{{short description|Immobilization or ankylosis of two or more vertebrae by fusion of the vertebral bodies}} {{Infobox medical intervention | Name = Spinal fusion | Image = File:Roe LWS Spondylodese L5-S1 seitlich.jpg | Caption = Fusion of L5 and S1 | ICD10 = M43.2 | ICD9 = {{ICD9proc|81.0}} | MeshID = D013123 | MedlinePlus = 002968 | synonyms = Spondylosyndesis |Field=Orthopedics, Neurology}} '''Spinal fusion''', also called '''spondylodesis''' or '''spondylosyndesis''', is a surgery performed by orthopaedic surgeons or neurosurgeons that joins two or more vertebrae.<ref>{{cite book | url=https://books.google.com/books?id=nqOLDwAAQBAJ&dq=spine%20surgery&pg=PA73 | title=Spine Surgery: A Case-Based Approach | isbn=978-3-319-98875-7 | last1=Meyer | first1=Bernhard | last2=Rauschmann | first2=Michael | date=4 March 2019 | publisher=Springer }}</ref> This procedure can be performed at any level in the spine (cervical, thoracic, lumbar, or sacral) and prevents any movement between the fused vertebrae. There are many types of spinal fusion and each technique involves using bone grafting—either from the patient (autograft), donor (allograft), or artificial bone substitutes—to help the bones heal together.<ref name=":0">{{Cite web|url=https://www.uptodate.com/contents/subacute-and-chronic-low-back-pain-surgical-treatment|title=Subacute and Chronic Low Back Pain: Surgical Treatment|last=Chou|first=Roger|date=March 11, 2016|website=UpToDate}}</ref> Additional hardware (screws, plates, or cages) is often used to hold the bones in place while the graft fuses the two vertebrae together. The placement of hardware can be guided by fluoroscopy, navigation systems, or robotics.
Spinal fusion is most commonly performed to relieve the pain and pressure from mechanical pain of the vertebrae or on the spinal cord that results when a disc (cartilage between two vertebrae) wears out (degenerative disc disease).<ref name=":1">{{Cite journal|last=Rajaee|first=Sean|year=2012|title=Spinal Fusion in the United States|journal=Spine|volume=37|issue=1|pages=67–76|doi=10.1097/brs.0b013e31820cccfb|pmid=21311399|s2cid=22564134 |doi-access=free}}</ref> It is also used as a backup procedure for total disc replacement surgery (intervertebral disc arthroplasty), in case patient anatomy prevents replacement of the disc. Other common pathological conditions that are treated by spinal fusion include spinal stenosis, spondylolisthesis, spondylosis, spinal fractures, scoliosis, and kyphosis.<ref name=":1" />
Like any surgery, complications may include infection, blood loss, and nerve damage.<ref name=":2">{{Cite book|title=Orthopaedic Surgery Essentials: Spine|last=Agulnick|first=Marc|publisher=Lippincott Williams & Wilkins|year=2017|isbn=978-1-49631-854-1|location=Philadelphia, PA|page=343}}</ref> Fusion also changes the normal motion of the spine and results in more stress on the vertebrae above and below the fused segments. As a result, long-term complications include degeneration at these adjacent spine segments.<ref name=":0" />
==Medical uses== thumb|Herniated disc pressing on spinal nerves.
