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Fusion Procedures

Spinal arthrodesis for degenerative disease, spondylolisthesis, and instability — fixation techniques, biomaterials, and management of pseudarthrosis or adjacent segment disease.

Overview

Spinal fusion procedures aim to achieve arthrodesis, though no completely reliable method exists, with success rates varying widely and often overestimated by roentgenographic methods [4]. Interbody arthrodesis using cages involves specific background, rationale, indications, techniques, results, and future developments [6]. Long-term follow-up after final fusion is necessary to determine true final results [1].

Careful selection of patients for lumbosacral fusion is essential, requiring persistent, disabling pain unrelieved by non-surgical treatment [8]. Surgical intervention for Scheuermann's kyphosis is indicated for severe curves, intractable pain, neurologic deficits, or cardiopulmonary compromise, with posterior-only approaches and careful selection of fusion levels being key to reducing complications like junctional kyphosis [23]. Long-level fusion maintains acceptable clinical and radiological outcomes compared to short-level fusion at a minimum of 10 years of follow-up [2].

Surgical outcomes are similar regardless of the addition of fusion surgery among patients with Meyerding grade 2 degenerative spondylolisthesis [10]. Oblique lumbar interbody fusion and transforaminal lumbar interbody fusion have comparable fusion rates, complication rates, and lumbar pain improvements [5]. The European multicenter trial on guided oblique lumbar interbody fusion is expected to serve as the key step in deciding whether a direct comparative trial with another fusion technique is warranted [15].

However, the addition of interbody fusion to posterolateral fusion for degenerative disc disease in the lumbar spine was associated with a higher risk for additional surgery and showed no advantages in patient-reported outcome [49]. Despite achieving fusion in 80% of cases, anterior revision surgery for pseudoarthrosis after anterior cervical discectomy and fusion may not result in relevant clinical improvements for patients [9].

Anatomy & Pathophysiology

Spinal Biomechanics and Alignment

Spinal fusion arrests deformity progression and improves posture in patients with globally involved cerebral palsy with scoliosis, though functional benefits remain unclear [16]. No randomized controlled trials compare spinal fusion with the natural history of the disease for scoliosis in this population [16]. In early onset scoliosis, both convex side short fusion combined with concave side single growing rod technique and traditional bilateral growing rod technique correct the Cobb angle of the main curve without significantly hindering spinal growth [61].

Restoring sagittal alignment matched to spinopelvic morphology during degenerative lumbar surgery optimizes surgical outcomes and helps prevent adjacent segment pathology [62]. Cervical sagittal profile undergoes compensatory changes after short lumbar fusion for global sagittal imbalance [60]. The most noticeable changes in spinopelvic sagittal alignment after lumbar fusion occur in the natural sitting position [66]. Longer spinal fusion or inclusion of the pelvis in the fusion critically impacts hip-spine biomechanics [27]. Inclusion of the pelvis significantly affects the ability to compensate in the standing-to-sitting transition [27]. Hip-lumbar mobility loss affects quality of life in patients undergoing both lumbar fusion and total hip arthroplasty [45]. Hip-lumbar mobility influences activity, particularly those requiring overall sagittal flexion [45].

Cervical Spine Fusion Mechanics

An appropriate correction range exists for cervical kyphosis correction, supported by the link between biomechanical data and complications [42]. Static biomechanical effects of modified anterior cervical discectomy and fusion (Mod ACDF) are intermediate between ACDF and anterior cervical corpectomy and fusion (ACCF) [54]. The risk of vertebral body collapse is lower with Mod ACDF than with ACCF [54]. Stress at the endplate-cage interface decreases as cage stiffness is reduced [55]. Subsidence is less likely to occur in cervical interbody fusion cages with lower stiffness [55].

Lumbar and Thoracolumbar Fusion Biomechanics

Anterior lumbar interbody fusion (ALIF) is preferable at L5/S1 due to biomechanical factors [38]. At L4/5, anterior lumbar interbody fusion and total disc arthroplasty give comparable results [38]. Preservation of the proximal multifidus muscle contributes to maintaining physiological mechanical behavior of adjacent segments during posterior lumbar interbody fusion [64]. Preserving the proximal multifidus muscle helps prevent the occurrence and development of adjacent segment disease (ASD) [64].

Higher magnitudes of cage subsidence (CS) are associated with worse clinical improvements following oblique lumbar interbody fusion combined with anterolateral fixation [69]. Higher magnitudes of cage subsidence are associated with lower intervertebral fusion rates [69]. Fusion and fixation range selection in intervertebral surgery for thoracolumbar and lumbar tuberculosis effectively restores physiological curvature of the spine [63]. This surgical approach reduces degeneration of adjacent vertebral bodies in the spinal column for tuberculosis cases [63].

Osseous Healing and Fixation Constructs

The biomechanical properties of a stable spinal fusion preceded the radiographic appearance of a solid fusion by at least eight weeks [51]. Immature woven bone provided substantial stiffness to the fusion mass before radiographic solidification [51]. All-pedicle-screw constructs are safe and biomechanically advantageous in the management of adolescent idiopathic scoliosis [67]. All-pedicle-screw constructs offer superior deformity correction compared with hook instrumentation in adolescent idiopathic scoliosis [67]. All-pedicle-screw constructs allow for shorter fusions compared with hook instrumentation in adolescent idiopathic scoliosis [67].

Indications for anterior column realignment with posterior osteotomy: * Patients aged ≥75 years * Severe osteoporosis * Rigid lumbar curve with dynamic change in lumbar lordosis <10° * More than four facet joints of Pathria grade 3 in the lumbar region [57]

Preoperative Planning and Reference

The book "Manual of Internal Fixation of the Spine" provides sections on anatomy, biomechanics, and preoperative planning for spinal internal fixation systems [43].

Classification

Long-term Follow-up: Long-term follow-up after final fusion is necessary to determine true final results for growing-rod treatment in early onset scoliosis [1].

