Orthopedics-Online

Spinal fusion

Synonyms

Spinal stiffening, ventral spondylodesis, dorsal spondylodesis, vertebral body fusion, stiffening operation of the spine, spinal stiffening, segment stiffening, back pain, spinal column surgery, herniated disc

definition

The term spondylodesis is understood to mean an operative therapy in which a therapeutically desired partial stiffening of the spine is brought about by various implants and techniques.

Spondylodesis mainly treats Wear-related spinal instabilities (spondylolisthesis) and unstable vertebral fractures. Spondylodesis is also used for corrections of the spine with a strong hunchback (kyphosis) or lateral bending (scoliosis).

The stiffening caused by the spondylodesis is permanent.

introduction

A major cause of Back pain are pathological mobility between vertebral bodies, so-called instabilities. Such instabilities are mainly caused by through wear-related spinal diseases (elderly patients; Osteochondrosis), especially of the intervertebral discs, but also in the case of congenital vertebral malformations (younger patients, Spondylolysis).
In old age, wear-related disc diseases occur more frequently with other wear-related spinal diseases (Spinal stenosis, Spondylarthrosis (facet syndrome)).

Such changes can become noticeable as severe local back pain. In advanced cases of illness, these will also be Spinal cord and the nerve roots emanating from the spinal cord are involved in the disease process. The spinal cord and nerve roots are pressurized by bone extensions (osteophytes) of the spine as well as by parts of the intervertebral discs and vertebral ligaments.
If the pressure is too strong (Irritation) of the nerve fibers, there is typically a transmitted neck or back pain to the arms or legs. In the end stage, wear-related spinal canals (Spinal stenosis) can even cause paralysis of the arms or legs. The task of a partial stiffening of the spine is to restore the original stability of the spine and to remove tight bones and soft tissue.

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The spine is difficult to treat. On the one hand it is exposed to high mechanical loads, on the other hand it has great mobility.

The treatment of the spine (e.g. herniated disc, facet syndrome, foramen stenosis, etc.) therefore requires a lot of experience.
I focus on a wide variety of diseases of the spine.
The aim of any treatment is treatment without surgery.

Which therapy achieves the best results in the long term can only be determined after looking at all of the information (Examination, X-ray, ultrasound, MRI, etc.) be assessed.

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For whom is spinal fusion necessary?

There are some diseases in which spinal fusion may be necessary. What they all have in common is that, for various reasons, the stability of the spine is no longer sufficiently guaranteed.
These include:

Disc disease caused by wear and tear
(Osteochondrosis)
Vertebral arch disorder (spondylolysis)
Disc and vertebral body infection (spondylodiscitis)
Vertebral fracture (vertebral body fracture)
Vertebral body tumor

1. Disc disease caused by wear and tear

Disc diseases caused by wear and tear (Pseudospondylolisthesis) represent the most common reason for a spinal fusion. In these cases it is no longer possible to achieve a therapeutic success through any other type of restorative operation on the intervertebral discs. Intervertebral disc operations, such as those performed in the case of a herniated disc (prolapse), are no longer possible in these cases. Even an intervertebral disc prosthesis can no longer restore lost spinal stability. On the contrary, spinal instability is a contraindication (Contraindication) for the installation of a disc prosthesis.
Spinal fusion may also be indicated in the context of persistent pain after a previous intervertebral disc operation (post-discectomy syndrome).

2. Vertebral arch disorder (spondylolysis)

This clinical picture is found more frequently in younger patients. Due to a congenital or acquired vertebral arch disorder (Lysis) the vertebral body slips (spondylolisthesis / spondylolisthesis / olisthesis) of the diseased vertebral body over the underlying healthy vertebral body. A common classification of this vertebral body sliding is the Meyerding classification (I-IV).

3. Disc and vertebral body infection (spondylodiscitis)

In some cases of bacterial disc and vertebral body infections, conservative treatment with antibiotics alone is not sufficient. Reasons for this can be that the inflammation threatens to spread to the spinal cord and thus threaten the brain or that the stability of the affected vertebral body section is no longer guaranteed due to advanced intervertebral disc and vertebral body destruction.

