Should I get a back fusion? is a question I hear from patients hundreds of times a year. For most patients, it’s just a bad idea that they will end up regretting. But unlike a “perm”, this one is a permanent choice that can never be undone.
Why is back fusion such a bad idea? Fusing any level of the spine with hardware will overload adjacent segments, leading to a condition called adjacent segment disease (ASD). I’ve discussed many issues with back fusions over the years, and research continues to show poor or ineffective outcomes, and today I’m going to provide you with a compilation of this material that supports my answer to the title question—my short answer for 95% of the patients I see who are offered fusions is a resounding no!
A good place to start is with the structure of the spine. Be sure to watch my short video above for illustrations.
The Structure and Function of the Spine
The spinal column is made up of vertebrae that stack on top of discs that stack on top of vertebrae. At the point where each vertebra meets at the next vertebra is the facet joint. Your spinal cord (the delicate cable of nerves that along with the brain makes up our central nervous system) is protected inside this strong column. Everything is held together by ligaments and kept stable by a series of back muscles called multifidus. Additionally, the spinal column has natural opposing curves to distribute our weight and provide stability.
Your spine is built to move, and the structure of the spine allows for this movement. I tell my patients that of all the back surgery options out there, fusion is the “dog with the biggest fleas,” and it’s because of that needed motion that fusion is such a problem. A fusion disrupts not only movement but also the stability and general functionality of the spine and leads to more problems.
Back Fusion and Adjacent Segment Disease (ASD)
A back fusion surgery “locks” together two or more vertebrae using hardware and screws. Back fusion surgery is commonly done when a patient has some type of degenerative disc disease, spinal stenosis (arthritis that’s putting pressure on the nerves), or other spinal injuries that cause pain or spinal instability. Fusions are lengthy and risky, and outcomes aren’t good as they put stress and pressure on adjacent levels, leading to more pain and degeneration!
ASD occurs when levels above or below a back fusion are overloaded and experience extra motion, resulting in arthritis (all due to the fusion). Symptoms would be pain above and/or below the fusion, and I see many, many back fusion patients with new problems. In ASD bone spurs can eventually press on nerves because of the arthritis caused by the fusion. So many patients end up right back where they began, needing another surgery.
A Back Fusion Is Probably Not Your Last Resort
Back fusions were initially designed to help stabilize catastrophic instability (where movement would cause the vertebrae to shift enough to injure the spinal cord or nerves). Somewhere along the way, we began performing this drastic surgery on patients who just had pain. The number of back fusions this past decade has skyrocketed, while the low-back surgery success rate has plummeted. This is less likely due to medical necessity (does the patient really need it) and more likely due to the high rates of insurance reimbursement for back fusions. And despite the fact that no high-level studies have shown fusion to be an effective solution for degenerative disc disease and back pain, and have in fact shown the opposite, surgeons are still doing them.
Reasons Back Fusions Are a Bad Idea
There are different types of back fusions. For example, one of the more common types is called a 360 degree fusion, which fuses together the vertebrae from both the front and back sides of the spinal column. I recently highlighted a study showing this 360 degree spinal fusion is definitely not worth it. In the study, patients experienced serious issues with progressive worsening following 360 degree fusions. The number of patients who underwent revision surgeries because of ASD increased significantly as time went on with 24 out of 73 undergoing revision by year post-op year 15.
More often than not, post-fusion patients require revision surgeries; need ongoing narcotics; 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, are you still asking yourself, Should I get a back fusion?
Also with laminectomy surgery, where an open decompression is performed for something like spinal stenosis, you should skip the back fusion because it adds too many complications. In the last 10–20 years, surgeons began performing back fusions with these laminectomies to try and make sure the operated area doesn’t move too much. The fusion increases postoperative complications. Research (see link above) has shown that a laminectomy surgery is 60–90% safer when it is not accompanied by a back fusion. In addition, adding the fusion is no better than avoiding the surgery based on one high level study.
So, Should I Get A Back Fusion?
The upshot? Remember my short answer to the question Should I get a back fusion? was no, and my long list of back fusion posts I’ve written over the years will provide you with additional material and studies that support this short answer. I have seen a few patients with severe instability or other issues that actually needed a fusion, but as a general rule, these patients are rare. In my 20-plus years of experience in treating patients who been told they need a fusion, most can be treated with the precise placement of the body’s own stem cells and platelets in the surrounding ligaments, muscles, joints, and nerves.