Fusion Level Selection: Long-level posterolateral fusion maintains acceptable clinical and radiological outcomes compared to short-level fusion at a minimum of 10 years of follow-up in lumbar degenerative disease [2]. Careful selection of patients for lumbosacral fusion is essential, requiring persistent, disabling pain unrelieved by non-surgical treatment [8].

Congenital Scoliosis Management: Proper treatment for congenital scoliosis entails early fusion if progression is demonstrated or will occur, with correction not needed in these instances [3].

Fusion Reliability: No completely reliable method of spine fusion has been developed, with success rates varying widely and often overestimated by roentgenographic methods [4]. There is an association between radiographic fusion status and clinical outcomes in single-level instrumented lumbar arthrodesis using local autologous bone graft [11].

Interbody Fusion Modalities: Oblique lumbar interbody fusion and transforaminal lumbar interbody fusion have comparable fusion rates, complication rates, and lumbar pain improvements in the treatment of lumbar degenerative diseases [5]. Interbody arthrodesis using cages has established background, rationale, indications, techniques, results, and future developments [6].

Pseudoarthrosis and Revision: Despite achieving fusion in 80% of cases, anterior revision surgery for pseudoarthrosis after anterior cervical discectomy and fusion may not result in relevant clinical improvements for patients [9]. There is no convincing published data on the effectiveness or safety of "topping off" hybrid systems for lumbar spine fusion [20].

Spondylolisthesis Classification and Outcomes: Surgical outcomes are similar regardless of the addition of fusion surgery among patients with Meyerding grade 2 degenerative spondylolisthesis [10]. Reduction and circumferential fusion performed by an experienced surgeon is safe and gives far better results than in situ fusion for severe lumbosacral spondylolisthesis in adolescents and children [56].

Other Considerations: Approximately one-third of adverse events after posterior lumbar fusion are diagnosed 31 to 90 days after surgery [7]. A practical classification system for cage retropulsion in degenerative lumbar disease has preliminary feasibility in surgical approach selection, suggesting that early revision may yield better outcomes [53].

Clinical Presentation

Long-term follow-up is necessary to determine true final results after fusion [1]. Long-level fusion maintains acceptable clinical and radiological outcomes compared to short-level fusion at a minimum of 10 years of follow-up [2]. Spinal fusion in patients with GMFCS IV or V cerebral palsy resulted in durable radiographic correction and sustained improvements in caregiver-reported quality of life over a minimum of 5 years [14].

Patient Selection: Careful selection of patients for lumbosacral fusion is essential, requiring persistent, disabling pain unrelieved by non-surgical treatment [8]. Proper treatment for congenital scoliosis entails early fusion if progression is demonstrated or will occur, with correction not needed in these instances [3]. Surgical outcomes are similar regardless of the addition of fusion surgery among patients with Meyerding grade 2 degenerative spondylolisthesis [10].

Preoperative Assessment: A systematic approach to treatment is required for adult patients presenting with late or chronic complications after spinal surgery, involving patient assessment, differential diagnosis formulation, and familiarity with different surgical approaches [28]. Heart disease presents an additional challenge to spine fusion patients who are undergoing a challenging and risky procedure [29]. A worse clinical result is associated with increasing patient comorbidities, pseudarthrosis in the thoracic spine, and subsequent breakdown caudad to the fusion in pedicle subtraction osteotomy for fixed sagittal imbalance [30].

Radiographic and Clinical Correlation: There is an association between radiographic fusion status and clinical outcomes in single-level instrumented lumbar arthrodesis using local autologous bone graft [11]. Patient reported outcomes and fusion rates were not adversely affected by risk factor profiles for non-union in lumbar spinal fusion using cellular bone allograft at 24-months follow-up [12]. Despite achieving fusion in 80% of cases, anterior revision surgery for pseudoarthrosis after anterior cervical discectomy and fusion may not result in relevant clinical improvements for patients [9].

Complication Patterns: Approximately one-third of adverse events after posterior lumbar fusion were diagnosed 31 to 90 days after surgery [7]. The incidence of symptomatic non-fusion segment disease after anterior cervical arthrodesis has multifactorial causes [13]. Patients treated with posterior or combined anterior and posterior arthrodesis were far more likely to develop clinical adjacent-segment pathology requiring surgery than those treated with posterior decompression or anterior arthrodesis [17].

Technique-Specific Outcomes: Both oblique lumbar interbody fusion and transforaminal lumbar interbody fusion have comparable fusion rates, complication rates, and lumbar pain improvements [5]. The anterior procedure for mid-thoracic spinal tuberculosis leads to early resolution of the disease and faster fusion compared to the posterior transpedicular approach [18]. No completely reliable method of spine fusion has been developed, with success rates varying widely and often overestimated by roentgenographic methods [4]. Interbody arthrodesis using cages involves background, rationale, indications, techniques, results, and future developments [6].

Investigations

Plain radiography: Long-term follow-up after final fusion is necessary to determine true final results [1]. Long-level fusion maintains acceptable clinical and radiological outcomes compared to short-level fusion at a minimum of 10 years of follow-up [2]. In congenital scoliosis, proper treatment entails early fusion if progression is demonstrated or will occur, with correction not needed in these instances [3]. No completely reliable method of spine fusion has been developed, with success rates varying widely and often overestimated by roentgenographic methods [4]. There is an association between radiographic fusion status and clinical outcomes in single-level instrumented lumbar arthrodesis using local autologous bone graft [11]. Spinal fusion results in durable radiographic correction and sustained improvements in caregiver-reported quality of life over a minimum of 5 years in patients with GMFCS IV or V cerebral palsy [14]. Pre-existing L5-S1 degeneration does not affect clinical and radiographical outcomes after isolated L4-5 fusion for spondylolisthesis [77].

MRI: After posterior lumbar fusion, the volume of the multifidus muscles was markedly decreased, and the degree of decrease was apparent on MRI [79]. Adding fusion to decompression increased the rate of new stenosis on two-year MRI, even when spondylolisthesis was present preoperatively [59].

CT: Computerized tomography plays an important role in investigating progressive non-infectious anterior vertebral fusion, split cord malformation, and situs inversus visceralis to improve understanding of the underlying pathology and the progressive fusion process [73].

