Spine Fusion eguide

Understanding Lumbar Spinal Fusion Surgery The Importance of Carefully Considering Your Options Nearly 500,000 spinal fusions are performed in the United States annually, six times the number that were performed 20 years ago. Lumbar spinal fusion can effectively treat back pain in many patients, but it’s important for you to understand whether this surgery is the best option for you, as well as the risks and benefits involved.

Use this guide to better understand lumbar spinal fusion surgery and whether it is the right treatment for you.

Would you like to talk to a spine specialist to get more information? Call South Denver Neurosurgery at 720.638.7500 to schedule a phone consultation or an appointment.

Table of Contents Page 1 What Is Lumbar Spinal Fusion Surgery?

Page 2 Spinal Fusions on the Rise Page 3 Before Considering Spinal Surgery Page 4 Who Benefits Most From Spinal Fusion?

Page 5 Benefits and Risks of Spinal Fusion Page 6 What to Consider About Imaging Page 7-8 How to Select a Spine Surgeon Page 9 How to Interview Your Surgeon Page 10 About South Denver Neurosurgery Page 11 Robotic Guidance Helps Improve Spine Surgery Outcomes Page 12 Meet Our Physicians Page 13 Our Locations Page 14 Questions and Notes Page 15 Research Sources

What Is Lumbar Spinal Fusion Surgery?

Spinal fusion is a surgical procedure that permanently fuses two or more vertebrae together. A spinal fusion can take place anywhere in the spine but is most commonly performed in the neck (cervical fusion) or lower back (lumbar fusion). This guide addresses spinal fusion in the lower back.

A spinal fusion is performed by using one of two methods to hold two or more vertebrae together. New bone then grows between the vertebrae and fuses them permanently. The two methods to join the vertebrae are: â—?U tilizing

bone from elsewhere in the body or a bone bank to create a bridge between the vertebrae

â—?U tilizing

metal implants to hold the vertebrae together

A spinal fusion can be performed using a traditional procedure (open) or a minimally invasive procedure, depending on the patient’s particular circumstances.

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Watch this video to understand why and how a spinal fusion is performed.

Spinal Fusions on the Rise The number of lumbar spinal fusions being performed in the U.S. has increased in the past decade. ●B etween

1998 and 2008, the number of hospital visits for lumbar fusions in the U.S. increased 137%, according to research published in the medical journal Spine.1

●S pine

fusion surgery jumped from the 41st most common patient procedure in 1997 to the 19th most common patient procedure in 2003, as reported in the medical journal Neurosurgery.2

Part of this increase in spinal fusion surgery reflects advancements in diagnosis and the surgery itself, as well as improved health in older Americans, which allows for surgery later in life. However, part of this increase may be due to unnecessary procedures, according to research published in Spine 3 and Journal of the American Medical Association.4

G The most important point for you to know is that spinal fusion may or may not be the optimal surgery to relieve your pain. It’s important to discuss your back pain treatment options with your primary care physician and take conservative approaches first. It’s also important to seek out scientific information and second opinions before deciding on spinal fusion surgery. G

All research sources cited throughout this document can be found on Page 15.

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Before Considering Fusion Surgery Low back pain is one of the most common reasons for visits to primary care providers, affecting nearly one out of five people annually and 60% of people during their lifetime. While some forms of back pain are symptoms of an illness or disease that require surgery, there are many conditions that may be helped by nonsurgical treatments.

Nearly 80% of people with spinal pain will find relief with conservative treatments like those described below.

Evidence published in the Journal of General Internal Medicine1 suggests that nonspecific low back pain may be alleviated through the following: ●L ow-stress

activities ● Physical therapy ● Pain-relieving medications such as acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs) including aspirin and ibuprofen ● Epidural steroids in patients with sciatica (although there is no evidence that these injections benefit patients with acute or chronic low back pain) All research sources cited throughout this document can be found on Page 15.

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There is little or no evidence showing benefits of: ●O pioids or muscle relaxants ●B ed rest ● Transcutaneous electrical nerve stimulations (TENS) ● B iofeedback ● Acupuncture

Who Benefits Most From Spinal Fusion?

Spinal fusions may be recommended in cases involving injury, misalignment of the vertebrae, or to address one of the following issues if conservative treatments have failed: ● Spinal stenosis (narrowing of the spinal column) ● Herniated disc ●S pondylolisthesis (when one vertebra slips in front of the other) ● Certain spinal deformities ● Infection Spinal fusion is not recommended for patients with nonspecific low back pain, with or without sciatica or degenerative disc disease, according to all current medical association and spine surgery guidelines.

Watch this video to learn more about spinal fusion.