Spinal fusion can be used to treat a variety of conditions affecting any level of the spine—lumbar, cervical and thoracic. In general, spinal fusion is performed to decompress and stabilize the spine.<ref name=":2" /> The greatest benefit appears to be in spondylolisthesis, while evidence is weaker for spinal stenosis.<ref>{{cite journal|last1=Yavin|first1=D|last2=Casha|first2=S|last3=Wiebe|first3=S|last4=Feasby|first4=TE|last5=Clark|first5=C|last6=Isaacs|first6=A|last7=Holroyd-Leduc|first7=J|last8=Hurlbert|first8=RJ|last9=Quan|first9=H|last10=Nataraj|first10=A|last11=Sutherland|first11=GR|last12=Jette|first12=N|title=Lumbar Fusion for Degenerative Disease: A Systematic Review and Meta-Analysis.|journal=Neurosurgery|date=1 May 2017|volume=80|issue=5|pages=701–715|doi=10.1093/neuros/nyw162|pmid=28327997|doi-access=free}}</ref>
The most common cause of pressure on the spinal cord/nerves is degenerative disc disease.<ref name=":7" /> Other common causes include disc herniation, spinal stenosis, trauma, and spinal tumors.<ref name=":2" /> Spinal stenosis results from bony growths (osteophytes) or thickened ligaments that cause narrowing of the spinal canal over time.<ref name=":2" /> This causes leg pain with increased activity, a condition called neurogenic claudication.<ref name=":2" /> Pressure on the nerves as they exit the spinal cord (radiculopathy) causes pain in the area where the nerves originated (leg for lumbar pathology, arm for cervical pathology).<ref name=":2" /> In severe cases, this pressure can cause neurologic deficits, like numbness, tingling, bowel/bladder dysfunction, and paralysis.<ref name=":2" />
Lumbar and cervical spinal fusions are more commonly performed than thoracic fusions.<ref name=":7" /> Degeneration happens more frequently at these levels due to increased motion and stress.<ref name=":7" /> The thoracic spine is more immobile, so most fusions are performed due to trauma or deformities like scoliosis, kyphosis, and lordosis.<ref name=":2" />
Conditions where spinal fusion may be considered include the following: * Degenerative disc disease * Spinal disc herniation * Discogenic pain * Spinal tumor * Vertebral fracture * Scoliosis * Kyphosis (e. g., Scheuermann's disease) * Lordosis * Spondylolisthesis * Spondylosis * Posterior rami syndrome * Other degenerative spinal conditions<ref name=":2" /> * Any condition that causes instability of the spine<ref name=":2" />
==Contraindications== Bone morphogenetic protein (rhBMP) should not be routinely used in any type of anterior cervical spine fusion, such as with anterior cervical discectomy and fusion.<ref name="NASSfive">{{Citation |author1 = North American Spine Society |author1-link = North American Spine Society |date = February 2013 |title = Five Things Physicians and Patients Should Question |publisher = North American Spine Society |work = Choosing Wisely: an initiative of the ABIM Foundation |url = http://www.choosingwisely.org/doctor-patient-lists/north-american-spine-society/ |access-date = 25 March 2013}}, which cites * {{cite web |url= https://www.fda.gov/MedicalDevices/Safety/AlertsandNotices/PublicHealthNotifications/ucm062000.htm |title=Public Health Notifications (Medical Devices)—FDA Public Health Notification: Life-threatening Complications Associated with Recombinant Human Bone Morphogenetic Protein in Cervical Spine Fusion |first=Daniel G. |last=Schultz |work=fda.gov |date=July 1, 2008 |access-date=25 March 2014}} * {{cite journal|last=Woo|first=EJ|title=Recombinant human bone morphogenetic protein-2: adverse events reported to the Manufacturer and User Facility Device Experience database.|journal=The Spine Journal|date=Oct 2012|volume=12|issue=10|pages=894–9|pmid=23098616|doi=10.1016/j.spinee.2012.09.052|url=https://zenodo.org/record/1000710}}</ref> There are reports of this therapy causing soft tissue swelling, which in turn can cause life-threatening complications due to difficulty swallowing and pressure on the respiratory tract.<ref name="NASSfive"/>
