The goal of spine surgery is to decrease pain and improve a patient’s function. When nerve compression is the main issue, a decompression procedure such as a laminotomy or laminectomy may suffice. However, if the vertebral level to be addressed is positioned or moving in such a way to be the main contributor to the pain, a fusion procedure may be warranted.
Who Can Benefit From Spine Fusion Surgery?
A spinal fusion is used to:
- Eliminate painful motion at a severely arthritic or degenerated level
- Stabilize abnormal or excessive motion (spondylolisthesis)
- Realign vertebrae (as for scoliosis, uneven degeneration, forward tilt)
- Recreate the normal height of a disc space (to free up a nerve pinched by the collapse)
There are times when removal of large or bulky bone spurs to free up a pinched nerve will predictably lead to a loss of stability at the spinal level. A fusion is thus needed. There are many options for how to accomplish a fusion. The goal is to accomplish the objective as least invasively and as securely as possible. In nearly all fusion procedures, the disc is removed in the front and an implant placed to restore the normal alignment and allow bone to heal across and fuse the two vertebral levels together.
Many surgeons have a single surgical method for fusions that they use every time for every patient.
That’s where Dr. Jackman is different. He tailors the surgery to the patient using such information as type of pathology, location of pathology, surrounding anatomy, patient health status, and a thought toward the future and what could possibly develop down the road in the patient’s spine.
Types of Spinal Fusion Surgery
There are many different methods to address spinal pathology and obtain a fusion of one or more levels of the spine. The variety of methods typically differ in how they obtain fusion across the disc space. The methods are termed based on how the surgeon access the disc space to obtain what we call the Lumbar Interbody Fusion.
This can be done via the following approaches:
- the front or anterior (ALIF)
- obliquely (OLIF)
- laterally (LLIF)
- from posterior through the neural foramen (transforaminal or TLIF)
- or posteriorly through the side of the neural canal (PLIF).
Anterior, oblique, and lateral approaches to the disc space permit more reliable removal of the disc in its entirety and placement of larger intervertebral spacers. The potential benefits of this approach are improved surface area for bone fusion and a larger more structurally supportive intervertebral spacer.
Any of these approaches may be further stabilized with the use of posteriorly placed pedicle screws, connected on each side by small rods. However, modern advances in the materials and devices we use have made it possible to avoid the use screws and rods in some select cases.
This section will discuss an anterior lumbar interbody fusion.
Anterior Lumbar Interbody Fusion
A direct anterior approach to the spine is accomplished with the assistance of a general surgeon to access the front (anterior) of the spine. There are times when just restoring the height of the disc space and providing stability will address the main patient symptoms. The general surgeon takes a retroperitoneal approach – meaning, although the incision is in the center of the abdomen in line with the belly button, we work around and behind the abdominal contents to access the spine. This provides direct visualization of the disc space, allowing us to place the largest implant to entirely fill disc space and support the vertebrae.
The anterior approach may not be appropriate for patients with prior extensive abdominal surgery, larger body types, or those with unusual vascular or intra-abdominal anatomy. Appreciating unique patient factors are part of the tailoring process in deciding which approach is best fitted for each patient.
How An Anterior Lumbar Interbody Fusion Is Performed
Anterior procedures are performed on the front of a person, whereas posterior operations involve creating an incision on a person’s backside. So as the name implies, an anterior lumbar interbody fusion involves operating on the spine through an incision on a person’s front. The process begins with the patient on their back after general anesthesia has been administered.
A general or vascular surgeon especially skilled in minimally invasive approaches to the spine begins the surgery. A small incision is made in the belly area, and a specialized x-ray is used to allow the surgeon to better visualize the site. Next, the general or vascular surgeon gently clears a path around the peritoneum, the thin sac that holds the abdominal contents and organs. These are not visualized during the procedure. Rather, we work around them, taking advantage of their mobility and flexibility. Large blood vessels on the front of the spine are carefully identified, protected, and occasionally shifted to the side to permit better visualization of the spine.
Once Dr. Jackman is satisfied a safe working portal to access the spine has been established, the location is verified with an intra-operative X-ray and the damaged disc or discs are carefully removed. Specialized tools are also used to prepare the vertebrae for the fusion procedure.
To restore the height of the disc space and provide stability, an implant is chosen that fills the intervertebral space – width, depth, and height. The implant may be made of either a hard plastic or titanium. Typically, they are held in place by either screws or blades that secure the implant to the vertebra on either side.
There are times when restoration of vertebral height and elimination of painful motion can be accomplished via the placement of this implant alone. This is called a “stand-alone” approach.
However, many patients will need further decompression of the nerve roots performed posteriorly via a laminectomy or laminotomy. Also, when instability of the spine was a concern, additional fixation with pedicle screws may be needed to hold the spine tighter to ensure a solid fusion of bone occurs.
Spine Fusion Surgery Recovery
Most patients will spend 1 to 3 nights in the hospital after a lumbar fusion. As the bone is healing together, it is important to avoid overstressing the low back. Thus, avoiding excessive bending, twisting, and lifting is paramount. We will closely follow the healing of the bone with xrays. Over time, we will watch the bone heal across the two vertebrae.
For more information about the treatment options for low back and leg pain, reach out to Dr. Jackman and his care team today.
