Source: Minimally Invasive Surgery of the Spine 2007, San Diego
Lumbar fusion rates have increased steadily since the 1990’s and accelerated after 1996 since the approval of the fusion cages. In 2001, 122,000 fusions were performed in the US, which represented an increase of 220 % from 1990. Despite the increasing use of fusion techniques in the lumbar spine, the re-operation rates have not been reduced and the patient overall ranking of results satisfaction does not exceed 60 %. Even though improvement has been demonstrated in approximately 60 % of the patients, approximately 40 % of patients’ condition after lumbar fusion remained unchanged or became even worse measured by LBP, leg pain and Oswestry at two year follow-up.
Our group represents those patients treated at the Back Institute in the past 5 years who had fusion recommended, and in most cases scheduled, by outside surgeons, but the patient decided to undergo our non-traumatic access out-patient discectomy instead. This procedure is a focused, precision discectomy. Our retrospective analysis goal was to determine whether these patients had undergone a later fusion. Our success is defined as those patients that have avoided fusion (94%).
33 patients were available for long term follow up and all were contacted directly by phone. 24 % were women (n=8) and 76 % men (n=25) with an average age of 48 years old, ranging from 28 to 63 years of age. All had significant lumbar disc protrusion/herniations pre-operatively. The average follow-up was 30 months.
4 patients underwent re-operation: 2 fusions, 1 disc decompression and 1 laminectomy/foraminotomy. Therefore, our success rate in this “fusion group” for avoiding fusion was 94 % and for avoiding any further procedure was 88%. Of the 4 patients that required further procedures all of them presented with tough (medium to hard) discs and bony foraminal stenosis. 67 % of the 33 patients showed excellent or good long term clinical results, which is superior to the results for fusion in general. Taking into consideration the presence of other pathological conditions, namely: osteophytosis, ligamentous hypertrophy, bony canal stenosis and bony foraminal stenosis, 56 % of the 29 non-reoperation patients presented with 2 or more of these factors in addition to the disc pathology, showing that these factors were not contra-indications to a pure discectomy. No complications occurred.
Fusion should only be considered after a careful evaluation of each individual case taking into consideration all factors involved, especially in view of the above results