1. Lumbar spinal fusion surgery involves permanently fusing together two or more vertebrae in the lower back to stop painful motion and decrease back pain from injuries like herniated discs or spondylolisthesis. 2. During the surgery, bone grafts and hardware like screws and rods are used to fuse the vertebrae together and create a solid, stable portion of the spine. 3. Minimally invasive techniques for lumbar fusion use smaller incisions and cause less muscle damage, resulting in less pain, blood loss, and shorter recovery times compared to traditional open fusion surgery.

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Elijah Walker
Lower Extremities
Professor Zeigler
April 22, 2014
Surgical Review: Lumbar Spinal Fusion
Back pain is an irritating condition that will affect 80% of adults sometime in
their lives (Spine Health.com). Not everyone enjoys having surgery performed on them
but when it is needed, it should be done. The newer spine fusion surgery techniques allow
for improved fusion rates, shorter hospital stays, and a more active and rapid recovery
period. Additionally, better diagnostic tools and better understanding of indications for a
spine fusion are improving outcomes. This essay will further explain background
information, the anatomy, types of injuries and their mechanisms, and surgical
procedures along with the advantages and disadvantages of lumbar spinal fusions.
Before discussing spine fusion surgery techniques it is important to note that very
few people with low back pain actually require surgery. Most individuals can contain
their back pain through a self-directed active physical therapy (exercise) program,
including stretching, strengthening, and a good aerobic conditioning. Unfortunately, for a
small percentage of people, even the most dedicated exercise program is not enough to
alleviate low back pain. In those situations where low back pain continues and limits a
patient's activities, a spine fusion surgery may be considered. Fusion of the lumbar spine

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does not create a normal back, nor does it necessarily "fix" a low back. Instead, the
objective of lumbar spine fusion is to stop the motion at a painful motion segment in the
spine, thus minimizing the pain and allowing the patient to increase his or her ability to
function and enjoy everyday activities.
A common type of spine fusion surgery is performed for low back pain. This type
of mechanical lower back pain occurs with increased activities and often times is
associated with degenerative changes in the discs such as degenerative disk disease. At
other times it may be due to slippage of the spine such as spondylolisthesis. When
considering the indications for lumbar spine fusion surgery, low back pain that lasts for
more than six months is the most general indication. The indications for fusing the low
back occurs primarily in situations where there is a large deformity (such as scoliosis) or,
more commonly, for back pain that does not get better with time or with a non-surgical
treatment. Much care and importance is stressed on our bodies large spine that keeps us
upright.
The spine is formed by 33 vertebral segments and divided into four distinct
portions. The spinal column and the muscles that interact with it control, give support to,
and protect the torso, skull and spinal cord. The portion relevant to this surgical
procedure is the lumbar spine. The lumbar spine provides a more equal balance between
protection of the spinal cord and its available range of motion. The body’s weight is
transmitted primarily along the spinal column by the vertebral bodies, whose size
correlates to the amount of force it transmits. The lumbar vertebrae are required to
transmit and absorb the weight of the entire torso, therefore having the largest vertebrae
and spinal columns. These very distinct vertebrae are situated anterior and makes up the

