Permanent restrictions after spinal fusion
Permanent restrictions after spinal fusion are ensured to maintain spinal stability after the surgery providing an optimal time for the spine to heal.
On the other hand, these permanent restrictions can have a significant impact on the person’s professional and personal life due to the limitations it is associated with.
Spinal stability can be defined as the ability of the spine to limit the patterns of displacement that it can undergo under different physiological loads so as to not damage or stimulate the spinal cord and nerve roots and in addition to prevent any deformities or pain that can occur due to any structural changes.
On the other hand, spinal instability is when the spine loses this ability and undergoes excessive displacement that results in neurological deficit, deformity or pain.
Spinal fusion is an operation that is performed to treat spinal instability but this is not always the case as it is sometimes also used to treat degenerative spine diseases without any overt instability.
In this article we will understand what do we mean by the procedure of spinal fusion, indications of surgery, how is it performed, contraindications, complications and permanent restrictions after spinal fusion.
What is a spinal fusion surgery?
Spinal fusion can be defined as a surgical procedure during which two or more vertebrae are joined permanently into one solid bone that is, the intervertebral joint space is lost.
The goal of this operation is to stop the movement between two bones and the prevention of back pain. It is a technique that is designed to mimic the natural healing process of broken bones.
The vertebral column consists of 33 bones called vertebrae and these bones are separated by intervertebral discs. The intervertebral disc is made up of fibrous cartilage and lies between the vertebrae, joining them together.
This structure makes the vertebral column a flexible structure and acts as a shock absorber. This vertebral disc consists of two parts: the nucleus pulposus and annulus fibrosus.
The nucleus pulposus is a jelly like structure which is surrounded by the tough and collagenous annulus fibrosus.
Sometimes nucleus pulposus ruptures and breaks through the annulus fibrosus, this deformity is termed as disc herniation.
This usually takes place in the posterolateral direction and leads to irritation of the nearby spinal nerves resulting in a number of neurological and muscular symptoms. In this process of spinal fusion, instead of the intervertebral disc an extra bone is used to fill the joint space between the two separate vertebrae.
Sometimes metal plates, screws or rods can also be used in place of bone. During this procedure, the vertebrae are not actually fused but a condition is created for the spine to be able to fuse and this process takes almost 3 to 6 months (up to 18 months) to occur. There are certain other names that can be used for this process that include:
- Arthrodesis
- Anterior spinal fusion
- Posterior spinal fusion
- Vertebral interbody fusion
What are the indications of spinal fusion?
When talking about the indications of spinal fusion surgery, the most general indication is a low back pain that lasts for more than six months.
The other indications of this procedure include:
Mechanical pain is defined as a type of pain that increases with activities and gets better at rest. This pain is often associated with degenerative changes in the intervertebral disc or sometimes due to slippage of the spine, termed as spondylolisthesis.
If the people with this back pain do not get relief by the use of extensive non-surgical treatments such as medications, physical therapy or limits their ability to function in their day to day activities at work or at home, the option of spinal fusion is considered for these patients.
Spinal stenosis occurs when the space or the foramen in between the vertebrae begins to narrow thereby reducing the space for the nerve roots to pass.
This process can take place within the spinal canal through which the spinal cord passes or in the intervertebral foramina from where the spinal nerves exit the spinal canal.
Depending on the degree of narrowing, this can lead to compression of the spinal nerve or spinal cord and cause pain, tingling, numbness or weakness.
When the patient shows symptoms of neurological deficits such as numbness or weakness, paresthesia, surgery may be considered if non-surgical treatments have not proven to be beneficial.
Fractures are considered to be one of the most common cause of constant back pain and tenderness that does not heal even at rest and causes limitations of functions and activities for the person.
These fractures usually occur in the thoracic part of the spine especially in the lower part or in the lumbar part.
Scoliosis can be defined as a deformity of the spine in which a person’s spine has a sideways curve that is usually “S” or “C” shaped over three dimensions. In some cases, this curvature remains stable while in others it may increase with time.
