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Low back pain can be debilitating.  When conservative care fails, back surgery starts to look attractive.  What is spinal fusion surgery?  What is PLIF surgery?  What is the success rate for spinal fusion surgery?  What are the complications?  Is there a regenerative option?  Let’s dig in.

What Is Spinal Fusion Surgery?

Spinal fusion is a major surgery where one or more spinal bones (vertebrae) are fused together using screws, bolts, and or plates.  The hardware may be placed in the front (anterior) or the back (posterior) of the spine. The disc between the spinal bones is often times removed and replaced with bone or a spacer.  Spinal fusion can be done in the neck, thoracic, and lumbar regions.  Lumbar fusion is a surgical treatment for patients with ongoing low back pain, and or, leg pain that has failed conservative treatment.  Lumbar fusion surgery has become increasingly popular.  Lumbar fusion rates have increased by 336% from 1996 to 2001 (1).

What Is PLIF?

PLIF is a specific type of lumbar fusion surgery.  It is an acronym that stands for the Posterior Lumbar Interbody Fusion (1).  Posterior refers to the approach used by the surgeon.  Posterior refers to the backside of the body vs anterior which refers to the front.  Lumbar is the section of the spine involved.  The spine is divided into cervical, thoracic, and lumbar.  Lumbar is your low back.  Interbody fusion refers to a specific type of fusion.  For example, in interbody fusion, the disc is surgically removed and a bone graft and spacer is inserted between the spinal bones (vertebral bodies).  The inserted bone graft is expected to grow together between the spinal bones creating a fusion.  Additional hardware including screws and plates are sometimes used to stabilize the spine.  The fusion is intended to stop the movement and pain from that portion of the spine.

So, a PLIF is a type of lumbar fusion that approaches the spine from the backside and inserts a bone graft or implant between the spinal bones where the disc was surgically removed.

Why Is PLIF Surgery Recommended?

Ongoing low back and or leg pain that is unresponsive to conservative care is the most common indication for PLIF surgery.  These symptoms typically arise from degenerative disc disease, lumbar spine instability, disc slippage, stenosis (narrowing of the spinal canal), and scoliosis (curvature) (2).

What Is the Success Rate for Spinal Fusion Surgery?

Studies vary depending upon the number of patients followed, duration of the study, the parameters examined, and whether additional hardware was used to stabilize the spine.  Let’s take a look.

A recent study followed 45 patients over 20 years after PLIF surgery without additional hardware (3).  Outcomes were only fair in 31% of the patients.  Non-union occurred in 11% of the patients, 50% of which required additional surgery.  Disc height and normal spinal alignment were not achieved long term, both of which can accelerate degeneration and injury to the discs and facets above and below the fusion.

Another study followed 60 patients over 1 year after PLIF surgery (4).  Pain complaints were evaluated using a numeric scale 0-10.  At 1 year after surgery leg pain and low back pain was only improved by slightly more than 50%.  3 patients had spinal fluid leaks that required treatment.

A 2016 study was particularly troubling.   73 patients who underwent lumbar fusion were followed for 15 years (5).  As time progressed more patients required additional surgery due to degeneration above and below the fusion.  The rates are alarming.

  • At 5 years after fusion surgery, 7 patients required revision.
  • At 10 years after fusion surgery, 18 patients required revision.
  • At 15 years after fusion surgery, 24 patients required revision.

A new study collected and analyzed data from 33 randomized controlled trials and other studies comparing spinal fusion to nonoperative solutions for low back pain and degenerative conditions (8).  Spinal fusion surgery was found to be no more effective than nonoperative treatment options such as physical therapy.

Complications Associated with PLIF Surgery

There are a significant number of complications associated with spinal fusion surgery.  The most common include failed fusion where the bones do not properly fuse.  Why would this occur?

Non-Union

Non-union occurs when the spinal bones that are bolted together fail to fuse or grow together.  Rates vary depending upon the specific type of lumbar spinal fusion procedure.  For procedures that require more bone, like a posterior fusion, the non-union rates are as high as 26-36% (6,7).

Hardware Breaking

spinal fusion complications years later

Broken Screws in Lumbar Fusion

Lumbar fusion involves screws, bolts, and plates that stabilize the spinal bones.  There are significant forces placed on the low back and the hardware.  Regrettably, as a result of these forces, the hardware can break creating spinal instability and pain. The incidence of hardware failure in one study was an alarming 36% (8).  Treatment of hardware failure often requires additional surgery to remove the broken hardware and replace it.

Hardware Becomes Loose

Screws are used in lumbar fusion to stabilize the spine.  The same forces that can cause the hardware to break can also cause the screws to become loose.  This, in turn, can create spinal instability and pain. Collectively about 1 in 10 patients who have a low back fusion will need a second surgery to fix non-union or hardware failure (9).

Complications from Lumbar Fusion

There a number of problems that arise as a direct result of lumbar fusion itself.  The two that you most need to know about are Adjacent Segment Disease and Spinal Muscle Injury.

Adjacent Segment Disease

The disc is an important shock absorber.  Fusion surgery removes this important shock absorber placing additional stress and forces on the discs and facet joints above and below the level of the fusion. This additional force in turn can lead to injury of these facet joints and discs leading to degeneration and arthritis.  This is a real problem, with an incidence of 9% (10).  This can lead to additional surgeries including fusions.  To learn more about this tragic complication please click on the video below.

