Spinal fusion
We often overlook the importance of our spine in our daily lives, realising its profound significance only when a medical condition arises. Serving as a silent pillar of support and the central axis for our body’s functions, its critical role becomes evident when pain or discomfort demands our attention.
Some conditions can lead to an instability of the spine. That’s when spinal fusion becomes a treatment option. Read on to find out just how this procedure is performed and how it’s different from other procedures.
What is spinal fusion surgery?
Spinal fusion surgery is a surgical procedure tackling various spine issues, including degenerative conditions, injuries, infections, and tumours. People with spinal problems who haven’t improved with other treatments might consider this surgery. Spinal fusion surgery aims to stabilise the spine, relieve nerve pressure, fix alignment issues, and correct deformities.
During the surgery, the doctor removes the damaged disc between vertebrae and inserts a cage or bone to help the bones fuse. This fusion helps create a stable, single-bone segment.
Spinal fusion can be performed using different techniques: minimally invasive, open surgery, and, more recently, endoscopic surgery. The selected technique depends on the specific case and the patient’s needs.
How spinal fusion back surgery differs from other spinal surgeries
Spinal fusion back surgery aims to join two vertebrae to stabilise the spine and limit movement in that area. It’s commonly used for issues like degenerative disc disease, spondylolisthesis, and certain spinal deformities to relieve nerve compression and achieve a solid fusion of the spinal segment.
On the other hand, procedures like discectomy, laminectomy (spinal decompression), and disc replacement specifically address problems like spinal stenosis, disc herniation, and degenerative disease to maintain movement in the treated spinal area after the surgery.
How is a spinal fusion surgery performed?
In spinal fusion surgery, two vertebrae are permanently joined using metal hardware at the back, along with a cage, bone graft, and bone substitutes between them. This procedure can be done with the patient under general anaesthesia or, in some cases, epidural anaesthesia and sedation.
The patient is placed on their stomach, and the fusion level is marked with fluoroscopy. The following are the steps for open posterior spinal and endoscopic fusion.
Open posterior spinal fusion:
- A 5-10cm incision is made in the midline.
- Back muscles are moved to expose the affected spinal bone segment.
- Instruments are used to remove bones and ligaments, compressing nerves.
- Nerves are retracted to expose the disc, which is prepared for the cage.
- Screws are placed using O arm, C arm, or free-hand methods.
Endoscopic fusion:
- A small 1.5cm incision is made for a camera and another for instruments under fluoroscopic guidance.
- No muscle stripping is needed.
- Instruments are placed directly on the target lumbar segment under endoscopic visualisation.
- The facet joint is removed, similar to open fusion.
- The disc is prepared, and the cage is inserted under endoscopic vision.
- Screws are placed through small incisions using O-arm navigation or C-arm guidance.
What are the types of spinal fusion surgery typically performed in our centre?
Open spinal fusion
Depending on the location and correction needed, various options, such as laminectomies, posterior fusions, and interbody fusions, are available for treating degenerative spinal diseases. Traditionally, these procedures were performed openly, offering good visibility but causing more pain and tissue damage.
Endoscopic spinal fusion
Endoscopic spinal fusion is a minimally invasive spine surgery, and its primary goal is to achieve maximum benefits with minimal soft tissue damage. This procedure calls for smaller incisions, less blood loss, and early hospital discharge.
Lateral spinal fusion
Lateral spinal fusion is a minimally invasive spine surgery, which involves going through the lateral part of the abdomen to approach the spinal column directly on the disc. This procedure can correct deformity and has smaller incisions, less blood lost but there is slight risk in vascular injury and thigh pain.
What are the available treatment options for spinal stenosis?
Spinal stenosis treatment can be split into conservative (non-surgical) and surgical treatments. Non-surgical treatments can be categorised into medication and physical therapy interventions.
What are the two types of endoscopic spinal fusion?
There is only one form of open spinal fusion. With endoscopic spinal fusion, however, there are two types, as shown below.
Uniportal endoscopic fusion
Uniportal endoscopic spinal surgery involves a single portal for instruments, irrigation, visualisation, and light. It reduces the risk of excessive blood loss and the need for blood transfusions.