Bone scan: 18F-fluoride PET/CT six weeks after posterior lumbar interbody fusion provides prognostic information on bony fusion at one year [71].

Other Considerations: Surgical exploration is the gold standard for diagnosing spinal non-union but is impractical for most patients, necessitating non-invasive radiologic methods despite the lack of consensus on the best approach [26]. An instrumented approach, a well-selected biologic adjunct, and achieving a solid fusion carry important long-term clinical advantages in avoiding revision surgery for nonunion [58]. Oblique lumbar interbody fusion and transforaminal lumbar interbody fusion have comparable fusion rates, complication rates, and lumbar pain improvements [5]. The European multicenter trial on guided oblique lumbar interbody fusion is expected to serve as the key step in deciding whether a direct comparative trial with another fusion technique is warranted [15]. Interbody arthrodesis using cages involves background, rationale, indications, techniques, results, and future developments [6]. Despite achieving fusion in 80% of cases, anterior revision surgery for pseudoarthrosis after anterior cervical discectomy and fusion may not result in relevant clinical improvements for patients [9]. Patients treated with posterior or combined anterior and posterior arthrodesis were far more likely to develop clinical adjacent-segment pathology requiring surgery than those treated with posterior decompression or anterior arthrodesis [17]. The anterior procedure leads to early resolution of the disease and faster fusion compared to the posterior transpedicular procedure in the treatment of mid-thoracic spinal tuberculosis in adults [18]. Patients with prior spinal fusion had worse outcomes after total hip arthroplasty than patients without prior spinal fusion [21].

Treatment

Non-Operative

Careful patient selection for lumbosacral fusion requires persistent, disabling pain that remains unrelieved by non-surgical treatment [8]. In situ arthrodesis is reserved for patients with Grade-III or IV spondylolisthesis whose pain interferes with lifestyle and is unresponsive to non-operative management [78].

Operative

Indications: Surgical intervention for Scheuermann's kyphosis is indicated for severe curves, intractable pain, neurologic deficits, or cardiopulmonary compromise [23]. For congenital scoliosis, proper treatment entails early fusion if progression is demonstrated or will occur, though correction is not strictly required in these instances [3]. Decompression alone demonstrates non-inferiority in efficacy for treating low back pain due to degenerative spondylolisthesis compared to fusion, offering additional benefits in operation time and blood loss [35]. Surgical outcomes for Meyerding grade 2 degenerative spondylolisthesis are similar regardless of the addition of fusion surgery [10]. Obesity is not a contraindication to lumbar spinal fusion [32].

Surgical Approach / Technique: Posterior-only approaches with careful selection of fusion levels are key to reducing complications like junctional kyphosis in Scheuermann's kyphosis [23]. Long-level posterolateral fusion maintains acceptable clinical and radiological outcomes compared to short-level fusion at a minimum of 10 years of follow-up in lumbar degenerative disease [2]. Oblique lumbar interbody fusion and transforaminal lumbar interbody fusion have comparable fusion rates, complication rates, and lumbar pain improvements in the treatment of lumbar degenerative diseases [5]. Modified transforaminal lumbar interbody fusion is a safe and effective treatment for lumbar degenerative disorders, with a high fusion rate and no significant difference between modified transforaminal lumbar interbody fusion and posterior lumbar interbody fusion [34]. Standalone oblique lateral interbody fusion and combined oblique lateral interbody fusion with percutaneous pedicle screw achieved similar fusion rates and clinical outcomes at 2 years of follow-up in spondylolisthesis [36]. The addition of a prophylactic posterior spinal arthrodesis is not indicated for the effect of age on the change in deformity after radical resection and anterior arthrodesis for tuberculosis of the spine [44].

Implant Selection: Interbody arthrodesis using cages has established background, rationale, indications, techniques, results, and future developments [6]. Intra-operative endplate management should be cautious to avoid post-operative cage subsidence in lumbar interbody fusion among rheumatoid arthritis patients [76]. Successful fusion rates and clinical improvement (VAS, ODI) were similar in instrumented interbody fusion and instrumented posterolateral fusion groups for degenerative lumbar diseases in uremic patients under hemodialysis [31].

Adjuncts: New hybrid "topping off" systems might improve the outcome of lumbar spine fusion, but there is no convincing published data on their effectiveness or safety [20]. The European multicenter trial on guided oblique lumbar interbody fusion is expected to serve as the key step in deciding whether a direct comparative trial with another fusion technique is warranted [15].

Other Considerations: Long-term follow-up after final fusion is necessary to determine true final results in growing-rod treatment for early onset scoliosis [1]. No completely reliable method of spine fusion has been developed, with success rates varying widely and often overestimated by roentgenographic methods [4]. Surgical exploration is the gold standard for diagnosing spinal non-union but is impractical for most patients; therefore, non-invasive radiologic methods are necessary, though consensus on the best approach does not exist [26]. Lumbar surgical procedures contribute to the development of new Modic changes, particularly non-fusion surgeries [68]. The incidence of symptomatic non-fusion segment disease after anterior cervical arthrodesis has multifactorial causes [13]. Patients with prior spinal fusion had worse outcomes after total hip arthroplasty than patients without prior spinal fusion [21]. There is limited published evidence reporting clinical outcomes for the use of bone graft substitutes in non-spinal orthopaedic arthrodesis surgery [75].

Complications

Long-term Outcomes and Fusion Success: Long-term follow-up after final fusion is necessary to determine true final results [1]. No completely reliable method of spine fusion has been developed, with success rates varying widely and often overestimated by roentgenographic methods [4]. At an average follow-up of 3.6 years, a solid fusion was obtained in all but six patients out of 222 treated for adult scoliosis [25]. Approximately 20% of patients undergoing upper cervical spinal fusion surgery experienced delayed bony union [24].

Non-union and Adjacent Segment Disease: Patient reported outcomes and fusion rates were not adversely affected by risk factor profiles for non-union when using cellular bone allograft at 24-months follow-up [12]. The incidence of symptomatic non-fusion segment disease after anterior cervical arthrodesis has multifactorial causes [13].

