Lumbar Spine Fusion

What is a Lumbar Spine Fusion?

Fusion or ‘arthrodesis’ of the lower (lumbar) spine involves positioning screws or plates along or through the vertebrae to keep the bones aligned.

This surgery is usually only appropriate for patients with severe symptoms (back pain, often with symptoms in the legs, buttocks or affecting bowel or bladder function) of disorders affecting the spine, including:

  • lumbar spinal stenosis,
  • disc herniation & sciatica
  • Spine instability or dislocation (see Spondylolisthesis) and deformity (see Scoliosis)

In many of the above conditions, non-surgical methods will have been attempted first. Surgery is only considered when all other methods have failed and symptoms are still persistent and significant, or when serious complications are thought to be imminent.

Fusion is often an effective method of relieving arthritic pain and stabilising the spine. It can also be combined with decompression of the spine and nerves to relieve symptoms of nerve irritation. However, the loss of movement in the vertebra leaves the back with reduced flexibility.

Who is this operation for? 

Lumbar spinal fusion surgery is used to treat: 

  • Severe ongoing back pain that is non-responsive to other measures – note that despite this, in many cases surgery is NOT appropriate for the treatment of back pain 
  • Recurrent disc herniation
  • Spinal canal stenosis
  • Deformity and instability of the spine (see Spondylolisthesis)
  • Some forms of trauma and fracture of the spine

What are the benefits of the operation?

Fusion or arthrodesis is a very effective method of straightening and stabilising the spine. Unfortunately, the cause of pain is not always related to the position or shape of the bones, and arthrodesis may not relieve pain. 

For this reason, fusion is usually only indicated when there are nerve symptoms, like shooting pains in the leg, or the surgeon is certain that 

  1. the tests show a defect in your spine that can be corrected, eg a slipped disc
  2. your pain and symptoms are definitely related to that defect 

When these conditions are met, spinal fusion successfully relieves pain and other symptoms in a majority of patients. 

Risks of not having the surgery

If you have serious spinal disease that is squashing your nerves, you may be at risk of developing more serious symptoms in the future. 

When can’t I have this surgery? 

There are a number of reasons why surgery may not be appropriate for you. Some of these include: 

  • Heavy smokers. Smoking reduces the ability of bones to heal and consequently increases the risk of non-union and fusion failure (see complications). 
  • Pain without nerve symptoms or without a clear defect visible on tests 
  • Conditions that may make major surgery and/or anaesthetic unsafe: 
    • Serious heart or lung disease 
    • Serious other medical illnesses, like kidney failure or diabetes
    • Very weak bones (see osteoporosis), or infection in the bones (osteomyelitis)

These points can usually be discussed with your surgeon. In many cases, it may be possible to improve your health in order to make surgery safe.

Complications

The risks and complications of a Lumbar Spine Fusion include:

  • Non-union of the bones. The purpose of fusion operations is to promote bones growing into one another and forming a single unit. Sometimes this fails to occur, and can be related to a number of factors, including poor blood supply or smoking. 
  • Injury to the nerves or spinal cord:
    • It is possible that during the operation nerves coming out of the spinal cord may be irritated. This can result in numbness, tingling or weakness in the legs or groin. This is usually temporary. 
    • Caudal equina injury
    • Injury to nerves in the arms and other areas in the body sometimes occurs during this operation. This is due to the position of your body while you are under general anaesthetic, and is similar to having your leg go to sleep when sitting with your legs crossed. Your arm may feel numb or have pins and needles for a short time after the operation. This is usually a temporary feeling, but occasionally symptoms of nerve irritation persist for some time. 
  • infection
  • Bleeding and bruising in and around the spine. 
  • Formation of blood clots in the leg (DVT) or clots in the lung. 
  • Dural tear – dural headache, leak. 
  • ‘Failure’ to improve symptoms 
  • Incision symptoms – bleeding, failure to heal, infection

For more information on the potential risks of any operation, see Complications of Surgery.

Before the operation

Perhaps the most important thing you can do to prepare for spinal fusion is understand the potential limitations of your surgery. 

Back pain is a notoriously difficult symptom to treat, and surgery does not always cure pain. Your surgeon will be able to give you some idea of the likelihood of pain reduction. Take the time to discuss the likely recovery with your doctor, surgeon and physiotherapist before you decide to have surgery. 

Preadmission Clinic | Preparing for Surgery

Before your operation, you will be seen at the Preadmission clinic to make sure you are fit for the operation and all the necessary tests are performed in preparation for the operation.