Dr Wu Pang Hung and the team have improved endoscopic fusion strategies with a uniportal posterolateral approach for more efficient decompression and fusion in spine surgery.
Biportal endoscopic fusion
Biportal endoscopic fusion surgery is a recently developed, minimally invasive technique used for treating lumbar spinal stenosis and disc herniation. This approach provides a magnified, clear view and allows easy handling of instruments, offering advantages like fewer limitations and enabling sufficient and safe decompression.
The biportal technique in endoscopic fusion surgery eliminates the need for specialised sets, allowing the use of standard arthroscopic and spine instruments. Because tools and the endoscope aren’t limited to a single portal, they can move freely and independently, reducing technical challenges.
What conditions can be treated with spinal fusion surgery?
Spinal fusion surgery is recommended for people with problems like lumbar degenerative diseases, spinal instability, spondylolisthesis, degenerative disc disease, and spinal deformities.
Standard surgical treatments for lumbar degenerative diseases, such as spinal stenosis and herniated intervertebral disc disease (HIVD), include laminectomy with foraminotomy and microdiscectomy.
How does lumbar fusion differ from spinal fusion surgery?
Spinal fusion and lumbar fusion are related terms that refer to surgical procedures aimed at stabilising and fusing two or more vertebrae in the spine. The main difference is the specific region of the spine that is targeted.
Spinal fusion is a broader term that encompasses fusion procedures performed in any region of the spine, including the cervical (neck), thoracic (mid-back), and lumbar (lower back) regions.
In contrast, lumbar fusion specifically refers to fusion procedures performed in the lower back region of the lumbar spine. The lumbar spine consists of five vertebrae labelled L1 to L5.
Lumbar spinal fusion surgery is recommended for a variety of conditions, including:
- Degenerative disc disease
- Spinal stenosis
- Spondylolisthesis
- Fractures or dislocations
- Spinal tumours
- Infections of the spine
What are the potential risks and complications associated with spinal fusion surgery?
There are three main complications associated with spinal fusion surgery:
- incomplete decompression
- dural tear
- nerve root injury
Less common issues include:
- temporary tingling
- postoperative headache
- postoperative hematoma
- malposition of implants and/or loosening
To minimise these potential problems, our team uses endoscopes to examine the nervous structure closely with magnification and irrigation during spinal fusion surgery.
How long does a spinal fusion surgery typically last?
The duration of surgery depends on the condition’s complexity, the patient’s size and the choice of approach. A typical open spinal fusion takes 2-3 hours. Once the fusion device is inserted without further issues, it is expected to last the patient for their lifetime once fusion occurs 6-18 months later.
What is the cost of spinal fusion surgery in Singapore?
The cost of spinal fusion spinal surgery in Singapore differs based on the approach used, the type of implant, how long the patient stays in the hospital after surgery, and the choice of hospital and room accommodation.
For more information about the surgery cost and coverage by your insurance, it’s recommended you talk to your spinal surgeon.
Spinal fusion and lumbar stenosis surgery in Singapore
If you are struggling with spine instability issues, spinal fusion surgery could be just what you need to return to your usual life.
At Achieve Orthopaedic Clinic, we see ourselves as partners in your recovery journey. Our team in Singapore will help you not just from the moment of your spinal fusion surgery but up till the moment you recover and come back for follow-up appointments. Your long-term well-being matters to us
Frequently Asked Questions (FAQs)
Spinal fusion surgery is advised for patients with conditions causing spinal instability, like spondylolisthesis and spinal deformity.
Yes, there are several alternatives to spinal fusion surgery, including:
Cervical/lumbar disc replacement (CDR):
- A substitute for fusion in the cervical spine.
- Relieves nerve pressure caused by disc degeneration or herniation.
Endoscopic lumbar discectomy/decompression:
- Minimally invasive technique for persistent leg and lower back pain.
- Limits collateral damage to spinal elements and soft tissue.
Coflex lumbar interlaminar device:
- Enlarges the lumbar spinal canal to provide more space for neural structures and relieve pressure from arthritic joints.
