This is a very difficult question to answer, as the issues can be quite varied. In general, spine surgery is rarely an emergency situation. The decision to undergo spine surgery is often related to the level of pain and dysfunction that a patient feels. How willing the patient is to put up with the disability caused by pain and dysfunction is also an important factor.
Many conditions of the spine that cause pain resolve on their own within six months. Therefore, we rarely perform surgery for such conditions prior to that point. Before considering surgery, it is important that the patient has undergone a thorough nonsurgical treatment program. If symptoms have failed to improve despite nonsurgical treatment, surgery may be considered.
The presence of severe or progressive neurologic deficit usually demands surgical attention more quickly. The specialists at CCSI know that if a patient develops progressive neurologic changes, then surgery may become more urgent or even emergently needed. Neurologic deficit includes progressive numbness or weakness, difficulty walking, numbness in the groin area, or difficulty controlling bowel and bladder function. If any of these symptoms occur, contact your doctor immediately.
Only rarely must surgery be done immediately. Interestingly, the type of surgery required in an urgent situation is usually no different than the type of procedure performed if the patient waits. In other words, one does not "burn the bridge" by waiting. It must be said though, that the longer a severely disabling condition continues, the longer the recovery process may take and the less complete the recovery seems to be.
Again, speaking in generalities, the pain from a spinal condition will tend to wax and wane in severity. Conditions may remain very stable over many years or may gradually deteriorate over time. It is best to assess your own situation and how your condition has changed over time to perhaps help predict the future.
Any condition that has gone on for six months to a year is most certainly chronic in nature. Decide for yourself if you can live with the condition in that state. Consider honestly how your "Quality of Life" is affected by the condition. Will this be acceptable for the long run?
Our philosophy at CCSI is to manage spinal disorders aggressively utilizing nonsurgical methods. Many times this can avoid the need for surgery in the future. If the patient does not get better, and does not feel that they can live with the severity of their symptoms, surgery will be discussed. It is indeed the option of last resort. If surgery is elected, a comprehensive approach with several surgical specialists, employing the latest and safest techniques, will be utilized for your problem.
Restrictions are certainly placed on a patient during recovery from fusion surgery. Many of these restrictions will be lifted between three and six months after surgery. All restrictions will be lifted before one year.
At CCSI, we do not believe that permanent restrictions should be placed on a patient after spine fusion surgery. Only in rare circumstances is a patient unable to return to virtually all reasonable activities.
Activities including uncontrolled collision and high impact sports, aggressive twisting racquet sports, or golf must be more carefully considered. The adage "You Pay to Play" applies well here. Having said this however, we strongly advocate the importance of good body mechanics, a comprehensive rehabilitative program, weight management, and a healthy dose of "common sense". To support our patients in this pursuit, we provide an ongoing rehabilitative program and visit with them annually to review their progress.
Most fusion surgeries involve the fusion and immobilization of only one or two levels. This does not appreciably limit ultimate flexibility. Indeed, with successful fusion and resultant pain relief, many patients find that they are more mobile and functional even if they have given up a slight amount of the maximal range of motion. Clearly, this is because they do not hurt as much any more!
The long segment scoliosis fusion can result in a greater amount of motion loss. At CCSI, new techniques are used that can limit the number of levels fused for scoliosis and therefore limits the loss of motion. The simple answer to this question however remains that the fused vertebrae will no longer move. It is clear therefore that some loss of motion must occur. The real issue seems to be whether this motion is critical to day-to-day function.
In most cases, the type of motion lost does not prevent most basic activities of daily living and sports. By comparison, if you consider yourself a great athlete, or are involved in excessive, uncontrolled types of collision sports, a fusion surgery must be carefully considered.
Rod instrumentation to facilitate fusion
The purpose of a thoracic or lumbar brace is in part to help to immobilize and support the spine after a fusion surgery. With the advent of newer and stronger internal fixation techniques, it has become less necessary to rely upon the brace for immobilization. As such, the doctors CCSI rarely utilize a rigid brace. A soft brace or corset may help support the muscles and can be used when needed. Without the rigid brace, we feel that the patient can return to more normal activities more quickly, thus accelerating overall recovery.
It is unusual when hardware causes any sort of problem after surgery. Once the fusion has become solid, the hardware no longer has any function or necessity. Nevertheless, it requires further surgery to remove this hardware. Therefore, we do not routinely recommend its removal. In rare instances, the hardware can be a source of muscle irritation. In this case we may recommend hardware removal. Hardware is not removed until the fusion is totally solid, or about one year after surgery.
It is unusual for spinal hardware to cause future problems. Under rare circumstances, hardware can irritate the surrounding muscles and cause pain. In such circumstances hardware removal may help reduce muscle pain.
Prior to considering this, a hardware block (injection) oftentimes is helpful to confirm if hardware removal would benefit the patient. Surgery to remove hardware is not as involved as the surgery to implant it. The hospital stay following this procedure is usually one or two days. The patient can return to normal activities as tolerated without restrictions or a brace.
Most hardware utilized today is made from titanium metal or a polymer (plastic - like) material. These materials allow the patient to undergo an MRI or other imaging study in the future. CCSI remains at the forefront of hardware and materials technology. In fact, some of the implants utilized now actually are bioresorbable. This means that the body will reabsorb the implant after it has done its job!
Will fusing my spine cause damage to adjacent areas?
When vertebrae are mobilized in the fusion process, the stresses that the vertebrae would normally absorb are mechanically transferred to adjacent areas. This does cause some accelerated degeneration in adjacent regions over the years. The intervertebral discs immediately adjacent (one or two levels) to the fused area are at the most risk. Of course, all discs degenerate over time. Degeneration is a time dependent process. Likewise, the effect of additional adjacent stress due to fusion is also a time dependent process.
It is clear that during the process of harvesting bone graft local tissue trauma does occur. Studies have reported a 30 percent incidence of residual bone graft harvest site pain in patients after fusion surgery.
CCSI surgeons use many minimally invasive techniques to harvest bone graft that make the process less traumatic. In fact, many patients are not aware from which side their bone graft was harvested! Additionally, use of bone substitutes has become more reliable and successful. Specifically, bone morphogenetic protein (BMP) may lead the way to eliminate the need to harvest bone graft from the iliac crest. CCSI surgeons are now using BMP for properly indicated fusion surgeries. Surgeons no longer harvest iliac crest bone and are therefore eliminating the patient's pain and discomfort from this procedure altogether.
Individual considering the use of BMP should review 2014 NASS POSITION STATEMENT FOR rhBMP2