When it comes to spinal fusion, surgeons say the challenge is increasingly knowing when less surgery becomes too little.
From stable degenerative spondylolisthesis and lumbar stenosis to cervical disease, spine surgeons told Becker’s there are cases in which decompression or motion-preserving procedures may be enough. But several cautioned that the push to avoid fusion can go too far when patients have true instability, deformity or other structural problems.
Twelve spine surgeons shared where they believe fusion is still overused, and where avoiding it may create problems of its own.
Ask Spine Surgeons is a weekly series of questions posed to spine surgeons around the country about clinical, business and policy issues affecting spine care. Becker’s invites all spine surgeon and specialist responses.
Next question: Endoscopic spine is expanding quickly, but adoption still varies widely. What would have to be true for you to make it a routine part of your practice, or decide it does not belong there?
Please send responses to Sophie Eydis at seydis@beckershealthcare.com by 5 p.m. Central time Sunday, Oct. 11.
Editor’s note: Responses were lightly edited for clarity and length.
Question: Where do you think spine surgeons are still too quick to fuse, and where has the pendulum swung too far against fusion?
Kasra Ahmadinia, MD. Spine Surgeon at Advanced Orthopedics of Oklahoma (Tulsa): We are still too quick to fuse for axial back pain with degenerative disc findings and no instability, and too quick to add levels because the MRI shows degeneration the patient isn’t feeling. A stable degenerative spondylolisthesis with leg-dominant symptoms can often be treated with decompression alone. In the neck, a younger patient with radiculopathy and healthy facet joints is often a better candidate for disc replacement than an anterior cervical discectomy and fusion, and motion preservation is still underused.
Where the pendulum has swung too far is deformity and true instability. Some patients get a series of smaller decompressions because surgeons or payers are wary of a bigger operation, and they end up with more total surgery and a worse result than if the underlying problem had been addressed the first time. The right construct is the smallest one that fixes the patient’s actual problem.
Joel Beckett, MD. Neurosurgeon at Lanman Spinal Neurosurgery (Beverly Hills, Calif.): Spine surgeons may still be too quick to fuse in the cervical spine. Despite the increasing market share and utilization of artificial disc replacement, fusion remains the predominant approach in the U.S. We are also continuing to push the envelope, so to speak, in considering arthroplasty for patients with more advanced disc degeneration or spondylosis. The extent of degeneration alone, however, should not determine candidacy. Facet integrity and bone quality are critical considerations, and in appropriately selected patients, motion-preserving surgery can produce excellent outcomes.
I also don’t believe the pendulum has swung too far against fusion. There are well-established indications where fusion has demonstrated durable long-term results and remains the appropriate surgical strategy, particularly in the setting of true spinal instability or biomechanical failure, including unstable spondylolisthesis. Ultimately, the goal is not to favor motion preservation or fusion categorically, but to apply each where the patient’s anatomy, biomechanics and pathology support it.
Jeffrey Carlson, MD. Orthopedic Spine Surgeon at Orthopaedic & Spine Center (Newport News, Va.): In our part of the country, single-level cervical disease is still treated with fusion. I understand the reluctance to move to motion preservation in the elderly and multilevel disease, but at this time, cervical arthroplasty for single-level disease should be leading fusion, especially in the younger patient. At least the option should be discussed with the patient to provide adequate shared decision-making.
There is some movement away from fusion in spondylolisthesis, and I don’t think this has been given enough thought. Spondylolisthesis is an instability that will not improve with removing bone that may be providing stability for the patient. Too often I see patients who have been destabilized but have been told the literature suggests grade 1 spondylolisthesis does better without fusion. The surgical intentions are good, but it may be the surgical execution that varies from the published studies and produces worsening outcomes. More detailed study should be done about the techniques that don’t lead to progressive instability.
