Spine surgery is necessary and often emergent when the patient has an acute focal neurological deficit such as weakness in the extremities, bladder and bowel incontinence, foot drop, or paralysis. This is the highest tier of surgical necessity. Usually, surgery is also necessary in patients with persistent uncontrollable back or neck pain caused by nerve root or spinal cord compression or spinal instability. If the nerves or spinal cord is compressed, the surgery lowers the pain level by providing decompression of the compressed nerves or spinal cord. Likewise, surgical fusion is necessary in cases of spinal instability created by weakened bones, spinal joints, or ligaments.

Lumbar back pain (LBP) is very common and ubiquitous. According to the National Institute of Neurological Disorders and Stroke, around 80% of adults will have lower back pain at some point in their lives. LBP usually develops due to overuse or a minor injury. Most LBP resolves in less than 1-2 months with a regimen of stretching exercises, rest, anti-inflammatory medications, physical therapy, and muscle relaxants. In most cases of temporary acute LBP, surgery is not necessary. When LBP persists or is recurrent, or is associated with radicular pain numbness or weakness, these symptoms indicate that need for further investigation and possibly surgery.

When I talk with patients, many patients relate stories of a friend who has had an instrumented spinal fusion and after the surgery, the patient never regained their previous quality of life. They hear cautionary tales from their friends warning them “not to have a surgery with screws and rods.” Many patients express anxiety about an instrumented fusion surgery. They often ask for my opinion on this issue. I usually try to provide them with more information that will help ease their anxiety and provide some understanding in this area.

Instrumented lumbar fusions (surgery with screws and rods) permanently changes the spinal biomechanics, which is the balance and mobility of the spine. The benefit of the instrumentation usually pedicle screw and rods are that it stabilizes an unstable spine segment that can occur with degenerative spine disorders, fractures, and tumors. In these circumstances of spinal instability, the instrumentation is essential to restore the spinal stability.

What is a spinal fusion? In simple terms, spinal fusion is a process which permanently joins spinal bones and eliminates the motion at the intervening discs between the vertebral bones. As in the above-mentioned cases of instability, spinal fusions are often highly successful, resulting in less pain and greater function for the spinal fusion patient.

Spinal fusions can also have some disadvantages. Spinal fusion causes more stress at adjacent spinal segments and can accelerate the degeneration of adjacent facet joints and discs above and below the fusion. Thus, there is a trend for repeat surgery after the initial fusion surgery. Thus, spinal fusions should only be done when absolutely necessary. Multi-level lumbar fusions can often result in more chronic back pain than the original condition.

Neurosurgeons are more likely to operate on the spine without spinal fusion. Most neurosurgeons have very limited indications for spinal fusion. Neurosurgeon’s favor preserving the normal range of motion of the spine and restoring normal spinal biomechanics. In contrast, orthopedic surgeons are more likely to perform spinal fusions especially since most of their residency and fellowship training is focused on performing fusion procedures.