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primary weight-bearing surface. Projecting just posterior from the body of the vertebrae
are the sturdy pedicles that form the anterior portion of the neural arch. The posterior
portion of the arch is composed of the lamina. Projecting laterally, the transverse
processes arise from the laminae and provide an attachment site for the spine’s ligaments
and muscles and increase the muscles’ mechanical leverage (force). The spinous
processes are the furthest posterior projections that act as attachment sites for muscles
and ligaments. The spinal cord passes through the neural arch, posterior, where a tunnel
protects the cord. Facet joints are also present that are formed by two sets of articular
processes. The first process, superior facts, articulate with the second inferior facets of
the vertebrae. These facet joint are on a frontal plane thus allowing lateral flexion but
restricts the rotation of the lumbar region. Flexion and extension of the lumbar region is
allowed on the sagittal plane.
Neurologically the spinal spine contains a network of nerve plexus’.
According to Examination of Orthopedic and Athletic Injuries, a nerve plexus is a
network formed by a consecutive series of spinal nerves that intermix sensory and motor
impulses. A total of 31 pairs of nerve roots exit the spinal column. The lumbar plexus is
formed by the 12th
thoracic nerve root and the L1-L5 nerve roots and innervates the
anterior and medial muscles of the thigh and the nerves of the medial leg and foot.
A number of injuries can cause the necessary surgical procedure of a
lumbar spinal fusion. In the case of a spinal fracture, the vertebrae of the spine will need
to be brought back together if possible using a spinal fusion. A slippage between the
vertebrae laterally, medially, anteriorly, or posteriorly and onto the bone below it
(spondylolisthesis) may need spinal fusion surgery in order to hold the vertebrae in a

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stable place. Scoliosis is also a spine deformity that can be fixed through a spinal fusion.
Although usually in the cervical region, scoliosis is a condition in which the curvature of
the spine is not straight in an area of the back; usually arched forward or presenting a s-
curve in the spine. Reoccurring disk herniation may need a spinal fusion if not eliminated
after sixth months. Reoccurring herniation may be gradual onset or be a sudden onset due
to certain movements. Although, physical therapy exercise and special treatment of a disk
may relieve and eliminate the herniated disk, thus making the surgery unnecessary. As
explained before, the degeneration of a disk is normal in most Americans with age. The
decreased function of the annulus fibers in the spine may become bad enough as to where
the motion of the torso decreases as well. Rarely, in most cases of disk degeneration
spinal fusion will not be necessary but in the cases where the degeneration inhibits gait,
walking, or movement it will be needed. The last case in which a possible lumbar spine
fusion may be necessary is that of a disk infection. This disk infection is also called
diskitis and although very rare, affects the lumbar region most commonly
(Medscape.com). Diskitis is an inflammation of the vertebral disk space often related to
infection.
The mechanisms of these injuries needing lumbar spine fusion can be alike or
different. In instances of scoliosis, a person will be born with it or it will be detected
before the age of 10 (Ceder’s Sinai.edu). A fracture to the lower spine can be caused by a
couple of mechanisms. Most of the mechanism that will fracture the spine will include a
blow, or a great force, to the spine. As stated in Professor Ziegler’s “Chapter 20: The
Spine” power point, the causes of a lumbar fracture is compression as a result from trunk
hyperflexion or falling from a height or direct blow. Although rare, lumbar dislocation

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can happen in these mechanisms as well. Spondylolysis and spondylolosthesis is when
one vertebrae above or below another. The cause of this is the degeneration of the
vertebrae due to congenital weakness (stress fracture results).
Just as fractures have multiple causes so does the herniation of a disk. Here, the
intervertebral disks either shift outward or creates a bubble like projection that causes
pain by putting pressure on a nerve(s). The cause of my personal injury was a herniated
disk. It happened during my senior year of high school in our opening game against the
alumni. I was on a fast break towards the hoop and there was only one other defender
back to guard me. As I powered towards the hoop he ran alongside me. I then went up for
the lay up and I as a rose above the ground so did he. To protect the ball I brought it
down by my side, in the air, twisting my body. We made contact in the air and instead of
contesting my shot the defender fouled me, hard. He threw his whole body into mine and
his arms cam down on top of my neck and I fell to the ground. This abnormal force and
the twisting and forward bend of my body is what caused an abnormal stress to put
pressure on the vertebral disks.
Based on a video from Spine-Health.com, it gives a clear picture of how a spinal
fusion surgery of the lumbar region can be performed to stop the motion at a painful
vertebral segment; which in turn should decrease the back pain from degenerative disk
disease or spondylolisthesis. During the procedure, the surgeon permanently joins two or
more vertebrae in the spine. The vertebrae will grow together to from a single, solid bone.
Spinal fusion is commonly performed in the neck and lower back to correct common
injuries or chronic injuries as discussed before. In preparation for the procedure the
patient is positioned and general anesthesia is administered. The surgeon creates an

