2 bones kept sliding around on each other and interfering with my nerves. I was always stumbling around, yes I had sciatic pain in both legs most of the time and a huge pain in my lower back all the time. I had meds i could take for the sciatic pain but nothing helped my lower back pain. Without the operation, I was becoming crippled. The instability was the worst part to me. I looked into gene therapy, disk replacement, I looked at doctors outside of the us. Even the disk replacement doctors said I had to have more disc than I had to be able to have a successful operation. My surgeon told me only 1 out of 10 people that have disk replacement have failure in the surrounding disks and 1 out of 3 that have a fusion have failure in the surrounding disks. He told me that my disk was too far gone to have a successful disk replacement, he confirmed what the other doctor had told me. I decided to go ahead with the fusion. I am 2 weeks past the fusion. Most of the sciatic pain is gone, my lower back pain is gone my instability is also gone. I still have a little pain from the incisions. But over all, i am doing i think a lot better. If I only get 10 to 15 years before the next disc goes, thats 10 to 15 productive years that i can work and enjoy my family. Before the operation, It hurt when my kids gave me a hug. That pain is gone now. I am 46. I didn't want to accept that my back was as bad as it was. If the discs are still stable even with back pain explore all your options. Diet and proper stretching and exercise are the best early preventatives. By the time I learned how to take care of my back it was too late. When I went to seek other options like stem cells, disk replacement and low invasive surgery, it was too late. My oppinion is fusion is worth it to a few. But shouldn't be for the masses.

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    RUSSELL M says

    Ps: Its my oppinion that if a fusion is nescessary, all other options should be explored and understood early on to keep the rest of the discs healthy. Because I have had 1 fusion I am at high risk for a second and as young as I am possibly a third.

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    Landon says

    So if fusion isn’t the answer, then what is? I have a dish that is herniated and is hitting nerves and causing me a lot of pain. What other option do I have? Physical therapy made it worse

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    Chris Centeno says

    Landon,
    Treating the issues with precise Interventional Orthopedic image guided injections of your own stem cells and platelets when possible. We treat herniated discs regularly. Please see: https://www.regenexx.com/stem-cell-disc-treatment/ and https://www.regenexx.com/the-regenexx-procedures/back-surgery-alternative/

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    Michael Quinn says

    II was 19 when lumbar fusion was encouraged. I'm 58 now and had L3/4-4/5 fused in 2008. Now its advised 2 more levels be done.ADD..
    I'm bedridden 12-15 hrs a day. Workout every day to slow the decline. Yoga & special training. I am terrified to go through with this. I abandoned pain killers 5 yrs ago. Lasted 20 months in the workplace post surgery and became disabled. I've always been a athlete. Never a back injury. Disc replacement would be ideal. But that's cash out of pocket. How does a disabled man get $50K+ to get surgery in Europe. Hopeless and scared..Suffer on way or another.

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    William Bloomquist says

    I am 65 and my neurosurgeon is suggesting a fusion at L4/5 as there is now a 6mm listhesis.
    I have had the spinal pain control injections since 2012. I have been on morphine and dilaudid daily since 2013. The last one about three months ago lasted 3 days. My surgeon wants to install the fusion hardware anteriorally and that requires a second surgeon to open me up and move all the "innards" to the side to expose his worksite.

    I have no fear at all of dying but having severe spine pain or even worse, increasing disability or lower body paralysis for the rest of my live scares the hell out of me. I would like to see some serious in-depth analysis and success rate stats on the stem cell, etc approach being suggested here.

    replies

    Chris Centeno says

    Bill, we don't usually use stem cells in situations like yours, but this DDD approach using platelet preps: https://www.regenexx.com/treating-functional-spinal-unit/

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    Edward Rico says

    I have surgery on 7-24-18 after 7 months I've been haveing leg pain and back pain once more ,I've been talking to my doctor ,now they wanted to put in a nerve stabilizer ,what would I have go through next if this doesn't work I've been trying to get SSI but I don't qualify do to I'm not disabled what would it take for me to get it ,would I have to lose my leg ability to get it.

    replies

    Regenexx Team says

    Hi Edward,
    Unfortunately, pain after back fusion is very common as it causes adjacent segment disease. Please see: https://www.regenexx.com/blog/pain-after-back-fusion-adjacent-segment-disease/ which we can usually help with. But we'd need to be able to examine you to answer your questions.

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    Chris says

    At age 55 I was using a cane or wheelchair from degenerative disc disease diagnosed a decade earlier. I had a disctectomy at Mao that did not help at all. Next a fusion of S1 to the L2 as I recall. Helped a couple years then went back and had to extend the fusion to the L3. Ya surgery is hell and a long recovery. But at 66 I work 40hrs, golf, ride my Harley. I am rather careful not to lift heavy objects but admitt I do more than I should. Fingers are crossed that I will need no further surgery. But thank god for my surgeons and the fusion option.

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    Regenexx Team says

    Hi Chris,
    In a small percentage of cases compared to those performed, Fusion is needed. Very glad to hear it helped in your case! Because Fusion is irreversible all noninvasive options should be tried first. The reason Fusion leads to more Fusion is Adjacent Segment Disease, which diagnosed before the damage is irrevocable, we can usually treat. Please see: https://www.regenexx.com/blog/pain-after-back-fusion-adjacent-segment-disease/

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    Tina Thomas says

    I've had bad pain since 2008 in my neck. They claim bad genes. I have degenerative disk issues. I made a bad mistake choosing an implant procedure that didn't work. Then, I had no choice, but to fuse that level. I have two levels above that aren't too good, but doctor expressed let's wait. Your to young for three levels. I'm still in terrible pain today. I regret it all. I have to constantly use ice packs, heat daily, and take lots of Gabapentin. Muscle relaxers worked best for me, so I could get some sort of rest. All of this makes life very depressing. I'm 49, and now my left shoulder is also bothering me.

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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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