If this deformity is mild, it does not lead to severe problems but severe cases can affect breathing as it can put pressure over the vital organs such as heart or lungs.
Management includes watchful observation, bracing and if these processes do not work, surgery is indicated.
Tumors of the spine can be benign (non-cancerous) or malignant (cancerous). These tumors are abnormal growths of tissue that are found inside the spinal column.
These tumors are rarely primary and mostly occur as metastasis from sources such as breast, prostate, lung, thyroid, and kidney cancers.
This tumor can be removed by surgical excision and then spinal fusion is performed to reconstruct and stabilize the spine.
How is the surgery performed?
There are two methods by which this surgery can be performed:
- Anterior lumbar interbody fusion : performed through the abdomen
- Posterior fusion: performed from the back.
After making the incision, the muscles and structures are moved to the side for a clearer access to the bony spine followed by the removal of damaged structures or painful disks if any. For fusion, pieces of bones called as bone grafts taken from other parts of the body such as the hip or pelvis can be used.
Screws, plates or rods can also be used. Sometimes instead of these, bone morphogenetic protein is placed into the spine.
What are the contraindications of spinal fusion surgery?
The contraindications of this procedure are absolute and relative. The absolute contraindications consist of:
- A neoplasm that is diffused and involves different levels of the spine such that no particular segment exists for engagement of instrumentation.
- Severe osteoporosis where the bones are too weak and would not support instrumentation
- Infection involving soft tissues adjacent to the spine or epidural infection that has not invaded the vertebral bone or disks, if in this condition fusion is performed, it would be at risk for infection.
Relative contraindications consists of:
- Osteoporosis
- Smoking
- Malnutrition
- Systemic infections
- Anemia
- Chronic hypoxemia
- Severe cardiac and pulmonary diseases
- Severe depression or psychological issues
What can be the complications of spinal fusion?
General complications that can take place due to spinal fusion surgery consist of the following:
- Infections involving bones, disk spaces or soft tissues.
- Bleeding that may sometimes require transfusion.
- Wound hematoma
- Epidural hematoma
- Spinal cord injury
- Cerebrospinal fluid leakage
- Vascular injury
- Wound dehiscence
Burning sensation after back surgery
Patients often complain about pain after a spine surgery. This pain occurs in many forms, some normal and some not normal.
A burning sensation is one such feeling that can occur even after a minimally invasive procedure.
The first thing that we need to discuss is what exactly the cause of this burning sensation is after spinal surgery. We know that every surgery is accompanied by some post-operative pain. Surgeries require the body to be cut, the incisions that are made no matter how small, require time to heal and this causes pain.
A burning sensation can directly be caused by these muscles and ligaments that are repairing themselves during the healing process. This phenomena is considered normal and is not considered alarming.
These sensations can also sometimes be caused by some nerve issues in the spine. During the spine surgeries, the spinal nerves or nerve roots are agitated, as they undergo the process of regeneration after the surgery thereby leading to sensations of burning, numbness or even tingling.
These sensations are expected to decrease over time following the procedure.
This burning sensation after a spine surgery is almost always considered normal and is taken as a side effect of the body healing itself after instrumentation.
However if this burning sensation increases and becomes severe or does not go away even after weeks or months, then there can be some reason that is causing this pain and requires medical attention.
Restrictions after spinal fusion operation
A spinal fusion surgery can be a life changing procedure for a person as it imposes some permanent restrictions due to which a person sometimes might need to change his job.
This transition from a full working profile to a sedentary life can be extremely difficult for a person,
Many people after the surgery don’t have restrictions on their activities after a span of 6 to 8 months from the procedure, however in certain circumstances permanent restrictions after spinal fusion are ensured.
For example, some people are advised to avoid contact sports post-op. Even after resuming exercise, the activity should be limited to certain amount depending upon the healing process of the spine.
The patient is restricted from rigorous workout sessions or any high-impact sport or postures that may lead to excessive bending of the spine.
Sometimes, running or jogging also need to be avoided.
Limitations during the first three months include avoidance of heavy lifting, twisting and bending.
