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Lumbar Fusion Surgery

What does “Lumbar Fusion” mean?

Here is the meaning of each word:

  1. Lumbar: the area of the spine located in the low back
  2. Fusion: to mend bones in the spine together; following a fusion there is now one long fused vertebra, instead to two vertebrae which can move.

Altogether, “Lumbar Fusion” means connecting two or more vertebrae of the low back together to allow them to form a bone bridge and mend themselves together permanently.

What is a Lumbar Fusion?

A Lumbar Fusion is a spine surgery in the low back where two or more vertebrae are connected together with titanium screws and rods to stop any painful motion between them. Bone or bone-like material is used to form a permanent bone bridge between the vertebrae.

  Why is a Lumbar Fusion done?            

                

  1. Lumbar fusions are done to stop motion between vertebrae. It is thought that the  abnormal motion at a diseased part of the spine causes pain. Stopping that motion should stop the pain.
  2. Another reason for a Lumbar Fusion is to stabilize spine segments which are unstable. Sometimes spine segments become unstable due to prior surgery or a degenerative condition. A fusion can give these segments stability to protect the spinal nerve supply and improve pain.
  3. Lumbar Fusions are also sometimes done after a diseased disc is removed. In some cases, the disc degeneration was so severe, that removing just a part of it will not stop the pain. In that case, most of the disc is removed and a fusion is done.
  4. Lumbar fusions are also done for infections or cancers of the spine. In this case, parts of the vertebrae have to be removed to eliminate the infection or cancer. Afterwards the spine is fused to give it stability.

What are the different types of Lumbar Fusions?

There are many different types of Lumbar Fusions. They are named by how the spine is approached and which part of the spine is fused.

A. Anterior Lumbar Interbody Fusion (ALIF)

  1. Here is the meaning of each word:
  • Anterior: the front of the spine
  • Lumbar: the part of the spine located in the low back
  • Interbody Fusion: a disc is removed and a fusion is carried out between the bodies of the vertebrae

Altogether, “Anterior Lumbar Interbody Fusion” means mending two or more vertebrae of the low back together using an approach from the front of the spine.

      2. What is an ALIF surgery?

This surgery is done through the abdomen to gain easy access to the front of the spine. An incision is made in the abdomen. The muscle of the abdomen is separated and the organs are pushed off to the side. The majority of the disc is then removed and a piece of bone or bone substitute (artificial bone) is put in its place. Sometimes a titanium metal plate and screws are attached to the front of the spine to support the new bone material.

B. Anterior/Posterior Lumbar Fusion

      1. Here is the meaning of each word:

  • Anterior: From the front

  • Posterior: From the back

  • Fusion: to mend two or more vertebrae together

Altogether, “Anterior/Posterior Lumbar Fusion” means to mend vertebrae together            

with a surgery done from the front and the back of the spine.

      2. What is an Anterior/Posterior Lumbar Fusion?

An Anterior/Posterior Lumbar fusion is a two-stage surgery. The anterior part of the operation is identical to the “Anterior Lumbar Interbody Fusion” surgery above. The posterior part of the operation places screws and rods into the vertebrae from the back of the spine in a separate surgery.

C. Posterior Lumbar Interbody Fusion (PLIF)

  1. Here is the meaning of each word:
  • Posterior: the back of the spine
  • Lumbar: the area of the spine located in the low back
  • Interbody Fusion: the disc is removed and a fusion is carried out between the vertebrae

Altogether, “Posterior Lumbar Interbody Fusion” means to mend two or more vertebrae of the low back together using an approach from the back of the spine.

      2. What is a PLIF surgery?

A PLIF surgery is done through the back of the spine. The muscles and tissue of the back of the spine are moved to the side. The lamina and spinous process bones on the back of the spine are removed (laminectomy). The majority of the disc is removed. Typically two spacers (cages) and bone or bone substitute (artificial bone) material is placed into the disc area. Titanium screws and rods are used to connect the vertebrae above and below where the disc was removed.

D. Transforaminal Lumbar Interbody Fusion (TLIF)

  1. Here is the meaning of each word:
  • Transforaminal: a surgery which is done through the foramen (hole on the side of the spine where the spinal nerve leaves)
  • Lumbar: are of the spine located in the low back
  • Interbody Fusion: the disc is removed and the vertebrae above and below the disc are fused together.

