The Indications For Fusion For Lower Back Pain

Dr. Corenman Discusses the Indications for Fusion for Lower Back Pain

Lower back pain is typically caused by a degenerative disc. As noted in the discussion of the anatomy and physiology of the disc (how the disc is designed on the microscopic level) on this web site, the disc develops degenerative changes as the nucleus (the jelly in the center of the disc) loses pressure and the wall of the disc (the annulus) buckles and tears.

The back of the disc wall is filled with pain receptors and they send pain signals to the brain when this wall is torn. Most of the time, these signals are mild to moderate in intensity. Physical therapy, core strengthening, certain activity restriction and medications including non-steroidal anti-inflammatories can mute these signals. These modalities and restriction reduce the intensity of the pain and make life “livable”.

The disc can continue to degenerate and develop “micro instability.” This causes abnormal forces to occur and chronically overloads the rings of the annulus. Multiple tears in these rings allow the disc to lose height and integrity. The inner jelly (nucleus) dries up further causing a greater drop in height. At this stage, the back can “go out” with certain activities. If these activities are avoided, the individual can live a guarded but acceptable life using the therapy noted above.

The disc can continue to degenerate and lose the ability to act as a shock absorber. The cartilage of the endplates erodes away. Damage to the bony endplates of the vertebra occurs as the bone endplate is overloaded with impact activity. Fractures of the endplate occur in a condition called isolated disc resorption or IDR.

Endplate healing can occur but the cause of the fracture (the loss of shock absorption) will still be present. Any activity in the next sixty days while the fracture is healing will disrupt the repair. Of course, no one is going to be placed in a body cast and lie perfectly flat while the fractures are in the state of repair. Also, the initial cause of the fracture (lack of shock absorption) is still continuously present. Any impact activity will cause further injury to the endplates.

You can see how the endplates of the vertebra would be in a continuous state of repair and disruption with any activity- even the act of stepping off a curb. This causes chronic inflammation, which is a setup for chronic pain. Not everyone with this exact condition has severe chronic lower back pain and some with this disorder may even not even notice pain. The answer why some will and some will not have pain will be a Nobel Prize winning answer.

It should be noted that not every disc will follow this degenerative pattern and it is not inevitable that all discs will continue down this pathway. Even though the damage to the disc is permanent (there is no blood supply to heal the disc), most discs do not suffer the endpoint fate of IDR.

An important aspect of isolated disc disruption is that even though the condition is significantly painful, it is not dangerous (as long as there is no concordant significant compression of the nerves in the spinal canal- a different story). Isolated disc disruption will not put the individual in a wheelchair or cause paralysis. The pain is similar to an arthritic hip or knee in that use of the degenerative area is painful.

Of course, even though this pain is not dangerous, it is debilitating. If the pain is intolerable, the removal of the overloading forces and the repair of the vertebral integrity is essential to reduce the pain. Bone is designed to transmit force without injury to itself. The purpose of fusion in the lumbar spine is to make a living bridge of bone from one vertebra to the next. This is a wonderful way to transmit force to the next vertebra by inducing a fusion of living bone and eliminate what is left of the motion that causes the pain.

Now an argument is made that taking away motion of a segment will put stress on the next level above or below. The obvious counterargument is that the degenerative forces have already made this level relatively immobile. You have to remember that this highly degenerative level is already quite stiff and relatively fixed.

Generally the normal L5-S1 level has about 25 degrees of motion. With the presence of IDR, the remaining motion in this level typically is about 1-2 degrees. You can see that living with this degenerative disc will not change the already stressed the level above. Providing a fusion generally eliminates the lower back pain without any additional stress to the surrounding levels.

Are you a candidate for lumbar fusion?

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(Please keep reading below for more information on this topic.)

Issues with Artificial Disc Replacement (ADR)

The concept of the artificial disc replacement (ADR) was born to try to preserve or improve spine motion. The idea itself has merit but the current implants are not satisfactory. The design of the artificial disc is not at this point a good reproduction of the normal disc that it is designed to replace.

The current lumbar ADRs do not have any shock absorption capabilities and do not dampen motion of the disc space as a normal disc would. The ADR’s lack of these normal discal characteristics puts more stress on the replaced segment than it was designed to tolerate. In addition, if there was substantial wear of the original disc space before surgical replacement, the artificial disc will still not relieve the lower back pain if there is damage to the other structures such as the facets.