Surgical Complications and Timing: Approximately one-third of adverse events after posterior lumbar fusion were diagnosed 31 to 90 days after surgery [7]. Patients with prior total hip arthroplasty undergoing long fusion to the pelvis experienced more surgical complications compared to those fused to the sacrum [37]. Patients with osteoporosis undergoing multilevel cervical fusion had a higher risk of adverse postoperative outcomes at two years [39].

Technique Comparisons: Oblique lumbar interbody fusion and transforaminal lumbar interbody fusion have comparable complication rates [5]. Endoscopic transforaminal lumbar interbody fusion is similar to minimally invasive transforaminal lumbar interbody fusion in terms of complication rates [33]. Minimally invasive techniques for transforaminal lumbar interbody fusion favor short-term outcomes such as decreased blood loss and shorter hospital stays, but literature remains equivocal regarding superior long-term results including patient-reported outcomes and arthrodesis success [22].

Patient-Reported Outcomes: Disability and health-related quality of life improved significantly after spinal fusion surgery during a one-year follow-up [19]. Long-level fusion maintains acceptable clinical and radiological outcomes compared to short-level fusion at a minimum of 10 years of follow-up [2]. Functional benefits of spinal fusion in patients with globally involved cerebral palsy remain unclear due to the absence of randomized controlled trials comparing fusion with the natural history of the disease [16].

Other Considerations: Patients with a previous history of lumbar spinal fusion have a significantly higher rate of dislocation of their total hip arthroplasty than age- and gender-matched patients without a lumbar spinal fusion [41]. Patients with a history of lumbar fusion had significantly greater rates of revision hip arthroscopy and conversion to total hip arthroplasty after primary hip arthroscopy compared with patients without previous fusion [48].

Recovery

Long-term follow-up after final fusion is necessary to determine true final results [1].

Light activity (weeks): Specific timelines for light activity are not defined in the available evidence.

Full activity (months): Specific timelines for full activity are not defined in the available evidence.

Complete recovery / outcome plateau (months): Patient reported outcomes and fusion rates were not adversely affected by risk factor profiles at 24-months follow-up [12]. Disability and health-related quality of life improved significantly after spinal fusion surgery during a one-year follow-up [19]. At an average follow-up of 3.6 years, 68 per cent of patients undergoing surgical treatment of adult scoliosis were free of pain and a solid fusion was obtained in all but six patients [25]. Spinal fusion resulted in durable radiographic correction and sustained improvements in caregiver-reported quality of life over a minimum of 5 years in patients with GMFCS IV or V cerebral palsy [14].

Rehabilitation protocol: Rehabilitation protocols are not specified in the available evidence.

Functional milestones: Patient reported outcomes and fusion rates were not adversely affected by risk factor profiles at 24-months follow-up [12]. Disability and health-related quality of life improved significantly after spinal fusion surgery during a one-year follow-up [19]. At an average follow-up of 3.6 years, 68 per cent of patients undergoing surgical treatment of adult scoliosis were free of pain and a solid fusion was obtained in all but six patients [25]. Spinal fusion resulted in durable radiographic correction and sustained improvements in caregiver-reported quality of life over a minimum of 5 years in patients with GMFCS IV or V cerebral palsy [14].

Other Considerations: Long-level posterolateral fusion in lumbar degenerative disease maintained acceptable clinical and radiological outcomes compared to short-level fusion at a minimum of 10 years of follow-up [2]. Approximately one-third of adverse events after posterior lumbar fusion were diagnosed 31 to 90 days after surgery [7]. Spinal fusion can arrest deformity progression and improve posture in patients with globally involved cerebral palsy, but functional benefits remain unclear [16]. Minimally invasive techniques for transforaminal lumbar interbody fusion generally favor short-term outcomes such as decreased blood loss and shorter hospital stays, but the literature remains equivocal regarding superior long-term results including patient-reported outcomes and arthrodesis success [22]. Approximately 20% of patients undergoing upper cervical spinal fusion surgery experienced delayed bony union [24]. Fusion length selection for posterior hemivertebra resection in congenital early-onset scoliosis should consider HV location, deformity severity, and kyphotic component to balance operative morbidity with long-term stability [46]. Both OLIF and PLIF yield comparable long-term functional and fusion outcomes in adjacent segment disease revision [47]. Fusion technique does not affect the long-term outcome of ACDF, as pain and disability improved substantially over time irrespective of surgical technique [50]. In the long term, OLIF combined with bilateral posterior fixation is superior to OLIF combined with unilateral posterior fixation in terms of clinical and imaging outcomes in patients with osteoporosis [52]. Independent risk factors for reoperation following final fusion after treatment of early-onset scoliosis with traditional growing rods include curve progression requiring reoperation during lengthening, an increasing number of levels spanned by the rods, and longer duration of treatment with the rods [70]. Favourable results with identical clinical outcomes and a high rate of fusion were seen in both groups using polyetheretherketone oblique cages with and without a titanium coating [72]. Of patients operated upon six months ago or longer, 95 per cent show fusion, though no exact conclusions should be drawn from this small series without longer follow-up [74].

