Why is fusion poor for back pain/good radiculopathy?

[ans]

I had a positive discogram for L5-S1 years ago. I'm considering a multi-level fusion but do not understand why fusion sucks for back pain. Naturally I know nothing about the surgery but does this have to do with torn annulus' that are pain generators?

Thank you in advance.

ans

[Maria]

Luck of the draw..and probably oh so many little interbody complexities. Sure wish spine surgery was as predictable as other areas of the bod. Oh those nasty nerves..ok slap me as this isn't what you want to know. You want the scientific reason for which we turn to our resident experts (either patients or practitioners). I'm waiting to hear the answer as well.

[dshobbies]

Allan,

I believe there are two reasons why fusion isn't the best course of action, especially for multi-level. Doing research prior to my 3 level, I discovered that fusing them was actually contra-indicated. The entire disc is removed and replaced by bone fragments surrounded by a cage, held in place with screws, to hold the fragments in place until it becomes solid. The two vertabrae 'fuse' together to form one solid bone.

The first and most obvious reason is restricted movement. You probably wouldn't miss the movement from S1/L5 but L4/5 is a different story. Add any additional levels to that and there's the possibility that climbing stairs would be difficult or even impossible... worst case scenario but you'd probably notice your movements were more limited.

Then, the remaining discs, especially those adjacent on top and/or bottom must take on the burden of movement from the fused ones, weakening their structure with the likilhood that they too will herniate... and DDD crawls up or down your spine.

Also, there is the possibility that over time, the hardware needed loosens and causes its own set of problems.

I know two people with single level fusions who are completely happy with their decisions. I know another woman who is completely disabled. Her doctor insists there's nothing wrong but hasn't ordered an x-ray or MRI in 2 years. Her pain is very possibily related to her hardware but without investigative tests, there's no way to know. I advised her to seek another opinion.

So ADRs are seemingly a better way to go. But also, as you know, these also have their own contra-indications, possible side effects and failures. I've often said that the best course of action starts with very skilled doctors. But you already know that.

Happy whatever, Dale

[Maria]

Of course I agree with what Dale has stated however I myself have waited so long to do anything that my facets are now showing degeneration that is supposedly contraindicated with ADR or so my OSS said on my last lumbar xray. Of course L5S1 has autofused so I don't see any reason to undo what has been naturally done and try to give the area more ROM when I think it feels better with less (the change I've noticed over the last few years).

So currently I have a disrupted L3 with anular tear and L4 is a definate pain generator on discogram (L5 was the worst previously). Seems like my current choice based on what my OSS stated would be a 2 level fusion at the very least. Someone else (other surgeon here or abroad) may have a different opinion.. not sure. I think I'd like to see the guy in La Jolla again (the Neurosurgeon) if I were thinking multi level fusion.

I just can't imagine myself having less pain with fusion tho then again I have 2previous back surgery probs which you do not have allan and at least this much could bode in your favor if nothing else.

re fusion being good for radiculopathy tho not for low back pain perhaps it has to do with cleaning up around the involved nerves and freeing them up re radiculopathy but then creating a more fixed limiting ROM for the lumbar spine plus and creating that domino sort of effect re next level up having to handle/accomodate new ROM adaptations, weight bearing load of existing discs and *stuff* like that.

What contributions have the Euro docs given you ans or is multi level fusion your only option to date?

[ans]

I'm not an ADR candidate due to facets.

My pain mgt. doc at UCLA said re: my pain that "this is as good as it's going to get"; I did not ask if he was thinking re: post-surgery.

But I'm thinking of articles I have read that say fusion is better for radicular pain than for discogram-confirmed spine pain. I don't get it but appreciate "stabs" (no pun)/hypotheses.

This may seem incredibly stupid but is the entire annulus taken out for the fused level? Hmm, maybe one problem is that (I"m reading Filler's book) it's damned difficult to understand all pain generators.

Thanks gang.

ans

[Maria]

Nobody can say for sure what's going to happen if we have surgery altho they can say what will happen if we don't in terms of degenerative changes tho not even with regard to pain. The body does what it does. That's my take on it.

Hopefully if surgery is warrented and the surgeon thinks there's a good chance of repairing something or making it better that's the goal. Most of us want pain relief as that's when we decide it's time to do something or when we are tired of not functioning the way we think we should be.

Again~ do the best you can with your research and weigh your options and then choose as wisely as you think you're able.

