Who really needs a spinal fusion? 7 questions with neurosurgeon W. Lee Warren, Jr., M.D.
By Kristy Bleizeffer Apr 18, 2016
Back pain is one of the leading causes of missed work and one of the top reasons people visit their doctors.
But surgery should almost never be the first option, says W. Lee Warren, Jr., M.D., a neurosurgeon at Advantage Orthopedics and Neurosurgery. If your surgeon recommends a spinal fusion to treat low back pain, you should slow down and get a second opinion. Here, Dr. Warren answers seven questions about spinal fusion surgery.
1. What is a spinal fusion, and what conditions does it treat?
Spinal fusion is a type of operation in which a surgeon implants some type of bone graft and hardware into the bones of your spine, with the goal of having two or more vertebrae grow together, or ‘fuse’ into a solid unit.
People often think that the surgery is actually the fusion, but actually the surgical procedure is designed to create an environment in which the bones have a chance to fuse. The hardware or instrumentation we place into the spine creates stability and eliminates excess motion, which gives you strength and safety while we are waiting on the fusion to occur biologically.
Biological fusion takes 12 months or more, so the hardware is important to allow you to return to your normal activities earlier and have less pain and limitations than you would if we only used bone graft. Thirty years ago, a lumbar fusion required you to be in bed in a body cast for months after surgery. But with modern spinal hardware and less invasive techniques, our patients can be up and walking on the same day as their surgery in most cases.
If the fusion fails, your hardware will eventually fail too, and this can lead to more surgery. Having a good result from fusion surgery requires several things to go well: the technical aspects of the procedure (which depends on the quality of the surgeon), the quality of your bone (whether you have osteopenia or osteoporosis), and your overall health (smoking, diabetes, advanced age and obesity all make it much harder to fuse).
Spinal fusion can be used to treat a variety of conditions including traumatic spinal fractures, instability of the spine (such as spondylolisthesis), recurrent disk herniations, scoliosis, tumors, severe infections, or degenerative disk disease and chronic neck or back pain.
2. Who is a good candidate for the surgery?
That’s a hard question, because the answer depends so much on why your doctor thinks you need surgery. I can tell you that almost no one needs a thoracic fusion, unless they have a fracture or tumor, or unless prior surgery has left them unstable. If you’re being told you need to be fused above L1, get a second opinion or ask your surgeon very specific questions as to why they are recommending it.
There is no doubt that spinal fusion is one of the most over-prescribed operations in the history of mankind. If you have never had back surgery before, and if your primary symptoms involve leg pain when you walk, spinal fusion is very rarely necessary as a first operation. One of the biggest causes of “failed back surgery syndrome” is that the operation was the wrong one, did too much damage, or created problems somewhere else in the spine or pelvis that create new pain later. This commonly leads to the surgeon telling you, “Well, now we need to fuse the next level.” Or, once you’re fused everywhere the surgeon can possibly fuse you, they might suggest another type of surgery, like SI joint fusion (which is almost never really necessary) or a spinal cord stimulator (which are only about 50 percent effective for 50 percent of people).
However, when used for the right reasons, done by the right surgeon in the right way, in the least invasive way, and when applied to the fewest number of vertebrae possible to solve the problem at hand, spinal fusion surgery can prevent paralysis, restore function and posture, and significantly reduce pain.
You need to ask a lot of questions, do a lot of research, and learn as much as you can before you have a spinal fusion operation. It’s critical that the first operation be right, if you really want to feel better.
3. Are there other non-surgical treatments available for people suffering back pain?
Of course, and except in rare circumstances they should all be tried before surgery is offered to a patient. If your back’s been hurting for less than three months, if you’re not having any weakness or trouble controlling your bladder or bowel, for example, it is statistically true that over 75 percent of low back and leg pain, as well as neck and arm pain, will get better on its own or with rest, anti-inflammatory medications and simple treatments like ice, heat or short-term use of pain medications.
If the pain is significant and longer lasting, we can use other treatments like physical therapy or chiropractic care, as long as we have made sure there are no dangerous conditions or worrisome exam findings. Some insurance companies are insisting that we use therapy before they will approve an MRI now days, but your doctor needs to make sure that this is safe. And when the pain is more severe, we can offer interventional treatments like epidural steroid injections, facet blocks, rhizotomies and other procedures that are not surgeries but can be highly successful.
4. What considerations do people need to make when deciding whether a spinal fusion is right for them?
My number one recommendation for people is this: if you’ve only had pain for a little while, don’t rush into surgery. If you’re 60 and you’ve been fine your whole life until you lifted something heavy last week, and now a surgeon is saying you need surgery, slow down a little. Ask more questions, explore your options. Surgery is rarely the first or only option for pain.
