Lumbar arthrodesis, better known as lumbar or interbody fusion, is surgery in which two or more vertebral bodies (somas) are fused to keep them permanently together. The objective of this surgery is to reduce pain in this vertebral segment.
Lumbar fusion, or arthrodesis, is spine surgery to help relieve low back pain from axial loading, caused by advanced disc degeneration and the resulting instability and inflammation. Lumbar fusion surgery is often performed in combination with nerve decompression measures, which can help reduce numbness, tingling sensation, and weakness in the extremities as well, with gradual restoration of nerve function.
Thanks to advances in medical technology in recent years, it is now possible to incorporate minimally-invasive surgical techniques, and intraoperative navigation and neurophysiological monitoring in lumbar fusion surgery, improving precision and reducing the risks of the operation.
When is lumbar fusion surgery recommended?
Lumbar fusion is used for patients with certain conditions: advanced degenerative pathology, recurrent lumbar hernias, traumatic or spontaneous vertebral fractures (for example, osteoporosis), severe instability in the spine, and in patients with prior failed lumbar spine surgeries.
The symptoms that these conditions can cause include back pain, loss of sensation or a tingling sensation in the extremities, or loss of mobility, among others. All this can significantly affect the patient’s ability to carry out their normal daily life.
In most cases, lumbar fusion surgery is the alternative of last recourse after trying to improve the patient's condition with other conservative treatments, such as medication, physical therapy, or pain clinic treatments. If these treatments are not effective and symptoms worsen and/or, if the patient show signs of nerve damage, the doctor will consider surgery.
Lumbar spinal fusion surgery is considered as a last option for patients with problems such as:
- Discogenic pain due to degenerative disc disease.
- Advanced osteoarthritis of the facet joints.
- Re-operations with osteoarthritis and iatrogenic instability.
- Extension of previous fusion surgery.
- Moderate-severe lumbar spondylolisthesis.
- Lumbar spinal stenosis with instability (or in cases where aggressive decompressions are required and need for stabilization is anticipated).
- Tumors, fractures and/or infections in the lumbar vertebrae.
What is involved in lumbar fusion surgery
Lumbar fusion surgery can be performed using different surgical techniques. The goal is to achieve the fusion of two vertebral bodies by placing an interbody cage (usually titanium) between two vertebrae, after removing much or all of the disc. Screws and surgical rods are usually implanted to stabilize and immobilize this fusion, however, this is not always necessary, for example, in the case of arthrodesis performed by anterior approach.
Most of the acronyms used for the surgical approaches used in fusion surgery end in the letters "LIF", standing for "lumbar interbody fusion". The most common approaches to lumbar fusion are:
- Posterior approach fusion. An interbody cage with bone graft is placed between two vertebrae, through the foramen (TLIF, transforaminal lumbar interbody fusion) or through the posterior region of the vertebra (PLIF, posterior lumbar interbody fusion), after removing much of the disc, accessing from the side producing symptoms. This is complemented by the placement of screws and rods to stabilize the construction; these can be placed either by open surgery or by minimally-invasive techniques.
- Anterior approach fusion. Making an incision below the navel, the surgeon accesses the vertebrae through the abdomen and removes the entire diseased disc. This offers extensive exposure of the area where the fusion will be performed. The nerve roots are released in front, and a solid titanium cage filled with bone graft material is implanted. Except in cases of certain pathologies, like spinal deformity, this surgery does not require the placement of screws by posterior approach. The fusion ratios in this procedure are higher than those using the posterior or lateral pathway. The technique is known as ALIF (anterior lumbar interbody fusion).
- Lateral approach fusion. A small incision is made in the patient’s symptomatic side, and using minimally invasive techniques, special retractors, and neuromonitoring, the surgeon crosses the psoas muscle using either the extreme lateral approach (XLIF,) or by an oblique angle (OLIF, oblique lumbar interbody fusion), to access the lateral/oblique face of the vertebral disc. The entire disc is removed, and an interbody cage with bone graft is implanted. This surgery is usually complemented with a posterior approach stabilization surgery, and the placement of these screws is almost always percutaneous.
At Instituto Clavel, we always opt for the least invasive surgical method appropriate for the patient’s case, and the surgery is designed precisely for the affected level of the spine. The Director of Instituto Clavel, neurosurgeon Dr. Pablo Clavel, was a pioneer in Spain in introducing the anterior approach technique.
In this article in El Confidencial, Dr. Clavel explains the anterior approach as "It consists of accessing the spine through the abdomen, that is, it is a different way to get to the same place. It has several advantages over the classic posterior approach, because means that it is not necessary to open the muscles of the back or manipulate the spinal nerves. Recovery is much faster and the success rate is 95%." You can read the article here:
Minimally-invasive surgical techniques
Recovery after lumbar fusion surgery
After lumbar fusion surgery, the patient usually stays in the hospital from 2 to 5 days, depending on the type of surgery that was performed and how the individual patient is recovering. In all cases, the patient will be able to walk within a few hours after the operation.
The time needed for the vertebrae to achieve a definitive fusion is at least half a year, but patients can expect to return to work and their normal daily activity between 8 and 12 weeks after surgery, depending on the type of activity and work they do.
For a full recovery after lumbar fusion surgery, a physical rehabilitation program is essential. The patient should begin by taking daily walks after leaving the hospital, and the specialized physical therapy team of IC Rehabilitation will provide a personalized rehabilitation plan with specific guidelines.
Iria Rabell, one of our physical therapists who specializes in advanced manual therapy, explains that it is important to consider the specifics of each patient. The rehabilitation plan is always completely adapted to the patient’s needs, and may vary depending on their physical condition before and after lumbar fusion.
In the following article, our physical therapist offers guidance on exercises for the lower back that can help you relieve pain and gain mobility in the spine.
Lumbar fusion rehabilitation exercise
If you have any questions about lumbar fusion or want to make an appointment to have your case evaluated, please don’t hesitate to contact us! We will be happy to help you.
Categories: Spine treatments, Surgery, Lumbar pain