What is Lumbar Fusion?

The development of spinal fusion has a history of nearly one hundred years. Only a few disc herniations or spinal canal stenosis are not associated with spinal degenerative spinal degeneration caused by functional fusion.

Spinal fusion

At present, fusion is used for a few disc herniation or spinal canal stenosis without functional disorders caused by spondylolisthesis. It is to make the original spinal movement segment no longer move and grow into a whole. It is usually applied when the stability of the spine is damaged or orthopedic is required, and it needs to cooperate with internal fixation.

The development of spinal fusion has a history of nearly one hundred years. In 1911, Albee and others used spinal fusion to treat spinal tuberculosis to prevent the spread of tuberculosis infection. In the same year, Hibbs and others used spinal fusion to control the development of deformities in patients with scoliosis. In 1959, Boucher et al. Made the first case of pedicle screw lumbar spine fixation. Since the 1980s, pedicle screw technology has been widely used. From 1996 to 2001, the number of spinal fusion patients in the United States increased by 77%, and the number of hip and knee replacements increased by 13% to 14% over the same period. Fusion surgery is expensive. Excluding doctors' surgery costs, the average cost per person per year in hospitals in the United States is no less than $ 34,000

Surgical implantation has been increasing in the proportion of spinal fusion. Clinical research reports on lumbar fusion show that the fixed placement rate has almost doubled from 1980 to 1990. Most implants are pedicle screws. Since 1996, Fusion stents are more commonly used. Subjective comparative studies were performed using pure bone graft fusion and pedicle screw fusion. Although both had good fusion rates, the experimental results concluded that the use of pedicle screws has no clinical advantage. A randomized experiment suggested that in order to achieve better surgical results, the internal fixation was expected to affect the effect of loosening due to severe bone resorption, and the internal fixation group was changed to the bone transplantation group. The results of other randomized experimental studies suggest that the use of pedicle screw fixation is better in clinical outcomes. The comparison of pedicle screw fixation and fusion results shows that patients with pedicle screw fixation have recurrence rates, complications, and nerve root damage. The incidence is high, blood loss is high, the operation time is long and the complexity of the operation is increased. Implants are expensive, the cost of each operation is multiplied, and there are potential risks. Therefore, mastering the indications for surgery is crucial to the success of the operation. At present, there are no standard indications for surgical indications, and it is necessary to prevent surgical indications from being too wide. For patients with simple disc herniation, no fusion is required. The clinical outcome of fusion depends not only on medical technology, but also on social, psychological, and environmental factors. Each patient must be fully evaluated, and strict criteria must be used to select patients. Successful and sturdy fusion does not necessarily achieve satisfactory clinical results. On the other hand, the formation of false joints after surgery does not necessarily indicate that the surgery has failed. Recently, a so-called indication is newly added as "disc-derived pain" or low back pain without sciatica caused by degenerative disc degeneration. The diagnosis of these diseases is controversial. Injecting a contrast agent into the nucleus pulposus that may damage the disc Will aggravate the pain of patients, discogenic pain is different from radicular pain caused by disc herniation, and disc herniation usually uses a simple discectomy. If intervertebral discogenic pain is surgically treated, the usual method is spinal fusion. Because the back pain and intervertebral disc degeneration are both onset of a wide range of ages, the result is an increase in the number of candidates for this procedure.

Column fusion is widely used around the world, but practice has shown that only a few disc herniations or spinal canal stenosis are not accompanied by spinal degenerative spinal degeneration. Fusion is retained. Whether degenerative disc disease requires fusion, more needs to be done. With more clinical research, the existing data are not enough to determine that the applied surgical implant can effectively improve clinical symptoms. Due to the many complications of spinal fusion, the frequency of secondary surgery and the high cost, patients should be informed before surgery that pedicle screws are only used when spinal spondylolisthesis, fractures, dysfunction, deformation, spinal tumors and pseudoarthrosis . Emerging internal implants, such as artificial discs, should be used with caution, and the safety and effectiveness of these devices have not been proven. Only by doing more and better clinical trials can the indications of spinal fusion surgery and the best treatment plan be clear.

