Marc Darrow, MD, JD.
In our practice we often see patients who are in severe back pain. Many have already been recommended to some type of fusion surgery. Their fusion surgery recommendation may be based on pain and it may be based on an MRI image that while showing degenerative changes in the spine, may not be showing what is the cause of the person’s pain. These people have an MRI, X-ray and/or scan that may show an inaccurate picture of what is causing their pain. What do I mean by inaccurate picture?
- The MRI cannot show muscle spasms from a simple back strain which can cause excruciating pain.
- Conversely, the MRI can show a large herniated disc which may be completely asymptomatic. But when people contact me about their back pain, they send in an MRI interpretation that is all about the disc herniation and that they say, is why they are having fusion surgery at the insistence of their doctor. As you will read in the research below, this recommendation to surgery is considered “unsupported enthusiasm for the surgical management of discogenic back pain.”
- I discuss this further in my article: “My MRI is suggesting back surgery.” In this article is a discussion of a new paper on the “catastrophization effects of an MRI report on the patient”
This article is about injection therapy that may be able to help with your back pain and help you avoid a surgical fusion. So let’s look first at why you were told to have a fusion.
The initial enthusiasm about new surgical methods including lumbar spinal fusion was followed by certain concerns about their clinical usefulness and their results.
This is from an April 2018 study. (1)
“(Spinal) Fusion is one of the most commonly performed spinal procedures, indicated for a wide range of spinal problems. Elimination of motion though results in accelerated degeneration of the adjacent level, known as adjacent level disease. Motion preservation surgical methods were developed in order to overcome this complication. These methods include total disc replacement, laminoplasty, interspinous implants and dynamic posterior stabilization systems. The initial enthusiasm about these methods was followed by certain concerns about their clinical usefulness and their results.”
In this study surgeons reassessed a few of the most commonly performed spinal fusion alternative surgical procedures. “(Motion preservation surgical methods) include total disc replacement, laminoplasty (cutting away of bone and other pressure causing material on the nerves), interspinous implants (spacers to hold nerve pathways open) and dynamic posterior stabilization systems (not a fusion but similar).”
Looking more closely at the comparison between interspinous spacers and laminectomy or laminotomy surgery, surgeons favored the spaces as “an effective, less invasive treatment option for patients with symptomatic lumbar spinal stenosis.” This is discussed in a February 2021 paper in the International journal of spine surgery (12). The authors of that study also write that both interspinous spacer placement and laminectomy or laminotomy have risks of complications and in “a direct comparison of complications between the two procedures,” they found 44.4% of patients in the interspinous spacer placement group experienced Device-specific complication (DSC) with 11.1% of patients experiencing device malfunction or misplacement (DM), 21.1% experiencing a spinous process fracture (SPF), 20.1% requiring device explantation (DE), and 24.3% requiring subsequent spinal surgery (SSS). Here the authors suggested ” Rates of 2-year Device-specific complication (DSC) within interspinous spacer and cumulative risk associated with these complications should be considered further as they likely represent need for additional procedures for patients . . . ”
Radiculopathy, stenosis and instability – more on adjacent segment disease following lumabr spinal fusion surgery
The previous 2018 study above discusses the problems of the elimination of motion caused by the spinal fusion and the resulting adjacent level or adjacent segment disease. Let’s move forward to an October 2021 paper which wrote (2) : “Spinal fusion is the most widely accepted treatment for lumbar disc degenerative disease. However, it has been associated with adjacent segment degeneration as a potential long-term sequel especially in those with preoperative risk factors, which may cause aberrant stress forces in these segments and lead to adjacent level degeneration. (The fixation at certain spinal levels now shifts the and creates new pressure patterns on the next available segment that has not been fused causing problems that joint.) Adjacent segment pathology can include adjacent segment degeneration and adjacent segment disease, although a clear and consensual definition of adjacent segment disease is missing. In most studies, adjacent segment degeneration is defined as radiographic changes in the intervertebral discs adjacent to the surgically treated levels, whereas adjacent segment disease is defined as the pathologic process associated with disc degeneration leading to clinical symptoms, such as radiculopathy, stenosis and instability. Nevertheless, there are a few reports considering reoperation rate as being the most reliable parameter to define adjacent segment disease, despite clinical symptoms.”
Not everyone is a good candidate for lumbar spinal fusion surgery
While they appear to be realistic surgical options for a complicated spinal problem, the initial enthusiasm about fusion surgery was followed by certain concerns about their clinical usefulness and their results.
- Not everyone is a good candidate for this type of spinal surgery: The main indications for total disc replacement are degenerative disc disease, but the numerous contraindications for this method make it difficult to find the right candidate.
- Application of interspinous implants has shown good results in patients with spinal stenosis, but a more precise definition is needed regarding the severity of spinal stenosis up to which these implants can be used.
- Laminoplasty has several advantages and less complications compared to fusion and laminectomy in patients with cervical myelopathy/radiculopathy.