Another important fact to consider in a much worn out disc level such as with IDR is that the body had adapted for years to the loss disc height and of motion. Implanting an artificial disc in a very worn out segment will increase motion and increase the height of the disc. All the associated structures that have adapted to the vertebral collapse and stiffness will become stretched and dysfunctional, increasing back pain in spite of an ADR.

After placement of an ADR and aging, the vertebral bone can becomes osteoporotic (especially in females) and the artificial disc metal endplate can fracture the endplate of the vertebra. This will cause the ADR to subside into the bone. The biomechanics of the disc are lost with malalignment and pain ensues.

Another problem is that these discs have to be placed from the front through an incision through the belly, which has its own potential complications. See ALIF-anterior lumbar Interbody fusion for an understanding of the potential complications of an anterior approach.

This is why the current gold standard for treatment is a fusion for lower back pain. The procedure works in over 90% of correctly selected patients.

Fusion for Lower Back Pain Types

Fusions for lower back pain can be performed in various ways. Fusion can be performed from various approaches:

From the front (an ALIF or anterior lumbar interbody fusion)
From the side (an XLIF, DLIF or extreme (direct) lateral interbody fusion),
From the back (TLIF/transforaminal lumbar interbody fusion, PLIF/posterior lumbar interbody fusion), (PLF/posterolateral lumbar fusion)
From the front and back at the same time (a 360).

Each fusion has its own indications, risks and benefits. See the discussion of each fusion in the surgical section.

To discuss the indications for fusions for lower back pain in greater detail, please contact the office of Dr. Donald Corenman, spine surgeon and back pain specialist offering diagnostic and surgical second opinions to patients in the USA and around the world.

Related Content

Click to Enlarge. IDR (isolated disc resorption) of the L5-S1 disc. The arrow points to the damaged disc. The bone surrounding the injured disc is whiter due to fractures of the endplates.

Donald Corenman, MD, DC

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81 reviews

Eric S

Sep 26, 2021

by Eric S on Donald Corenman, MD, DC

Successful pars repair at 46 years old

Back in November of 2018 (at 46 years old) I came from Vancouver BC to have a pars repair done with Dr. Donald Corenman at the Steadman Clinic in Vail Colorado. I'm finally posting this review nearly three years later in late 2021. The reason I waited so long was I wanted to know the final result before I posted my review. Unfortunately in that time Dr. Corenman has retired. Nevertheless, I want to post this review of Dr. Corenman and his staff at the Steadman Clinic in their excellent treatment of my L5 pars interarticularis.

I fractured my pars at age 42 back in 2014 when rolling on the gym floor, and was denied treatment by the Canadian healthcare system, probably due to my age. First my GP told me there was no surgical option for a pars defect, which was quite incorrect! I tried to live with it, but the symptoms worsened (periodic random spine slippage and weeks of resultant pain after just bending over to tie my shoe, so I eventually learned to mostly squat and hardly bend). When I finally consulted with Canadian spine surgeons, I was told they believed my pars defect had been congenital (since birth). This was absurd, considering I had done extreme martial arts (including jiu jitsu) for years prior, as well as 5 years of reinforcing steel full time in my 20s, probably the hardest job on the back you can find. No pars defect like mine would possibly have allowed this--ergo it was impossible that I had had the defect since birth. I did however have an asymptomatic congenital spina bifida occulta that made me more susceptible to a pars fracture. In 2014 in one instant, I went from having the strongest back people I knew said they'd ever seen, to being unable to safely bend over and tie my shoe without a non-negligible risk of my spine slipping randomly (which would lead to weeks of pain after each occurrence). This was due to the unilateral L5 pars defect, otherwise known as spondylolysis. It was when lying in pain on the floor 4 years later after maybe the 6th spine slippage event post injury, that I had had enough, and resolved to have surgery. If Canada's "universal health care" said no, I would make lemonade from lemons, and find the very best surgeon in the world at pars repairs. That was Dr. Donald Corenman. Dr. Corenman back in 2018 ran a website https://neckandback.com/ that dedicated many pages to the science of every aspect of pars repairs, from eligibility (good discs on MRI), to best surgical techniques (minimal open compared to minimally invasive), best imaging to use (i.e., O-Arm with Stealth imaging vs. older fluoroscopy), the ideal amount of BMP to use and why not use too much or too little, and much more, all to do with pars repairs, pages upon pages of his site just on the pars, with scientific references and his own extensive expert opinion. As a health research statistician, I was very impressed with this. It was in stark contrast to the websites of other spine surgeons which barely gave the pars a word or two, focusing almost exclusively on fusions. I had found the best surgeon in the world for pars repairs, and so after Dr. Corenman personally screened my MRI to ensure my discs were healthy, I booked the surgery.