Key Evidence

  • [L4] Long-term follow-up after final fusion is necessary to determine true final results. (10.2106/jbjs.15.01334)
  • [L3] The long-level fusion group maintained acceptable clinical and radiological outcomes compared to the short-level fusion group at a minimum of 10 years of follow-up. (10.1186/s12891-015-0836-3)
  • [L4] Proper treatment entails early fusion if progression is demonstrated or will occur; correction is not needed in these instances. (10.2106/00004623-198163040-00011)
  • [L4] No completely reliable method of spine fusion has been developed, with success rates varying widely and often overestimated by roentgenographic methods. (10.2106/00004623-196850010-00017)
  • [L1] Both methods have comparable fusion rates, complication rates, and lumbar pain improvements. (10.3389/fsurg.2024.1374134)
  • [L3] Approximately one-third of adverse events after posterior lumbar fusion were diagnosed 31 to 90 days after surgery, highlighting the importance of looking past the 30-day mark for adverse event characterization. (10.5435/jaaos-d-21-01121)
  • [L3] Despite achieving fusion in 80% of cases, anterior revision surgery may not result in relevant clinical improvements for patients. (10.1186/s12891-023-06819-7)
  • [L3] The surgical outcomes were similar regardless of the addition of fusion surgery among patients with grade 2 DS. (10.1186/s12891-022-05850-4)
  • [L3] However, there was an association between radiographic fusion status and clinical outcomes. (10.5435/jaaos-d-23-01124)
  • [L2] Patient reported outcomes and fusion rates were not adversely affected by risk factor profiles. (10.1186/s12891-024-07456-4)
  • [L3] The incidence of symptomatic non-fusion segment disease after anterior cervical arthrodesis has multifactorial causes. (10.1186/s13018-018-0717-1)
  • [L4] Spinal fusion resulted in durable radiographic correction and sustained improvements in caregiver-reported quality of life over a minimum of 5 years. (10.2106/jbjs.25.00186)
  • [L4] Despite its limitations, the study is expected to serve as the key step in deciding whether a direct comparative trial with another fusion technique is warranted. (10.1186/1471-2474-11-199)
  • [L5] It notes that while spinal fusion can arrest deformity progression and improve posture, there are no randomized controlled trials comparing fusion with the natural history of the disease, and functional benefits remain unclear. (10.2106/jbjs.n.00468)
  • [L3] Patients treated with posterior or combined anterior and posterior arthrodesis were far more likely to develop clinical adjacent-segment pathology requiring surgery than those treated with posterior decompression or anterior arthrodesis. (10.2106/jbjs.m.01482)
  • [L3] Moreover, the anterior procedure leads to early resolution of the disease and faster fusion. (10.1186/s12891-019-2945-x)
  • [L3] Disability and HRQoL improved significantly after spinal fusion surgery during a one-year follow-up. (10.1186/1471-2474-14-211)
  • [L2] New hybrid systems might improve the outcome of lumbar spine fusion, but to date there is no convincing published data on effectiveness or safety of these topping off systems. (10.1186/1471-2474-12-239)
  • [L3] This study demonstrates that patients with prior spinal fusion had worse outcomes after THA than patients without prior spinal fusion. (10.1016/j.arth.2017.03.031)
  • [L1] While minimally invasive techniques generally favor short-term outcomes such as decreased blood loss and shorter hospital stays, the literature remains equivocal regarding superior long-term results, including patient-reported outcomes and arthrodesis success, necessitating further study. (10.5435/jaaos-d-15-00756)
  • [L5] Surgical intervention is indicated for severe curves, intractable pain, neurologic deficits, or cardiopulmonary compromise, with posterior-only approaches and careful selection of fusion levels being key to reducing complications like junctional kyphosis. (10.5435/jaaos-d-17-00748)
  • [L3] Approximately 20% of patients undergoing upper cervical spinal fusion surgery experienced delayed bony union. (10.1186/s12891-025-08582-3)
  • [L4] At an average follow-up of 3.6 years, 68 per cent of patients were free of pain and a solid fusion was obtained in all but six patients. (10.2106/00004623-198163020-00013)
  • [Paper] Surgical exploration is the gold standard for diagnosing spinal non-union but is impractical for most patients; therefore, non-invasive radiologic methods are necessary, though consensus on the best approach does not exist. (10.1016/j.injury.2010.11.041)
  • [L3] Longer spinal fusion or inclusion of the pelvis in the fusion critically impacts hip-spine biomechanics and significantly affects the ability to compensate in the standing-to-sitting transition. (10.1016/j.arth.2017.04.051)
  • [L5] A systematic approach to treatment is required for the adult patient presenting with late or chronic complications after spinal surgery, involving patient assessment, differential diagnosis formulation, and familiarity with different surgical approaches. (10.5435/jaaos-d-16-00530)
  • [L3] Heart disease presents an additional challenge to spine fusion patients who are undergoing a challenging and risky procedure. (10.5435/jaaos-d-21-00850)
  • [L4] A worse clinical result is associated with increasing patient comorbidities, pseudarthrosis in the thoracic spine, and subsequent breakdown caudad to the fusion. (10.2106/00004623-200303000-00009)
  • [L3] Successful fusion rates and clinical improvement (VAS, ODI) were similar in IBF and PLF groups. (10.1186/s12891-020-03815-z)
  • [L1] Based on these results, obesity is not a contraindication to lumbar spinal fusion. (10.1302/0301-620x.97b10.35724)
  • [L1] Endo-TLIF is similar to MIS-TLIF in terms of long-term clinical outcomes, fusion rates, and complication rates. (10.1186/s13018-024-04549-7)
  • [L3] M-TLIF is a safe and effective treatment for lumbar degenerative disorders, with a high fusion rate and no significant difference between M-TLIF and PLIF. (10.1186/s13018-024-04531-3)
  • [L1] Decompression alone demonstrates non-inferiority in terms of efficacy for treating low back pain due to DS compared to fusion, with additional benefits in operation time and blood loss. (10.1186/s13018-025-06550-0)
  • [L3] Both standalone OLIF and combined OLIF achieved similar fusion rates and clinical outcomes at 2 years of follow-up. (10.1186/s12891-020-03192-7)
  • [L3] Patients with prior THA undergoing long fusion to the pelvis experienced longer length of stay, more surgical complications, and a lower rate of spinal revisions compared to those fused to the sacrum. (10.5435/jaaos-d-22-00897)
  • [L1] ALIF is preferable at L5/S1 due to biomechanical factors, while at L4/5, both procedures give comparable results. (10.1302/0301-620x.107b6.bjj-2024-1646.r1)
  • [L3] Among patients who underwent multilevel cervical fusion, those with osteoporosis had higher risk of adverse postoperative outcomes at two years. (10.5435/jaaos-d-22-00361)
  • [L3] Patients with a previous history of lumbar spinal fusion have a significantly higher rate of dislocation of their THA than age- and gender-matched patients without a lumbar spinal fusion. (10.1302/0301-620x.99b5.bjj-2016-0657.r1)