Altogether, “Transforaminal Lumbar Interbody Fusion” means mending two or more vertebrae of the spine together by approaching the disc from the back, next to the spinal nerves.

      2. What is a Transforaminal Lumbar Interbody Fusion (TLIF)?

A TLIF is a spine surgery done from the back of the spine. The muscles and tissue of the low back are moved to the side. The lamina bone and sometimes the spinous process bone are partially or fully removed. Most of the disc material is removed from an area next to the spinal nerve. A spacer and bone or bone-like material (bone susbstitute) is placed into the disc space. This can often be done just from one side of the spine. Titanium screws and rods are used to connect the vertebrae above and below the disc.

A “Mini-TLIF” is a minimally invasive version of the TLIF. Small, tube like retractors are used to gain access to the disc. The disc is removed and bone or bone-like material (bone substitute) is placed. The screws and rods are then placed minimally invasively as well.

E. Extreme Lateral Lumbar Interbody Fusion (XLIF)

  1. Here is what each word means:
  • Extreme Lateral: means the surgery is done from the side of the spine.
  • Lumbar: area of the spine located in the low back.
  • Interbody Fusion: the disc is removed and the vertebrae above and below the disc are fused together.

Altogether, “Extreme Lateral Lumbar Interbody Fusion” means mending two or more vertebrae of the low back together by approaching the spine from the side.

      2. What is an Extreme Lateral Interbody Fusion (XLIF)?

An X-LIF surgery is done from the side, i.e. from the patient’s flank (side of the abdomen). The advantage is that the structures of the low back (muscles, bone, ligaments, etc.) are not part of the operation. Since the patient is already suffering from low back pain, avoiding a surgery that involves the low back can have benefits.

During surgery, the patient is placed on their side and a cut is made over the flank. A minimally invasive tube like retractor device is placed through the muscles and tissue until the spine comes into view. A portion of the disc is removed and spacer, bone or bone-like material is placed in its place. Sometimes a titanium plate and screws can be placed over the disc area from this same approach. Other times, the patient is placed on their stomach in order to place the screws and rods into the spine through the lower back.This can be done minimally invasively with small retractors.

The XLIF procedure typically cannot be done at the lowest disc in the spine (L5/S1).

F. Posterior-Lateral Lumbar Fusion (PLF)

  1. Here is what each word means:
  • Posterior-Lateral: on the back and off to the side of the spine
  • Lumbar: area of the spine located in the low back.
  • Fusion: two or more vertebrae are mended together

Altogether, “Posterior-Lateral Lumbar Fusion” means mending two or more vertebrae of the low back together using an approach from the back of the spine.

      2. What is a Posterior-Lateral Lumbar Fusion (PLF)?

A PLF is a spine surgery which does not treat the disc, but rather fuses a part of the vertebrae together to avoid motion of the disc. The surgery is done through the low back. Once the muscles and tissue are moved to the side, bone or bone substitute is placed between the wings of the vertebrae (transverse processes) on each side. Pedicle screws and rods are then placed.

G. Axial Lumbar Interbody Fusion (Axia-LIF)

Here is what each word means:

  • Axial: Along the axis of the spine
  • Lumbar: area of the spine located in the low back
  • Interbody Fusion: the disc is removed and the vertebrae above and below the disc are fused together.

Altogether, “Axial Lumbar Interbody Fusion” means mending two or more vertebrae of the low back together by approaching the spine from an area consistent with the axis of the spine.

      2. What is an Axial Lumbar Interbody Fusion (Axia-LIF)?

An Axia-LIF procedure is done through a different approach than the other types of Lumbar Interbody Fusions. A hollow rod is placed around the tailbone underneath the S-1 Vertebra. The rod is then advanced through the S-1 Vertebra and into the L5/S1 disc. The core of the L5/S1 disc is removed and bone growth material placed. The rod is then advanced into the L5 Vertebra, creating a large channel. A screw is placed through the rod and advanced into the L5 vertebra where it is turned to raise the L5/S1 disc upward. The screw is then secured and the rod removed. The screw locks the L5 and S1 vertebrae together.

 

How long does it take for the spine to fuse?