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Caution Advised Fusion of vertebrae in the lumbar region (low back) is recommended only for patients who have no physical deformity or neurological deficits, only after exhausting all conservative approaches, including pain medication, modified activity, and daily exercise, followed by rehabilitative and cognitive-behavioral therapy. This recommendation is made by: z Th e International Society for the Advancement of

Spine Surgery z Updated guidelines for the performance of fusion procedures for degenerative disease of the lumbar spine; Part 1: Introduction and Methodology (published in Journal of Neurosurgery and Spine) z The American Association of Neurological Surgeons Lumbar Fusion Guidelines z C linical guidelines and payer policies on fusion for the treatment of chronic low back pain (published in Spine) z Diagnosis and treatment of low back pain: A joint clinical practice guideline from the American College of Physicians and the American Pain Society (published in the Annals of Internal Medicine)

Benefits and Risks of Spinal Fusion If you are a candidate for lumbar spinal fusion, it’s important to understand the benefits and risks. This information is not meant to scare you away from spine surgery but rather to provide you with realistic expectations.

Benefits ●C an

significantly reduce or eliminate back pain. Various studies show success rates between 60% and 90%. ● Can prevent recurrence of back pain. ●N ewer plastic and titanium intervertebral devices, plates, and screws greatly increase stability after spinal fusion surgery so that grafts can fuse more quickly and fully.

Risks ● As

with any surgery, there is always a risk of infection, anesthesia reaction, or impact on other health conditions. You should talk with your surgeon about these risks and any other risks specific to your health history. ● Although success rates are high for properly selected patients overall, there is no certainty how much pain can be relieved on an individual basis. ● Some patients experience degeneration and pain in vertebrae above or below a fusion, but research has not yet determined if this is due to the fusion or whether it is due to other factors, such as genetics.

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This article posted on Spine Universe provides a more in-depth review of the pros and cons of spinal fusion.

What to Consider About Imaging Advanced imaging, typically an MRI or CT scan, is nearly always needed in advance of spine surgery. However, be cautious about obtaining imaging tests in the beginning before you have tried nonsurgical treatments.

Research published in the Journal of the American Medical Association (JAMA)1 found little benefit to early imaging: ● Less

than 1% of imaging studies identify a specific cause of low back pain ● Many of the abnormalities that are discovered through imaging are just as common in patients who are not suffering from back pain ● Imaging in early, acute low back pain increases the likelihood that surgery will be recommended more than imaging with X-rays While early imaging may not be necessary, there are acute instances when it is critical: ● Progression of symptoms ● Sudden onset of pain ● Weakness in the extremities ● Neurological deficits If your physician recommends imaging, you shouldn’t automatically reject the recommendation but rather ask good questions about the reasoning.

All research sources cited throughout this document can be found on Page 15.

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How to Select a Spine Surgeon Neurosurgeon vs. Orthopedic Surgeon

Both neurosurgeons and orthopedic surgeons perform spine surgery. Neurosurgeons, like those at South Denver Neurosurgery, undergo more extensive training than other surgeons and have specific expertise with nerves to ensure consideration is given to the central and peripheral nerves during surgery, maximizing your success and minimizing pain.

Why a neurosurgeon for spine surgery? ● Six

years or more training than most orthopedic surgeons ● Experience assisting in hundreds of spinal procedures during residency and fellowship training ● Expertise in dealing with nerves and brain function, critical components of any surgery involving the spinal cord or spine area

Spine Fellowships Both neurosurgeons and orthopedic surgeons can complete specialized spine fellowship programs to gain more in-depth training.

Fellowships are typically one year in length and can require producing peer-reviewed publications.

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Ben Guiot, MD, neurosurgeon, has completed three specialized spine fellowships and is board-certified by both the American Board of Neurological Surgery and the Royal College of Physicians and Surgeons of Canada.

How to Select a Spine Surgeon Experience Matters

Experience matters when it comes to spine surgery. ● Reduced complication rates: Complication rates are, on average, lower among more

experienced surgeons. In surgeries for spinal stenosis, for example, complication rates were 38% higher among surgeons who performed fewer than 15 surgeries in four years than surgeons who had performed more than 80 procedures during the same time period, according to a study published in Neurosurgery.1 ● Lower infection rates: Less experienced surgeons often take longer to perform surgery, which has been found to lead to increased infection rates, according to a study published by The University of Chicago Press.2 ● Decreased length of hospital stays: In general, more experienced surgeons are more accurate and efficient during surgery, resulting in less complications, anesthesia, and infections, all of which lead to shorter hospital stays and better outcomes. ● More careful patient screening: Spine surgeons with 15 years or more in the field are more likely to properly screen candidates for surgery, resulting in better outcomes, according to a survey published in the Journal of Spinal Disorders and Techniques.3 ● Reduced reoperation rates: Many reports highlight infection as a primary reason for reoperation, which a surgeon’s experience plays a significant role in, according to 2014 research on reoperation within 30 days of fusion surgery.4

All research sources cited throughout this document can be found on Page 15.