- Dynamic posterior stabilization could replace conventional fusion in certain cases, but also in this case the results are successful only in mild to moderate cases.”
Repeat spinal surgery after lumbar fusion is a treatment option with diminishing returns.
One of the concerns was the need to repeat the spinal surgery, to fix something the spinal surgery made worse or did not correct the first time. Repeat spinal surgery falls under the laws of diminishing returns. This was in the Asian Spine Journal (3) :
- “Repeat spinal surgery is a treatment option with diminishing returns. Although more than 50% of primary spinal surgeries are successful, no more than 30%, 15%, and 5% of the patients experience a successful outcome after the second, third, and fourth surgeries, respectively“
- “The decision to perform surgery in patients with predominantly axial (mechanical low back pain) pain should be made with the understanding that many patients may not respond to the treatment.”
A study in Journal of back and musculoskeletal rehabilitation (4) offers the same warnings:. “Four to fifty percent of patients will develop Failed Back Surgery Syndrome following lumbar spine surgery. Repeated surgeries lead to escalating costs and subsequent decreases in success rate.”
What is being said in the above research and the below research is, spinal fusions may not be as helpful as doctors thought.
In a 2013 editorial from the Department of Neurosurgery, University of Virginia, doctors found: “Without prospective trials with non-conflicted surgeons and standardized selection criteria, the true role for sacroiliac joint fusion procedures in the treatment of chronic lower back pain will remain murky. The consequences of the unsupported enthusiasm for the surgical management of discogenic back pain still negatively impacts the public perception of spinal surgeons.(5)
Why are total disc replacement surgeries becoming much less popular?
In April 2019, a paper in the journal International orthopaedics (6) found conflicting and confusing recommendations patients and doctors were being given in the medical research concerning the aspects of fusion and total disc replacement surgery.
In this paper, 69 research studies were examined exploring the benefit or lack of benefit of total disc replacement. In 40 of the 69 papers, the general assessment was positive for a total disc replacement procedure, five were negative towards the total disc replacement, 24 papers could not clearly decide if the procedure was helpful or not.
The long term results of total disc replacement were examined in 11 studies. In 7 of the papers, total disc replacement was seen in a positive light. In the other four studies total disc replacement benefits were not clearly seen.
The research came to this suggestion for doctors: “It is concluded that problems with anterior surgery, imbursement (cost, reimbursement, coverage) policy, and potential problems with salvage surgery are major reasons for losing popularity of total disc replacement policy surgery.”
“Poor outcomes after spine surgery are so common that practitioners in this area have created a unique term for this condition: failed back surgery syndrome.”
This is highlighted segments from the University of Minnesota’s Department of Orthopedic Surgery’s research in ClinicoEconomics and outcomes research:
- “Back pain is complex to diagnose and expensive to treat . . .inaccurate diagnosis leading to treatments that do not target the underlying disease exposes patients to risk without benefit.
- Poor outcomes after spine surgery are so common that practitioners in this area have created a unique term for this condition: failed back surgery syndrome.
- Although the number of reported studies of lumbar fusion is large, well-controlled studies have shown that only approximately 60% of patients derive clinically important benefits from lumbar surgery.”(7)
The 60% may be considered an improvement over results found in other studies. In a heavily cited 2006 landmark study from the Schulthess Clinic in Zurich Switzerland, doctors reported on 17 patients with chronic low back pain, with a positive response to specific diagnostic tests for sacroiliac joint dysfunction who a bilateral sacroiliac fusion procedure.
At the time of follow-up (on average 39 months after surgery),
- Of the 17 patients: three patients reported moderate or absent pain
- Eight had 8 marked pain and
- 6 severe pain.
- Eighteen percent of the patients were satisfied, but in the other 82% the results were not acceptable.
- Reoperation was performed in 65% of the patients.
- Our results with bilateral posterior SIJ fusion were disappointing, which may be related with difficulties in patient selection, as well as with surgical technique. Better diagnostic procedures and possibly other surgical techniques might provide more predictable results, but this remains to be demonstrated.(8)
Back to MRI assessment of the cause of low back pain
A new patient will come into our office with severe back pain and an MRI, X-ray, and/or scan that can show an inaccurate picture in determining a treatment plan. For instance, a patient can have muscle spasm from a simple back strain which can cause excruciating pain and may limit one’s ability to walk or even stand. Conversely, a large herniated disc may be completely
painless. However, it is often the large herniated disc that will send the patient for surgery when that will not at all help the pain.
Is MRI to blame? Doctors at the Leiden University Medical Center in the Netherlands questioned whether or not MRI has any value in determining sciatica treatment or diagnosis and why surgeons rely so heavily on the readings.(9) We often see patients who visited the doctor who had unsupported enthusiasm for sacroiliac joint dysfunction surgery because they had an MRI showing a herniation between the L5 and S1 vertebrae and a prognosis of impending surgery.
In our practice, we often see patients who have a diagnosis of herniated discs based on pain in their back and pain in their legs. Upon a physical examination, we often find that it is not a disc problem but referral pain from a ligament, meaning they have a sprain. So the pain from “Degenerative Disc Disease” is not from the disc but from instability caused by ligament laxity
surrounding the vertebrae.
