Spinal fusion has long been a cornerstone of spine surgery, but advances in artificial disc replacement, endoscopic techniques and motion-preserving procedures are giving surgeons more opportunities to avoid it. The question is no longer simply whether fusion can be avoided, but when it should be.
For some surgeons, the expanding range of alternatives represents an opportunity to reduce surgical disruption, preserve mobility and prevent unnecessary stabilization. Others caution that avoiding fusion at all costs can leave underlying instability or degeneration untreated, potentially leading to more complex procedures down the road.
Across recent interviews with Becker’s, spine surgeons have described a shifting threshold for fusion, with patient selection, long-term durability and the underlying pathology increasingly driving decisions.
The case for doing less
For Wilson Z. Ray, MD, a neurosurgeon at St. Louis-based Washington University School of Medicine, advances in cervical disc replacement, endoscopy and minimally invasive decompression are making fusion a more selective procedure.
“That threshold for fusion is definitely becoming more selective,” Dr. Ray told Becker’s. “Increasingly, we’re trying to avoid a fusion or the need to treat the pathology via a fusion.”
That shift is also reflected in the practice of Alexander Chung, MD, a spine surgeon at Phoenix-based Banner Health, who estimated that 50% to 60% of his cases involve endoscopic or motion-preserving approaches. For Dr. Chung, avoiding fusion does not necessarily mean replacing it with another implant. In some patients, decompression alone may adequately address the source of symptoms while preserving the spine’s natural motion.
“My bias isn’t toward motion preservation or fusion,” he said. “My bias is toward the least disruptive operation that reliably treats the pathology, and if motion preservation surgery is an option, that is generally what I recommend.”
When preserving motion becomes the risk
Not every patient benefits from maintaining spinal motion, however, and some surgeons warn that the push toward less invasive procedures can come at the expense of addressing the underlying condition.
Jonathan Baskin, MD, a neurosurgeon at Morristown, N.J.-based Atlantic Brain and Spine, said he generally favors artificial disc replacement when both fusion and motion preservation are reasonable options. But he cautioned that preserving movement may be counterproductive when abnormal motion contributes to a patient’s symptoms.
“It’s not always appropriate to preserve all motion if the motion is part of the problem,” he said. Dr. Baskin also questions whether increasingly sophisticated technology has made surgeons more willing to recommend procedures that may not be necessary.
“Just because you can do something safely and accurately, is it the right thing to do?” he told Becker’s.
Daniel Riew, MD, chief of cervical spine surgery, co-director of the spine fellowship and professor of orthopedic surgery at Columbia University in New York City, has spent more than two decades performing artificial disc replacement. Although he sees substantial value in preserving motion for appropriately selected patients, his experience has also challenged some of the early expectations surrounding the technology.
“We thought, ‘If we do this, there will be no more adjacent-level disease,'” he said. “That was kind of naive.”
His perspective reflects a broader concern that motion preservation, while beneficial for certain patients, does not necessarily eliminate the long-term degenerative processes that can lead to additional surgery.
The cost of avoiding fusion at all costs
For surgeons who routinely treat failed procedures and complex spinal conditions, the consequences of avoiding fusion can become especially apparent.
Farah Musharbash, MD, a spine surgeon at Atlantic Brain and Spine, favors minimally invasive and motion-preserving approaches when appropriate but considers fusion necessary when alternatives cannot adequately address the underlying pathology.
“To me, a fusion is sort of the last resort,” he told Becker’s. “But many times, it’s the right thing to do.”
He cautioned against allowing the desire to preserve motion to overshadow the fundamental goal of surgery.
“If your solution or technique doesn’t fix the patient’s problem because you didn’t want to do a fusion, then you haven’t solved the problem,” he said.
James Mooney, MD, a complex and minimally invasive spine deformity surgeon at Richmond-based Virginia Commonwealth University, similarly emphasized matching the extent of surgery to the patient’s condition rather than favoring one technique over another.
“The goal should be to match the magnitude of surgery to the magnitude of the problem,” he said. “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.”
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