The development of spinal fusion has a history of nearly one hundred years. In 1911, Albee and others used spinal fusion to treat spinal tuberculosis to prevent the spread of tuberculosis infection. In the same year, Hibbs and others used spinal fusion to control the development of deformities in patients with scoliosis. In 1959, Boucher et al. Made the first case of pedicle screw lumbar spine fixation. Since the 1980s, pedicle screw technology has been widely used. From 1996 to 2001, the number of spinal fusion patients in the United States increased by 77%, and the number of hip and knee replacements increased by 13% to 14% over the same period. Fusion surgery is expensive. Excluding the cost of doctors' surgery, the average cost per person per year for hospitals in the United States is no less than $ 34,000 [1]. The largest increase in the use of fusion is for elderly patients who undergo laminectomy due to spinal stenosis. Advances in anesthesia and spinal imaging have also prompted this type of surgery to increase rapidly in the elderly. At the same time, the expansion of the indications for fusion surgery has increased the scope of application of spinal fusion. This article reviews the research progress of fusion.

Spinal Degeneration and Fusion

Spinal canal stenosis involving lumbar spondylolisthesis is a degenerative change. Patients undergoing spinal fusion surgery can achieve different degrees of improvement. Random experiments have shown that the choice of laminectomy and fusion is better than simple laminectomy. The study by Moller et al. Showed that a group of patients with isthmic spondylolisthesis with intermittent low back pain for at least 1 year had better results of fusion than non-surgical treatment of the same patients. Studies by Katz and others show that the effect is good without using a fusion device, but for patients with spinal canal stenosis without spondylolisthesis, the effect of single laminectomy and laminectomy plus fusion is the same in randomized clinical trials. Although clinical experiments have shown that cervical discectomy with fusion has the same effect, the rate of cervical fusion surgery has increased. A Swedish scholar conducted a study that randomized fusion and non-surgical treatment for patients with 1 or 2 segments of disc degeneration. The results showed that such patients can be treated with fusion. The non-surgical group chose individual treatment options including physical therapy, Nerve electrical stimulation, acupuncture, drug injection, and subjective cognitive training, the surgical treatment effect is significantly improved compared with non-surgical treatment symptoms, pain relief, compression symptoms, and functional recovery, 63% of patients who received surgery said "very satisfied "And" more satisfied. " The Swedish study showed that the effect of fusion was not satisfactory. The improvement in pain and function was about 30%. Only 1/6 of patients completely relieved the pain, and the number of patients who improved after surgery was reduced in 1 to 2 years of follow-up. , Indicating that the surgical effect may be temporary. A recent large randomized trial was to perform fusion on patients with discogenic pain. Compared with non-surgical patients undergoing standard rehabilitation training, the results show that surgery has no significant effect on pain relief and functional improvement. The efficacy of pain fusion is limited. The results of a systematic retrospective analysis by Gilbson and others in 1999 showed that there is no evidence that any form of fusion is effective for degenerative lumbar spondylolisthesis, vertebral instability, and back pain. Patients who have undergone fusion for cervical degeneration due to neck pain There are similar results. Spine fusion also lacks a reliable and solid fusion method. There is no necessary connection between solid fusion and pain relief. Although solid fusions provide some degree of pain relief, many patients who fail to perform solid fusions (pseudo-articular joints) later experience great pain relief, while others with better fusions perform poorly. Psychological factors cannot be ignored in anticipating clinical results. Related factors include income, age, whether legal compensation and depression are involved.