4. Vertebral fracture (vertebral body fracture)

With the development of kyphooplasty / vertebroplasty, many, especially Vertebral body fractures caused by osteoporosis can now be stabilized by a minimally invasive surgical procedure. Stable, injury-related (traumatic) If necessary, vertebral body fractures can be treated conservatively in a corset or bodice. In the case of unstable vertebral body fractures with involvement of the posterior edge of the vertebral body that delimits the vertebral canal, there is a risk of spinal cord injury with the development of paraplegic symptoms. In such cases, the spine must be stabilized with a spinal fusion.

5. Vertebral tumor

Benign vertebral body tumors or aggressively growing vertebral body tumors or vertebral body metastases (Daughter tumors) can weaken a vertebral body to such an extent that a spinal fusion operation may be necessary for stabilization. During this stiffening operation, a complete vertebral body replacement may have to be carried out.

Diagnosis before a spinal fusion

Spinal fusion is a major operation and can take several hours, depending on the scope of the planned procedure. Detailed preparation for the operation is necessary in order to determine the extent of the operation. On the one hand, with regard to the mobility of the spine and the duration of the operation, only those parts of the spine with disease value should be operated on; on the other hand, all changes that cause symptoms must be eliminated in order to achieve an optimal surgical result.

1. Anamnesis / examination

The patient's history of suffering is usually long and characterized by a large number of conservative therapeutic measures. Only when all conservative therapeutic measures have been exhausted without any results should a spinal stiffening operation be considered.

Typical complaints are:

Local back pain
Back pain radiating into arms or legs
Feeling weak in the arms or legs
Significant reduction in the maximum walking distance
Sensory disturbances

2. X-ray

The X-ray examination is the basic examination of imaging diagnostics for spondylodesis. Signs of wear and tear and instabilities of the spine can be easily recognized. In addition, the vertebral arc disruption can be seen well on so-called oblique images.

3. Magnetic resonance imaging (MRI)

Magnetic resonance tomography makes it possible to assess changes in soft tissue (intervertebral discs, nerve roots, spinal cord, etc.). Spinal canal genes and nerve root pressures can be recognized, and statements can be made about the state of wear of the intervertebral discs. In addition, new and old vertebral body fractures can be differentiated and infections of the intervertebral discs and vertebral bodies can be recognized.

4. Myelography / Myelo-CT

In myelography, contrast agent is injected into the spinal cord tube for diagnostic purposes of the spinal fusion. Spinal canal genes with displacement of the spinal cord and the outgoing nerve roots can best be assessed here. The vertebral joints are also particularly easy to assess.

Prepare for the operation

The preparation for a spinal fusion takes place in the hospital. The patient is usually admitted to the hospital the day before.

The attending physician first collects a detailed medical history and informs the patient about the course of the operation and the possible risks of the procedure.

In the course of a blood sample, the current blood values are examined.

In addition, an up-to-date X-ray image or magnetic resonance imaging (MRI) is required for the operation. The imaging enables the bony structures and the intervertebral discs to be precisely assessed and a suitable surgical technique to be selected.

For more information about MRI exams, see: Procedure of an MRI

Course of the operation

Spinal fusion is a surgical procedure in which the spine is stiffened. The vertebral bodies are connected to one another by plates and screws, thereby stabilizing the spine.

The operation takes place under general anesthesia. Usually the patient lies on his stomach and access to the spine is from the back (from the dorsal side). The surgeon pushes the back muscles aside and can thus stiffen the vertebral segments on the spine. In the section that is to be stiffened, titanium screws are inserted into the vertebral bodies and these are then connected with a rod. The affected section is immobilized by the screw connection.

In many cases, the intervertebral discs between the vertebrae are also removed and replaced with so-called cages. These are placeholders made of plastic or titanium that are implanted and grow together over time with the neighboring vertebrae.

Although spinal fusion is a serious procedure, the operation is associated with relatively few complications.

Are you more interested in this topic? You can find detailed information about this at: Surgical principles for a spinal fusion

What surgical techniques are there?

There are several surgical techniques for stiffening the spine during spinal fusion surgery. The most common methods are

PLIF (Posterior Lumbar Interbody Fusion),
TLIF (Transforaminal Lumbar Interbody Fusion) and
ALIF (Anterior Lumbar Interbody Fusion).

With PLIF, the operation is performed from behind (posterior) across the patient's back. The back muscles are pushed aside and the intervertebral disc between the vertebrae is replaced by an implant (cage). Then two screws are inserted into the vertebral body and the vertebrae are connected to one another via a rod.

