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Spinal fusion has become an increasingly common procedure, particularly among men with aging spines. However, caution is advised, and the decision to consider back surgery, especially spinal fusion, should only come after exploring nonsurgical or conservative options.
Spinal fusion is a major operation where the surgeon connects two adjacent vertebrae to create a single unit. The procedure aims to stabilize an unstable joint to prevent motion that may cause pain. Despite being a well-known and frequently performed surgery, spinal fusion often falls short of providing a lasting solution and is associated with risks and expenses. In recent years, the number of spinal fusions has risen significantly.
Dr. Steven Atlas, an associate professor of medicine at Harvard Medical School, warns men with aging spines to be cautious about spinal fusion and its promises. He notes that, based on the evidence, the indications for fusion are limited, yet the procedure continues to be performed more frequently than necessary. Spondylolisthesis, a misalignment of the vertebrae, is one common indication for fusion, and the procedure may involve the use of metal screws and rods to stabilize the spine. It is crucial for individuals to carefully consider the evidence, risks, and potential benefits before opting for spinal fusion.
Fusion: the gray areas
Men often undergo spinal fusions for various reasons, with some cases showing signs of changes in the spine that could potentially explain the pain, such as the breakdown of spinal discs between vertebrae. However, for cases of “nonspecific” low back pain where the pain’s origin is challenging to pinpoint, research indicates that the benefits of fusion are inconsistent.
Research suggests that about half of those undergoing fusion for nonspecific low back pain experience significant pain relief, but the results can be unpredictable. Pain relief, when achieved, is often limited, reducing pain by approximately 50%. The relief may be temporary, lasting only a few years before the condition worsens again.
One concern with fusion is that it transfers the motion of the spine to adjacent joints, potentially accelerating wear-and-tear in those areas. Despite these concerns, many men with nonspecific low back pain opt for fusion after trying other nonsurgical measures without success.
An alternative to fusion is an intensive, long-term back rehabilitation program aimed at controlling pain and maintaining function. Studies indicate that such programs can be as effective as fusion without the need for surgery and the associated risks.
However, one challenge is that high-quality back rehabilitation programs involving a team of specialists can be expensive, and health insurance may not fully cover the costs. In contrast, surgery is generally covered if a doctor recommends it. The decision between surgery and rehabilitation should be carefully considered, taking into account the individual’s specific condition, preferences, and the potential risks and benefits of each approach.
Damaged discs
When the pain can be traced to a specific spinal disc, particularly if it is causing sciatica, the appropriate surgical procedure is often a discectomy rather than fusion.
As spinal discs stiffen and break down, they may protrude outward, putting pressure on nearby nerves. In some cases, the walls of the discs may split open, leading to a herniation where the softer, gelatinous material inside pushes outward. Sciatica, characterized by pain radiating down the buttock, thigh, back of the leg, or calf, is a common symptom of disc problems.
For new disc pain, conservative care is usually the initial recommended approach. If sciatica persists or worsens despite conservative measures, discectomy may be considered as a surgical option to relieve pain by removing the portion of the disc pressing on nearby nerves.
It’s important to note that studies suggest that a year of conservative therapy is generally as effective as discectomy. Therefore, the decision to undergo a discectomy should be based on factors such as the preference for more immediate pain relief rather than the potential long-term outcomes.
Surgery for spinal stenosis
Spinal stenosis, a common issue in the aging spine, refers to the narrowing of the space around the spinal cord. This narrowing can result from bulging discs, overgrowth of bone and ligaments, and can lead to pressure on the nerves, causing pain. In some cases, fusion may be considered as part of the solution for spinal stenosis.
Common signs of stenosis include pain that improves when sitting down after standing, increased pain when leaning back but reduced when leaning forward, and pain in the groin, buttocks, and upper thigh, without radiating pain down the back of the legs.
If conservative measures, such as pain relievers and physical therapy, are insufficient in controlling the pain, and if the pain affects mobility, surgery may be a viable option. The most common surgical procedure for stenosis is a laminectomy, involving the removal of the bony plate (lamina) on the back of a vertebra. This procedure aims to create more space for the spinal nerves. Laminectomy is considered a simpler and safer alternative to fusion, with a high success rate of 80% to 90% pain relief.
No slippage? No fusion
Fusion is a consideration for spinal stenosis only if there is a condition called spondylolisthesis, where a vertebra has slipped forward with respect to its neighbor. According to Dr. Atlas, if there is no evidence of spondylolisthesis on an X-ray and spinal stenosis is present, a laminectomy should be considered. If a doctor recommends fusion without the presence of spondylolisthesis, seeking a second opinion is advisable.
It’s crucial to exercise caution, particularly with “complex” fusions that involve joining more than two vertebrae with hardware. Such procedures increase the risks, and older individuals undergoing complex fusion face a significant rise in the risk of death compared to a simple laminectomy. The risk of death increases from around two or three deaths per 1,000 procedures to 10 to 20 deaths per 1,000 with complex fusion.
Before opting for spinal fusion, it’s essential to thoroughly understand the cause of the pain and carefully evaluate whether fusion is a reasonable and necessary option. Like any surgical procedure, spinal fusion comes with both risks and potential benefits, and it should be considered thoughtfully rather than as a “last resort” without a clear understanding of the underlying issues.
What is conservative care for back pain?
For new or recurring back pain, consider the following measures before opting for surgery:
1. Wait: Give it time. Back pain often improves on its own. However, seek medical attention promptly if you experience “red flag” symptoms like fever or loss of bowel or bladder control.
2. Apply ice and heat: In the early or acute stage of back pain, use ice to numb the pain and reduce inflammation. After a few days, switch to heat for comfort, improved blood flow, and reduced stiffness.
3. Take pain relievers: Over-the-counter pain relievers can alleviate discomfort and some reduce inflammation. Acetaminophen (Tylenol) is stomach-friendly but doesn’t reduce inflammation. Anti-inflammatory options include ibuprofen (Advil, Motrin), naproxen (Aleve), or aspirin.
4. Stay physically active: While short periods of bed rest or sitting may be beneficial during the acute phase, prolonged bed rest is not recommended. Keep moving within your comfort level to maintain functionality.
5. Stretch and strengthen gently: As the intense pain subsides, incorporate gentle stretching and strengthening exercises. Consult your doctor or a physical therapist for personalized guidance.
Surgery should be considered only after exploring these conservative measures and receiving professional advice based on your specific condition.
