Overview of Spinal Fusion Surgery
DISEASES OF THE SPINE such as spinal stenosis, degenerative disc disease, scoliosis, a spinal tumor, spondylolisthesis or traumatic spine injury may require surgical intervention. Typically, when the resulting neck or back pain becomes so severe patients will seek treatment. Often, the pain symptoms can be treated with conservative care such as physical therapy, over the counter medications or steroid injections which are the preferred methods to prevent or delay the need for surgery. If these treatments do not resolve the discomfort within a few weeks, or the pathology is already too severe, depending on the diagnosis and long-term goals of the patient, one type of surgical intervention is a spinal fusion. A spinal fusion entails surgical procedures that rebuild damaged unstable vertebral bone and spine joints. The aim of this operation is to structurally strengthen and stabilize the unhealthy parts of the spine to the adjacent health segments of the spine. Spinal fusions are extremely effective when performed by experienced, skilled surgeons such as those at Centers for Neurosurgery, Spine, & Orthopedics. The CNSO dedicated team has years of successfully diagnosing, conservatively managing, and if necessary, performing the correct spinal surgery for our patients.
When is Spinal Fusion Necessary?
A spinal fusion may be necessary if the vertebral bones are significantly misaligned with one another or are severely deformed or damaged. One or a combination of these defects can occur at one or more levels of the spine. In every case, the patient is chronically uncomfortable or is losing the ability to function because nerves or the spinal cord itself is being pinched. Depending on the medical conditions being addressed, a spinal fusion will also resolve problematic pinched nerves and pressure on the spinal cord. Both the neural decompression and spine fusion surgery would be performed in one surgical session. Below is the description of each category of surgery:
- Neural Decompression Surgery – Used to remove and free a pinched nerve or spinal cord. The spinal cord and nerves normally travel in tunnels within the bones and joints that make up the spinal column. Many disease states, usually arthritis and trauma, can narrow these tunnels, causing the neural structures to become compressed. This compression causes pain, tingling sensations, weakness and a loss of function which can escalate to dysfunction or even paralysis. When this weakness or loss of function occurs, surgical decompression of the neural elements by a neurosurgeon or an orthopedic spine surgeon is required. Depending on which part of the spine is problematic, such as a slipped disc or arthritic bone spur growth, surgical procedures called discectomy, facetectomy, foraminotomy, or laminectomy may be used. These surgeries remove compressive bone or disc pathology off neural elements allowing the patient to be pain free again.
- Spinal Fusion Surgery – When joints or vertebral bones of the spine become severely arthritic, damaged by trauma, or brittle because of invasive malignant bone tumor, the spinal column may become unstable and impinge on the surrounding nerves and spinal cord itself. Or if a spinal cord tumor, such as an astrocytoma or meningioma of the spine develops, it must be removed. In order to access the tumor, however, the surrounding bone must be removed. Whether the spine pathologic condition is within the bone or within the spinal cord, it may be necessary to surgically restructure and stabilize the surrounding vertebral bone after the diseased area is removed.
What Happens in Spine Fusion Surgery?
The goal of fusion surgery is to restore the normal anatomical alignment of the vertebral bones and permanently secure the alignment in the most functional biomechanical position. This allows the patient to move with little to no discomfort.
The spine fusion procedure starts with a small incision, directly above the area in need of repair. Next, the damaged spine vertebra or intervertebral disc that has become problematic and painful is most likely trimmed back or if necessary, is removed. If the goal is to remove a spinal cord tumor, the least amount of vertebral bone is removed in order to clearly access the tumor and successfully remove all of it.
Once this has been accomplished, the bones of the spine are restored to their normal anatomical alignment. Then bone or bone-like filler, called a bone graft, and perhaps a synthetic device will be placed in the necessary spinal column areas to maintain the original or correct spine height.
This prosthetic, usually made of carbon fiber, plastic, or 3-D printed titanium, maintains the restored distance and alignment of the bones, creating a solid fusion across the joint space.
Lastly, to assure that the bones hold their position and new bone growth takes place, the addition of stabilization hardware such as pedicle screws or a titanium plate will be applied.
Examples of Common Spinal Fusion Surgery
- Anterior Cervical Discectomy and Fusion (ACDF): The cervical neck disc that is herniated or torn is approached from the front or anterior side of the patient. The problematic portion of the vertebral bone and cervical disc is removed. A construct is then placed to leave the native spinal column securely in place and enabling the patient to comfortably resume all physical activities for the rest of their life.
- Anterior Lumbar Interbody Fusion (ALIF): The operation is performed at the level of the lower back by anteriorly accessing the lumbar spine. The benefit of an ALIF is less time under anesthesia allowing for a quicker recovery compared to the older technique of resolving a lumbar spine condition by a posterior lumbar spine surgery followed by an anterior lumbar surgery both performed on the same day. With an ALIF approach, patients also have significantly less postoperative discomfort compared to an Anterior/Posterior open staged surgery.