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How much experience is needed?

There is no magic number when it comes to experience. The general consensus judges “experience” by two marks: ● Having performed the procedure for at least five years; or ● Conducting at least 30 surgeries of the specific procedure (i.e., 30 disc fusions) overall

Specially trained spine neurosurgeons at South Denver Neurosurgery have performed thousands of spine surgeries over more than 20 years using researchsupported approaches.

How to Interview Your Surgeon Rarely is spine surgery an emergency. Before undergoing spine surgery, it’s important to select a surgeon right for you and your condition. Take your time to interview possible surgeons and their staff to ensure the right fit.

Ask your potential surgeon the following questions:

● Have you completed this procedure before? If so, how many times? ● W hat is your complication rate when performing this procedure? What are

the most common complications of this procedure? ● W hat is your infection rate? ● Do you have any statistics in regard to your surgical success? ● W hat does recovery from this procedure entail? ● W hat research have you conducted? ● W here do you perform your surgeries?

Also be sure to note details that will make you more comfortable: ● Do you have the surgeon’s full attention?

● Do you feel comfortable with the surgeon? ● Does the surgeon’s hygiene reflect the attention to detail you hope to see in the operating room? ● Are the surgeon’s nurses and office staff friendly? ● Do they address your concerns? ● H ow helpful are they with paperwork, travel plans, scheduling, etc.?

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Here are additional tips for selecting a spine surgeon.

About South Denver Neurosurgery The surgeons and staff of South Denver Neurosurgery are committed to building a relationship based on trust and caring with each of our patients. We work hard to make sure our patients understand their medical problem and are comfortable with their treatment decisions because we know that patients who are confident in their care have better outcomes.

Why choose South Denver Neurosurgery? ● Features

one of the most extensively fellowshiptrained spine neurosurgeons in the country ● Offers the latest surgical advancements, including minimally invasive surgery and robotic-guided procedures ● Achieves complication and infection rates equal to or better than national averages ● Provides unbiased information that is supported by medical research, offering patients information on all treatment options regardless of whether they choose treatment at South Denver Neurosurgery

Would you like a second opinion on your back pain? Call South Denver Neurosurgery to schedule an appointment at 720.638.7500.

New patients are seen within five days.

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Robotic Guidance Helps Improve Spine Surgery Outcomes Dr. Ben Guiot, a neurosurgeon with South Denver Neurosurgery, performs nearly all spine surgeries using the Mazor Robotics Renaissance Guidance System. This system allows him to preplan surgery in a threedimensional field and then helps guide Dr. Guiot during surgery, ensuring superior accuracy even if a patient’s anatomy shifts during surgery.

With the Renaissance system, Dr. Guiot can plan the spine surgery before entering the operating room. That plan is then input into the three-dimensional Renaissance system, which helps provide Dr. Guiot with unparalleled precision, resulting in consistent, optimal results for spine surgery patients. In a study of 112 cases, compared to freehand surgery, Mazor Robotics technology1 resulted in: ● Improved implant accuracy ● May have reduced fluoroscopy (56% reduction in this clinical case series) ● Reduced complication rates, reoperations, and post-op opioids ● Reduced average length of stay

All research sources cited throughout this document can be found on Page 15.

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South Denver Neurosurgery spine specialists use the Mazor Robotics Renaissance Guidance System to ensure pinpoint accuracy during delicate spine surgery.

Meet Our Physicians South Denver Neurosurgery is proud to offer one of the top teams of spine neurosurgeons in the nation.

Bernard Guiot, MD Dr. Guiot specializes in many aspects of spine care, including nonoperative and operative management of spinal problems extending from the skull base to the sacrum. He is experienced in all aspects of complex spinal reconstruction, including minimally invasive and robotic-assisted spinal technologies. Meet Dr. Guiot and learn more about his surgery techniques here.

J. Adair Prall, MD Dr. Prall has been board-certified by the American Board of Neurological Surgery since 2001 and is a leader in his field with more than 20 years of neurosurgical experience. He specializes in all types of cranial and spinal surgery, and is nationally renowned for his expertise in vascular compression syndromes, including trigeminal neuralgia.

Meet Dr. Prall and understand his expertise in spine surgery here.

David P. VanSickle, MD, PhD Dr. VanSickle joined South Denver Neurosurgery in 2007. Board-certified by the American Board of Neurological Surgery, Dr. VanSickle specializes in functional neurosurgery, neuro-oncology, surgery for epilepsy, and spinal disorders. Get to know more about Dr. VanSickle here.

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Questions and Notes Use this space to gather more information from your primary care physician to better understand the cause of your low back pain and what treatment options may be right for you.