A spinal fusion typically takes place over 6-12 months. Here are some issues which can have an impact on the fusion:

  1. Smoking: nicotine has been shown to interfere with a fusion. In fact, the chance of developing a fusion is at least cut in half.
  2. Non-Steroidal Anti-inflammatory medications (NSAIDS): NSAIDS such as Ibuprofen or Naproxen Sodium when taken in prescription strength for a period of time have been shown to interfere with a fusion.
  3. Osteoporosis (bone thinning): having true Osteoporosis can create bone weakness at the site of the fusion. Potentially the screws may not hold well within weakened bone. Also, new bone may not form completely.
  4. Activity Level: engaging in high impact activities soon after a fusion surgery can weaken the metal screws and rods, potentially causing them to fail.

 

How is a Lumbar Fusion Surgery actually done?

 

Here are some of the steps for each Lumbar Fusion technique:

  1. Anterior Lumbar Interbody Fusion (ALIF)
  • An intravenous catheter (IV) is started and antibiotics are given
  • The patient is taken to the Operating Room
  • The patient is placed on the back (supine) and a General Anesthetic is given.
  • The abdomen is cleaned with a sterile surgical antiseptic solution
  • Sterile sheets (drapes) are placed around the surgical area
  • The surgeon makes a cut (incision) through the skin of the abdomen
  • The tissue under the skin is opened
  • The rectus muscle and its envelope (fashia) can now be seen.
  • The rectus muscle and its envelope (fascia) are opened and pushed aside
  • The peritoneum (sac which contains the organs of the abdomen such as intestines, liver, etc.) is seen. It is not opened, but gently pushed aside with specialized retractors (metal instrument designed to push tissue aside)
  • Behind the peritoneum, some the large blood vessels of the body are seen.
  • Some of the blood vessels are gently pulled to the side, others are tied off (ligated).
  • The spine is now seen from the front.
  • The disc is removed with a surgical knife and specialized instruments.
  • Bone or a bone-like material (bone substitute) are placed into the space where the disc was removed from (disc space). Sometimes other materials are added to increase the chance for a fusion to occur.
  • At this point the surgeon may have options:
    1. Place a titanium plate and screws over the new bone to protect it.
    2. Close the abdomen and turn the patient on their stomach.

Place titanium screws and rods on the back of the spine at the segment of the fusion. Sometimes this is done with a special minimally invasive technique.

  • The retractors are removed and the peritoneum allowed to slide back to its normal position.
  • The rectus muscle and its fascia (envelope) are closed.
  • The skin is closed.
  • A bandage (dressing) is placed over the site of the surgery.
  • The patient is awoken from Anesthesia and brought to the Recovery Room, where often more X-Rays are taken.

      2. Anterior/Posterior Lumbar Interbody Fusion

  • An intravenous catheter (IV) is started and antibiotics are given
  • The patient is taken to the Operating Room
  • The patient is placed on the back (supine) and a General Anesthetic is given.
  • The abdomen is cleaned with a sterile surgical antiseptic solution
  • Sterile sheets (drapes) are placed around the surgical area
  • The surgeon makes a cut (incision) through the skin of the abdomen
  • The tissue under the skin is opened
  • The rectus muscle and its envelope (fashia) can now be seen.
  • The rectus muscle and its envelope (fascia) are opened and pushed aside
  • The peritoneum (sac which contains the organs of the abdomen such as intestines, liver, etc.) is seen. It is not opened, but gently pushed aside with specialized retractors (metal instrument designed to push tissue aside)
  • Behind the peritoneum, some the large blood vessels of the body are seen.
  • Some of the blood vessels are gently pulled to the side, others are tied off (ligated).
  • The spine is now seen from the front.
  • The disc is removed with a surgical knife and specialized instruments.
  • A spacer, bone or a bone-like material (bone substitute) are placed into the space where the disc was removed from (disc space). Sometimes other materials are added to increase the chance for a fusion to occur.
  • The retractors are removed and the peritoneum allowed to slide back to its normal position.
  • The rectus muscle and its fascia (envelope) are closed.
  • The skin is closed.
  • A bandage (dressing) is placed over the site of the surgery.
  • The patient is carefully placed on their stomach.
  • The low back is cleaned with a sterile surgical antiseptic solution
  • Sterile surgical sheets (drapes) are placed around the area.
  • The surgeon makes a cut (incision) over the spine.
  • The tissue under the skin is opened.
  • The muscles are separated from the bone and pulled out of the way
  • The lamina bone and spinous process are now seen
  • With the help of an X-Ray machine, Titanium screws are placed into the pedicle (bone bridge between the body of the vertebra and the arch of the vertebra) of the vertebra above and below the disc from both sides.
  • Titanium rods are secured to the screws and placed vertically between them.
  • Bone and other materials are placed next to the screws and rods between the “wings” of the vertebrae (transverse processes).
  • The tissue and skin is closed.
  • Sterile bandages (dressings) are placed on the wound.
  • The patient is awoken from Anesthesia and brought to the Recovery Room, where often more X-Rays are taken.