  • [L5] The link between biomechanical data and complications after cervical kyphosis correction supported the existence of an appropriate correction range. (10.1186/s13018-025-06368-w)
  • [L5] This book provides an objective review of currently available systems for internal fixation of the spine, with excellent sections on anatomy, biomechanics, and preoperative planning, though it lacks discussion on regulatory issues and patient selection for axial back-pain syndrome. (10.2106/00004623-199803000-00028)
  • [L3] Therefore, the addition of a prophylactic posterior spinal arthrodesis is not indicated. (10.2106/00004623-199405000-00011)
  • [L3] This study confirmed that hip-lumbar mobility is a factor that influences activity, most of all those requiring overall sagittal flexion. (10.1302/0301-620x.107b1.bjj-2024-0406.r1)
  • [L3] Fusion length selection should consider HV location, deformity severity, and kyphotic component to balance operative morbidity with long-term stability. (10.1186/s13018-025-05971-1)
  • [L1] Both OLIF and PLIF yield comparable long-term functional and fusion outcomes in ASD revision. (10.1186/s13018-025-06317-7)
  • [L3] Patients with a history of lumbar fusion had significantly greater rates of revision hip arthroscopy and conversion to THA compared with patients without previous fusion. (10.1016/j.arthro.2024.08.026)
  • [L3] The addition of interbody fusion to posterolateral fusion was associated with a higher risk for additional surgery and showed no advantages in patient-reported outcome. (10.1302/0301-620x.101b12.bjj-2019-0427.r1)
  • [L1] The results do not support the idea that fusion technique affects long-term outcome of ACDF, as pain and disability improved substantially over time irrespective of surgical technique. (10.1186/s12891-023-06503-w)
  • [L5] The biomechanical properties of a stable spinal fusion preceded the radiographic appearance of a solid fusion by at least eight weeks, suggesting that immature woven bone provided substantial stiffness to the fusion mass. (10.2106/00004623-199711000-00013)
  • [L3] In the long term, OLIF combined with bilateral posterior fixation is superior to OLIF combined with unilateral posterior fixation in terms of clinical and imaging outcomes. (10.1186/s13018-023-04262-x)
  • [L4] The study proposes a practical classification system with preliminary feasibility in surgical approach selection for cage retropulsion, suggesting that early revision may yield better outcomes. (10.1186/s12891-026-09616-0)
  • [L5] The static biomechanical effects caused by Mod ACDF are intermediate between ACDF and ACCF, and the risk of vertebral body collapse is lower than that by ACCF. (10.1186/s13018-023-04033-8)
  • [L5] We also observed that the stress of the endplate-cage interface decreased as the reduction of the cage's stiffness, indicating that subsidence is less likely to occur in the cage with lower stiffness. (10.1186/s12891-021-04244-2)
  • [L4] Reduction and circumferential fusion performed by a surgeon with experience in this type of surgery is safe and gives far better results than an in situ fusion. (10.2106/00004623-198163040-00012)
  • [L3] Indications for the procedure include patients aged ≥75 years, severe osteoporosis, rigid lumbar curve with dynamic change in LL <10°, or more than four facet joints of Pathria grade 3 in the lumbar region. (10.1186/s12891-022-05915-4)
  • [L5] Recent long-term studies show that although imaging remains difficult, an instrumented approach, a well-selected biologic adjunct, and achieving a solid fusion all carry important long-term clinical advantages in avoiding revision surgery for nonunion. (10.5435/jaaos-22-08-503)
  • [L1] Adding fusion to a decompression increased the rate of new stenosis on two-year MRI, even when a spondylolisthesis was present preoperatively. (10.1302/0301-620x.104b12.bjj-2022-0340.r1)
  • [L3] Cervical sagittal profile would have compensatory changes after short lumbar fusion. (10.1186/s12891-024-07518-7)
  • [L3] Both techniques can correct the Cobb angle of the main curve without significantly hindering spinal growth. (10.1186/s12891-024-07457-3)
  • [L5] Restoring sagittal alignment matched to spinopelvic morphology during degenerative lumbar surgery can optimize surgical outcomes by preventing adjacent segment pathology. (10.5435/jaaos-d-24-00749)
  • [L3] It effectively restores the physiological curvature of the spine and reduces the degeneration of adjacent vertebral bodies in the spinal column. (10.1186/s12891-021-04335-0)
  • [L5] The preservation of the proximal multifidus muscle contributes to the maintenance of the physiological mechanical behavior of adjacent segments, thus preventing the occurrence and development of ASD. (10.1186/s12891-023-06649-7)
  • [L3] The most noticeable changes in spinopelvic sagittal alignment occurred in the natural sitting position after lumbar fusion. (10.1186/s12891-020-03777-2)
  • [L5] All-pedicle-screw constructs are safe and biomechanically advantageous in the management of adolescent idiopathic scoliosis, offering superior deformity correction and shorter fusions compared with hook instrumentation. (10.5435/00124635-200909000-00002)
  • [L3] Lumbar surgical procedures contribute to the development of new Modic changes, particularly non-fusion surgeries. (10.1186/s13018-022-02971-3)
  • [L3] Higher magnitudes of CS were associated with worse clinical improvements and lower intervertebral fusion. (10.1186/s12891-022-05165-4)
  • [L4] Independent risk factors for reoperation following final fusion include curve progression requiring reoperation during lengthening, an increasing number of levels spanned by the rods, and longer duration of treatment with the rods. (10.2106/jbjs.20.00312)
  • [L2] 18F-fluoride PET/CT six weeks after PLIF provides prognostic information on bony fusion at one year. (10.1186/s13018-025-05814-z)
  • [L1] Favourable results with identical clinical outcomes and a high rate of fusion was seen in both groups. (10.1302/0301-620x.99b10.bjj-2016-1292.r2)
  • [L5] The authors emphasize the important role of computerized tomography in investigating these patients to improve understanding of the underlying pathology and the progressive fusion process. (10.1186/1471-2474-7-94)
  • [L4] Of patients operated upon six months ago or longer, 95 per cent show fusion, though the author notes no exact conclusions should be drawn from this small series without longer follow-up. (10.2106/00004623-195840020-00019)
  • [L1] This systematic review found limited published evidence reporting clinical outcomes for the use of bone graft substitutes in non-spinal orthopaedic arthrodesis. (10.5435/jaaos-d-25-01307)
  • [L3] Intra-operative endplate management should be cautious to avoid post-operative cage subsidence. (10.1186/s12891-021-04531-y)
  • [L3] Pre-existing L5-S1 degeneration does not affect clinical and radiographical outcomes after isolated L4-5 fusion. (10.1186/s13018-015-0186-8)
  • [L3] In situ arthrodesis provides acceptable results for the patient who has Grade-III or IV spondylolisthesis and pain that interferes with life-style and that is unresponsive to non-operative treatment. (10.2106/00004623-198769070-00002)
  • [L3] After posterior lumbar fusion, the volume of the multifidus muscles was markedly decreased, and the degree of decrease was apparent in the MRI. (10.1186/s12891-020-3104-0)