==Epidemiology== According to a report by the Agency for Healthcare Research and Quality (AHRQ), approximately 488,000 spinal fusions were performed during U.S. hospital stays in 2011 (a rate of 15.7 stays per 10,000 population), which accounted for 3.1% of all operating room procedures.<ref name="Weiss AJ, Elixhauser A, Andrews RM">{{cite journal |vauthors=Weiss AJ, Elixhauser A, Andrews RM | title = Characteristics of Operating Room Procedures in U.S. Hospitals, 2011. | journal =HCUP Statistical Brief |issue=170 | publisher = Agency for Healthcare Research and Quality | location = Rockville, MD | date = February 2014 | pmid = 24716251 | url = http://hcup-us.ahrq.gov/reports/statbriefs/sb170-Operating-Room-Procedures-United-States-2011.jsp }}</ref> This was a 70 percent growth in procedures from 2001.<ref>{{cite journal | vauthors = Weiss AJ, Elixhauser A | title = Trends in Operating Room Procedures in U.S. Hospitals, 2001–2011. | journal =HCUP Statistical Brief |issue=171 | publisher = Agency for Healthcare Research and Quality | location = Rockville, MD | date = March 2014 | pmid = 24851286 | url = http://hcup-us.ahrq.gov/reports/statbriefs/sb171-Operating-Room-Procedure-Trends.jsp | access-date = 2014-05-19 | archive-date = 2014-03-28 | archive-url = https://web.archive.org/web/20140328235555/http://hcup-us.ahrq.gov/reports/statbriefs/sb171-Operating-Room-Procedure-Trends.jsp }}</ref> Lumbar fusions are the most common type of fusion performed ~ 210,000 per year. 24,000 thoracic fusions and 157,000 cervical fusions are performed each year.<ref name=":7">{{Cite journal|last1=Rajaee|first1=Sean S.|last2=Bae|first2=Hyun W.|last3=Kanim|first3=Linda E.A.|last4=Delamarter|first4=Rick B.|title=Spinal Fusion in the United States|journal=Spine|volume=37|issue=1|pages=67–76|doi=10.1097/brs.0b013e31820cccfb|pmid=21311399|year=2012|s2cid=22564134 |doi-access=free}}</ref>
A 2008 analysis of spinal fusions in the United States reported the following characteristics: * Average age for someone undergoing a spinal fusion was 54.2 years – 53.3 years for primary cervical fusions, 42.7 years for primary thoracic fusions, and 56.3 years for primary lumbar fusions <ref name=":7" /> * 45.5% of all spinal fusions were on men <ref name=":7" /> * 83.8% were white, 7.5% black, 5.1% Hispanic, 1.6% Asian or Pacific Islander, 0.4% Native American <ref name=":7" /> * Average length of hospital stay was 3.7 days – 2.7 days for primary cervical fusion, 8.5 days for primary thoracic fusion, and 3.9 days for primary lumbar fusion <ref name=":7" /> * In-hospital mortality was 0.25% <ref name=":7" />
== Effectiveness == Although spinal fusion surgery is widely performed, there is limited evidence for its effectiveness for several common medical conditions. For example, in a randomized controlled trial of Swedish adults with spinal stenosis, after 2 and 5 years, there were no significant clinical benefits of lumbar fusion in combination with decompression surgery in comparison to decompression surgery alone. The study enrolled 247 patients from 2006 to 2012 and further found increased medical costs for those who received fusion surgery as a result of increased surgery time, hospital stay duration, and cost of the implant.<ref>{{Cite journal|last1=Försth|first1=Peter|last2=Ólafsson|first2=Gylfi|last3=Carlsson|first3=Thomas|last4=Frost|first4=Anders|last5=Borgström|first5=Fredrik|last6=Fritzell|first6=Peter|last7=Öhagen|first7=Patrik|last8=Michaëlsson|first8=Karl|last9=Sandén|first9=Bengt|date=2016-04-14|title=A Randomized, Controlled Trial of Fusion Surgery for Lumbar Spinal Stenosis|journal=New England Journal of Medicine|language=EN|volume=374|issue=15|pages=1413–1423|doi=10.1056/nejmoa1513721|pmid=27074066|issn=0028-4793|url=http://openarchive.ki.se/xmlui/bitstream/10616/46584/3/Thesis_Gylfi_O%cc%81lafsson.pdf|hdl=10616/46584|doi-access=free|archive-date=2021-09-24|access-date=2019-09-24|archive-url=https://web.archive.org/web/20210924030402/https://openarchive.ki.se/xmlui/bitstream/handle/10616/46584/Thesis_Gylfi_O%20lafsson.pdf;jsessionid=F915D3BA930F88E70B433CFA1924549B?sequence=3|url-status=dead}}</ref>
=== Motion-preserving alternatives ===
Motion-preserving approaches aim to maintain segmental mobility while relieving symptoms, in contrast to the rigid stabilization provided by fusion. Two such alternatives include:
* '''Artificial disc replacement (ADR)''' – Involves implanting a prosthetic disc at the affected level, preserving motion and potentially reducing adjacent segment degeneration. ADR is a recognized alternative to fusion in selected patients.<ref>Zigler J, Delamarter R. "Five-year results of the ProDisc-L versus circumferential fusion for the treatment of degenerative disc disease." ''Journal of Neurosurgery: Spine''. 2012;17(6):493–501. doi:10.3171/2012.9.SPINE11510.</ref> * '''Facet arthroplasty (e.g., the TOPS System)''' – A posterior-based implant designed to preserve five degrees of freedom—flexion-extension, lateral bending, rotation, and translation—while maintaining spinal stability. In a prospective randomized controlled trial published in the ''Journal of Bone and Joint Surgery'', patients with grade I degenerative spondylolisthesis and lumbar stenosis treated with the TOPS System demonstrated higher rates of clinical success, improved functional outcomes, and motion preservation compared with transforaminal lumbar interbody fusion (TLIF).<ref>Nassr A, Coric D, Pinter ZW, Sebastian AS, Freedman BA, Whiting D, Chahlavi A, Pirris S, Phan N, Meyer SA, Tahernia AD, Sandhu F, Deutsch H, Potts EA, Cheng J, Chi JH, Groff M, Anekstein Y, Steinmetz MP, Welch WC (2024). "Lumbar Facet Arthroplasty Versus Fusion for Grade-I Degenerative Spondylolisthesis with Stenosis: A Prospective Randomized Controlled Trial." ''Journal of Bone & Joint Surgery''. 106 (12): 1041–1053. doi:10.2106/JBJS.23.00719. PMC 11593996. PMID 38713762.</ref>
== Technique == There are many types of spinal fusion techniques. Each technique varies depending on the level of the spine and the location of the compressed spinal cord/nerves.<ref name=":2" /> After the spine is decompressed, bone graft or artificial bone substitute is packed between the vertebrae to help them heal together.<ref name=":0" /> In general, fusions are done either on the anterior (stomach), posterior (back), or both sides of the spine.<ref name=":2" /> Today, most fusions are supplemented with hardware (screws, plates, rods) because they have been shown to have higher union rates than non-instrumented fusions.<ref name=":2" /> Posterior lumbar spinal fixation using the conventional pedicle screw trajectory is the most common technique used in lumbar spine fusion. However, the stability of pedicle screws can be compromised in individuals with reduced bone density, which may lead to implant failure and pseudoarthrosis. The cortical bone trajectory (CBT) screw technique has been introduced as an alternative to the traditional pedicle screw trajectory for posterior spinal fixation. CBT screws are smaller and inserted along a caudo-cranial, mediolateral pathway. By engaging the denser cortical bone, CBT screws provide greater anchorage and may be more suitable for patients with osteoporosis.<ref>{{Cite journal |last=Song |first=Tengfei |last2=Hsu |first2=Wellington K |last3=Ye |first3=Tianwen |date=2014-11-05 |title=Lumbar pedicle cortical bone trajectory screw |journal=Chinese Medical Journal |volume=127 |issue=21 |pages=3808–3813 |doi=10.3760/cma.j.issn.0366-6999.20141887 |issn=0366-6999|doi-access=free }}</ref><ref>{{Cite journal |last=Wang |first=Yuetian |last2=Feng |first2=Tianhao |last3=Wang |first3=Shijun |last4=Fu |first4=Haoyong |last5=Li |first5=Chunde |last6=Sun |first6=Haolin |date=April 2023 |title=Midline Lumbar Fusion Versus Posterior Lumbar Interbody Fusion Involving L5–S1 For Degenerative Lumbar Diseases: A Comparative Study |url=https://linkinghub.elsevier.com/retrieve/pii/S1878875022017351 |journal=World Neurosurgery |language=en |volume=172 |pages=e86–e93 |doi=10.1016/j.wneu.2022.12.031|url-access=subscription }}</ref> Minimally invasive techniques are also becoming more popular.<ref name=":8">{{Cite journal|last1=Phan|first1=Kevin|last2=Rao|first2=Prashanth J.|last3=Mobbs|first3=Ralph J.|date=2015-08-01|title=Percutaneous versus open pedicle screw fixation for treatment of thoracolumbar fractures: Systematic review and meta-analysis of comparative studies|journal=Clinical Neurology and Neurosurgery|volume=135|pages=85–92|doi=10.1016/j.clineuro.2015.05.016|issn=1872-6968|pmid=26051881|s2cid=31098673 }}</ref> These techniques use advanced image guidance systems to insert rods/screws into the spine through smaller incisions, allowing for less muscle damage, blood loss, infections, pain, and length of stay in the hospital.<ref name=":8" /> The following list gives examples of common types of fusion techniques performed at each level of the spine: thumb|Anterior approach to cervical spine.