Can you tell what precisely is the cause of my back pain?

What nonsurgical treatment options are best for me based on medical research?

When should I consider surgery?

Am I a good candidate for lumbar spinal fusion surgery?

What neurosurgeons in the area would you recommend?

Do these surgeons offer more than spinal fusion?

I have additional questions about‌

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Research Sources All information contained in this guide is based on research published in peer-reviewed journals. In order of appearance in this guide, the following studies were cited: Page 2:

Page 8:

1. Rajaee SS; Bae HW; Kanim LE; and Delamarter RB. “Spinal fusion in the United States: analysis of trends from 1998 to 2008.” Spine. Jan. 2012: 67-76. PubMed ID: 21311399. Web. 9 Mar 2015. http://www.ncbi.nlm.nih.gov/pubmed/21311399

1. Dasenbrock HH; Clarke MJ; Witham TF; Sciubba DM; Gokaslan ZL; and Bydon A. “The impact of provider volume on the outcomes after surgery for lumbar spinal stenosis.” Neurosurgery. June 2012: 1346-53. PubMed ID: 22610361. Web. 9 Mar 2015. http://www.ncbi.nlm.nih.gov/pubmed/22610361

2. Cowan JA Jr; Dimick JB; Wainess R; Upchurch GR Jr; Chandler WF; and La Marca F. “Changes in the utilization of spinal fusion in the United States.” Neurosurgery.

July 2006: 15-20. PubMed ID: 16823295. Web. 9 Mar 2015. http://www.ncbi.nlm.nih.gov/pubmed/16823295 3. Weinstein JN; Lurie JD; Olson PR; Bronner KK; and Fisher ES. “United States’ trends and regional variations in lumbar spine surgery: 1992-2003.” Spine. Nov. 2006: 2707-14. PubMed ID: 17077740. Web. 9 Mar 2015. http://www.ncbi.nlm.nih.gov/pubmed/17077740 4. Richard A. Deyo, MD, MPH; Sohail K. Mirza, MD, MPH; Brook I. Martin, MPH; William Kreuter, MPA; David C. Goodman, MD, MS; and Jeffrey G. Jarvik, MD, MPH. “Trends, Major Medical Complications, and Changes Associated with Surgery for Lumbar Spinal Stenosis in Older Adults.” Journal of the American Medical Association. April 2010: 1259-65. PubMed ID: 2885954. Web. 9 Mar 2015. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2885954 Page 3: 1. Steven J Atlas, MD, MPH; and Richard A Deyo, MD, MPH. “Evaluating and Managing Acute Low Back Pain in the Primary Care Setting.” Journal of General Internal Medicine.

Feb 2001: 120-31. Springer. “Pub Med ID: 1495170. Web. 9 Mar 2015 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1495170 Page 6: 1. Nortin M. Hadler, MD. “MRI for Regional Back Pain: Need for Less Imaging, Better Understanding.” Journal of the American Medical Association (JAMA). 2003: 2863-2865. ID: 196655. Web. 9 Mar 2015 http://jama.jamanetwork.com/article.aspx?articleid=196655

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2. Rebecca Wurtz, MD, MPH; Beth Wittrock RN, MD, MPH; Mary Alice Lavin, RN; and Anne Zawacki, RN, MPH. “Do New Surgeons Have Higher Surgical-Site Infection Rates?” Infection Control and Hospital Epidemiology. Vol. 22, No. 7. June 2001.n. pag.

The University of Chicago Press. Web. 9 Mar 2015. http://www.jstor.org/stable/10.1086/501916 3. JHM Media Team. “Survey Shows Spine Surgeons Need to Screen More Patients for Anxiety and Depression.” Recommended presurgical psychological screening assessments Largely ignored. John Hopkins Medicine. 1 April 2014. Web. 9 Mar 2015. http://www.hopkinsmedicine.org/news/media/releases/survey_shows_spine_ surgeons_need_to_screen_more_patients_for_anxiety_and_depression 4. Zheng Li; Jianxiong Shen; Guixing Qiu; Haiquan Yu; Yipeng Wang; Jianguo Zhang; Hong Zhao; Yu Zhao; Shugang Li; Xisheng Weng; Jinqian Liang; and Lijuan Zhao.

“Unplanned Reoperation within 30 Days of Fusion Surgery for Spinal Deformity.”

PLOS One. 4 Mar 2014. Article ID: 10.1371/journal.pone.0087172. Web. 9 Mar 2015. http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0087172 Page 11: 1. Kantelhardt SR; Martinez R; Baerwinkel S; Burger R; Giese A; and Rohde V. “Perioperative course and accuracy of screw positioning in conventional, open roboticguided and percutaneous robotic-guided, pedicle screw placement.” Eur Spine J. 2011; 20(6): 860-868.