In 2015, nearly 200,000 lumbar fusion surgeries were performed in the U.S.1 But while the number of surgeries continues to increase, that doesn’t necessarily mean all patients are benefitting from them. In fact, the number of reoperations seems to be rising in proportion to the greater number of surgeries—an indicator that spinal fusion is not as successful as some would like to think.
Does reoperation automatically mean that a fusion has failed? “Failure” could mean different things to different people, depending on the circumstances involved. In this article we’ll examine the multiple meanings of a “failed spinal fusion,” and your options for moving forward if it happens to you.
What is a failed spinal fusion?
When people talk about a failed spinal fusion, they usually mean one of two things:
- After removal of the joint, solid fusion of the vertebrae was never achieved. This “nonunion” is referred to as pseudoarthrosis, a complication of surgery that often indicates failure.
- Someone has undergone more than one fusion and, even though the bones have solidly fused, they continue to experience significant pain. For many surgeons, this type of spinal fusion failure is also characterized as “failed back surgery syndrome.” (Patients might consider failed back surgery syndrome to be the result of numerous ineffective surgical procedures—fusion among them.)
Now, let’s look at each of these in more detail.
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Pseudoarthrosis is the leading cause of failed spinal fusions.2 In general, this failure of the vertebrae to meld into one solid piece of bone is usually caused by one of the following:
- An infection in the bone that prevents healing from taking place. The risk is low, but if infection does happen, it’s highly likely that normal healing will not be possible.
- Some fixation devices are less effective at promoting fusion than others. However, this complication is happening less frequently as spinal hardware devices become more and more rigid.
- Displacement through activity. If a patient doesn’t appropriately moderate his or her activities post-surgery the hardware may loosen, causing the bones to move around.
- Patient factors play a role with regard to pseudoarthrosis. Smoking, in particular, inhibits healing and increases the risk of a spinal fusion failure.3 Most surgeons require patients to quit smoking before surgery to minimize this risk.
Otherwise healthy, non-smoking patients should fuse more than 90% of the time for a single-level fusion; however, keep in mind that fusing multiple levels at once decreases that percentage.
Patients often ask, “How do I know if my spinal fusion has failed?” In the case of pseudoarthrosis, it’s likely you’ll feel better in the first few weeks after surgery, but over time the motion in that area will cause pain (similar to a broken bone that never heals). An x-ray or CT scan can determine if your fusion is healing properly. And it’s important to note that not all patients experiencing pseudoarthrosis have pain. In these cases, partial healing—producing some bone and fibrous tissue—may be enough to keep the area stable.
Multiple Ineffective Fusions
Another common definition of a failed spinal fusion is continuously experiencing a significant amount of back and leg pain despite multiple fusions.
The failure of fusion to address pain over the long term is evidenced by both the high rate of reoperation, and a growing body of research indicating fusion patients’ continued opioid dependency after surgery.
- Numerous studies have shown that lumbar fusion patients have a high likelihood of reoperation.5, 6 Why? Because problems naturally occur as a result of losing a joint in your spine. Even the removal of a single joint changes the environment of that level, transferring the stress caused by your daily movements to the levels above and below the fused location. The additional burden on those adjacent levels causes them to degenerate more rapidly and become painful in the years following the fusion, increasing the chances you’ll need future surgery to address the pain. (This condition is referred to as adjacent segment degeneration.) As a result, many patients end up having multiple surgeries, exacerbating poor posture, pain, and muscle fatigue.
- While you’d expect that fusion surgery would eliminate your pain—and your need for painkillers—studies have shown that’s not usually the case. For many patients, the use of opioids after fusion surgery (beyond the normal recovery period) is due at least in part to the failure of fusion to relieve pain. One study showed that fewer than one in 10 people taking long-term opioids for back pain before surgery discontinued their medication after lumbar spinal fusion—and some patients who weren’t taking the drugs prior to surgery began doing so after.7 While some long-term usage can certainly be attributed to drug addiction, this trend is also occurring in part due to a continuous cycle of unrelieved pain. (Note, too, that some researchers have found that chronic opioid users also have a higher risk of complications after fusion surgery, making reoperation more likely.)
