Pain After Back Fusion: Adjacent Segment Disease

By Chris Centeno, MD /

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Your spine is built for movement, but it also has to be stable. In essence, it’s this duality that confuses many physicians and patients and often leads to a back fusion, which stops movement in patients with degenerative or painful back issues, such as degenerative disc disease, and spinal stenosis (arthritis that’s putting pressure on nerves). But fusing any level of your spine with hardware can overload other areas of the spine, weakening and damaging those areas as well and causing pain after back fusion. This is called adjacent segment disease (ASD).

The Basic Anatomy of the Back

To understand ASD, you first need to understand the basic anatomy of the back (watch my brief video above for illustrations of the spinal structures). The back is made up of 24 movable vertebrae, or back bones, that stack one of top of the other, stretching from the neck to the lower back. A disc sits between each vertebra, and the vertebrae come together in the back at the facet joint. Protected between the vertebrae and the facet joints, there is a canal that houses the spinal cord, a big bundle of nerves that transmits feeling and tells our muscles what to do.

This is all held together by ligaments and kept stable by a series of muscles called multifidus, and the spinal column has natural opposing curves to distribute our weight and provide stability.

Back Fusion Permanently “Locks” the Vertebrae, Leading to ASD

Fusion surgery is done when vertebrae become so unstable that movement affects the nerves or causes pain. A back fusion is a surgery that uses hardware and screws to permanently “lock” together two or more vertebrae, and the purpose is to indeed make the damaged section of spine immovable. Fusion surgeries are lengthy, risky, and painful.

The fact that a fusion takes a structure in our body that gives us flexibility in movement and makes a portion of it immovable is a big enough problem, but it gets worse. This forced lack of movement puts more stress on and overloads the vertebrae above and below the fused levels. This can cause significant pain after back fusion as bone spurs at those levels and degenerative arthritis in the facet joints can press on the nerves and lead to adjacent segment disease (ASD), that predictable breakdown in the neighboring unfused levels.

So I Have Pain After Back Fusion Due to ASD, Should I Get Another Fusion?

NO! The solution is certainly NOT to get another fusion. More fusions will simply create more problems and more ASD and more fusions—a never-ending cycle. Spinal fusion is not worth it.

In a New England Journal of Medicine study on back and neck fusion that I shared on the blog a couple of weeks ago, researchers concluded that fusion surgeries didn’t improve outcomes at two or five years after surgery! 

So fusion patients are being exposed to higher surgical risks and are developing ASD (commonly enough that the condition was given a name—adjacent segment disease), and yet this high-level study supports the lack of any clinical value in the fusion surgery. I’ve personally seen more patients harmed than helped over the last two decades by back fusion surgery. So the fact that surgeons continue to do them is perplexing.

Even more concerning than the studies we do have is the studies we don’t have: we don’t have any high-level evidence that spinal fusions are effective to treat pain. There are low-level studies published by spine surgeons and fusion-device manufacturers that seem to show that fusion works. However, this doesn’t fit with the clinical experience of anyone who sees so many patients struggling with significant pain after back fusion. And it certainly doesn’t mesh with high-level studies such as the one in my article above.

ASD Isn’t the Only Problem Post-Fusion Patients Experience

While I have seen a few patients who have a severe instability that can only benefit from a fusion, it’s rare. More often than not, post-fusion patients require revision surgeries; need ongoing narcotics following surgery; experience complications due to their surgery, such as irrevocable damage to the multifidus muscle; and spend a lot of money on a serious surgery providing very little to no long-term returns. With results this poor and so much research showing reasons not to, why would you want to treat your ASD with another fusion?

In addition, in spinal stenosis, for example, spinal fusions are far more dangerous due to their complication rates than the decompression surgery they’ve gradually added to over the last 10–20 years.

ASD Can Be Treated Without Fusion Surgery

Unfortunately, we can’t reverse the original fusion, but in my experience, the resulting ASD can be treated with advanced Interventional Orthopedics. This involves precise placement of your body’s own stem cells and platelets to help the ligaments, muscles, joints, and nerves above and below the back fusion.

The upshot? Your spine is made for movement, and when part of it is forced into immobility, adjacent parts of your spine will compensate and try to keep you moving. Unfortunately, this stresses and overloads those vertebrae and can cause pain after back fusion and lead to adjacent segment disease. Once you’ve developed ASD, opt out of additional fusion surgery, and consider stem cells and/or platelet injections to treat your ASD.

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16 thoughts on “Pain After Back Fusion: Adjacent Segment Disease

  1. ROBERT SASSO

    Can you send me some info one the success of gene therapy for a hip that has cartilage
    loss

    1. Regenexx Team Post author

      Robert,
      We don’t do Gene therapy. However if you mean Hip Stem Cell Therapy, you will find the information you’re looking for here: http://www.regenexx.com/the-regenexx-procedures/hip-surgery/

  2. Bonnie Granahan

    I have a Question regarding Lumbar Spinal Stenosis. My MRI Diagnosis sounds like this:
    L3-4 Degenerative Disc Disease and Facet Osteoarthritis resulting in bilateral foraminal narrowing and severe spinal stenosis.
    I have been offered Laminectomy /Fusion Spinal Surgery with NO Promise of Pain Relief.
    Would Stems Cell/Platelet Injection be able to Help Better my Condition?