During the visit, you will be seen by a

  • doctor
  • nurse
  • anaesthetist (if necessary)

You may need a specialised anaesthetic assessment prior to surgery. 

Tests

Tests that may be ordered for you include:

  • blood tests
  • Xray of your Chest
  • Urine Test
  • ECG

If your doctor is concerned about your fitness for surgery, you may be asked to perform a ‘stress test’. This test involves monitoring your heart, lungs and breathing while your perform exercises, usually riding a stationary bike,

Preparing Your Skin

Your skin should not have any infections or irritations before surgery. If either is present, contact your orthopaedic surgeon for a program to improve your skin before surgery.

Tip

Carry a list of your medications with you including the name, dosage and how often you take it.

Medications

Our doctors will advise you which medications you should stop or can continue taking before surgery.

Get some help from your friends and family

Although you will be able to walk with crutches or a walker soon after surgery, you will need some help for several weeks with such tasks as cooking, shopping, bathing, and laundry. If you live alone, your orthopaedic surgeon’s office, a social worker, or a discharge planner at the hospital can help you make advance arrangements to have someone assist you at your home. A short stay in an extended-care facility during your recovery after surgery also may be arranged.

You may need to see an Occupational Therapist when you are released home. They can help you with 

  • home modification
  • returning to your normal daily activities

About the Operation

There are a number of different techniques used to fuse the spine, and the operation will consequently vary depending on the method used. 

Usually, you will be taken to the operating theatre and put to sleep (general anaesthetic). You will then be rolled onto your stomach, side or placed on your knees and carefully positioned so that injury to other nerves in your body is minimal. Once this is done, your surgeon will clean (‘sterilise’) your back and make a long cut or ‘incision’ along the centre of your spine. The size of the cut will vary depending on which vertebrae need to be fused, but shouldn’t reach above the level of your belly button. 

Once a cut has been made, your surgeon will careful separate and push aside the muscles and ligaments between your spine and skin. Screws can then be carefully positioned through the sides of the vertebra (lamina or transverse process) and into the main bone (vertebral body). Once screws have been placed, your surgeon has a number of options: 

  • Rods can be connected to the screws and used to straighten the spine, or to open up areas where nerves were being compressed (distraction to enlarge the foramen). 
  • Ligaments in and around the spinal cord and nerves can be trimmed to reduce compression of the nerves
  • Sections of bone can be removed to reduce compression on the spinal cord. 

Once all the necessary procedures have been performed, your surgeon will carefully clean the area and gradually stitch the tissues back together. 

It may be necessary for the surgeon to place drain tubes around the spine. This is done when significant swelling or bruising is expected. The drains remove the excess fluid and help with healing.

After the Operation

When you leave surgery, you will wake up lying on your stomach or flat on your back. You may have: 

  • Dressings (like gauze or bandages) on the cut over your spine. 
  • Ongoing pain relief from the anaesthetic used during the surgery. While this will help control your pain it may also make you feel drowsy, nauseous or constipated. 
  • Drains in your back. These will need to remain in place for some time, usually 24hrs to a few days, while you are in hospital. 
  • Catheter. This is a small tube that enters your bladder and helps to drain urine. 
  • Thick white stockings on your legs (called ‘Teds’) that help to prevent DVT. 

Your nurses and ward doctors will help you with ongoing pain relief and any other symptoms, like nausea. If you develop a headache, make sure you notify your doctor. 

After awaking you will be seen by a physiotherapist who can 

  • Discuss when and how much you can move. Usually, you will be encouraged to get up and about as soon as possible. 
  • Help you to breathe deeply while lying in bed. 

Your doctors can talk to you about when you will be discharged, but this will usually be after a few days when your wound is healing well, you are able to move around independently and you do not have a fever.

Recovery and Rehabilitation 

Coming soon…

F.A.Q.s | Frequently Asked Questions

What are the alternative treatments to having a Lumbar Spine Fusion?

When the primary symptom to be treated is back pain rather than nerve symptoms, there are a number of other treatments that can be tried first, including exercise, medication and physical therapy (see Low Back Pain and Exercise Guide for Low Back Pain). These should always be trialled first before surgery is considered. 

Other procedures and surgery used to treat certain conditions includes: 

References

Briggs, T., Miles, J., Aston, W., (Eds), ‘Operative Orthopaedics: The Stanmore Guide’, Hodder Arnold, UK, 2010, pp 37-40. 

Carragee, E. J., ‘The role of surgery in low back pain’, Current Orthopaedics, Vol. 21, 2007, pp. 9–16.