- Implants the Coflex device to offer stability without compromising mobility.
Endoscopic/fluoroscopic rhizotomy:
- It is the least invasive and most successful for chronic lower back pain related to arthritic joint structures.
- Provides pain relief for up to five years.
Intracept procedure:
- Non-invasive technique to target small neural structures responsible for pain perception from intervertebral disc endplates.
- Relieves chronic back pain in a carefully selected group of patients.
After open spinal fusion, standing or sitting for long periods can be challenging for the first few weeks, and it may take four to six weeks to resume light tasks. Full recovery might take six months to a year, and wearing a back brace may be necessary. However, our experience indicates that endoscopic spinal fusion can lead to a faster recovery, approximately twice as fast.
Generally, spinal fusion is considered a safe surgery. However, as with any other surgery, it carries some pertinent risks.
- Infection
- Poor wound healing
- Bleeding
- Blood clots
- Damage to blood vessels or nerves in and around the spine
- Pain at the bone graft site
- Return of symptoms
Yes. Physical therapy will help enhance your mobility and reduce pain after back surgery. Even though back surgery provides some pain relief, the procedure is sufficient.
Avoid activities like weightlifting, jogging, biking, or aerobics until your doctor says it’s okay. Refrain from driving for two to four weeks after surgery. Try not to sit in a car for more than 30 minutes during this period.
Cervical instrumentation
- Cranial screws are positioned at the base of the skull and connected to the cervical screws by rods.
- Anterior cervical plates fastened to vertebrae by bolts or screws
- Occipital plates fastened to the base of the skull by bolts or screws
- Interbody cages raise the spinal segment back to its original height following discectomy.
- Standalone cages are anchored into the bones without the need for screws or plates. These cages may lower the chance of postoperative dysphagia and hoarseness of voice.
- Cervical pedicle screws with rods (FDA-approved) are positioned at the pedicles of cervical vertebrae.
- Cervical lateral mass screws with rods are typically used from C3 to C7.
Thoracic instrumentation
- Pedicle screws with or without rods
- Interbody cages
- Lamina hooks with or without pedicle screws
Lumbar instrumentation
Many of the devices mentioned above, such as pedicle screws, rods, plates, and cages, are used as instrumentation during lumbar interbody fusion surgeries. Surgical approaches and techniques can also determine the kinds of instrumentation used in lumbar spine surgery.
ALIF: ALIF cages must be supported by plates or screw-rod structures. Large, angled cages can help the spine’s natural curve.
PLIF: Cages are used in conjunction with rods and pedicle screws
TLIF: Spacers with a potential crescent shape that are positioned in front of the disc space may be used
XLIF and OLIF: Permits the placement of a larger cage; hence, these techniques are more beneficial for treating scoliosis
In our practice, returning to an office or a sedentary job usually takes 4 to 6 weeks in open surgery and two weeks in endoscopic fusion. However, returning to more physically demanding activities may take up to 3 months.
No, the age at which spinal surgery can be performed is not set in stone. Age is not the main factor in determining whether or not spinal surgery is an option because spinal issues can affect both young and elderly patients.
More people needing revision surgery have arisen as open and endoscopic spine procedures for degenerative spine issues have become more common. Revision surgery with endoscopic discectomy, decompression, and fusion techniques have several advantages.
- Lower infection risk: Minimally invasive techniques create more minor wounds and involve less soft tissue dissection, reducing the risk of wound dehiscence and infection. Continuous irrigation during endoscopic spine surgery further lowers this risk.
- Preventing durotomy: Magnified endoscopic views and lateral dissection of the dural scar tissue can be performed to reduce the chance of unintentional durotomy.
- Preserving tissue: Endoscopic vision allows for reduced soft tissue and bone dissection, preserving enough tissue to prevent instability and the need for fusion.
- Multiple approaches: Endoscopic spine surgery allows various approaches to the same target site. For example, a contralateral approach may reach the same foraminal region previously accessed through a paraspinal or transforaminal approach.
Whether you are suitable for endoscopic spine surgery as a revision surgery will depend on your condition and your surgeon’s assessment.