 

      3. Posterior Lumbar Interbody Fusion (PLIF)

  • An intravenous catheter (IV) is started and antibiotics are given
  • The patient is taken to the Operating Room.
  • The patient is placed on the back (supine) and a General Anesthetic is given.
  • The patient is carefully placed on the stomach (prone).
  • The low back is cleaned with a sterile surgical antiseptic solution.
  • Sterile sheets (drapes) are placed around the surgical area.
  • The surgeon makes a cut (incision) over the spine.
  • The tissue under the skin is opened.
  • The muscles are separated from the bone and pulled out of the way
  • The lamina bone and spinous process are now seen. They are both removed with specialized instruments.
  • The dura (lining of the spinal cord) and spinal nerves are seen.
  • The surgeon makes sure the dura and spinal nerves are free of compression.
  • The disc located underneath the dura and spinal nerves is partially removed.
  • Typically two spacers, as well as bone or a bone-like material (bone susbstitute) is place in the disc space.
  • With the help of an X-Ray machine, Titanium screws are placed into the pedicle (bone bridge between the body of the vertebra and the arch of the vertebra) of the vertebra above and below the disc from both sides.
  • Titanium rods are secured to the screws and placed vertically between them.
  • Bone and other materials are placed next to the screws and rods between the “wings” of the vertebrae (transverse processes).
  • The tissues and skin are then closed.
  • The patient is carefully turned on their back (supine) and awoken from Anesthesia.
  • The patient is transported to the Recovery Room, where often more X-Rays are taken.

 

4. Transforaminal Lumbar Interbody Fusion (TLIF)

  • An intravenous catheter (IV) is started and antibiotics are given
  • The patient is taken to the Operating Room.
  • The patient is placed on the back (supine) and a General Anesthetic is given.
  • The patient is carefully place on the stomach (prone).
  • The low back is cleaned with sterile surgical antiseptic solution.
  • Sterile plastic sheets (drapes) are placed around the surgical site.
  • The surgeon makes a cut (incision) over the spine.
  • The tissue under the skin is opened.
  • The muscle is carefully removed from the bone and pushed aside.
  • The spinous process and lamina bones are visible.
  • A portion or all of the spinous process and lamina bones are removed.
  • The dura and the spinal nerves are seen.
  • The surgeon makes sure the dura and spinal nerves are free of compression.
  • The area above the spinal nerve (foramen) is freed up.
  • The disc is removed from this area.
  • A spacer, bone or bone-like material (bone substitute) is placed into the disc space.
  • With the help of an X-Ray machine, Titanium screws are placed into the pedicle (bone bridge between the body of the vertebra and the arch of the vertebra) of the vertebra above and below the disc from both sides.
  • Titanium rods are secured to the screws and placed vertically between them.
  • Bone and other materials are placed next to the screws and rods between the “wings” of the vertebrae (transverse processes).
  • The tissues and skin are then closed.
  • The patient is carefully turned on their back (supine) and awoken from Anesthesia.
  • The patient is transported to the Recovery Room, where often more X-Rays are taken.

      5. Extreme Lateral Interbody Fusion (XLIF)

  • An intravenous catheter (IV) is started and antibiotics are given
  • The patient is taken to the Operating Room.
  • The patient is placed on the back (supine) and a General Anesthetic is given.
  • The patient is carefully placed on their side.
  • The side of the abdomen (flank) is cleaned with a sterile surgical antiseptic solution.
  • The surgeon makes a small cut (incision) of the flank.
  • The patient’s spinal cord and spinal nerves are usually monitored for their function during this surgery (neuromonitoring).
  • Dilating tubes (plastic tubes which are dull and make a track for other instruments) of increasing sizes are placed.
  • A minimally invasive retractor system is placed all the way down to the spine.
  • The disc is removed with special instruments
  • A spacer, bone or bone-like material is placed into the disc space.
  • At this point, the surgeon may have options:
  1. Place a titanium plate and screws over the disc space, connecting the vertebrae above and below the disc.
  2. Close the incision, and place screws and rods minimally invasively over the back of the spine at the site of the fusion.
  • The retractor is now removed.
  • The fascia, tissue and skin are closed
  • The patient is turned on the back and awoken from Anesthesia.
  • The patient is now brought to the Recovery Room.

