For some patients, a multilevel fusion—the fusing of more than one spinal disc level—is not an option but a necessity. If you’re suffering from scoliosis, for example, or a major fracture or tumor that requires the permanent removal of multiple spinal joints, a multilevel fusion might be your only option. But multilevel fusion is a complex surgery that should be undertaken only when there’s a good reason. Add to that the generally poor outcomes of even single-level fusions1 and it’s no wonder fewer multilevel fusions are being done today than in years past.

So what is the multilevel spinal fusion success rate, and what factors do surgeons weigh before they decide to do a multilevel fusion? In this article, we take a look at what plays into their decision—and, ultimately, yours.

The Multilevel Fusion Decision

As a surgeon, I see plenty of patients who are experiencing back pain associated with degenerative changes; my goal is always to minimize their pain as best I can.

Many have spondylolisthesis with stenosis, usually at L4/L5 or L5/S1, with signs that an adjacent level may also be degenerative. (L4 and L5 are the lowest vertebrae in the lumbar spine, close to the pelvis; they bear the most weight of our body’s movements and are therefore most susceptible to degradation.) The issue then becomes this: If we fuse L4/L5, for example, and there’s only one level between that and the pelvis, L5/S1 will encounter a great deal of increased mechanical stress as a result of the missing L4/L5 joint and will almost certainly degenerate. (This condition is called adjacent segment degeneration.) Therefore, location sometimes plays a role in the decision of whether or not to perform a multilevel fusion.

If you’re looking for an alternative to fusion, you could be a candidate for an alternative new procedure—find out more here.

The number of levels to be fused is also a consideration. The more levels fused, the more it will affect your motion and posture.

Your spine naturally curves in an “S” shape, from the cervical spine (the neck) to the thoracic spine (the base of the neck to the abdomen) to the lumbar spine (the lower back). Lordosis refers to the curves at the top and bottom; the middle curvature is called kyphosis. These curves, together with the spine’s intricate arrangement of bones and discs, all work together efficiently to handle activities of daily living, and help you to maintain balance and posture in all positions, both sitting, standing, or even slumped sitting.

You can imagine, then, how removing one or more of those joints through fusion would impact your posture and your ability to move fluidly from one position to another. And the more levels that are fused, the faster the levels adjacent to the fusion will degenerate as they strain harder to compensate for the lost motion of the fused levels.

It can be a difficult decision to determine exactly how many levels to fuse. If a single degenerated segment is isolated and the other levels are normal, the decision about what to fuse is clear. But if there are multiple degenerated levels, and the adjacent levels are mildly to moderately degenerated, it’s probable they’ll break down relatively quickly, which could lead to more pain shortly after surgery. Some people may also have a genetic predisposition for disc degeneration making adjacent levels more apt to break down, complicating things further.2

What is the multilevel spinal fusion success rate?

While we don’t have clear data on multilevel fusion and success rates, several studies paint a mixed picture:

  • Multilevel fusion has a high risk of major complications, with reoperation rates of up to 40%.3
  • Patients undergoing multilevel (three or more) lumbar fusion procedures demonstrate increased hospitalizations4, costs, complications, and mortality rates.
  • The risk of pseudarthrosis (the vertebrae failing to fuse together) significantly increases for multilevel fusions spanning three or more spinal levels.5

To increase the chances of success, most surgeons will require patients to stop smoking (smoking increases the likelihood of pseudarthrosis6) and stop taking opiods (which have been linked to poor surgical outcomes).7

A Potential Alternative To Multilevel Fusion: Total Joint Replacement

The BalancedBack Total Joint Replacement is an innovative new procedure that preserves the mobility of the spine, which makes it very different from fusion.

Rather than removing a joint like in a fusion, the BalancedBack implant replaces the function of both the damaged disc and the facet joints, re-establishing stability. BalancedBack patients adjust their posture naturally to stand, sit, or even slouch comfortably, without stressing the adjacent segments.

For patients who have degeneration occurring at more than one level of the spine, the BalancedBack procedure is especially beneficial. The technique has been used in up to three levels at a time, above an existing fusion, or below a fusion. The key is maintaining mobility, to reduce the likelihood of “hyper-physiologic motions” causing breakdown of adjacent segments and the need for additional surgery in the future.

Find out if you’re a good candidate for BalancedBack, or visit our website to learn more.

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1 Dhillon K. S. (2016). Spinal Fusion for Chronic Low Back Pain: A 'Magic Bullet' or Wishful Thinking?. Malaysian orthopaedic journal, 10(1), 61–68.

2 Feng, Y., Egan, B., & Wang, J. (2016). Genetic Factors in Intervertebral Disc Degeneration. Genes & diseases, 3(3), 178–185. doi:10.1016/j.gendis.2016.04.005

3 Röllinghoff, M., Schlüter-Brust, K., Groos, D., Sobottke, R., Michael, J. W., Eysel, P., & Delank, K. S. (2010). Mid-range outcomes in 64 consecutive cases of multilevel fusion for degenerative diseases of the lumbar spine. Orthopedic reviews, 2(1), e3. doi:10.4081/or.2010.e3

4 Smorgick, Y., Park, D. K., Baker, K. C., Lurie, J. D., Tosteson, T. D., Zhao, W., ... & Weinstein, J. N. (2013). Single versus multilevel fusion, for single level degenerative spondylolisthesis and multilevel lumbar stenosis. Four-year results of the spine patient outcomes research trial. Spine, 38(10), 797.

5 Chun, D. S., Baker, K. C., & Hsu, W. K. (2015). Lumbar pseudarthrosis: a review of current diagnosis and treatment. Neurosurgical focus, 39(4), E10.

6 Bydon, M., De la Garza-Ramos, R., Abt, N. B., Gokaslan, Z. L., Wolinsky, J. P., Sciubba, D. M., ... & Witham, T. F. (2014). Impact of smoking on complication and pseudarthrosis rates after single-and 2-level posterolateral fusion of the lumbar spine. Spine, 39(21), 1765-1770.

7 Jain, N., Phillips, F. M., Weaver, T., & Khan, S. N. (2018). Preoperative chronic opioid therapy: a risk factor for complications, readmission, continued opioid use and increased costs after one-and two-level posterior lumbar fusion. Spine, 43(19), 1331-1338.

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