See Also

References

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[2] Long-term outcomes of long level posterolateral fusion in lumbar degenerative disease: comparison of long level fusion versus short level fusion: a case control study. BMC Musculoskeletal Disorders. 2015. DOI: 10.1186/s12891-015-0836-3

[3] Surgical treatment of congenital scoliosis with or without Harrington instrumentation.. The Journal of Bone & Joint Surgery. 1981. DOI: 10.2106/00004623-198163040-00011

[4] Methods of Lumbar Fusion. The Journal of Bone & Joint Surgery. 1968. DOI: 10.2106/00004623-196850010-00017

[5] Fusion rate and complications of oblique lumbar interbody fusion and transforaminal lumbar interbody fusion in the treatment of lumbar degenerative diseases: a meta-analysis. Frontiers in Surgery. 2024. DOI: 10.3389/fsurg.2024.1374134

[6] MCAFEE, PAUL C. M.D.++, TOWSON, MARYLAND. The Journal of Bone and Joint Surgery. American Volume. 1999.

[7] Adverse Events After Posterior Lumbar Fusion Are Not Sufficiently Characterized With 30-day Follow-up: A Database Study. Journal of the American Academy of Orthopaedic Surgeons. 2022. DOI: 10.5435/jaaos-d-21-01121

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[9] Pseudoarthrosis after anterior cervical discectomy and fusion: rate of occult infections and outcome of anterior revision surgery. BMC Musculoskeletal Disorders. 2023. DOI: 10.1186/s12891-023-06819-7

[10] Surgical outcomes between posterior decompression alone and posterior decompression with fusion surgery among patients with Meyerding grade 2 degenerative spondylolisthesis: a multicenter cohort study. BMC Musculoskeletal Disorders. 2022. DOI: 10.1186/s12891-022-05850-4

[11] Association of Poor Bone Quality with Pseudarthrosis and Poor Clinical Outcomes in Single-Level Instrumented Lumbar Arthrodesis Using Local Autologous Bone Graft. Journal of the American Academy of Orthopaedic Surgeons. 2024. DOI: 10.5435/jaaos-d-23-01124

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[13] Risk factors for non-fusion segment disease after anterior cervical spondylosis surgery: a retrospective study with long-term follow-up of 171 patients. Journal of Orthopaedic Surgery and Research. 2018. DOI: 10.1186/s13018-018-0717-1

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[31] Instrumented Posterolateral fusion versus instrumented Interbody fusion for degenerative lumbar diseases in uremic patients under hemodialysis. BMC Musculoskeletal Disorders. 2020. DOI: 10.1186/s12891-020-03815-z

[32] Outcome of lumbar spinal fusion surgery in obese patients. The Bone & Joint Journal. 2015. DOI: 10.1302/0301-620x.97b10.35724

[33] Comparison of clinical outcomes and complications between endoscopic and minimally invasive transforaminal lumbar interbody fusion for lumbar degenerative diseases: a systematic review and meta-analysis. Journal of Orthopaedic Surgery and Research. 2024. DOI: 10.1186/s13018-024-04549-7

[34] Comparison of safety and efficacy of posterior lumbar interbody fusion (PLIF) and modified transforaminal lumbar interbody fusion (M-TLIF) in the treatment of single-segment lumbar degenerative diseases. Journal of Orthopaedic Surgery and Research. 2024. DOI: 10.1186/s13018-024-04531-3

[35] Decompression, decompression plus fusion and decompression plus dynamic stabilization for degenerative lumbar spondylolisthesis: a network meta-analysis. Journal of Orthopaedic Surgery and Research. 2025. DOI: 10.1186/s13018-025-06550-0

[36] Standalone oblique lateral interbody fusion vs. combined with percutaneous pedicle screw in spondylolisthesis. BMC Musculoskeletal Disorders. 2020. DOI: 10.1186/s12891-020-03192-7

[37] Evaluating Outcomes of Spinopelvic Fixation for Patients Undergoing Long Segment Thoracolumbar Fusion with a Prior Total Hip Arthroplasty. Journal of the American Academy of Orthopaedic Surgeons. 2023. DOI: 10.5435/jaaos-d-22-00897

[38] A comparison of the long-term results of anterior lumbar interbody fusion and total disc arthroplasty: a prospective randomized controlled trial with a mean follow-up of 14 years. The Bone & Joint Journal. 2025. DOI: 10.1302/0301-620x.107b6.bjj-2024-1646.r1

[39] The Impact of Osteoporosis on 2-Year Outcomes in Patients Undergoing Long Cervical Fusion. Journal of the American Academy of Orthopaedic Surgeons. 2023. DOI: 10.5435/jaaos-d-22-00361

[41] Dislocation of a primary total hip arthroplasty is more common in patients with a lumbar spinal fusion. The Bone & Joint Journal. 2017. DOI: 10.1302/0301-620x.99b5.bjj-2016-0657.r1