In the TLIF, similar to the PLIF, the patient is operated on on the back, but the operation is more likely to be done on the side of the spinal canal. The spinal canal does not have to be cut, as the implant can be inserted through the intervertebral hole. As a result, the muscles are only minimally injured and the procedure is less traumatic.

The procedure for ALIF is similar, but here the procedure is performed from the front (anterior). The surgeon makes an incision in the middle or on the side in the lower abdominal region to access the vertebrae in the lumbar area. The intervertebral discs are removed, the implant inserted and the vertebral bodies fused.

What is ventrodorsal spondylodesis?

Spinal fusion surgery can be performed either from the front (ventral), from the back (dorsal) or from both sides (ventrodorsal).

The ventrodorsal spondylodesis is a special surgical technique in which the vertebral bodies are connected via two separate approaches from the front and rear. The back is opened and the muscles pushed aside. The vertebral bodies are then connected to one another with screws, rods and plates. The abdomen is opened at the front via a second access and the intervertebral discs between the vertebrae are removed from the ventral side. Then an implant (cage) is inserted.

Differences in spinal fusion at the cervical and lumbar spine

Spinal fusion can be done either on the cervical spine (Cervical spine) or on the lumbar spine (lumbar spine).

The cervical spine is usually stiffened from the front (ventral). The vertebral bodies are exposed either via a longitudinal access (longitudinal section) along a neck muscle (the sternocleidomastoid muscle) or via a transversal access (cross section). The intervertebral disc is then removed and a placeholder (cage) with the body's own bone fragments is inserted between the vertebrae to be stiffened. The vertebral bodies are also connected to one another by plates and screws. After the operation, the spaces between the fixed vertebrae ossify and the operated section stiffens.

Access to the stiffening of the spine in the lumbar spine is either from the rear (dorsal), from the front (ventral) or from the side (lateral). In most cases, the patient lies on his stomach and the procedure is carried out from behind over the back. The back muscles are pushed to the side, exposing the spine. Then the intervertebral discs are removed, replaced with implants and the vertebral bodies screwed. After the operation, patients must wear a lumbar brace for several weeks. The corset supports the spine and accelerates the ossification process of the vertebrae.

You can read more information about this topic in the next articles:

Spinal fusion of the cervical spine
Spinal fusion of the lumbar spine

Duration of the operation

The patient is placed under general anesthesia during spinal fusion. The duration of the operation depends on how many vertebral bodies are connected and which surgical technique the surgeon has chosen. The procedure usually takes between three and five hours.

After the operation

Pain after the operation

After a spinal fusion, the freshly operated wound is of course painful, whereas the doctors administer medication so that the patient is almost pain-free.

In general, the back pain is much better after a successful operation. Sometimes, however, pain can occur in the areas next to the fixed vertebrae as they are more stressed.

Another risk of spinal fusion is that the vertebrae do not grow together properly and that the remaining mobility of the spine leads to loosening of the screws. In such cases, the back pain recurs.

Aftercare

After the operation, the patient is transferred from the recovery room to the ward and monitored. The patient can get up and walk short distances just one day after the procedure. A physiotherapist provides support and helps with the gradual mobilization.

In most cases, a spinal fusion is associated with a hospital stay of five to ten days.

The sutures are pulled by the family doctor after 10 to 14 days.

While the surgical wound heals and the fixed vertebral bodies grow together with the implant, the patient has to wear a corset or a lumbar corset for three months. After a few days, the patient can start moving again and should go for a walk regularly.

After six weeks, light sports such as jogging or swimming can be started again.

Through physiotherapy or a stay in rehab after the operation, the patient learns to deal with the stiff spine and to cope with the restricted range of motion.

After 13 months, the spine can be fully loaded again.

You can find more information about aftercare in the next article under: General physiotherapy

Long-term consequences of a spinal fusion

The primary goal of spinal fusion is to improve the patient's condition and quality of life after the operation. Thanks to the new surgical techniques, the exact location of the implant can be calculated with millimeter precision prior to the operation and the procedure planned accordingly. This stabilizes the spine, reduces incorrect loads and there is a good chance that the patient will be free of symptoms for longer after the spinal fusion.