=== Cervical spine === * Anterior cervical discectomy and fusion (ACDF)<ref name=":2" /> * Anterior cervical corpectomy and fusion<ref name=":2" /> * Posterior cervical decompression and fusion<ref name=":2" />
=== Thoracic spine === * Anterior decompression and fusion<ref name=":2" /> * Posterior instrumentation and fusion – many different types of hardware can be used to help fuse the thoracic spine including sublaminar wiring, pedicle and transverse process hooks, pedicle screw-rod systems, vertebral body plate systems.<ref name=":2" />
=== Lumbar spine === thumb|X-ray of Transforaminal Lumbar Interbody Fusion (TLIF) thumb|right|Stabilization rods used after spinal fusion surgery. * Posterolateral fusion is a bone graft between the transverse processes in the back of the spine. These vertebrae are then fixed in place with screws or wire through the pedicles of each vertebra, attaching to a metal rod on each side of the vertebrae. * Interbody Fusion is a graft where the entire intervertebral disc between vertebrae is removed and a bone graft is placed in the space between the vertebra. A plastic or titanium device may be placed between the vertebra to maintain spine alignment and disc height. The types of interbody fusion are: *# Anterior lumbar interbody fusion (ALIF) – the disc is accessed from an anterior abdominal incision *# Posterior lumbar interbody fusion (PLIF) – the disc is accessed from a posterior incision *# Transforaminal lumbar interbody fusion (TLIF) – the disc is accessed from a posterior incision on one side of the spine *# Transpsoas interbody fusion (DLIF or XLIF) – the disc is accessed from an incision through the psoas muscle on one side of the spine *# Oblique lateral lumbar interbody fusion (OLLIF) – the disc is accessed from an incision through the psoas muscle obliquely *# Midline lumbar fusion (MIDLF) is a recent minimally invasive interbody fusion technique in which cortical bone trajectory (CBT) screws are inserted and interbody fusion is performed through a small midline posterior incision.<ref>{{Cite journal |last=Samal |first=Filip |last2=Sterba |first2=Albert |last3=Haninec |first3=Pavel |last4=Jurek |first4=Patrik |last5=Waldauf |first5=Petr |last6=Filip |first6=Michal |last7=Linzer |first7=Petr |date=October 2021 |title=Long-Term Outcome After Midline Lumbar Fusion for the Treatment of Lumbar Spine Instability Due to Degenerative Disease |url=https://linkinghub.elsevier.com/retrieve/pii/S1878875021011177 |journal=World Neurosurgery |language=en |volume=154 |pages=e641–e648 |doi=10.1016/j.wneu.2021.07.108|url-access=subscription }}</ref>
== Risks == Spinal fusion is a high risk surgery and complications can be serious, including death. In general, there is a higher risk of complications in older people with elevated body mass index (BMI), other medical problems, poor nutrition and nerve symptoms (numbness, weakness, bowel/bladder issues) before surgery.<ref name=":2" /> Complications also depend on the type/extent of spinal fusion surgery performed. Smokers and people who are Vitamin D deficient are at a higher risk of spinal fusion failure.<ref name=":5">{{Cite journal |last1=Yang |first1=Shudong |last2=Zhou |first2=Beijun |last3=Mo |first3=Jiaxuan |last4=He |first4=Ruidi |last5=Mei |first5=Kunbo |last6=Zeng |first6=Zhi |last7=Yang |first7=Gaigai |last8=Chen |first8=Yuwei |last9=Luo |first9=Mingjiang |last10=Tang |first10=Siliang |last11=Xiao |first11=Zhihong |date=2024-06-07 |title=Risk factors affecting spinal fusion: A meta-analysis of 39 cohort studies |journal=PLOS ONE |language=en |volume=19 |issue=6 |article-number=e0304473 |doi=10.1371/journal.pone.0304473 |doi-access=free |issn=1932-6203 |pmc=11161075 |pmid=38848350|bibcode=2024PLoSO..1904473Y }}</ref> There are three main time periods where complications typically occur:
