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SPINAL DISORDERS SPINAL FUSION SURGERY

Spinal Fusion Surgery

Before handling the spinal fusion surgery topic, a brief information on vertebrae will be helpful. The spine is formed from bones called “vertebra”. Strong connective tissues between each vertebra connects one vertebra to another, structures named discs act as cushions between them. (Figure 1) The discs allow movement of the vertebra and enable humans to make forward, backward, and turning movements in their necks and lower backs. The type and amount of movement varies according to the different sections of the spine: cervical (neck), thoracic (back), or lumbar (lower back). The cervical spine is a very active region that enables our movement in every direction. The thoracic spine is more rigid due to the presence of the ribs, and is constructed to protect the heart and lungs. The lumbar spine allows mostly forward and backward bending movements (flexion and extension).

What is fusion?

Attachment of one or more vertebra to each other without leaving any space in between is called fusion. The fusion concept is similar to the welding procedure in industry, however the vertebra are not welded to each other during fusion surgery. Bone grafts harvested from the patient’s own bones or from cadavers are placed around the spine. The body heals these grafts within a few months – similar to fracture healing – and this unites the vertebra by fusing them together.

When is fusion necessary?

Spinal Füzyon Cerrahisi Fusion may be performed in the treatment of a broken vertebra, in the correction of a spinal deformity (spinal curves, scoliosis or slipping), in the elimination of pain resulting from painful movement, in the treatment of instability or some cases of slipped cervical discs.

One of the less controversial requirements for spinal fusion are vertebral fractures. Despite the fact that not all spinal fractures need surgery, some fractures – especially those related to spinal cord or nerve injuries – need fusion. Some spinal deformities (for example, scoliosis), are treated with spinal fusion. scoliosis is an “S” shaped curve of the spine that may be seen in children and adolescents. Fusion may be necessary for very big curves or smaller curves that tend to progress.

Sometimes a thin fracture line may cause the vertebra to slip over one another towards the front. This is called spondylolisthesis and can be treated with fusion surgery. In cervical disc hernias (neck hernia) that require surgery, fusion is often needed after removal of the herniated disc. During this procedure the disc is often removed by a small cut in the front part of the neck, and either a piece of small piece of bone or titanium mesh is inserted instead of the disc.(figure-2)

Although disc removal is often carried out together with fusion in the cervical area, this is not true for the lumbar area.

Spinal Füzyon Cerrahisi Spinal fusion may be occasionally considered for the treatment of a painful spine that does not have an obvious deformity. The biggest obstacle to the succesful management of spinal pain using fusion is the difficulty in determining the source of patient’s pain. Theoretically, the source of the pain is painful movement, and fusing the vertebra together will eliminate the pain. Unfortunately, by using the available techniques it is not always possible to understand exactly which of the numerous complicated structures in the lower back or the neck is the source of pain. Because finding the source of pain is so difficult, treatment of isolated lower back and neck pain with spinal fusion is controversial. In these conditions, fusion is often regarded as the last resort, and should be considered only when other conservative (nonsurgical) precautions have failed.

In addition, mobile disc prostheses introduced recently and that preserve movement instread of fusion may be considered as a management alternative. (Figure 3 )

How is fusion made?

There are numerous surgical approaches and methods to fuse the spine and all include insertion of bone grafts between the vertebrae. Approach to the spine and insertion of the grafts are performed from the back (posterior approach), from the front (anterior approach), or a combination of both. Anterior approach is more commonly used in the neck, whereas lumbar and thoracic fusions are made often from the posterior.

The main goal of fusion is to establish a constant union between two or more vertebrae. Additional hardware (instrumentation) including rods, screws, and cages may or may not be used. Instrumentation is sometimes used to correct a deformity, however they are generally used to hold the vertebrae together while bone grafts are healing.

Regardless of the presence or absence of any instrumentation, the use of bone grafts or bone substitutes are important to fuse the vertebra together. Bones that will be used during the operation may be harvested from another bone of the same patient (autograft) or can be taken from a cadaver (allograft). Fusion using the patient’s own bone has a long history and it results in a predictable healing. Autograft is currently the golden standart bone source. Allograft (cadaver bone) can be used as an alternative to the patient’s own bone. Although healing and fusion are not as predictable, there is no additional incision for bone harvest therefore it results in less pain.

