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Lumbar Fusion

Lumbar Fusion

What is a Lumbar Fusion? 

The lumbar area of the spine is better known as the lower back. A lumbar fusion is an operation to stabilize the lower back by creating bony bridges between at least two vertebrae and eliminating motion between them. It can be done by fusing the vertebral bodies in front (anterior) or by fusing the facet joints and lamina in the back (posterior). Bone or bone substitutes can be placed on and between the lamina and the facet joints. Metal screws and rods or plates may be attached to the bones to secure the fixation while the bony bridge heals.

During the operation, an incision is made in your lower back and the muscles supporting the spine are divided. Bone (lamina) covering the spinal cord may be removed along with any ruptured disc material or bone spurs that are pinching the nerves or spinal cord. The site is then prepared for fusion by obtaining bone graft and/or bone substitute and laying it on the bone and/or between the vertebrae bodies. Metal screws and rods may be attached to the bones to secure fixation while the bone heals.

The operation typically takes around 4 hours; however it may be longer, depending on the complexity of the problem, the number of vertebrae needing to be fused, and the type of fusion performed.

Who is a Candidate for a Lumbar Fusion? 

Lumbar fusion may be recommended to treat a number of spine problems. However, the majority of people with these conditions will be successfully treated with conservative measures – that is, without surgery. Only after conservative measures have failed to relieve symptoms will surgery be considered. Problems that may be treated with lumbar fusion include:

Sciatica – Sciatica is one of the most common reasons for lumbar fusion. It is the irritation of a spinal nerve or nerves, usually by a herniated or bulging disc.

Spondylolisthesis – This term describes a particular type of abnormal movement of the vertebrae. With spondylolisthesis, one vertebra has slipped forward over another. If the vertebra continues to slip back and forth, the spinal nerves may be affected, causing leg pain, numbness, tingling and/or weakness.

Degenerative Disc Disease – Age and wear and tear can cause the discs that act as cushions between each vertebrae to shrink, allowing abnormal movement. This abnormal movement can again result in an unstable area in the spine, and compress the nerves, causing leg pain and numbness.

Arthritis – Arthritis of the spine can lead to spinal stenosis, a narrowing of the spinal canal caused by bony spurs forming on the vertebrae, narrowing the openings through which the nerves and nerve roots must travel. This narrowing can cause pressure on the nerves, resulting in pain, numbness, tingling or weakness down the legs.

Where Does the Bone for a Fusion Come From? 

The bone graft can be taken from you or from a bone bank. If using your own bone, the bone is removed from the back of your pelvis adjacent to the spine; sometimes a second incision is needed, but often the donor site can be reached from the spinal incision. Bone from a bone bank is a good option if your own bone is weak or damaged from osteoporosis. A number of artificial bone substitutes are also available that can help create a bony bridge.

What Are the Risks?

While uncommon, complications can occur during and after surgery. Nerves are exposed and nerve damage is therefore a risk. There is also a risk that the bony bridge will not form and thus a fusion is not established. Breakage or loosening of the screws or plates can also occur. These complications could result in the need for another operation. Other complications that may occur with any surgery include wound infection, blood loss requiring transfusions, and blood clots. General medical issues such as pneumonia or heart issues can be precipitated by surgery. Your surgeon and health care team will be taking great care to help prevent these and other complications.

How Long is the Hospital Stay? 

The time spent in the hospital after a lumbar fusion depends on several factors, including your overall health and the extent of your particular surgery. Many people will leave the hospital in 4 days. Some patients may benefit from inpatient rehabilitation after discharge.

How Long Will it Take to Recover? 

Recovery time after lumbar fusion varies depending on your particular situation, the number of levels involved, as well as your general health. The key to a successful recovery is maintaining a positive attitude. You will be able to take short walks while in the hospital, and need to gradually increase the distance and frequency of your walks once at home. It can take up to three to four months for the bones to completely fuse together. During this time you may need to wear a brace to protect the operative area. Your doctor will give you specific instructions on activity levels, including when you can resume driving and return to work.

Frequently Asked Questions

Lumbar Fusion

What is wrong with my back? What is required to fix the problem?

You have one or more damaged discs and/or areas of arthritis in your back. This produces pain, and may produce abnormal motion, or misalignment of your spine. Discs are rubbery shock absorbers between the vertebrae, and are close to nerves that travel down to the legs. If the disc is damaged, part of it may bulge or even burst free into the spinal canal, putting pressure on the nerve and causing leg pain, numbness or weakness. Arthritis and resultant bone spurs may also cause similar pressure.

Your condition may benefit from a nerve decompression (freeing the nerves from pressure) and/or a spinal fusion. In many cases, both nerve decompression and spinal fusion are done to decompress and stabilize the spine.

What is spinal fusion?