During the next three months, bending very slowly and slightly should be preferred, during this time even light weighted things should be lifted with caution.
Strenuous exercises should be avoided, besides, based on a patient’s conditions, additional restrictions can be implied by the physician.
Activities such as driving are not permitted after back surgery at least for the first three to four week, the reason being the lack of spinal control while siting. When the patient resumes driving, he should limit this to periods of not more than 20 minutes.
Sitting should also be limited to 20 minutes for the first two weeks after the surgery and this duration can be increased to 40 minutes by four weeks. Being active is what can help a person heal.
Permanent restrictions after spinal fusion are considered one of the most common side effect of this procedure.
This happens due to the loss of spinal flexibility and therefore leads to limited range of motion; many post-surgical patients experience a loss in spinal flexibility that in turn leads to certain activity restrictions.
These patients may not be able to participate in many of the activities they want to be a part of and this can put a huge impact on their quality of life.
Besides this, the fused spine is more prone to injuries and due to the absence of the intervertebral disc that acts as a shock absorber, it is not able to effectively absorb and distribute shock from the impact, thereby leaving a psychological impact on the patients as they become fearful of performing or trying new things as it may damage their spine.
These permanent restrictions after spinal fusion are also accompanied by pain as the spine is less flexible and does not perform its optimal function, putting strain on the surrounding muscles as it becomes difficult for them to support the spine and can lead to sore or strained muscles.
Permanent restrictions after cervical fusion also leads to loss of flexibility in the neck, limited range of motion, sore muscles and pain, this can also cause tension headaches.
After lumbar fusion, permanent restrictions include the limitations in bending and twisting movements and this can lead to restriction of activities involving bending and trunk rotations.
What happens if a person bends after spinal fusion?
Spinal fusion surgery can be performed at a single level or multi-level that involves a set of vertebrae, in the latter the limitations and restrictions after spinal fusion are more as compared to the earlier.
Most people can bend after the procedure but bending in the immediate days following the surgery should be avoided.
After the spinal fusion, the spine needs to heal and this can only happen in the absence of strain. Therefore different motions such as twisting and bending are restricted until the fusion sites are fully healed.
Common problems after spinal fusion
Surgical procedures are almost always accompanied by certain risks. Likewise, the procedure of spinal fusion is also associated with certain risks that are related to the placement of spinal instrumentation and includes malposition, loosening or displacement of the instrumentation.
Some patients may have allergy to the metal of which the instrument is made of.
The most common problems that can take place after the procedure include failure of the bone to heal, a condition known as pseudarthrosis. This leads to spinal instability or vertebral fractures.
Fusion causes permanent restrictions as the spinal segments are fused and increases strain. This increased strain can lead to the formation of bone spurs and hypertrophy of the ligaments that can cause spinal canal narrowing and can irritate the nerve above or below the segment of fusion called as the adjacent segment disease.
These problems can easily be diagnosed by standard imaging such as X-rays and MRI.
Some studies have been conducted to study the effect of spinal fusion 20 years after the procedure where it was found that the patients had complaints of pain but in early stages (not severe) and spinal instability was also noticed in some candidates but abnormalities and manifestations were less severe than anticipated after a long duration of 20 years, although some evidences of deterioration were observed.
Summary
Nowadays, issues such as low back pain and spinal instability are very common even at a younger age sometimes the reason being degenerative bone disease and the other times causes include deformities such as scoliosis, trauma, infection and tumors.
When physical therapy or medications do not work after months, people opt for surgeries and spinal fusion is one such procedure that is used to strengthen the stability of the spine.
However this surgery comes with certain risks, complications and limitations. One such limitations are the permanent restrictions after spinal fusion that can have a huge impact on a person’s life.
These restrictions prohibits the patient from indulging in certain activities that sometimes can be important for the person and may leave a huge impact on their lives.
Besides after the procedure, the spine loses its optimal function putting strain on the adjacent muscles and soft tissues causing episodes of pain.
It is believed that the spinal-fusion surgery should always be the last resort, after all other treatment options have been explored.