Failed Spinal Fusion: Your Options For Treatment
If you’re not experiencing pain as a result of pseudoarthrosis, one option is to not do anything. The condition only needs to be corrected if it isn’t providing the stability your spine needs to function normally.
If you do have pain, you will need to re-stabilized the segment with additional instrumentation. In most cases this will require a new fusion, but some patients can be converted to a motion procedure. Surgeons might also opt to use a bone morphogenetic protein (BMP) the second time around. BMP is a protein that encourages bone growth. (It produces chemicals the body produces already but in a higher concentration.) BMP is often not used in the first instance of a spinal fusion because most people heal without it. It can be beneficial, but it also has some potential downsides in that it can produce swelling and/or create bone where it’s not wanted.4
For Multiple Ineffective Fusions:
If you’ve already had multiple fusions and continue to experience back and leg pain, there’s little you can do to reverse the effects of the surgeries that have already been done on your spine. However, you can try to break the cycle by looking into alternatives to another spinal fusion.
Some patients are benefitting from a BalancedBack Total Joint Replacement instead of fusion.
Maintaining mobility in your spine is key to spine health. And while fusion removes a joint and limits mobility—causing more pain—BalancedBack replaces the function of the affected joint, allowing you to keep moving naturally. The new, productive joint allows the levels above and below it to function naturally, reducing the need for future revision surgery.
Plus, BalancedBack allows surgeons to address a wide range of problems that cause back and leg pain, including pinched nerves, spinal stenosis, arthritis in the facet joints, and sagittal imbalance. That means you’re able to solve the root cause of the problem and gain protection against adjacent segment degeneration at the same time.
Even if you’ve had one or more fusions already, BalancedBack may still be an appropriate solution for your condition. So whether you’re considering your first, second, or even third fusion, we encourage you to continue researching your options. Get in touch with us for more information, or schedule a free clinical call to find out if BalancedBack might be a good choice for you.
1Martin, B. I., Mirza, S. K., Spina, N., Spiker, W. R., Lawrence, B., & Brodke, D. S. (2019). Trends in lumbar fusion procedure rates and associated hospital costs for degenerative spinal diseases in the United States, 2004 to 2015. Spine, 44(5), 369-376.
2Steinmann, J. C., & Herkowitz, H. N. (1992). Pseudarthrosis of the spine. Clinical orthopaedics and related research, (284), 80-90.
3Berman, D., Oren, J. H., Bendo, J., & Spivak, J. (2017). The Effect of Smoking on Spinal Fusion. International journal of spine surgery, 11, 29. doi:10.14444/4029
4 James, A. W., LaChaud, G., Shen, J., Asatrian, G., Nguyen, V., Zhang, X., … Soo, C. (2016). A Review of the Clinical Side Effects of Bone Morphogenetic Protein-2. Tissue engineering. Part B, Reviews, 22(4), 284–297. doi:10.1089/ten.TEB.2015.0357
5Martin, B. I., Mirza, S. K., Comstock, B. A., Gray, D. T., Kreuter, W., & Deyo, R. A. (2007). Reoperation rates following lumbar spine surgery and the influence of spinal fusion procedures. Spine, 32(3), 382-387.
6Maruenda, J. I., Barrios, C., Garibo, F., & Maruenda, B. (2016). Adjacent segment degeneration and revision surgery after circumferential lumbar fusion: outcomes throughout 15 years of follow-up. European Spine Journal, 25(5), 1550-1557.
7Deyo, R. A., Hallvik, S. E., Hildebran, C., Marino, M., OʼKane, N., Carson, J., ... & Wakeland, W. (2018). Use of prescription opioids before and after an operation for chronic pain (lumbar fusion surgery). Pain, 159(6), 1147-1154.