A fusion is the formation of a bony bridge between at least two bones; in this case, two vertebrae in your spine. The vertebrae are the blocks of bone that make up the spinal column, like building blocks stacked on top of each other to make a tower. Normally each vertebra moves within certain limits in relationship to its neighbors. In spinal disease, the movement may become abnormal and painful, or the vertebrae may become unstable and move out of alignment, putting pressure on the spinal nerves and other structures. In cases like this, surgeons try to stabilize the vertebrae using pieces of bone called bone graft. The bone graft may be obtained from the patient, (usually from the pelvis), or from a bone bank. There are advantages and disadvantages to either source. The bone graft is either laid next to the vertebrae or actually placed between the vertebral bodies (the disc that normally lies between the vertebrae must be removed). In either case, the bone graft has to heal and fuse to the adjacent bones before the fusion becomes solid. Spine surgeons often use screws and rods to protect the bone graft and immobilize this area while the fusion heals.

How is the operation performed?

An incision is made in the middle of the lower back. Muscles supporting the spine are pushed aside temporarily. The spinal nerves are exposed, moved aside and protected, and the ruptured disc or bone spur is removed to free the nerve(s). The fusion is performed as described above. The wound is then closed and dressings are applied. The operation typically takes a minimum of four hours and may be longer, depending on the complexity of the problem. Sometimes the spinal fusion is performed with an anterior approach. In this case, the surgeon would make an incision in the lower abdomen, gently move the internal organs aside, and proceed with the surgery as described above.

Who is a candidate for lumbar fusion, and when is it necessary?

When the back and nerve problems cannot be adequately addressed without surgery or with a simpler procedure or when doing so would cause more instability or abnormal movement, a fusion should be considered. Some of the conditions which require spinal fusion are discussed in the answer to “What is Spinal Fusion?”

Who performs this surgery? Could I be paralyzed? Are there other risks involved?

Both orthopedic surgeons and neurosurgeons who specialize in spine surgery may perform this procedure, either individually or as a team.

The chances of neurological injury with spine surgery are very low; and the possibility of catastrophic injury, such as paralysis, impotence or loss of bowel or bladder control are highly unlikely. Injury to a nerve root with isolated numbness and/or weakness in the leg is possible.

There are general risks with any type of surgery. These include, but are not limited to, the possibility of wound infection, uncontrollable bleeding, collections of blood clots in the wound or in the veins of the leg, abdominal problems, dural tear/spinal leak, pulmonary embolism (a blood clot to the lungs), or heart attack. The chances of any of these happening, particularly to a healthy patient, are low. Rarely, death may occur during or after any surgical procedure. There is also a chance that the bones may not fuse despite our best efforts. This risk is higher in patients with diabetes, a history of smoking, obesity, chronic steroid use and other chronic conditions.

Will my back be normal after surgery? What are my chances of being relieved of my pain?

No. Even if you have excellent relief of pain, the spine is not completely normal after a fusion. Stiffening one segment of the spine with the fusion may put additional strain on other areas. Other discs may have already started to wear out. Even if they aren't causing you pain now, they may do so in the future. For these reasons, you may have ongoing back pain. However, most people can resume almost all of their normal activities after their fusion has healed.

More than 90 percent of patients get relief of their nerve symptoms or leg pain. Relief of back pain is less predictable, occurring about 70 percent of the time. Some residual back pain is not uncommon. Other conditions such as fibromyalgia may lead to chronic pain post-op.

How long will I be in the hospital? When can I return to work?

The hospital stay is generally three to four days.

Returning to work should be discussed individually with your surgeon. Generally, patients may return to sedentary jobs whenever they are comfortable, which is usually within three to six weeks. If you drive more than 30 minutes to get to work, your surgeon may want you to wait longer. It takes much longer to get back to work that requires strenuous physical activity due to the increased stress these activities play on the healing bone.

What can I do after surgery? What shouldn't I do after surgery?

You should get up and move around frequently as soon as you feel like it. You are encouraged to walk daily. If you are feeling well enough, you may begin driving in two to three weeks with your back brace on as long as you are no longer taking pain medicine.

Generally, you should avoid bending, lifting and twisting (B.L.T.’s) for six to nine months. Even if screws or rods are used, 6 to 12 months are required for the fusion to heal completely. You must protect your spine during this time. Your surgeon will usually prescribe a brace for you to wear for part of this time. If you are a smoker, you definitely should not smoke until your fusion is completely solid, since smoking interferes with bone healing.

Could this happen to me again? Should I avoid vigorous physical activity?

Unfortunately, yes. A fusion may add stress to the levels above and below the fusion. If the fusion doesn't heal solidly, even with rods and screws, your symptoms may recur and additional surgery may be needed.

And no, exercise is good for you! You should get some sort of vigorous, low-impact aerobic exercise at least three times a week. Walking either outside or on a treadmill, using an exercise bike and swimming are all examples of exercise that is appropriate for spine patients. (Swimming, after the wound is fully healed.) You may start these activities as soon as you are comfortable.

Contact Us

Make an appointment with our Spine Care Coordinator to learn more about our patient-centered process for back surgery or to schedule a tour.

Dave Smith, Spine Care Coordinator

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