=== During surgery === * Patient positioning on operating table<ref name=":2" /> * Blood loss<ref name=":2" /> * Damage to nerves and surrounding structures during procedure<ref name=":2" /> * Insertion of spinal hardware<ref name=":2" /> ** Conventional Pedicle screws increased the risk of failure compared to Expandable Pedicle screws<ref name=":5" /> * Harvesting of bone graft (if autograft is used)<ref name=":2" /> * Patients who used the allograft were at a higher risk of fusion failure.<ref name=":5" />
=== Within a few days === * Moderate to severe postoperative pain<ref>{{Cite journal|last1=Yang|first1=Michael M. H.|last2=Riva-Cambrin|first2=Jay|last3=Cunningham|first3=Jonathan|last4=Jetté|first4=Nathalie|last5=Sajobi|first5=Tolulope T.|last6=Soroceanu|first6=Alex|last7=Lewkonia|first7=Peter|last8=Jacobs|first8=W. Bradley|last9=Casha|first9=Steven|date=2020-09-15|title=Development and validation of a clinical prediction score for poor postoperative pain control following elective spine surgery|journal=Journal of Neurosurgery. Spine|volume=34 |issue=1 |pages=3–12|doi=10.3171/2020.5.SPINE20347|issn=1547-5646|pmid=32932227|doi-access=free}}</ref> * Wound infections - risk factors include old age, obesity, diabetes, smoking, prior surgery<ref name=":2" /> * Deep vein thrombosis (DVT)<ref name=":2" /> * Pulmonary embolism (PE)<ref name=":2" /> * Urinary retention<ref name=":2" /> * Malnutrition<ref name=":2" /> * Neurologic deficit<ref name=":2" /> * Shock, sepsis and cerebrovascular infarction<ref>{{Cite journal |last1=Pumberger |first1=Matthias |last2=Chiu |first2=Ya Lin |last3=Ma |first3=Yan |last4=Girardi |first4=Federico P. |last5=Vougioukas |first5=Vassilios |last6=Memtsoudis |first6=Stavros G. |date=August 2012 |title=Perioperative mortality after lumbar spinal fusion surgery: an analysis of epidemiology and risk factors |journal=European Spine Journal |volume=21 |issue=8 |pages=1633–1639 |doi=10.1007/s00586-012-2298-8 |issn=0940-6719 |pmc=3535239 |pmid=22526700}}</ref>
=== Weeks to years following surgery === * Infection – sources of bacterial bioburden that infiltrate the wound site are several, but the latest research highlights repeated reprocessing of implants before surgery and exposure of implants (such as pedicle screws) to bacterial contaminants in the "sterile-field" during surgery as major risk factors.<ref name=":2" /><ref>{{Cite web|title=11 Investigates: Surgical implants raising contamination concerns|url=https://www.wtol.com/article/news/investigations/11-investigates/11-investigates-surgical-implants-raising-contamination-concerns/512-fce90bbd-a673-45ff-b005-e88b09a29366|access-date=2020-07-28|website=wtol.com|date=5 July 2019 |language=en-US}}</ref><ref>{{Cite web|title=Ban 'Reprocessing' of Spinal Surgery Screws, Experts Say|url=http://www.medscape.com/viewarticle/913233|access-date=2020-07-28|website=Medscape}}</ref><ref>{{Cite web|last=Hudson|first=Jocelyn|date=2019-01-16|title=Banned in the USA: Petition calls for FDA to prohibit reprocessed pedicle screws|url=https://spinalnewsinternational.com/petition-reprocessed-pedicle-screw-ban/|access-date=2020-07-28|website=Spinal News International|language=en-GB}}</ref><ref>{{Cite web|last=Korol|first=Shayna|title=Current use of contaminated pedicle screws & required practice for asepsis in spine surgery — 2 Qs with Dr. Aakash Agarwal|url=https://www.beckersspine.com/orthopedic-a-spine-device-a-implant-news/item/43040-current-use-of-contaminated-pedicle-screws-required-practice-for-asepsis-in-spine-surgery-2-qs-with-dr-aakash-agarwal.html|access-date=2020-07-28|website=www.beckersspine.com|date=15 October 2018 |language=en-gb}}</ref> * Deformity – loss of height, alignment, and failure of fusion<ref name=":2" /> * Pseudarthrosis – nonunion between fused bone segments. Risk factors include tobacco use, nonsteroidal anti-inflammatory drug use, osteoporosis, revision procedures, decreased immune system.