I chose PM for a pretty long haul now because the post surgery pain I had was so truly horrific for so long post 2nd surgery and I've been much more functional than I was for a long long time. Medicated~ yes.. tho more stable with overall spinal stuff. At least for the present. If there were big changes and much more pain or dramatic pain that I couldn't control with the meds I would probably very much consider surgery. I definately am not closing my door to that option even if it is fusion.

Good luck. I know you're struggling with this decision altho I hope your consultations will give you good explanations that answer your questions.

Then do what you think is right or what you think you need to do. Oh yes editing to add I'd be interested to hear what your consultations have to say and if you've seen Dr.Dillon yet. Perhaps you told me and I've forgotten. So much Cinderella work here..

[Jim M2]

The question about annulus removal is a good question. I may have known at one time. It would seem if the annulus is between the two bones, they may not fuse. I sure I've heard of good fusions that alleviate radicular pain and low back pain.

[Maria]

I think I've read that some surgeons have removed all the annulus and some haven't. It's a good question to ask whoever you're consulting w/ and I wonder if that reduces chances of pain re some type of pain fiber that has become embedded in the annulus.. Mark chime in here as I think I'm fabricating at this point.. or someone who knows please/has a *real* answer/reply. sorry can't do better ans

[johnb]

I'd say one size doesn't fit all. Spine problems are complex. My facet joints fused together, inside their capsules, after dynesys (they were a major undiagnosed pain generator) and I've been doing well since having the dynesys removed. They fused becuase their wasn't hardly any cartilage left on them, they were that bad but not diagnosed by a harvard trained, well respect surgeon in the southeast U.S. I still have the same detiorated discs but they aren't painful. In fact, L5-S1 looks is flat as a pancake but not painful AT ALL. I've met surgeons that don't share the fact that discs can lose their ability to generate pain at the latter stages of the deterioration process (of course, stenosis can develop with low disc height). In fact, I had one surgeon awhile back who told me that discs always become more painful the more they deteriorate. This was an obviously sales tactic to get me on the operating table. That kind of dishonesty is dispicable.

I kept hope alive but I honestly thought, especially after dynesys inplantation disabled me more instead of helping, that my situation was not going to improve as I've been dealing with back problems for over 15 years. I thought I was avoiding fusion but ended up with an unintended posterior fusion that has reduced my pain. Only time will tell if I have adjacent problems in the near term but I've been enjoying this reduction in pain. Get a good diagnosis and multiple opinions before decided on a course of action.

[ans]

Thanks for the responses and John, I hope that this fusion will work well till you're 100.

Hmm, my sense is that there really aren't any good methods to deal with annulus' pain e.g. IDET, nucleoplasty (is this relevant?), or any means. I hope I"m wrong. Also, I read that discs that are not positive for pain in a discogram can have painful annulus'.

I will check up on disograms that aim to alleviate pain as an indicator versus provoking pain. In the same vein, I wonder if - and this is dumb b/c a disc would have to be lifted up, if an annulus could be sprayed with lidocaine to r/o this as a pain generator.

Yap, a 2-3 level fusion's outcome from my research certainly has low success rates.

Be well folks. - ans

[mmglobal]

Surgeries that very effectively decompress the offended nervers are more effective at dealing with the radiculopathy associated with nerve compression. Wide laminectomies in which the posterior elements are removed are effective, but they also destablize the area. Typical decompression surgeries are trade-offs between how much they decompress vs. how much damage and destabilization they do.

With fusion surgeries, they have more license to do more decompression because when motion is halted extra structural support is added, they don't have to worry about destabilizing the system.

IMHO, the reason that they are are SOMETIMES not so hot for back pain are for 2 reasons. First is collateral damage from the surgery... big invasive surgery... especially big open posterior surgeries. The second is that most of us (especially those needing multi-level surgery) have multi-focal problems. The fusion will tend to overload the adjacent levels, accellerating degeneration and amplifying pain generators.

I don't think the annulus is in play here. Even in a posterior only fusion with the annulus left intact; once the system is immobilized the annulus will not be loaded substantially. In a 360 or anterior fusion, the posterior annulus will likely be removed or completely unloaded/immobilized.

John's point that 'one size doesn't fit all' is important. There are so many things that can go wrong and any of them can ruin our lives. Unfortunately, we often don't know which issues are important to us unless we are on the wrong side of a failed surgery.

Mark