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Home > Why do I Need Spinal Fusion Surgery?

Why do I Need Spinal Fusion Surgery?

Jeffrey R. Carlson, MD, CPE, FAAOSJeffrey R. Carlson, MD, MBA, FAAOS, CPE

When I have a discussion with patients about potential spinal surgery, they often ask “how extensive will the surgery be and how much of my spine will be affected by the procedure?”  Generally, my answer is “only what will make you, the patient, better!”

In lumbar spine surgery, there are usually two main goals. The first goal is to remove whatever is compressing the nerves.  This may be a disc, bone spurs (osteophytes), or arthritic cysts that cause pain due to the pressure (commonly called “pinching”) on the nerve.  Each nerve has a specific path in our bodies, which gives the spine surgeon an idea about which nerve is being compressed.  Decompressing or removing that pressure should relieve the nerve pain and help the patient return to better function.

The second goal of lumbar spine surgery is the long-term stabilization of the spinal column.  In some cases, the spinal bones will shift, due to arthritis or a lack of solid connections, which will also compress the nerves in the back.  This shifting of the bones , a condition known as spondylolisthesis, is a much bigger factor in back pain than most people realize.  When the bones are not stable in the spine, the vertebrae will slide either forward or backward, leading to ongoing pain.

The treatment for the shifting of the spinal bones (vertebrae) is to provide stability, which we call “fusion”.  Fusion provides a solid connection or union between bones that are usually mobile through their associated joints.  In the spine, there are two types of joints that connect the vertebral bodies, either discs or facet joints. These cartilaginous connections allow the bones to move against themselves, however, abnormal motion related to arthritis or instabilities can be very painful.  Stopping the deviant motion in these joints can relieve that pain.

Sometimes, I must do both types of surgery on the same patient.  If the patient has pressure along the nerve causing pain as well as instability or slippage of the bones, only relieving the nerve pressure will provide a short-lived solution.  With time, as the arthritis increases, the slippage of the bones will also increase and the patient will experience the nerve pain again as well as the ongoing back pain related to the unstable bones.

A study published in The Journal of Neurosurgery in February 2023 (Kayoumars) illustrates this point.  Surgeons performed either decompression or decompression with fusion on patients that had compressed nerves and slippage of the vertebral bones.  The surgeons were able to evaluate these patients over the next two years and found that those patients that had decompression alone had more leg pain and were worse functionally than those patients that had decompression and fusion.  In fact, they found that 20% of the patients that only had a decompression were in enough pain to proceed with a fusion within those two years.  There were no patients in the decompression and fusion group of the study that needed more surgery.

As a spinal surgeon who wants the best long-term outcome for my patients, those patients with bones that are not stable will do best with a fusion procedure in addition to the nerve decompression.  We know that having several surgeries on the same area of the spine can lead to an increase in back pain, so I would like to ensure that my patients have the least likelihood of needing a second surgery on the same area of the spine. I believe in doing the right amount of surgery for the problem, no more, but no less.  In that way, the patient is best served and the problem is best treated.

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