Spinal Fusion and Indications

Surgical implantation has been increasing in the proportion of spinal fusion. Clinical research reports on lumbar fusion show that the fixed placement rate has almost doubled from 1980 to 1990. Most implants are pedicle screws. Since 1996, Fusion stents are more commonly used. Subjective comparative studies were performed using pure bone graft fusion and pedicle screw fusion. Although both had good fusion rates, the experimental results concluded that the use of pedicle screws has no clinical advantage. A randomized experiment suggested that in order to achieve better surgical results, the internal fixation was expected to affect the effect of loosening due to severe bone resorption, and the internal fixation group was changed to the bone transplantation group. The results of other randomized experimental studies suggest that the use of pedicle screw fixation is better in clinical outcomes. The comparison of pedicle screw fixation and fusion results shows that patients with pedicle screw fixation have recurrence rates, complications, and nerve root damage. The incidence is high, blood loss is high, the operation time is long and the complexity of the operation is increased. Implants are expensive, the cost of each operation is multiplied, and there are potential risks. Therefore, mastering the indications for surgery is crucial to the success of the operation. At present, there are no standard indications for surgical indications, and it is necessary to prevent surgical indications from being too wide. For patients with simple disc herniation, no fusion is required. The clinical outcome of fusion depends not only on medical technology, but also on social, psychological, and environmental factors. Each patient must be fully evaluated, and strict criteria must be used to select patients. Successful and sturdy fusion does not necessarily achieve satisfactory clinical results. On the other hand, the formation of false joints after surgery does not necessarily indicate that the surgery has failed. Recently, a so-called indication is newly added as "disc-derived pain" or low back pain without sciatica caused by degenerative disc degeneration. The diagnosis of these diseases is controversial. Injecting a contrast agent into the nucleus pulposus that may damage the disc Will aggravate the pain of patients, discogenic pain is different from radicular pain caused by disc herniation, and disc herniation usually uses a simple discectomy. If intervertebral discogenic pain is surgically treated, the usual method is spinal fusion. Because the back pain and intervertebral disc degeneration are both onset of a wide range of ages, the result is an increase in the number of candidates for this procedure.

Complications and Reoperations of Spinal Fusion

Compared with simple discectomy and laminectomy, spinal fusion often removes the cortex at the bone graft site, which exposes a larger area and prolongs the operation time. Therefore, fusion has more complications than other spinal procedures. However, even with successful surgery, recurrence of symptoms can occur years later. Deyo et al. Reported that patients who underwent fusion were younger and had different conditions than those who did not undergo fusion, but the result was a twofold increase in the risk of complications of fusion, the proportion of transfusions, and mortality within 6 weeks after surgery. Common complications include failure of the fusion device, with an incidence of about 7%, chronic pain at the donor site, infection rate of about 11%, nerve root injury rate of about 3%, emphysema, 2%, and surgical infection rate of 3%. Complications of vascular injury have been reported less frequently, but the potential risks are extremely high. Approximately 15% of cases do not result in a firm fusion or false joints. Postoperative blindness is rare, and may be due to insufficient blood volume to form ischemic injury and is related to the patient's position during the operation.

Kuslich et al's follow-up of 196 patients who underwent lumbar spinal fusion for 4 years showed that the incidence of late complications was 13.8% (27/196), and 8.7% (17/196) of patients underwent secondary surgery, and 3.1 involved internal fixation. % (6/196). Gehrehen et al reported that 112 patients were followed up for 4 years after fusion. The total satisfaction rate was 70%, and the reoperation rate was 18%. Chen Liang et al reported that 13 cases (11%) had complications during 118 cases of intervertebral fusion surgery, and 9 cases (7.6%) had complications after operation. Complications included dural tear, nerve root injury, and position of the fusion cage. Good, postoperative fusion cage movement and sinking, secondary adhesion arachnoiditis and so on. Zhang Shaodong et al reported that 156 cases of posterior lumbar interbody fusion were performed, of which 15 (9.7%) underwent reoperation due to complications. The reoperation rate of fusion is slightly higher than that of laminectomy and discectomy without fusion, and the reoperation rate of fusion with internal fixation and pure bone fusion is similar.

Application prospects of spinal fusion

Spinal fusion is widely used around the world, but practice has shown that only a few disc herniations or spinal canal stenosis are not associated with functional disorders caused by spondylolisthesis and spinal degeneration. Fusion is still used. Does degenerative disc disease require fusion? With more clinical research, the existing data are not enough to determine that the applied surgical implant can effectively improve clinical symptoms. Due to the many complications of spinal fusion, the frequency of secondary surgery and the high cost, patients should be informed before surgery that pedicle screws are only used when spinal spondylolisthesis, fractures, dysfunction, deformation, spinal tumors and pseudoarthrosis . Emerging internal implants, such as artificial discs, should be used with caution, and the safety and effectiveness of these devices have not been proven. Only by doing more and better clinical trials can the indications of spinal fusion surgery and the best treatment plan be clear.