Todd Lanman, MD. Spinal Neurosurgeon at Lanman Spinal Neurosurgery (Beverly Hills, Calif.): There are several situations where spine surgeons may be too quick to fuse. One is lumbar spinal stenosis with degenerative spondylolisthesis when symptoms are predominantly radicular pain or neurogenic claudication with minimal low back pain. In appropriately selected patients, decompression alone can provide outcomes comparable to decompression with fusion, yet fusion is still used relatively quickly.
I also see younger patients with severe mechanical low back pain and degenerative disc disease who are offered fusion despite being good candidates for artificial disc replacement. In selected patients, arthroplasty can address the symptomatic disc while preserving motion.
Revision surgery is another area for caution. Patients with persistent pain after prior surgery are sometimes offered additional fusion without first establishing whether the existing fusion or another source is driving the symptoms.
I wouldn’t say that the pendulum has swung too far against fusion. There may be isolated cases in which surgeons try to avoid fusion when it remains the appropriate operation, but I don’t think that is common. Fusion remains an important operation; the goal should be to use it when it is truly necessary rather than as the default.
Philip Louie, MD. Spine Surgeon at the University of Washington (Seattle): Grade 1 degenerative spondylolisthesis is an overused example in this debate, but it is still the best one to highlight because it is one of the most common presentations we see. People tend to be dogmatic about it. Some surgeons find a bit of motion in nearly every case and fuse, while others almost always decompress, and most of us probably fall somewhere in the middle.
I think we are still too quick to fuse the older patient with a stable slip and mostly leg pain, where a decompression alone often does well. I also think some surgeons have moved too far from fusion in patients with clear instability on dynamic films or significant mechanical back pain. And now there are so many new techniques and implants to apply as well: disc replacements, facet joint replacements, to name a couple.
We do not have many recent prospective studies with longer follow-up, and payers still go back and forth on coverage. As we prepare for the future, the best plan is likely to track which patients do well with each approach over several years, really document the clinical, radiographic and demographic components, and pay for the operation that gives the best outcome for that patient at a reasonable total cost of care.
James Mooney, MD. Complex and Minimally Invasive Spine Deformity Surgeon at Virginia Commonwealth University (Richmond): I think we are still too quick to fuse when fusion is being used as a substitute for identifying the actual pain generator. A patient with back pain, multilevel degeneration on MRI and no clear instability, deformity or mechanical target does not automatically benefit from fusion. The same is true for many cases of focal stenosis or disc herniation where adequate decompression can preserve motion without committing the patient to a larger operation.
The question is: What is the minimum operation that reliably addresses the pathology? If I can preserve a motion segment without compromising the durability of the result, I generally think that is valuable.
At the same time, I think the pendulum has swung too far against fusion in patients with real instability, deformity or structural disease. We sometimes become so focused on being “minimally invasive” or avoiding fusion that we undertreat the underlying mechanics. A decompression that destabilizes an already compromised segment, or a limited operation in a patient whose symptoms are driven by deformity, may simply trade a smaller operation today for a revision several years later.
The goal should be to match the magnitude of surgery to the magnitude of the problem. The artistry is knowing when preservation is durable and when reconstruction is actually the less invasive strategy over the course of a patient’s lifetime.
Farah Musharbash, MD. Spine Surgeon at Atlantic Brain and Spine (Morristown, N.J.): For years, spinal fusion was the most trusted and effective solution for a wide range of conditions, including disc degeneration, herniated discs and spinal stenosis. For the right patient and condition, it can still be the right choice. However, motion-preserving procedures can treat the same underlying problems while retaining the spine’s natural range of motion.
Younger patients with cervical radiculopathy are a common group where I see spinal fusion recommended when it is not necessarily the best long-term option. For generally healthy and active patients with proper spinal alignment, lack of arthritis and good bone density, the goal should be to preserve motion whenever possible. Cervical disc arthroplasty and minimally invasive cervical foraminotomies are alternatives that reduce the risk of adjacent segment disease in the future.
At the same time, there are still cases where fusion is the best option. Conditions such as unstable or high-grade spondylolisthesis, deformity/scoliosis and severe up-down lumbar foraminal stenosis often do better long term with fusion.