Being 46 years old at the time of surgery in 2018, with a 4-year-old pars fracture from 2014 combined with a congenital SBO meant my pars fragment was somewhat atrophied, but it was "very solid", said Dr. Corenman in the operative report. Nevertheless, it was challenging with two things to fix, the pars and SBO, and OR time was around 4 hours. Recovery over the following months was guided by a very clear "Spine binder" from the Steadman Clinic with strict rules of "no BLT" (no bending, lifting or twisting), and illustrated physiotherapy guidelines. They even warned patients to avoid fish oil supplements, which could excessively dampen inflammation and hence slow bone healing. They answered many questions I had during months of recovery, with responses coming from the very supportive Lori Fugate (then director of Dr. Corenman's practice), and Ehrich Bean (then physician's assistant at the practice), as well as a couple calls with Dr. Corenman himself after two of the CT scans. Ehrich Bean offered great advice for taking the spine binder conservatively due to the nature of pars repairs vs. fusions. The final post-op CT scan I had was a couple weeks ago at 34 months post-op, and Dr. Corenman had retired, but I got a very positive and informative call from Eric Strauch (current PA at the Steadman Clinic under Dr. Corenman's replacement there, and who had also worked with Dr. Corenman previously). The staff at the Steadman Clinic were extremely supportive all the way through the process. I should mention, the local Canadian spine surgeon did offer me very good post-operative support including antibiotics as needed to deal with a mild surface incision-site infection early on, booking numerous x-rays when I felt something was amiss, as well as booking all four of my post-op CT scans. I am very grateful for that support also.

My final result shows plenty of solid bone across the pars and a healed SBO, with my vertebral body now a solid bone ring instead of being broken at two places as it was pre-op. Does my spine hold up in the real world? You bet! I have recently dug and moved several yards of dirt and sand and gravel by myself (shovel and wheelbarrow!) to fix our water main, pulled roots from the yard, moved several "portable" (these are HUGE) air conditioners up several flights of stairs my myself, and lifted weights. I now run 2 miles (3.2 KM) several times weekly with a hard 100 meter dash in the middle. I bend deeply before each run I go on, with no spine slippage. My spine feels amazing. I can bend over to do exercise, or real word tasks, with no risk of spine slippage.

My sincere thanks to God, Dr. Donald Corenman, Lori Fugate, Ehrich Bean, Eric Strauch, and the Steadman Clinic, as well as the Canadian spine surgeon who offered me excellent post-operative care back in Canada. You have all given me a new lease on life.

Sincerely,
Eric S

Robert S

May 11, 2021

by Robert S on Donald Corenman, MD, DC

Back Fusion Surgery

I had my entire lumbar spine fused in November of 2018. I had scoliosis , with pinched nerves that were so painful I could hardly walk - and standing for more than a few minutes was impossible. Even sitting was painful.
The fusion surgery produced immediate relief! And the recovery was much easier than I expected.
To this day I can do all the activities I love from hiking, to standing in a stream fly fishing to riding my bike long distances - or just walking down the street with my wife.
Kudos to Dr. Corenman and his staff, (including the two Erics) for taking such good care of me!

Leslie R

Jul 9, 2020

by Leslie R on Donald Corenman, MD, DC

TLIF

I had my TLIF surgery on 6/24/2020 by Dr. Corenman, I can not say enough good things about the Dr or his staff. I was always treated with respect and explained everything throughly, that made it easy for everyone to understand. I highly recommend Dr. Corenman and the Steadman Clinic.

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Dr. Corenman Discusses the Indications for Fusion for Lower Back Pain

Are you a candidate for lumbar fusion?

Issues with Artificial Disc Replacement (ADR)

Fusion for Lower Back Pain Types

Related Content

About the Author: Donald Corenman, MD, DC