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incision to aces the lumbar spine. The surgeon removes the lamina, the protrusion of the
rear of the vertebra, which covers the nerve roots. Removing the lamina creates more
space for the nerve roots to. Next, the surgeon clears any bone or debris that may be
pressing against the nerve roots; this relieves pressure and pain. The surgeon will then
place bone grafts against the vertebrae that may be taken from the patient’s own body,
typically, from the pelvis. Then, the surgeon inserts hardware (four screws placed in a
square pattern) to hold the vertebrae together. During this process the surgeon will use
screws and rods or plates to create a metal-like backbone. Usually, two rods are placed
through the screws vertically to support either side of the vertebrae. When the procedure
is complete, the incision is closed and bandaged. The patient may be placed in a back
brace to restrict movement of the spine and will be able to leave the hospital after two or
three days. As the spine heals, the bone grafts will fuse with the bone of the vertebrae to
create a solid, stable mass of bone with continued support of the rods and screws.
Aside from the technique described above there is new technique to perform
spinal fusion called minimally invasive lumbar spinal fusion. Minimally invasive lumbar
spinal fusion is similar to traditional lumbar spinal fusion, but it uses smaller incisions
and causes less damage to the surrounding tissues during surgery. As with traditional
lumbar spinal fusion, there are many specific techniques available to try to fuse the
vertebrae together using minimally invasive techniques. This can be done through the
abdomen, from the back, from the side, or with any combination of these. Fusion with
screws and rods can be performed through the back using several 1-2 inch incisions. In
these cases a series of increasingly larger dilators (hollow tubes with solid inserts) are
inserted through the incisions to help spread the muscles apart. Once the muscles have

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been moved away, the screws and rods can be placed through the dilator tubes. The major
advantage of all of these minimally invasive techniques is that there is less damage
caused to the surrounding tissues. Unfortunately, in traditional spinal surgery it is
necessary to cut through muscles and move them out of the way in order to reach the
spine. This can cause a large amount of pain following surgery, and it can lengthen the
recovery time. Instead of cutting and moving muscles, the minimally invasive techniques
can more gently spread through the muscles to allow access to the spine. This is much
less painful for the patient, and it does not require as long of a recovery period for the
muscle to heal. Another benefit of less muscle damage is less blood loss and thus a
reduced need for blood transfusions using the minimally invasive techniques. There is
often less need for narcotic pain medications following this form of surgery, and a shorter
hospital stay (Medicine Net.com). As with any new technique, one of the major
disadvantages is the additional time needed to perform the procedure. While a surgeon
may be very comfortable with the traditional surgical fusion techniques, it will take time
to be able to achieve the same outcome using these new methods. Surgeons with more
experience can now perform lumbar spinal fusion in equal or even less time than with the
traditional techniques but not all surgeons perform these techniques. Because this is a
relatively new technique, many insurance companies consider this to be an
investigational surgery and do not provide insurance coverage for it.
To end my story of my herniated disk I fortunately did not need surgery or a
lumbar fusion. Instead, I was out of the basketball season for 5 months doing strenuous
physical therapy in order to relive the inflammation and pain in my back. I was able to
finish off the last 2 ½ months of basketball with an 85% healthy back. Although I do

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have pain in the back to this day, it is only rare and slight pain that can be alleviated
though stretches and core strength. Spinal lumbar fusion is a surgical procedure that may
be needed due to multiple injuries such as my herniated disk. This surgery that involves
fusing two vertebrae together is neither easy or pain free. The result is a solid portion of
the spine coated with hardware and unable to be flexed. In some instances it is necessary
to have the procedure done buy in most cases it is not even needed.