Over 95% of operations are successful and the goal of spinal stiffening is achieved. The screwing together of two adjacent vertebral bodies results in a restricted range of motion of the spinal column, which the patient has to get used to.

After several months, the vertebrae should be completely fused together and the patient can fully load the spine again. After the fixed section has been ossified, the screws and implants used do not have to be removed again, but remain in the back permanently.

What are the risks after the spinal fusion?

With spinal fusion, it cannot be ruled out that complications may occur, even if they are rare.

The main risks include problems that generally occur after major surgery, such as nausea, vomiting, and pain. General anesthesia puts a strain on the cardiovascular system and, in rare cases, a heart attack or circulatory failure can occur. The surgical wound can become infected and heal poorly. In addition, the restricted movement after the operation increases the risk of thrombosis. During the operation and the first few hours after the operation, the patient wears a urinary catheter through which germs can rise and lead to urinary tract infections.

The removal of the intervertebral discs and the fixation of the vertebral bodies can damage the nerves and the spinal cord. In most cases, the damaged nerve recovers after the operation, but in severe cases the nerve damage can also lead to symptoms of paralysis and sensitivity disorders.
Large vessels, such as the aorta and vena cava, that can be injured by the operation, run in the area of the spine. Another risk of the procedure is the development of a pseudarthrosis. This is a "wrong joint" that is caused by the stiffened vertebrae not growing together and causing pain. In such a case, the patient has to undergo another operation.

As a result of the stiffening, the adjacent areas of the spine are increasingly stressed, which can lead to irritation and again severe back pain.

Furthermore, the screws used can loosen or break through the vertebra, causing the patient severe pain and having to operate again.

Screw loosening complication

A complication of spinal fusion is screw loosening. The screws can either move forward or break through the vertebra.

The main cause of screw loosening is insufficient adhesion of the connected vertebral bodies. Due to the continued mobility, the screws loosen and cause pain as a result.

Older women are at greater risk of screw loosening because osteoporosis often causes bone breakdown. This makes the screws unstable and can loosen. In the event of a screw loosening, the patient must undergo another procedure to fix the screws again.

What is a corrective spondylodesis?

Corrective fusion is a surgical procedure in which curvatures and rotations of the spine are treated. Corrective spondylodesis are primarily used to treat Scoliosis. During the operation, the vertebral bodies are brought into the best possible position and this position is fixed mechanically with screws and metal plates. The aim of a corrective spondylodesis is to straighten the curved spine in order to subsequently achieve a better posture for the patient and to alleviate the symptoms.

There are various surgical techniques that can be used to perform a corrective spondylodesis. A basic distinction is made between dorsal and ventral procedures in which the spine is made accessible either via the back or from the front.

The decision as to which technique to use depends primarily on the clinical picture. Corrective spondylodesis is a difficult procedure that involves various risks and complications. Rotating and straightening the spine can damage blood vessels and nerves in the back. In some cases, the spine is not sufficiently stiffened after the operation because the vertebrae do not grow together and ossify properly. The patients then have to undergo another operation.

What is the cage in spinal fusion?

Often one or more intervertebral discs have to be completely removed as part of a spinal fusion.The missing intervertebral discs are replaced by so-called cages. These are small cups made of metal (usually titanium), plastic (carbon, PEEK) or ceramic, which are inserted between the vertebral bodies and serve as spacers. Cages are considered to be well tolerated. After insertion, the small cups are fixed between the vertebral bodies using screws and plates. The shape and thickness of the cages are based on the natural intervertebral discs.

The implants are important to help the fixed vertebral bodies grow together and to maintain the anatomically correct curvature of the spine.

In the course of the healing process, the inserted implant should grow together with the surrounding vertebrae and further stiffen the spine in this section. In addition to the cages, the surgeon can also insert small bone fragments that arise during the operation into the operated vertebral segment to promote ossification.

What degree of disability is there for a spinal fusion?

A spondylodesis is a difficult procedure that cannot be reversed and in some cases involves considerable mobility restrictions for the patient.

Whether and what degree of disability (GdB) there is for a spinal fusion depends on how many vertebrae were stiffened and the pain that may exist after the operation. If large parts of the spine are stiffened, those affected are entitled to a GdB between 50 and 70. In less severe cases, patients receive a GdB of 20 to 40.