I discuss the challenges of MRI accuracy in my article: My MRI is suggesting back surgery
Complicated fusion surgery can be avoided if we look at the spinal ligaments
Many times a patient will come into our office with a nondescript diagnosis of back pain and/or accompanying hip pain. Despite numerous treatments which may include epidural steroid or cortisone injection, the patient still has pain and now has been recommended to a spinal procedure because something has shown up an an MRI. But is it in fact the disc problems on MRI causing the patient’s pain? Medical investigators are asking, “maybe we should look at the spinal ligaments?”
In a paper Japanese doctors came up with a scoring system to help clinicians determine if sacroiliac joint pain was originating from the posterior longitudinal ligament of the spine.
- This pain manifests in not only the buttocks but also the groin and lower extremities and may be difficult to discern from pain secondary to other lumbar disorders, such as degenerative disc disease and stenosis – problems that usually mean surgery.(10)
The ligaments are important as attested to by researchers at University of Mississippi Medical Center. (11) “As important as the vertebral ligaments are in maintaining the integrity of the spinal column and protecting the contents of the spinal canal, a single detailed review of their anatomy and function is missing in the literature.”
- Ligaments and tendons are weakened by age, overuse syndrome, or injury. In the sacroiliac joint, because it supports the torso and has large nerves running through it all the way to the feet, these injuries to the sacroiliac ligaments can mimic other injuries such as disc herniation and lead to an incorrect diagnosis which could lead to an unnecessary lower back surgery. For more on this subject please see my article “When a simple sprain is mistaken for degenerative disc disease“
Why not get a consultation to see if the ligaments are the cause of your back pain before your embark on surgery?
1 Gelalis ID, Papadopoulos DV, Giannoulis DK, Tsantes AG, Korompilias AV. Spinal motion preservation surgery: indications and applications. Eur J Orthop Surg Traumatol. 2018 Apr;28(3):335-342. doi: 10.1007/s00590-017-2052-3. Epub 2017 Oct 6. Review. PubMed PMID: 28986691.
2 Pinto EM, Teixeira A, Frada R, Atilano P, Miranda A. Surgical risk factors associated with the development of adjacent segment pathology in the lumbar spine. EFORT Open Reviews. 2021 Oct;6(10):966-72.
3 Daniell JR, Osti OL. Failed Back Surgery Syndrome: A Review Article. Asian Spine J. 2018;12(2):372-379.
4 Clancy C, Quinn A, Wilson F. The aetiologies of failed back surgery syndrome: a systematic review. Journal of back and musculoskeletal rehabilitation. 2017 Jan 1;30(3):395-402.
5 Shaffrey CI, Smith JS. Editorial: Stabilization of the sacroiliac joint. Neurosurg Focus. 2013 Jul;35(2 Suppl):Editorial. doi: 10.3171/2013.V2.FOCUS13273.
6 Kovač V. Failure of lumbar disc surgery: management by fusion or arthroplasty?. Int Orthop. 2019;43(4):981–986. doi:10.1007/s00264-018-4228-9
7 Polly DW, Cher D. Ignoring the sacroiliac joint in chronic low back pain is costly. ClinicoEconomics and Outcomes Research: CEOR. 2016;8:23-31. doi:10.2147/CEOR.S97345.
8 Schütz U1, Grob D. Poor outcome following bilateral sacroiliac joint fusion for degenerative sacroiliac joint syndrome. Acta Orthop Belg. 2006 Jun;72(3):296-308.
9 el Barzouhi A, Vleggeert-Lankamp CL, Lycklama à Nijeholt GJ, Van der Kallen BF, van den Hout WB, Koes BW, Peul WC; Leiden-Hague Spine Intervention Prognostic Study Group. Predictive value of MRI in decision making for disc surgery for sciatica. J Neurosurg Spine. 2013 Dec;19(6):678-87. doi: 10.3171/2013.9.SPINE13349. Epub 2013 Oct 18.
10 Kurosawa D, Murakami E, Ozawa H, Koga H, Isu T, Chiba Y, Abe E, Unoki E, Musha Y, Ito K, Katoh S, Yamaguchi T. A Diagnostic Scoring System for Sacroiliac Joint Pain Originating from the Posterior Ligament.Pain Med. 2016 Jun 10. pii: pnw117..
11 Butt AM, Gill C, Demerdash A, Watanabe K, Loukas M, Rozzelle CJ, Tubbs RS. A comprehensive review of the sub-axial ligaments of the vertebral column: part I anatomy and function. Childs Nerv Syst. 2015 May 1.
12 Welton L, Krieg B, Trivedi D, Netsanet R, Wessell N, Noshchenko A, Patel V. Comparison of adverse outcomes following placement of superion interspinous spacer device versus laminectomy and laminotomy. International Journal of Spine Surgery. 2021 Feb 1;15(1):153-60.