Smoking, drugs that you use for other illnesses and your general health status may affect your healing and the rate of fusion.

There are currently promising results on synthetic bone grafts which are hoped to replace autografts or allografts. When the time comes synthetic bone products, bone forming proteins and growth factors (BMP) may replace routine use of autograft or allograft bones.

Spinal fusion can be made through smaller surgical incisions with the novel “minimal invasive” surgical techniques. The indications for minimal invasive surgery are the same as those for the traditional big incision surgery; however it is necessary to understand that a smaller incision does not mean that the surgery is less risky.

How is the postoperative phase in fusion surgery?

Pain and discomfort immediately after spinal fusion is generally greater than other spinal operations. However, there are excellent methods to control postoperative pain. These include oral painkillers and intravenous injections. Another option is the postoperative pain control pump (PCA), which is controlled by the patient. In this method, the patient presses on a button which triggers the release of a predetermined amount of narcotic painkiller into a vein. This is used commonly during the first few days after the operation.

The recovery period that follows fusion surgery is generally longer than other spinal operations. The patients are hospitalized for five to seven days after the operation, however a longer stay in the hospital after a more comprehensive surgery is not uncommon.

Similarly, returning back to a normal and active lifestyle after fusion surgery takes a longer time compared to other spinal operations. This is due to the fact that you will have to wait until your surgeon sees evidence of bone healing. Fusion proceeds differently in every patient; the body incorporates bone grafts in a manner that will provide healthy union of the vertebrae. Healing after fusion surgery is very similar to bone healing. Especially, the earliest signs of bone healing do not appear on X rays before six weeks after the operation.

During this period the patient’s activities are often restricted. A good bone healing does not take place before six months after the operation. Although there is still evidence that bone healing continues one year after the operation, increase in activities are allowed after three-four months following the operation.

The time needed for the patient to return back to work depends both on the type of surgery and the patient’s occupation. The doctor’s report ranges from 4-6 weeks in a young, healthy individual working on the desk and undergoing a single level fusion to 4-6 months in an older patient doing heavy labor. Use of a brace after fusion treatment: In addition to limiting the activities, a brace may be used in the early postoperative period. There are numerous types of braces. Some are limiting and seriously limit the activities, whereas others are used to comfort the patient and give some support. Whether a brace will be used or not, and if it is going to be used, then which type of brace will be used depends on your surgeon’s preference and other factors depending on the type of surgery.

Rehabilitation phase after fusion treatment

Your surgeon may recommend you a postoperative rehabilitation program after spinal fusion surgery. In this rehabilitation program, there may be exercises to strengthen the back, a program which strengthens the cardiovascular system (aerobic), and a program specially designed for the workspace and which will enable the patient to return back to work as soon as and as safe as possible. The decision to continue with a postoperative rehabilitation program depends on a number of factors. These are factors related to surgery (the type and extent of surgery), and factors related to the patient (age, health condition, expected activity level). Rehabilitation may be initiated as early as 4 weeks in a young patient who underwent a single level fusion.

Is there a side effect of spinal fusion surgery?

Although fusion is a treatment for some spinal diseases, it does not return your spine to “normal”. In a normal spine, there is some movement between the vertebrae. Fusion eliminates the ability for movement between the fused vertebra. This will cause more loads to be exerted on the vertebrae located above and below the fusion. Fortunately, a fusion fractures (breaks) very rarely once it has healed. However, fusion creates more loads on the vertebrae adjacent to the fusion. Therefore it has the potential to accelerate the degeneration in these segments. These risks certainly differ between different people. Therefore, most surgeons recommend their patients to avoid lifting heavy loads and making turning movements in order to minimize the loads around the fusion.

The decision to proceed with spinal fusion or not is very complicated, and is closely associated with factors related to the treated disease, patient’s age and health condition, and expectations concerning activities after the operation. As a result, when making a decision you have to be very careful and discuss everything in detail with your surgeon.

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