[42] Biomechanical analysis of the patient-specific appropriate correction angle for cervical kyphosis in multilevel anterior cervical discectomy and fusion: a finite element analysis. Journal of Orthopaedic Surgery and Research. 2025. DOI: 10.1186/s13018-025-06368-w

[43] MANUAL OF INTERNAL FIXATION OF THE SPINE. Edited by John S. Thalgott and Max Aebi. Philadelphia, Lippincott-Raven, 1996. $149.00, 320 pp.. The Journal of Bone & Joint Surgery. 1998. DOI: 10.2106/00004623-199803000-00028

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[55] A lattice topology optimization of cervical interbody fusion cage and finite element comparison with ZK60 and Ti-6Al-4V cages. BMC Musculoskeletal Disorders. 2021. DOI: 10.1186/s12891-021-04244-2

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b. if You include all or a substantial portion of the database contents in a database in which You have Sui Generis Database Rights, then the database in which You have Sui Generis Database Rights (but not its individual contents) is Adapted Material; and

c. You must comply with the conditions in Section 3(a) if You Share all or a substantial portion of the contents of the database.

For the avoidance of doubt, this Section 4 supplements and does not replace Your obligations under this Public License where the Licensed Rights include other Copyright and Similar Rights.

Section 5 -- Disclaimer of Warranties and Limitation of Liability.

a. UNLESS OTHERWISE SEPARATELY UNDERTAKEN BY THE LICENSOR, TO THE EXTENT POSSIBLE, THE LICENSOR OFFERS THE LICENSED MATERIAL AS-IS AND AS-AVAILABLE, AND MAKES NO REPRESENTATIONS OR WARRANTIES OF ANY KIND CONCERNING THE LICENSED MATERIAL, WHETHER EXPRESS, IMPLIED, STATUTORY, OR OTHER. THIS INCLUDES, WITHOUT LIMITATION, WARRANTIES OF TITLE, MERCHANTABILITY, FITNESS FOR A PARTICULAR PURPOSE, NON-INFRINGEMENT, ABSENCE OF LATENT OR OTHER DEFECTS, ACCURACY, OR THE PRESENCE OR ABSENCE OF ERRORS, WHETHER OR NOT KNOWN OR DISCOVERABLE. WHERE DISCLAIMERS OF WARRANTIES ARE NOT ALLOWED IN FULL OR IN PART, THIS DISCLAIMER MAY NOT APPLY TO YOU.

b. TO THE EXTENT POSSIBLE, IN NO EVENT WILL THE LICENSOR BE LIABLE TO YOU ON ANY LEGAL THEORY (INCLUDING, WITHOUT LIMITATION, NEGLIGENCE) OR OTHERWISE FOR ANY DIRECT, SPECIAL, INDIRECT, INCIDENTAL, CONSEQUENTIAL, PUNITIVE, EXEMPLARY, OR OTHER LOSSES, COSTS, EXPENSES, OR DAMAGES ARISING OUT OF THIS PUBLIC LICENSE OR USE OF THE LICENSED MATERIAL, EVEN IF THE LICENSOR HAS BEEN ADVISED OF THE POSSIBILITY OF SUCH LOSSES, COSTS, EXPENSES, OR DAMAGES. WHERE A LIMITATION OF LIABILITY IS NOT ALLOWED IN FULL OR IN PART, THIS LIMITATION MAY NOT APPLY TO YOU.

c. The disclaimer of warranties and limitation of liability provided above shall be interpreted in a manner that, to the extent possible, most closely approximates an absolute disclaimer and waiver of all liability.

Section 6 -- Term and Termination.

a. This Public License applies for the term of the Copyright and Similar Rights licensed here. However, if You fail to comply with this Public License, then Your rights under this Public License terminate automatically.

b. Where Your right to use the Licensed Material has terminated under Section 6(a), it reinstates:

1. automatically as of the date the violation is cured, provided it is cured within 30 days of Your discovery of the violation; or

2. upon express reinstatement by the Licensor.

For the avoidance of doubt, this Section 6(b) does not affect any right the Licensor may have to seek remedies for Your violations of this Public License.

c. For the avoidance of doubt, the Licensor may also offer the Licensed Material under separate terms or conditions or stop distributing the Licensed Material at any time; however, doing so will not terminate this Public License.

d. Sections 1, 5, 6, 7, and 8 survive termination of this Public License.

Section 7 -- Other Terms and Conditions.

a. The Licensor shall not be bound by any additional or different terms or conditions communicated by You unless expressly agreed.

b. Any arrangements, understandings, or agreements regarding the Licensed Material not stated herein are separate from and independent of the terms and conditions of this Public License.

Section 8 -- Interpretation.

a. For the avoidance of doubt, this Public License does not, and shall not be interpreted to, reduce, limit, restrict, or impose conditions on any use of the Licensed Material that could lawfully be made without permission under this Public License.

b. To the extent possible, if any provision of this Public License is deemed unenforceable, it shall be automatically reformed to the minimum extent necessary to make it enforceable. If the provision cannot be reformed, it shall be severed from this Public License without affecting the enforceability of the remaining terms and conditions.

c. No term or condition of this Public License will be waived and no failure to comply consented to unless expressly agreed to by the Licensor.

d. Nothing in this Public License constitutes or may be interpreted as a limitation upon, or waiver of, any privileges and immunities that apply to the Licensor or You, including from the legal processes of any jurisdiction or authority.

Creative Commons is not a party to its public licenses. Notwithstanding, Creative Commons may elect to apply one of its public licenses to material it publishes and in those instances will be considered the “Licensor.” The text of the Creative Commons public licenses is dedicated to the public domain under the CC0 Public Domain Dedication. Except for the limited purpose of indicating that material is shared under a Creative Commons public license or as otherwise permitted by the Creative Commons policies published at creativecommons.org/policies, Creative Commons does not authorize the use of the trademark "Creative Commons" or any other trademark or logo of Creative Commons without its prior written consent including, without limitation, in connection with any unauthorized modifications to any of its public licenses or any other arrangements, understandings, or agreements concerning use of licensed material. For the avoidance of doubt, this paragraph does not form part of the public licenses.

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