<ref name=":2" /> * Adjacent segment disease – a condition where spinal levels next to the fused segments develop progressive degenerative change.<ref>{{cite journal |last1=Chu |first1=ECP |last2=Lee |first2=LYK |date=February 2022 |title=Adjacent segment pathology of the cervical spine |journal=Journal of Family Medicine and Primary Care |volume=11 |issue=2 |pages=787–789 |doi=10.4103/jfmpc.jfmpc_1380_21 |pmc=8963601 |pmid=35360775 |doi-access=free}}</ref> It is distinct from adjacent segment degeneration, which refers only to radiographic changes without symptoms.<ref name="Ghiselli2011">Ghiselli G, Wang JC, Bhatia NN, Hsu WK, Dawson EG. "Adjacent segment degeneration in the lumbar spine." ''The Spine Journal''. 2011;11(5):401–408. doi:10.1016/j.spinee.2010.12.006.</ref> Long-term studies have reported that about 22% of patients require additional surgery for ASD within 10 years of lumbar fusion, with rates rising to 40% after three or more fused levels.<ref name="Ghiselli2011" /> Risk is further increased by factors such as older age, female sex, obesity, osteoporosis, sagittal imbalance, and certain genetic predispositions, while younger patients with single-level fusions have lower risk.<ref name="Chou2021">Chou D, Mummaneni PV. "Patient-related risk factors for the development of lumbar spine adjacent segment pathology." ''Orthopedic Reviews''. 2021;13(2):24915. doi:10.52965/001c.24915.</ref> * Epidural fibrosis – scarring of the tissue that surrounds the spinal cord<ref name=":2" /> * Arachnoiditis – inflammation of the thin membrane surrounding the spinal cord, usually caused by infection or contrast dye.<ref name=":2" />
== Recovery == Recovery following spinal fusion is extremely variable, depending on individual surgeon's preference and the type of procedure performed.<ref>{{Cite journal|last1=McGregor|first1=Alison H.|last2=Dicken|first2=Ben|last3=Jamrozik|first3=Konrad|date=2006-05-31|title=National audit of post-operative management in spinal surgery|journal=BMC Musculoskeletal Disorders|volume=7|article-number=47|doi=10.1186/1471-2474-7-47|issn=1471-2474|pmc=1481518|pmid=16737522 |doi-access=free }}</ref> The average length of hospital stay for spinal fusions is 3.7 days.<ref name=":7" /> Some patients can go home the same day if they undergo a simple cervical spinal fusion at an outpatient surgery center.<ref name=":3">{{Cite journal|last1=Shields|first1=Lisa B. E.|last2=Clark|first2=Lisa|last3=Glassman|first3=Steven D.|last4=Shields|first4=Christopher B.|date=2017-01-19|title=Decreasing hospital length of stay following lumbar fusion utilizing multidisciplinary committee meetings involving surgeons and other caretakers|journal=Surgical Neurology International|volume=8|doi=10.4103/2152-7806.198732|issn=2229-5097|pmc=5288986|pmid=28217384|page=5 |doi-access=free }}</ref> Minimally invasive surgeries are also significantly reducing the amount of time spent in the hospital.<ref name=":3" /> Recovery typically involves both restriction of certain activities and rehabilitation training.<ref name=":4">{{Cite journal|last1=McGregor|first1=Alison H.|last2=Probyn|first2=Katrin|last3=Cro|first3=Suzie|last4=Doré|first4=Caroline J.|last5=Burton|first5=A. Kim|last6=Balagué|first6=Federico|last7=Pincus|first7=Tamar|last8=Fairbank|first8=Jeremy|date=2013-12-09|title=Rehabilitation following surgery for lumbar spinal stenosis|journal=The Cochrane Database of Systematic Reviews|volume=2013|issue=12|article-number=CD009644|doi=10.1002/14651858.CD009644.pub2|issn=1469-493X|pmid=24323844|pmc=11972841}}</ref><ref>{{Cite web|date=2021-02-08|title=Permanent Restrictions after Spinal Fusion – What Do the Doctors Say?