If you have had a lumbar disc surgery, does that mean you will have a fusion surgery in
the future?
More specifically, if you have a lower back discectomy surgery, does that mean you will
have a more significant fusion operation in the future?
As a spinal surgeon, I know that is a possibility,
but how frequently does it really happen?
This is the best way I can answer that question.
Do you have more than a 50% chance of having a fusion operation after you have had a discectomy surgery?
The answer is a definitive no.
Before we get into the specifics, we do need to make sure everybody understands the difference
between these two operations.
Discectomy means removing a piece of disc from the back, that is a source of pain.
Most the time, the reason you would have this surgery is because the disc component is pressing
on a nerve and causing a very defined pain, numbness, and weakness pattern.
Statistically, properly chosen patients who undergo discectomy surgery have about a 95%
chance of success after the operation.
Success being defined as a significant decrease in pain and the ability to return back to
normal functions.
Please note, there may still be some residual numbness and some pain, but the person is
getting back to activities.
Currently there is about 450,000 lumbar discectomies being performed in the United States on an
annual basis.
A fusion surgery is different.
Fusion means making the body think 2 separate bones are actually a broken bone, and then
body then mends these 2 broken bones together.
The reason fusions to the lower back are performed is because abnormal movements between the
bones cause intermittent or constant irritations of the nerves near these bones.
The medical term for this condition is instability.
Instability can be caused by a congenital problem, degeneration, and even more serious
conditions like broken bones, cancer, or infections.
Fusions are much bigger operations, and unfortunately not as predictable in their ability to return
people back to full activity compared to a discectomy.
Latest data indicates approximately 200,000 elective lumbar fusions
being performed in the United States annually.
If you just take the raw number, you can mistakenly think that anybody with a discectomy
will have a moderate chance of having a fusion operation at a later date.
But the numbers are misleading, because many of the lumbar fusion operations are being
performed by other diagnoses such as scoliosis, spondylolisthesis, spinal stenosis, and more
serious conditions including cancer and infection.
In March 2019, a paper was published by Castillo, et al from the University of Chicago Medical
Center.
While it was a retrospective review, it followed approximately 200,000 discectomy patients,
to identify the rates these patients will have lumbar fusions, compared to a matched group
of patients with similar diagnoses who did not have any operation at all.
While the patient’s with discectomy did have a higher rate of fusions overall compared to patients who never had an operation, the
actual percentage of patients with prior discectomies who ending up having fusions after 10 years
was still less than 9%.
The author compared their data to other reports.
Depending on the country of origin, the fusion rates could be significantly lower.
A study from Finland had around 5%.
There has been other studies following discectomy with fusion rates significantly less than
5%.
The bottom line is the rate of fusion surgery after discectomy is not very high.
Another factor that must be considered is the changing numbers of fusions that are being
performed in the United States compared to the past. When comparing the data
from 2004, to 2015, there has been a 62% increase in the use of fusions In the United States.
While there can be some changes related to the aging of the population, we cannot explain the significant increase
in the use of this technique solely based on clinical outcomes.
There has been enough population studies to show that despite increasing utilization of advanced
spinal technologies and spinal operations, it has not resulted in any better clinical
outcomes, return to work, return to function, or improved overall healthcare parameters.
Costs have significantly gone up.
Various entities have generated significant revenue from this trend.
But, the health of the US population did not improve.
Its no wonder the payors of these very expensive spinal fusion treatments are questioning their efficacy
and justification.
Sorry to digress, and lets get back to the main point of the video.
To summarize, while discectomy is a beneficial surgical treatment for the right patient,
the concerns for needing a future spinal fusion should be taken into the context of the statistics.
From a large population standpoint, the chance of needing fusion surgery after a lumbar discectomy
is less than 10% over 10 years, in the US.
Its even less in other first world industrial nations.
The low rate of additional fusions has also been my experience.
The vast majority of my patients did well after discectomy, especially at the L5-S1
level.
Fusion in my practice was limited to patients who had instability secondary to spondylolisthesis,
multiple recurrent disc herniations, or in a more serious conditions of infection,
fracture, or tumor.
If you are having discectomy surgery, while there is a potential for a fusion at a later
time, the risks are relatively small.
But please have this discussion with your surgeon.
Thanks for watching.
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