Things to think about when considering spine surgery

As I talk to patients about what options are out there for back or neck pain, inevitably we talk about the pros and cons of surgical intervention. 

There are a spectrum of options out there for management of neck and back pain.  I live in a region that has one of the highest rates of lumbar fusion in the country [Spine J. 2007 Sep-Oct;7(5):552-7.]

I must say first and foremost, that as a physiatrist my goal usually is to keep people away from surgeons. So, my opinion may be a little biased.  As I have stated in other posts, my goals for pain treatment usually center around working on exercise interventions to empower individuals to address some of the underlying muscle, posture, and biomechanical imbalances that create pain issues.  An expert in the area of back pain treatment suggests that “Instead of patients taking responsibility and coping with their own situation, they have handed over responsibility, lost control, and now wait helplessly to be “fixed” with all the negative effects on disability and outcomes.” [Back Pain Revolution]

Surgery in general and fusion surgery is the right fix for some conditions.  A fusion surgery involves some form of fixation with screws, rods or bone to take motion out of a disc and joint segment.

This fusion or fixation of a disc segment addresses some of the issues that create pain (such as a herniated disc or joint arthritis).  However, in pain circles we have all seen people that go in for one spine surgery and then end up having a series of more spine surgeries over time.  I see every day people that have had one level fused in their spine and then later wear out the adjacent discs/joints and go down a road of fusion for other segments.

A recent article published in the journal Spine sheds some light on this issue.  Posted below is a copy of the abstract that highlights the adjacent segment degeneration that can come after a spinal fusion.

Spine (Phila Pa 1976). 2010 Jan 1;35(1):36-43.

Anterior cervical decompression and fusion accelerates adjacent segment degeneration: comparison with asymptomatic volunteers in a ten-year magnetic resonance imaging follow-up study.

STUDY DESIGN: Prospective 10-year follow-up magnetic resonance imaging (MRI) study of patients who underwent anterior cervical decompression and fusion (ACDF) and healthy control subjects. OBJECTIVE: To clarify the incidence of adjacent segment degeneration during 10 years after ACDF. METHODS: Sixty-four patients who underwent ACDF (48 males, 16 females, mean age 47.3 years, mean follow-up 12.1 year) and 201 asymptomatic volunteers who underwent MRI in our previous study (113 males, 88 females, mean age; 41.1 year, mean follow-up; 11.7 years) were included in this study. The patients and control subjects underwent follow-up MRI in this study. Following MR findings were evaluated using a numerical grading system from C2-C3-C7-T1: (1) Decrease in signal intensity of disc (DSI), (2) Posterior disc protrusion (PDP), (3) Disc space narrowing, and (4) Foraminal stenosis. When an increase in at least one grade in any of the radiographic parameters was detected between the 2 time points, progression of disc degeneration was judged as present at the level of interest. RESULTS: Progression of DSI was significantly more frequent in ACDF group than in control group at C4-C5, while progression of PDP was significantly more frequent in ACDF group than in control group at all levels except for C5-C6. Progression of disc space narrowing and foraminal stenosis was significantly more frequent in ACDF group at C3-C4 and at C6-C7, respectively. CONCLUSION: Although both ACDF patients and control subjects demonstrated progression of disc degeneration during 10 years, ACDF patients had significantly higher incidence of progression of disc degeneration at adjacent segments than control subjects, while progression of disc degeneration at adjacent segments was not always related to development of clinical symptoms.

Comments

[JJ]

I wonder how many of these patients had conditions that would have led to further degeneration anyway. Connective tissue diseases, rheumatoid arthritis... and other more subtle conditions that the medical community may not yet be able to recognize. Where is the control group of those who would have qualified for ADCF but chose not to have surgery? Would they have developed disease at adjacent levels as well?

Not everyone can be an athlete. Blaming the patient for being ill is cruel. Yes, I'm sure you see some who seem to be healthy yet neglect their health by smoking, drinking, using, being lazy and eating poorly. But you may see others who have been taking relatively good care of themselves who still develop this problem. You may not be able to help them. That's not your fault and it may not be theirs either.

[The Back Exercise Doctor]

I appreciate your sentiment. I do not mean in this post (or others) to place blame on individuals for back pain. Genetics probably play a bigger role than most other factors and those certainly are not in the realm of people's control.

With this post on "Things to consider when thinking about spine surgery" I really just wanted to highlight the fact that surgery is not always a perfect fix. I see a lot of people that have a fusion surgery and then end up down the road needing more surgery because of degenerative changes in adjacent segments.

Generally, I am not trying to place blame on people for having back pain issues. Rather, I hope to give people a tool with exercise to hopefully manage some of their symptoms.

Hope that helps.

Shane Mangrum, MD