Jonathan Rasouli, MD. Spinal Neurosurgeon at NeuroSpine Plus (Paramus, N.J.): I think we are still too quick to fuse patients with degenerative lumbar spinal stenosis who do not have dynamic instability on flexion-extension X-rays or a convincing mechanical component to their low back pain. In those patients, the question should be whether adequate decompression alone can address their symptoms.
On the other hand, the pendulum has swung too far when avoiding fusion becomes the goal in patients with clear instability or symptomatic deformity. Fusion should be driven by the pathology we are treating, rather than a preference for or against the procedure.
Issada Thongtrangan, MD. Endoscopic and Minimally Invasive Spine Surgeon at MicroSpine (Scottsdale, Ariz.): I think we still fuse too readily for straightforward lumbar stenosis and many cases of stable grade 1 degenerative spondylolisthesis. If the problem is neural compression without convincing dynamic instability, deformity or a major mechanical back-pain component, a tissue-preserving decompression is often enough.
This is where endoscopic spine surgery can be particularly valuable. In appropriately selected patients, endoscopic decompression can address neural compression while minimizing disruption of the paraspinal muscles, facet joints and other stabilizing structures. The goal is adequate decompression while preserving as much normal spinal anatomy and biomechanics as possible.
The pendulum can also swing too far in the opposite direction. Patients with true instability, progressive slip, significant sagittal or coronal imbalance, or cases in which adequate decompression itself will destabilize the segment may benefit from fusion. Fusion also remains an important option in appropriately selected isthmic spondylolisthesis, deformity and revision cases.
The key is not “fusion versus no fusion” or “endoscopic versus open vs. ADR” as an ideology. The real question is: Are we treating neural compression alone, or neural compression plus a mechanical problem? When the problem is primarily compression, I favor the least disruptive operation that can safely and effectively decompress the nerves, including endoscopic decompression when appropriate, while preserving motion and avoiding unnecessary fusion.
David Weiner, MD. Assistant Professor of Orthopedic Surgery at MedStar Health (Columbia, Md.): We can be too quick to fuse when degenerative findings on imaging substitute for a clear explanation of a patient’s symptoms. In selected patients with stenosis and a stable, low-grade slip, adequate decompression may address the problem without the added burden of fusion. Disc replacement can also offer a motion-preserving alternative. The choice should follow the patient’s pathology and symptoms rather than a default preference for fusion.
Jacky Yeung, MD. Director of Neurosurgical Oncology, Fairfield Region at Hartford (Conn.) Healthcare: We are still too quick to fuse some patients with low-grade, stable degenerative spondylolisthesis. If there is no clear dynamic instability, minimally invasive techniques, especially endoscopic decompression, can often relieve the stenosis while preserving the facet and stabilizing anatomy. This can avoid unnecessary fusion and often translates into less tissue disruption and a faster recovery.
Christian Zimmerman, MD. Spinal Neurosurgeon at St. Alphonsus Medical Group and SAHS Neuroscience Institute (Boise, Idaho): Fortunately, the regressive practice of spinal fusion, especially multilevel, pan-segmental superintendence, has been corrected over time. For inviolability, cost and outcomes, scrutiny from underwriters, peers and patients has curtailed the exaggerated and exuberant with more stringent recommendations and surgical guidelines. More appropriate conservative mindsets and analytics have restituted the specialty of spine in this country to its essential state of actualization and substance.
There remain autonomous surgical sites where subtle directives initiate surgical diagnosis more frequently than desired, and disastrous results have occurred. These inclinations persist secondary to paltry systems of oversight where attenuated metrics and cost defrayal are cultural attitudes, and surgical outcomes have been replaced by esurient and creative administrative methods.
At the Becker’s 32nd Annual Meeting: The Business and Operations of ASCs, taking place October 29-31 in Chicago, ASC leaders, surgeons and healthcare executives will explore strategies to drive growth, enhance operational performance, navigate reimbursement challenges and prepare for the future of ambulatory surgery. Apply for complimentary registration now.