In my practice, there are only a few patients I’ll offer surgery the day I meet them: people whose scans show something that’s going to kill or paralyze them without surgery, people who have had everything else done that could possibly help them before we met, people whose problems have zero chance of improvement without surgery (like severe cervical stenosis, infections, etc.), or people who have had prior surgery and there’s something wrong that cannot possibly get better without surgery.
You should never rush into surgery for pain. Take the time to make sure you’ve done everything else you can do first. And then, if you really need it, make sure you’re comfortable with your surgeon and your hospital.
5. Can the surgery be done with minimally invasive techniques?
In many cases, yes. Spinal surgery has come a long way, especially in the past five years. My mother had a microdiskectomy in 1985, and the procedure kept her in the hospital for a week and at home on bed rest for six weeks! Now my patients usually go home the day after surgery and are back to work in a few weeks.
Now we can perform multi-level fusions and complex spinal surgeries through very small incisions, with hardly any blood loss, and often we do not need braces or long periods of inactivity after surgery.
It is important, though, to understand that the term “minimally invasive” has become a marketing tool in a lot of places. It’s not as much about the size of the incision as it is about the quality of the work. You hear a lot about “laser” surgery, for example. All modern operating rooms are equipped with lasers, and in neurosurgery we use them for certain tumors, removing scar tissue and a few other indications. But you can’t put in a screw with a laser, you can’t remove a bone spur with a laser, and you can’t fix spinal stenosis with a laser.
The truth is, most recently trained surgeons, and those of us who are committed to keeping ahead of the curve on technology, are well versed in all aspects of modern, minimally invasive spinal surgery. However, what you need is for your surgeon to offer you the most appropriate and effective procedure for your specific problem, if surgery is necessary at all. A minimally invasive operation that you didn’t need, or one that wasn’t done well, won’t magically cure your pain.
6. What are the benefits of spinal fusion for appropriate candidates?
Decreased pain, increased mobility, prevention of neurologic symptoms like weakness or numbness, and preservation or restoration of spinal alignment, balance and posture. Our goal is to get you back to your life, your family, your work, and to do so in the least invasive and most effective way possible. Modern spinal fusion surgery, when done in the right way at the right time for the right reason and in the right patient, can truly offer patients a new lease on life.
7. What questions should patients ask when considering spinal fusion, and when should they seek a second opinion?
Don’t assume your doctor knows everything. Ask questions. Ask around.
Specifically, I offer every patient I see a chance to get a second opinion, and will even help them find a doctor to give them one. Why? Because I want them to be comfortable and confident in the plan I’ve proposed and in me as their surgeon. If they’re not comfortable, I want them to go somewhere else.
If you’re thinking of having back surgery – any surgery really – here are a few questions you should ask your doctor:
- How often do you do this operation, and how many have you done?
- What is your complication rate? Not what it says online for the average complication rate, but what is YOUR complication rate for this operation?
- Who actually does my surgery? Do you do it all yourself, or do you have someone else do it while you’re in another operating room doing something else?
- Who puts in my screws? You or your assistant?
- What are my other options?
- What happens if I wait a while to have this done?
- Should I get a second opinion?
If your surgeon seems offended by you asking questions, you need to find another doctor. All competent, confident surgeons should be happy to have you seek another opinion. If they tell you there’s no time, that it’s an emergency, or that you’ll likely be paralyzed or die if you don’t have surgery immediately, be aware that this is rarely true.
As I said before, there are some true emergencies that need to be operated RIGHT NOW. Those are rare, often involve trauma or cancer, and you generally will have some kind of neurologic problem you’re well aware of (like incontinence or serious weakness) that will intellectually make sense to you when the surgeon explains what’s happening and why it can’t wait to be repaired.
But if your problem is pain, especially chronic pain, be wary of a surgeon you meet today and who wants to operate tomorrow.
Dr. Warren is a board-certified neurosurgeon and a retired major of the U.S. Air Force. After serving the country for 14 years, including a deployment as a combat surgeon in Iraq, he retired as chairman of neurosurgery at Wilford Hall Medical Center in San Antonio. He is founder of the Air Force’s Comprehensive Epilepsy Management Center and the Center for Minimally Invasive Neurosurgery. He also served as Director of Cerebrovascular, Skull Base, and Neurotrauma Surgery. In his spare time, he writes and podcasts about the influence of neuroscience on mental wellness and personal development at his website www.wleewarrenmd.com.