    1. Regenexx Team Post author

      Bonnie,
      While you would need to go through a Candidacy evaluation, the general answer for situations like yours is, YES! This will explain our approach, and also contains a Candidate form: http://www.regenexx.com/the-regenexx-procedures/back-surgery-alternative/

  3. Roy Stevens

    I have Spondylolisthesis at the L5-S1. I am considering surgery. Can your treatment help someone like me?

    1. Regenexx Team Post author

      Roy,
      Spondylolisthesis is something we treat regularly. Please see: https://regenexx.com/blog/back-pain-in-a-competitive-figure-skater-and-platelet-rich-plasma/ and https://regenexx.com/blog/a-hip-stem-cell-treatment-in-an-akido-master/ and https://regenexx.com/the-regenexx-procedures/back-surgery-alternative/ To see if your particlar situation would be a good candidate, please submit the Candidate form.

  4. Daniel Anderson

    So I’m confused, I had a L4, L5, L5, S1 fusion November 2015 and then had the hardware removed December 2016 to try and reduce the ongoing pain I’m having. This is a workers compensation case and I just had a PCE or FCE a few days ago. I asked the physical therapist who did the evaluation what about the discs above the levels fused and with lifting 50 pounds frequently (Which he said I could do frequently) . Anyway he said there is no such thing as Adjacent Segment Disease, I’m confused who is right and who is wrong? And he also said back surgery is something that should never ever ever be done, so again I’m more confused. But more interested in the ASD debate here.

    Thank you.

    1. Regenexx Team Post author

      Daniel,
      Given the body of research, and seeing and treating ASD in patients regularly, it is a very real and damaging complication of fusion. It was the reason disc replacements were created – unfortunately they didn’t solve the issue. Please see: https://regenexx.com/blog/disc-replacement-side-effects/ and https://regenexx.com/blog/yet-another-rason-low-back-fusion-mostly-dumb-idea/ and https://regenexx.com/blog/should-i-get-a-back-fusion/

  5. Laurie

    My husband had SI Joint fusion on his right side about a year and a half ago. He has been in constant pain ever since. He has had MRI’s and X-rays within the first year and no one seemed to find anything wrong. He just recently went to a chiropractor who took another set of x-rays and it appears that his L5 area is bending like a question mark and highly inflamed. Could this be the result of the fusion pulling his trunk (sacrum) to the right? I see that you would not recommend another fusion on the other side (which we do not want at all) but what could possibly be our other options?
    Thank you, feeling hopeless.

    1. Chris Centeno Post author

      Yes, an SI joint fusion would be expected to cause overload of the L5-S1 level. The best that can be done is to work on ligament tightening injections at L5-S1 to withstand the extra forces.

  6. Maureen

    I had fusion surgery in late January 2018. I felt great after the surgery & my pain was gone. In early July 2018, I thought I had messed up my implant. Another CT & MRI followed. The PA put adjacent segment disease on the MRI sheet. I also have 2 bulging disks. The doctor is planning an injection for pain & said I didn’t have anything to be concerned about. I am.

    1. Regenexx Team Post author

      Maureen,
      Fusion is irreversible and you’re right to be concerned as ASD gets worse over time. Thankfully, we treat ASD and bulging discs regularly. Please see: https://regenexx.com/the-regenexx-procedures/back-surgery-alternative/ and https://regenexx.com/blog/neck-epidural-failed/ and https://regenexx.com/blog/should-you-get-your-disc-injected-with-stem-cells/

  7. Alison Hughes

    My son, at 19 had 2 section fusion (already had one section that had fused itself) and a cage fitted. 2 years later he is in worse pain. Diagnosed with degenerative disc disease and osteosteoarthritis. Is there anything can be done to help?

    1. Regenexx Team Post author

      Alison,
      Adjacent Segment Disease, as it explains in the Blog is a very common issue post fusion. There likely is, but we’d need more information through the Candidacy process. At what level is the fusion?

  8. Amelia

    Hi
    I am 49 yrs active female , work as a gyneacologist and need to do long surgery at work
    Most of the days …. I am average weight BMI 26
    I had L4-5 fusion ( minimal access surgery ) with cage and bone graft in 2015 after sever “ degenerative “ changes where the disc completely gone into pieces …. I was doing very well apart from some odd pains and stiffness which I manage with NSAID till few months ago when I started going to HIITS gym classes and start feeling sever low back pain , SPECT scan done and showed that L3-4 intervertebral disc is degenerative and the above completely disappeared with the two vertebrae crushing on top of each other , I have sever back pain , stiffness , difficult to sit or stand still for more than 5 minutes and difficult to sleep more than 1 hr . Walking is the only thing relief the pain a little …
    the surgeon suggested another fusion which I am concerned about now reading your article …. he suggested cortisone injection but might not work !!
    Do you think that stem cell injection can work in my case giving the severity of disc damage ??

    1. Regenexx Team

      Hi Amelia,
      Fusion leads to more Fusion if you don’t treat the resulting ASD. We’d need more information through a Candidacy review to see if we can help. Please submit the Candidate form here: centenoschultz.com

Chris Centeno, MD

Regenexx Founder

Chris Centeno, MD is a specialist in regenerative medicine and the new field of Interventional Orthopedics. Centeno pioneered orthopedic stem cell procedures in 2005 and is responsible for a large amount of the published research on stem cell use for orthopedic applications.
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