|url=https://thehealthytalks.com/permanent-restrictions-after-spinal-fusion/|access-date=2021-03-18|website=The Healthy Talks|language=en-US}}</ref> Restrictions following surgery largely depend on surgeon preference. A typical timeline for common restrictions after a lumbar fusion surgery are listed below: * Walking – most people are out of bed and walking the day after surgery<ref name=":4" /> * Sitting – can begin at 1–6 weeks following surgery<ref name=":4" /> * Lifting – it is generally recommended to avoid lifting until 12 weeks<ref name=":4" /> * Driving – usually can begin at 3–6 weeks<ref name=":4" /> * Return to sedentary work – usually between 3–6 weeks<ref name=":4" /> * Return to manual work – between 7–12 weeks<ref name=":4" /> Rehabilitation after spinal fusion is not mandatory. There is some evidence that it improves functional status and low back pain so some surgeons may recommend it.<ref name=":4" />
==Usage== According to a report by the Agency for Healthcare Research and Quality (AHRQ), approximately 488,000 spinal fusions were performed during U.S. hospital stays in 2011, a rate of 15.7 stays per 10,000 population, which accounted for 3.1% of all operating room procedures.<ref name="Weiss AJ, Elixhauser A, Andrews RM"/>
== References == {{reflist}}
== Further reading == * [http://www.webmd.com/back-pain/cervical-spinal-fusion Cervical Spinal Fusion.] WebMD. * [http://www.umm.edu/spinecenter/education/anterior_cervical_fusion.htm A Patient's Guide to Anterior Cervical Fusion.] University of Maryland Medical Center. * Boatright, K. C. and S. D. Boden. Chapter 12: Biology of Spine Fusion. In: Lieberman, J., et al., Eds. ''Bone Regeneration and Repair''. Totowa, New Jersey: Humana Press. 2005. pp. 225–239. {{ISBN|978-0-89603-847-9}}. * Holmes, C. F., et al. Chapter 9: Cervical Spine Injuries. In: Schenck, R. F., AAOS. ''Athletic Training in Sports Medicine.'' Jones & Bartlett Publishers. 2005. pp. 197–218. {{ISBN|0-89203-172-7}} * Camillo, F. X. Chapter 36: Arthrodesis of the Spine. In: Canale, S. T. and J. H. Beaty. ''Campbell's Operative Orthopaedics 2''. (11th Ed.). Philadelphia: Mosby. 2007. pp. 1851–1874. {{ISBN|978-0-323-03329-9}}. * Williams, K. D. and A. L. Park. Chapter 39: Lower Back Pain and Disorders of Intervertebral Discs. In: Canale, S. T. and J. H. Beaty. ''Campbell's Operative Orthopaedics 2''. (11th Ed.). Philadelphia: Mosby. 2007. pp. 2159–2224. {{ISBN|978-0-323-03329-9}}. * Weyreuther, M., et al., Eds. Chapter 7: The Postoperative Spine. ''MRI Atlas: Orthopedics and Neurosurgery – The Spine''. trans. B. Herwig. Berlin: Springer-Verlag. 2006. pp. 273–288. {{ISBN|978-3-540-33533-7}}. * {{cite journal | author = Tehranzadehlow J. |display-authors=etal | year = 2005 | title = Advances in spinal fusion | journal = Seminars in Ultrasound, CT and MRI | volume = 26 | issue = 2| pages = 103–113 | doi=10.1053/j.sult.2005.02.007|pmid=15856812 }} * Resnick, D. K., et al. ''Surgical Management of Low Back Pain'' (2nd Ed.). Rolling Meadows, Illinois: American Association of Neurosurgeons. 2008. {{ISBN|978-1-60406-035-5}}. * [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4652919 Oblique Lateral Lumbar Interbody Fusion (OLLIF): Technical Notes and Early Results of a Single Surgeon Comparative Study.] NIH.
==External links== * Wheeless, C. R., et al., Eds. [http://www.wheelessonline.com/ortho/fusion_of_the_spine Fusion of the Spine.] ''Wheeless' Textbook of Orthopaedics''. Division of Orthopedic Surgery. Duke University Medical Center. * [http://orthoinfo.aaos.org/topic.cfm?topic=A00348 Spinal Fusion.] American Academy of Orthopaedic Surgeons. June 2010. Accessed 1 June 2013. * Spinasanta, S. [http://www.spineuniverse.com/treatments/surgery/what-spinal-instrumentation-spinal-fusion What is Spinal Instrumentation and Spinal Fusion?] SpineUniverse. September 2012. Accessed 1 June 2013. * [http://www.surgeryencyclopedia.com/Pa-St/Spinal-Fusion.html Spinal fusion.] Encyclopedia of Surgery. Accessed 1 June 2013.
{{Operations and other procedures on the musculoskeletal system}}
Category:Neurosurgical procedures Category:Orthopedic surgical procedures