      6. Posterior-Lateral Lumbar Fusion (PLF)

  • An intravenous catheter (IV) is started and antibiotics are given
  • The patient is taken to the Operating Room.
  • The patient is placed on the back (supine) and a General Anesthetic is given.
  • The patient is carefully place on the stomach (prone).
  • The low back is cleaned with sterile surgical antiseptic solution.
  • Sterile plastic sheets (drapes) are placed around the surgical site.
  • The surgeon makes a cut (incision) over the spine.
  • The tissue under the skin is opened.
  • The muscle is carefully removed from the bone and pushed aside.
  • The spinous process and lamina bones are visible.
  • The “wings” of the vertebra are located.
  • Bone or bone like material is placed between the wings
  • With the help of an X-Ray machine, Titanium screws are placed into the pedicle (bone bridge between the body of the vertebra and the arch of the vertebra) of the vertebra above and below the disc from both sides.
  • Titanium rods are secured to the screws and placed vertically between them.
  • Bone and other materials are placed next to the screws and rods between the “wings” of the vertebrae (transverse processes).
  • The tissues and skin are then closed.
  • The patient is carefully turned on their back (supine) and awoken from Anesthesia.
  • The patient is transported to the Recovery Room, where often more X-Rays are taken.

      7. Axial Lumbar Interbody Fusion (Axia-LIF)

  • An intravenous catheter (IV) is started and antibiotics are given
  • The patient is taken to the Operating Room.
  • The patient is placed on the back (supine) and a General Anesthetic is given.
  • The patient is carefully place on the stomach (prone).
  • The tailbone area is cleaned with sterile surgical antiseptic solution.
  • Sterile plastic sheets (drapes) are placed around the surgical site.
  • The surgeon makes a cut (incision) over the side of the coccyx.
  • A small metal rod is placed underneath the tailbone and advanced upward until it makes contact with the S1 Vertebra. This is done with the help of an X-Ray machine.
  • Dilator tubes are placed over the metal rod to widen the area
  • A larger hollow rod is placed over the dilator tubes, which are withdrawn.
  • A drill is placed through the larger hollow rod to drill a hole through the S1 Vertebra until it reaches the L5/S1 disc
  • The core of the L5/S1 disc is removed and bone fusion material placed.
  • A hole is drilled into the L5 Vertebra and a screw placed across the L5/S1 disc.
  • By turning the screw, the L5/S1 disc is raised.
  • The screw is secured
  • All devices are removed
  • The patient is carefully turned on their back
  • The patient is awoken from Anesthesia and brought to the Recovery Area for observation.

How long does a Lumbar Fusion take to complete?

Depending on the different types of Lumbar Fusion surgeries listed above, it can take 2-4 hours or more to complete this surgery.

What is the recovery like from a Lumbar Fusion surgery?

Here are some of the steps of the recovery process:

  1. The patient is usually admitted to the hospital for at least an overnight stay, often 2-3 days.
  2. A low back brace is often used.
  3. A physical therapist may help with the initial recovery after surgery.
  4. After discharge from the hospital, specific instructions on activity are given. Lifting, bending, and twisting are often limited.
  5. A low back brace will often be recommended for several weeks or more after the surgery.
  6. The cuts (incisions) often take 4-6 weeks to heal depending on the type of Lumbar Fusion surgery.
  7. The surgeon will usually reevaluate the patient within several weeks. Often new X-Rays are taken at that time.
  8. The process of a full spinal fusion to develop may take 6 months to 1 year to complete. This does not mean that a patient would necessarily have pain during that process.

What benefit can patients gain from a Lumbar Fusion?

The benefit from a Lumbar Fusion depends on the original problem for which the spinal fusion was done for. Here are some possible improvements:

  1. Improved leg pain, numbness or weakness
  2. Improved stability of the low back
  3. Improved low back pain after the healing is complete

Even after a complete bone fusion of the spine has occurred, some of the original symptoms may remain. Some patients develop new spine symptoms.