The term “spinal fusion” covers a variety of surgical techniques used to treat diseases of the spine. This category of spine surgery termed “fusion” can be the only solution and extremely effective when used to correct certain pathology. These procedures are more likely to be successful performed by experienced and skilled surgeons who are board-certified neurosurgeons or fellowship trained orthopedic spine surgeons. Both specialties are specifically trained to diagnose spine pathology and determine whether conservative care or surgically treatment is best for the patient. Surgical treatment includes considering both the short- and long-term goals of each patient.
What is Spinal Fusion?
Spinal fusion refers to surgical techniques used along with arthroplasty to rebuild damaged, painful, or unstable joints or bones in the spine then secure the new construction so that it can withstand the patient’s use and aging process. Conceptually, spinal fusion surgery is similar to joint reconstruction surgery in other parts of the skeleton, such as knees and hips. Because spinal joints in the thoracic region or lumbar region naturally have a very limited range of motion yet are the center foundation upon which sitting, standing, and any movement is based they must be rebuilt with sturdy prosthetics, such as titanium cages. Cervical prosthetics can use similar material or can be made from highly mobile prosthetics similar to artificial knees and hips. Commonly, a cervical disc replacement using a mobile prosthetic can be performed when rebuilding a portion of the spine in the neck.
Rebuilding diseased joints or vertebral bones the using a fixed prosthetics is called a fusion or arthrodesis because the result is a rebuilt joint and bone that is adherent to the adjacent healthy bone. During the recovery period, the body grows bone across the rebuilt joint and prosthetic, further fusing the segments involved to each other and the adjacent joints. This bone growth process further secures the spine in place and is accomplished with minimal loss of overall flexibility.
In the cervical spine, where there is more natural movement than in other parts of the spine, mobile prosthetics are best used to preserve motion as opposed to a fusion. This is commonly referred to as “cervical arthroplasty” or cervical “disc replacement.” For the right candidate, this is a better choice for the right patient as opposed to a cervical fusion but there are many factors that go into determining what is best for the individual patient.
Most people take for granted that their knee and hip joints may become arthritic with age. As this occurs, these joints can become “achy,” especially in the morning or after excessive activity. As arthritis becomes more advanced, the resulting pain and loss of function may become so severe that the arthritic joint needs to be rebuilt. Knee and hip replacement surgeries are very effective at returning patients to their active lifestyles.
The same arthritic process that leads to crippling knee and hip pain can happen to the joints in the spine. There are 76 joints in the human spine, including discs, facets, and sacroiliac joints. They are all subject to wear and tear, can become inflamed, grow bone spurs, or even become unstable. The result? Arthritic joint pain, typically in the neck or low back. If a nearby spinal nerve gets pinched, then arm and leg pain will also result.
Most arthritic pains in the spine and pinched nerves respond well to conservative measures such as core strengthening, physical therapy and injections. However, just as some knee and hip patients require their painful joints to be surgically rebuilt with prosthetics, a small number of spine patients will also need their painful joints or bones rebuilt.
Fortunately for spine patients, rebuilding a spine joint is biomechanically much simpler than rebuilding a knee or hip. This is because spine joints do not move as much as other joints in the body. A knee joint moves almost 180 degrees. When rebuilding a knee, this motion must be perfectly reproduced, with a precisely placed and balanced prosthetic. Hips are even more complicated because they move in three dimensions.
In contrast, native spine joints move only 3-5 degrees which is very little compared to a knee joint. Therefore, when this joint needs to be rebuilt, the focus becomes restoring proper height and alignment of the disc, joint, and adjacent vertebral bones plus ensuring that the surrounding nerves and spinal cord are no longer compressed. This nerve impingement, spinal cord compression, or a loss in disc height, disc herniation, or vertebral facture is the cause of the patient’s pain or loss of function in an arm, leg or both.
Therefore, rebuilding a damaged joint or bone in the lumbar spine and securing it to the adjacent normal vertebral bone is called a “fusion,” whereas rebuilding a damaged knee, hip joint, or cervical disc space that allows the adjacent bone structure to move is called “replacement.” Conceptually they are similar but with a knee, hip joint, or cervical disc, the native bone is resurfaced a mobile prosthetic that allow the joint to continue with the necessary wide range of movement is inserted and secured in place.
The Role of Technology – Minimally Invasive Spine Fusion and Robotics
Historically, spinal fusion surgery required large incisions and lengthy hospital stays. Fortunately, the more modern neurosurgeons and technology have drastically reduced the length of incisions, reduced blood loss, reduced the length of stay in the hospital and reduced the associated pain. Spinal fusions are now performed routinely using minimally invasive techniques, often in an outpatient setting, with some patients returning home within hours of surgery. Most patients who have a spine fusion with a CNSO surgeon are off pain medications within one month after surgery.
In addition, advances in perioperative imaging, intraoperative spine navigation systems, and robotics allow for greater precision and greater intraoperative safety.
Together, these innovations allow surgeons to operate through small incisions using microscopes and microsurgical instruments. With CNSO neurosurgeons and orthopedic spine surgeons there is far less tissue damage to the patient and minimal blood loss. The results are patients who recover much more quickly and return to normal life within days or weeks, rather than months to years.
When surgically indicated, a spine fusion will drastically improve the patient’s ability to function, restore mobility, and significantly reduce back pain.
What factors should I consider when choosing a neurosurgeon or spine doctor?