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Spinal Muscle Injury

The spinal muscles provide critical stability and support for the spine.  Unfortunately, lumbar fusion significantly compromises the health and integrity of these muscles. This is in turn can lead to spine instability and additional injuries including degeneration and arthritis.  VA is a recent patient seen in the clinic who experienced this complication.  VA underwent lumbar fusion several years ago for severe low back pain.  Unfortunately, after the surgery, the pain never changed.  His low back MRI is below and is most significant for the death of the critical low back muscles.  The MRI is a cross-section image.  On the right, the yellow arrows point to dark healthy spine muscles that were present prior to the surgery.  The image on the left is after the surgery.  The yellow arrows point to the muscles that were injured and now are dead as a result of the fusion surgery.

Is There an Alternative to PLIF Surgery?

Absolutely.  At the Centeno-Schultz Clinic, we believe in a comprehensive approach to the treatment of spinal pain.  We view and approach the spine as a Functional Spinal Unit.  This functional unit includes discs, facet joints, ligaments, fascia, and muscles.  These structures work with one another in a highly specialized and dependent manner.  Therefore for the very best results, the spine and all its parts need to be evaluated and treated together.  This novel, comprehensive approach can help you avoid lumbar fusion and its complications.  Treatment options include PRP and your own bone marrow-derived stem cells.  PRP is rich in growth factors which can increase blood flow and healing.  To better understand how to avoid lumbar fusions by using precisely guided PRP and stem cell injections please click on the video below.

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In Conclusion

PLIF surgery stands for Posterior Lumbar Interbody Fusion.  It is a specific type of lumbar fusion for patients with degenerative disc disease, instability, stenosis, or scoliosis with ongoing pain that has not responded to conservative care.  The overall success rate is low and a recent high-level study that examined 33 randomized controlled studies found fusion surgery no more effective than nonoperative treatment.  The complications are extensive and include failed fusion due to nonunion, hardware breaking, and hardware becoming loose.  Adjacent segment disease and spinal muscle injury are additional complications that arise directly from the fusion itself.  FSU is a comprehensive approach used at the Centeno-Schultz Clinic that evaluates and treats the spine as a whole.  Precise injections of platelets and stem cells are an effective, natural alternative to PLIF surgery in those patients with ongoing low back and leg pain.  PRP and stem cell injections have none of the complications or extensive rehabilitation associated with surgery.

If you or a loved one suffers from low back or leg pain please consider a Telemedicine consultation with a board-certified physician from the comfort of your home.  Learn more about your pain condition and regenerative injection treatment options. Don’t be a prisoner to pain.  Schedule today

 


1.Clinical and radiological outcome of anterior-posterior fusion versus transforaminal lumbar interbody fusion for symptomatic disc degeneration: a retrospective comparative study of 133 patients.
Faundez AA, Schwender JD, Safriel Y, Gilbert TJ, Mehbod AA, Denis F, Transfeldt EE, Wroblewski JM
Eur Spine J. 2009 Feb; 18(2):203-11.

2.Christensen FB, Hansen ES, Eiskjaer SP, et al. Circumferential lumbar spinal fusion with Brantigan cage versus posterolateral fusion with titanium Cotrel-Dubousset instrumentation: a prospective, randomized clinical study of 146 patients. Spine (Phila Pa 1976) 2002;27:2674–2683.

3..Baeesa SS, Medrano BG, Noriega DC. Long-Term Outcomes of Posterior Lumbar Interbody Fusion Using Stand-Alone Ray Threaded Cage for Degenerative Disk Disease: A 20-Year Follow-Up. Asian Spine J. 2016;10(6):1100-5.

4.Fan G, Wu X, Yu S, et al. Clinical Outcomes of Posterior Lumbar Interbody Fusion versus Minimally Invasive Transforaminal Lumbar Interbody Fusion in Three-Level Degenerative Lumbar Spinal Stenosis. Biomed Res Int. 2016;2016:9540298.

5.Maruenda JI, Barrios C, Garibo F, Maruenda B. Adjacent segment degeneration and revision surgery after circumferential lumbar fusion: outcomes throughout 15 years of follow-up. Eur Spine J. 2016;25(5):1550-7.

6.Tsutsumimoto T, Shimogata M, Yoshimura Y, Misawa H. Union versus nonunion after posterolateral lumbar fusion: a comparison of long-term surgical outcomes in patients with degenerative lumbar spondylolisthesis. Eur Spine J. 2008;17(8):1107–1112. doi: 10.1007/s00586-008-0695-9.

7.Herkowitz HN, Kurz LT. Degenerative lumbar spondylolisthesis with spinal stenosis. A prospective study comparing decompression with decompression and intertransverse process arthrodesis. J Bone Joint Surg Am. 1991 Jul; 73(6):802-8. https://www.ncbi.nlm.nih.gov/pubmed/2071615/

8.Harris IA, Traeger A, Stanford R, Maher CG, Buchbinder R. Lumbar spine fusion: what is the evidence. Intern Med J. 2018;48(12):1430-4.

9.Greiner-Perth R, Boehm H, Allam Y, Elsaghir H, Franke J. Reoperation rate after instrumented posterior lumbar interbody fusion: a report on 1680 cases. Spine (Phila Pa 1976). 2004 Nov 15;29(22):2516-20.

10.Okuda S, Yamashita T, Matsumoto T, et al. Adjacent Segment Disease After Posterior Lumbar Interbody Fusion: A Case Series of 1000 Patients. Global Spine J. 2018;8(7):722-7.