- Transforaminal Lumbar Interbody Fusion (TLIF): Departing on the part of the lower back that is causing the patient’s pain and discomfort, the transforaminal approach may allow the least invasive angle to correct the spine pathology while using a minimally invasive approach. For the TLIF, once the patient is anesthetized the patient will be placed, face down, in the prone position. The surgical incision will be placed on the posterior lower back side of the patient, 45-50 mm lateral to the midline of the spine. This access point angle will allow the neurosurgeon or orthopedic spine surgeon to visualize both the lateral and anterior side of the spine where the correction of the spine pathology and the stabilization of the spine needs to occur. This technique can be used for a number of spine conditions including spondylolisthesis.
- Robotic surgery: With the use of robotics and spine navigation systems, incisions can be minimized and OR time further reduced. The use of robotics is especially beneficial if the patient has a multilevel spine condition, spinal deformity, or is in need of spine revision CNSO neurosurgeons and orthopedic spine surgeons use robotics for these complex cases in New Jersey hospitals. If a multi-side approach is necessary, robotics help minimize anesthesia time by limiting the need to reposition the patient during the operation which is required for more traditional surgical access positions.
What to Expect if You Need Spinal Fusion Surgery
A routine spinal fusion can often be performed using minimally invasive surgical techniques in the outpatient setting. Total surgical time is around two hours and patients are able to walk independently within hours of the procedure. Surgical discomfort can be minimal or managed with oral pain medication for a few days until it subsides. Most patients will transition to over-the-counter pain medication within two weeks of the surgery with a significant amount of pain relief compared to the pre-operation pain level. Normally within one month after their operation they will be pain free.
Recovery from a spinal fusion will vary depending on your age, general health, and the extent of the surgery done. In general, you will avoid bending, lifting, and twisting (BLT) for two weeks after surgery. During this time, you will be encouraged to remain active by walking.
Sometime between 2 and 6 weeks post-operatively, you will begin structured rehabilitation and exercise with physical therapy. By 12 weeks, most patients can be back to normal, non-strenuous activity. For patients who must engage in heavy lifting and bending (e.g. construction workers), return to work may be delayed until 6 months after surgery.
If you have other comorbidities, medical clearance may be necessary in preparation for the surgery. If you are taking any blood-thinning medication (such as aspirin, warfarin, Xarelto, Plavix, Pradaxa), it will need to be adjusted or stopped five to seven days before the procedure. Please ask your treating physician for the recommended guidelines prior to spine surgery. Also note that common over-the-counter medications such as ibuprofen, naproxen, and aspirin can also affect your body’s ability to clot, and will need to be temporarily discontinued. Similarly, commonly taken supplements (including garlic, ginko biloba, flaxseed oil, saw palmetto, ginger, ginseng, fish oil, vitamin K and vitamin E) also have anticoagulant effects. You should inform and ask both your surgeon and primary doctor whether to discontinue any medications or supplements at least two weeks prior to your scheduled surgery.
On the day of surgery, you will need to refrain from eating or drinking for at least 8 hours prior.
Risks of the Surgery
Spinal fusions done by the neurosurgeons and spine surgeons at Centers for Neurosurgery, Spine, and Orthopedics have a long track record of safety and efficacy. CNSO surgeons use minimally invasive microsurgical techniques as well as robotics especially for mutli-level spinal deformities. Similar to any type of surgery, spine fusions entail some degree of risk. For spinal fusion, these include:
- Nerve damage
- Spinal fluid leak
Fortunately, these complications are rare. When they do occur, they can typically be managed successfully without adversely affecting long-term health or the corrective goal of the spine surgery.
After patients have been properly diagnosed and have either exhausted all conservative measures or have been deemed to unstable to attempt, a spine surgery may be considered. Patients who need spine surgery including those who undergo a spinal fusion have significantly better outcomes than patients who continue to attempt only physical therapy for more than 6 weeks or more than 3 epidurals. After a spine surgery or spine fusion by CNSO neurosurgeons or orthopedic spine surgeons, patients are free of pain medication within one month. They progress to living more active lives than those patients who should have had a spine fusion but elected not to progress with their treatment. Improvement after surgery is usually fully appreciated by the patient and their family within three months, when patients are back to their previous activities and are living pain free. When surgery is further followed by postoperative lifestyle changes, including weight loss, exercise, and proper posture, the benefits of a spinal fusion can be even more positively consequential. To schedule an appointment with one of the neurosurgeons or orthopedic spine surgeons at Centers for Neurosurgery, Spine, & Orthopedics, contact us today.