What is lumbar fusion?

Lumbar fusion consists of fixing or immobilizing two or more vertebrae in order to permanently fuse the vertebrae together. This is done by inserting a stabilizing element and a graft of bone or artificial material, which will allow fusion to take place.

Spinal fusion surgery is a current technique, and a perfectly useful effective treatment for certain spinal pathologies. Innovations in technology in recent years have allowed the application of minimally invasive spine surgery, intraoperative navigation and robotics, improving the precision of the technique and reducing the margin of error.

 

What cases is it used for?

Lumbar fusion is used for cases of traumatic or spontaneous vertebral fractures (such as in patients with osteoporosis), severe instability of the spine (such as in spondylolisthesis or after oncological surgeries that have required resection of part of the spine), in severe degenerative pathology (severe facet osteoarthritis), in recurrences of lumbar hernias and in correction of failed lumbar spine surgery. 

What does the surgery involve?

Lumbar fusion can be performed using a variety of surgical techniques all involving the use of some immobilizing element (plates screws and rods): posterior lumbar interbody fusion using transpedicular screws and rods (TLIF); anterior fusion by abdominal approach (ALIF), lateral fusion (XLIF), or a combination of these (combined approach). Below, we explain each of the approaches:

  • Posterior approach fusion: through a small posterior incision or through a single central incision, pedicle screws are placed in the affected vertebrae, and an intervertebral cage with bone graft material is inserted.
  • Anterior approach fusion: with a small incision below the navel, the approach is made by displacing the peritoneal content until reaching the vertebrae, requiring manipulation of the nerve bundle to access the disc. The affected disc is completely removed, releasing the nerve roots, and a solid titanium prosthesis filled with bone graft and an intervertebral plate are inserted.
  • Lateral approach fusion: through a small incision in the lateral side of the abdomen, using a minimally invasive technique and neuromonitoring, we pass through the psoas muscle to approach the side of the vertebral disc. It is almost completely removed and the interbody cage with bone wax or other material is inserted. This is usually accompanied by a posterior approach to provide stabilization.

Recovery and rehabilitation after lumbar fusion

The hospital stay is usually between 2 to 5 days, depending on the procedure used, and the particulars of each patient. In all cases, we recommend that the patient begin walking in the first few hours after surgery. 

After leaving the hospital, the recovery continues at home. We recommend taking daily walks, and physical therapy treatment by specialized physiotherapists, in coordination with the medical team. Our Preparation, Empowerment, and Recovery (PER) program includes specific protocols to help our patient through recovery. 

Although completion of the healing process after fusion usually takes at least 6 months, all patients can return to their normal activity level within 8 to 12 weeks following surgery.

Risks of lumbar fusion

The immediate risks, or risks during surgery for each approach, are as follows:

Anterior approach

Vascular injury due to direct manipulation of the iliac arteries or veins, aorta or cava. In most cases, the defect can be corrected with suture during the surgery, but sometimes more specific treatment is required. For this reason, we always require a pre-surgical reserve of blood. Much less frequent is injury to the ureter, and in men, retrograde ejaculation.

Posterior approach

The placement of the screws, the interbody cage, or the neurological decompression maneuvers can incur manipulation of the spinal nerves and provoke temporary effects (very rarely permanent), as well as fistulas of cerebrospinal fluid. The latter must be corrected during the surgery..

Lateral approach

The main complications are neurological lesion of the nerve plexus running through the psoas muscle, as well as hematomas in the same area.

Other risks that may appear later on:

Mid-term

Infection of the surgical would or of the stabilizing material, lack of fusion at the operated level or affectations of the sagittal equilibrium (in profile) of the spine.

Long-term

Degeneration of the vertebrae adjacent to the fusion, due to excess mechanical stress, and progression of whatever prior degeneration pathology they may have had.

Who are the doctors who perform lumbar fusion at Instituto Clavel?

As these are fundamental techniques in surgery for spinal pathologies, all doctors of our team perform lumbar fusion by both anterior and posterior approach. Dr. Català and Dr. Caiazzo are well-known specifically for expertise in the lateral approach.

Sources

  • Neurosurgery. 2017 May 1;80(5):701-715. doi: 10.1093/neuros/nyw162. Lumbar Fusion for Degenerative Disease: A Systematic Review and Meta- Analysis. Yavin D1,2, Casha S1,3, Wiebe S2,3,4,5, Feasby TE2,3,4,5, Clark C2, Isaacs A1, Holroyd-Leduc J2,3,6, Hurlbert RJ7, Quan H2,5, Nataraj A8, Sutherland GR1,3, Jette N2,3,4,5. - Cochrane Database Syst Rev. 2016 Nov 1;11:CD012421. Surgical options for lumbar spinal stenosis. Machado GC1, Ferreira PH, Yoo RI, Harris IA, Pinheiro MB, Koes BW, van Tulder MW, Rzewuska M, Maher CG, Ferreira ML.
  • Orthopedics. 2018 Sep 1;41(5): e655-e662. doi: 10.3928/0147744720180711-06. Epub 2018 Jul 16. Stand-alone Anterior Lumbar Interbody, Transforaminal Lumbar Interbody, and Anterior/Posterior Fusion: Analysis of Fusion Outcomes and Costs. Bozzio AE, Johnson CR, Fattor JA, Kleck CJ, Patel VV, Burger EL, Noshchenko A, Cain CMJ.
  • Orthopade. 2019 Jan;48(1):50-58. doi: 10.1007/s00132-018-03670-w. Lumbar fusion-Indications and techniques. Schnake KJ1, Rappert D2, Storzer B3,4, Schreyer S2, Hilber F2, Mehren C3,4.

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