1). Judgement: While experience does lead to technical expertise and improved outcomes, it also leads to better clinical judgment. In many ways, a doctor’s judgment is even more important than his or her technical skill, because a great deal of consideration goes into deciding whether a patient even needs surgery, and if so, what type of surgery. This careful consideration cannot be rushed and cannot be made with a cookie-cutter approach. Rather, MRI findings must be interpreted within the context of what the patient reports to the doctor, and what the doctor finds on a careful examination.
It is only when the patient’s symptoms, findings on exam, and MRI results closely correlate can a surgical decision be made. Furthermore, this decision can only be made after the appropriate conservative options have been exhausted. Unfortunately, the CNSO surgeons have seen patients receive large, unnecessary surgeries with poor outcomes because their surgeon treated the MRI findings and not the patient.
2). Experience: The most important factor to consider is experience. There is no substitute. Repetition yields excellence in results. When choosing a surgeon to treat your spine, you should ask how many procedures he or she performs on a routine basis, and what are the outcomes. In addition, ask whether prior patients would be willing to discuss their pre-operative and post-operative journeys.
3). Conservative Approach: When choosing your spine doctor, make sure he or she has a very conservative approach to care, offering surgery only as a last resort. The vast majority of patients (>90%) who suffer from spine ailments do not require surgery, even if their MRIs look severely abnormal. The human body has a tremendous capacity to heal itself, and it is your spine doctor’s job to show you how that can be achieved. Surgery should be reserved only for those rare cases where this healing process is not possible.
4). Breadth of knowledge and skills: There are over 200 distinct types of operations that can be offered for the treatment of spine conditions. Some can be performed via a same-day, minimally invasive surgical approach, while others require a more complex reconstruction. Every one of these operations represents a tool in the surgeon’s armamentarium, uniquely suited to address a specific surgical need.
Unfortunately, not all surgeons have a broad range of surgical skills. Some may limit themselves to the simpler procedures, that are only effective for more routine conditions. However, if your condition is more complex, you may be taking them out of their comfort zone, or they may offer surgical solutions that are not appropriate for your unique circumstance.
Ask your surgeon about the range of spine conditions he or she treats, from simple disc herniations to scoliotic deformities. Is your surgeon equally comfortable with a multi-level deformity correction as with a microdiscectomy? Can your surgeon explain the difference between cervical disc replacement versus fusion, and offer either technique if appropriate? Many surgeons will offer cervical fusion simply because they lack qualifications for disc replacement.
Equally important, make sure your spine doctor has mastered the latest technological innovations in spine surgery. Can he or she perform the surgery using minimally invasive techniques, with less tissue trauma, blood loss, and recovery time? Will your spine surgeon utilize intraoperative navigation and robotics to make your surgery safer?
5). Time spent listening and educating: Many surgeons rush to diagnose off an MRI scan. This is the primary reason that patients may feel dissatisfied with the results of their spine surgery. The surgery itself may have been performed well, but if there continues to be severe pain and dysfunction, chances are there may be a mistake in the diagnosis.
Why does this happen so often? Because most spine surgery is performed for something that cannot be measured – i.e., pain. Pain is not like temperature or blood pressure, which can be objectively quantified and treated if too high. Rather, pain is very subjective; something that causes misery to one person may be minimally bothersome to another. To further complicate matters, pain is difficult to localize. There are many things in the spine that can cause pain, such as herniated or degenerated discs, unstable facet joints, arthritic SI joints, deconditioned muscles, or compressed nerve roots. Unfortunately, these can be packed very close together anatomically, and can all cause pain in the same general area.
Finally, a joint or disc can look abnormal on XRay or MRI, but not cause pain. In fact, the vast majority of normal people will have degenerated discs and bone spurs by their sixties yet have no symptoms at all. This is a normal part of aging.
Considering all these factors, it can be very difficult to accurately identify the pain generator in any particular patient. If the original diagnosis is inaccurate, then even well-executed spine surgery can leave the patient in pain, because the true source of pain was never accurately identified. Worse, there may be unnecessary complications from surgery, and scar tissue, that creates even more pain.
The only way to overcome the difficult problem of accurate diagnosis in spine care is this – The doctor must spend enough time listening to the patient and asking a lot of questions. With enough time, important clues in the patient’s story can help a doctor identify the underlying problem. The doctor must also perform a thorough and detailed examination searching for all the little clues that lead to a proper diagnosis. This takes time and patience. Sometimes, it takes multiple visits and several specialists to accurately identify the pain generator. But with the insights gained, the doctor now can make sense of a patient’s complicated MRI, where many joints and discs look abnormal, but only one is causing a problem that may need to be fixed.
NJ’s Only Comprehensive Center for Spinal Fusion, Evaluation, Treatment, and Follow-up Care
The dedicated team at Centers for Neurosurgery, Spine, and Orthopedics (CNSO) understands how neck, back, and joint problems can impact your daily life. By working with this team of renowned, board-certified neurosurgeons, orthopedic surgeons, non-surgical physicians, physiatrists, rehabilitation specialists, and certified physical therapists, you will receive comprehensive and coordinated care, so you can quickly resume a healthy, less painful lifestyle free from disability. CNSO offers multiple convenient locations spanning across northern New Jersey, including offices in nearby Bergen, Passaic, Morris, Essex, Hudson, and Sussex Counties. Northern NJ patients can learn more about spinal fusion by contacting the providers at CNSO today.
If you are suffering from neck or back pain, schedule an initial evaluation with Centers for Neurosurgery, Spine & Orthopedics today to discuss treatment options or a second opinion before committing to spine surgery. You will be glad you did.