Are You a Good Candidate for Spinal Fusion?
Though increasingly used for the treatment
of back pain, spinal-fusion surgery benefits only a small subset
The use of spinal-fusion surgery has increased drastically in
recent years, from 150,000 procedures in 1993 to 300,000 in 2001.
Although many long-established uses exist for spinal fusion—for
the treatment of severe scoliosis, spinal tuberculosis, and vertebral
fractures—doctors are increasingly using it to treat back
pain resulting from degenerative changes in the spine, disk disorders
such as herniated disks, and spinal stenosis. However, there
is no convincing evidence that spinal fusion works for most patients
with back pain from these conditions.
So Many Fusions, So Little Evidence
Why, despite little evidence to support it, do doctors consistently
recommend spinal fusion surgery to their patients? The answer
may lie in part with what some have called a “triumph of
technology over reason.” Because the technology of spinal
fusion has advanced enough that the surgery can be done relatively
safely, surgeons may be quicker to suggest fusion than they were
in the past, even if the patient is not an excellent candidate
for the procedure. The attitude may be that “it can’t
hurt to try.”
There is some evidence, however, that spinal fusion may help
a very select group of patients. According to a 2001 study published
in Spine of 294 patients with chronic low back pain, back pain
was reduced by 33% in patients randomized to receive spinal fusion
compared with 7% in those undergoing physical therapy. However,
to achieve success, the authors of this study point out that
patients must be carefully selected for surgery (see the section
below) and well informed about its potential outcomes.
Not For Everyone With Back Pain
If your doctor recommends spinal fusion for treatment of degenerative
changes, a herniated disk, or spinal stenosis, how do you know
if you’re actually a good candidate? First, you should
have severe disability from your back pain—for example,
being unable to perform activities of daily living (such as dressing
or bathing yourself) or to do your job. Second, you already should
have tried conservative care—such as self-treatment, pain
relievers, and exercise—at least for six months without
success. Third, the back problem should be localized, that is,
confined to a small area (one to two levels) of the spine, with
no associated deformity.
In addition, potential candidates for spinal fusion should have
no significant psychosocial problems. Research has consistently
shown that people with back pain who have problems such as depression,
large debts, an unhappy marriage, or jobs that involve repetitive
manual labor do not experience improvement in pain after a fusion.
Their pain tends to be magnified because of their psychological
issues, and fixing the physical problem has little benefit. These
patients should instead seek psychological counseling.
Patients who choose spinal fusion also should have realistic
goals regarding the outcomes of the procedure. They should anticipate
a hospital stay of two to six days and be prepared for a long
recovery time. Although some patients are able to return to work
in as little as six weeks, others may need as much as six months
to a year. The amount of time depends in part on the person’s
previous lifestyle and job. Someone with a desk job likely will
have a shorter recovery time than someone who engages in physically
demanding work. In addition, people who undergo spinal fusion
should not expect to fully recover their former physical abilities.
For example, a 50-year-old tennis player who has played only
doubles because of discomfort will likely not go back to playing
singles like he or she did at age 25.
Also, people with nerve problems, such as sciatica, associated
with the back pain (with the leg pain being greater than the
back pain) are not good candidates for spinal fusion; they do
best with decompression surgery (see page 33). However, if the
person has a long history of back pain or evidence of abnormal
motion on imaging studies, decompression might be combined with
The Bottom Line
Although studies have not clearly shown that spinal fusion is
effective for spinal degenerative changes, herniated disks, or
spinal stenosis, some people with these conditions report pain
relief from the procedure. Deciding who will benefit most from
the procedure requires a careful analysis of the patient’s
particular situation—both physical and psychological. To
reduce your odds of undergoing a surgical procedure that will
provide no benefit, get a second opinion before yielding to the
knife. Also, many doctors now increasingly consider disk replacement
as an alternative to spinal fusion.