An estimated 300 000 spinal fusion surgeries are done in the USA annually. Lumbar fusion surgery is considered when your chronic back pain does not respond to non-surgical treatment, like physiotherapy rehabilitation. Lower back fusion fixates adjoining vertebrae to prevent pain causing movement and enhance stability. Consider it as needed customisation for your body’s mechanics. But as you are human, not robot, you need time for integration after back fusion surgery. Having all the facts and knowing what to prepare for ensures a smooth recovery.
What do my back bones do?
Your spine is the scaffolding of your back. The bones provide structural stability, protection for your nerves, attachment for muscles and a leverage system for movement. The vertebrae are stacked on each other. You have 24 vertebrae in total, from your neck down to your tailbone. Seven bones in your neck, 12 in your trunk and five segments forming the lumbar spine, named L1 – L5, counted from top to bottom.
The vertebral bodies have discs in between them, which are like shock absorbers. The rest of the vertebrae’s structure, the lamina, transverse and spinous processes, fit together snugly, like lego pieces stacked on top of each other to create a tower. These “snug fits” are the facet joints or zygapophyseal joints. You have one on each side of a vertebra, where the one on the top slides on the one below. This forms four facet joints per vertebra. Ligaments connect the different vertebrae together and provide extra static stability. Between each vertebra, a nerve root exits on each side, branching out to form your peripheral nerves.
What is a lower back fusion exactly?
During lumbar fusion surgery, the moveable “lego pieces” of the spine are fused with hardware, similar to proper metal scaffolding you see on a construction site. Metal screws, plates or rods are used to create a linkage or bridge between adjoining vertebrae. Each piece is chosen by your surgeon for your unique situation, which means no two surgeries will be exactly the same. In some cases bone grafts, where bone fragments are harvested from your ilium (hip), are also used to facilitate bone growth.
The immediate effect of surgery is stability and space. No more compression on nerve roots or uncontrolled movements in the case of instability (spondylolisthesis). This means less symptoms. The long term effect is that segmental movement is limited between the vertebrae. This changes force distribution and load in everyday movements and may cause increased wear and tear on the vertebrae above and below.
When is back fusion indicated?
Spinal fusion surgery can be recommended by your doctor in certain scenarios. Most doctors would recommend a course of non surgical treatment with a physiotherapist first.
Specific injuries necessitate quick surgical intervention, like:
- Traumatic injuries and fractures
Where instability may lead to spinal cord or nerve damage, in case of a fracture, immediate stabilisation is needed.
- Deteriorating nerve function
If you notice muscle weakness, inability to stand on your toes and areas of complete numbness, you should seek immediate care. Changes in bowel or bladder behaviour and control or loss of sensation in the area covered by your underwear should also be investigated.
Longstanding and chronic back pain, that does not respond to non-surgical intervention, can be considered for spinal fusion surgery, like:
- Lumbar stenosis
- Degenerative disc disease
- Disc prolapse
- Scoliosis
- Spondylolisthesis
Possible post lumbar fusion complications
- Deep vein thrombosis (DVT)
Any surgical procedure is a risk for blood clots. That is why you may be on blood thinners in the hospital. The inflammatory process initiated by your lower back fusion can cause blood clots and being less active after surgery can contribute too. This is why getting up and moving as soon as possible is important. It hastens healing and improves circulation and digestion after your surgery.
- Wound infection
The length of your scar will be proportional to the amount of fused vertebrae and may look less impressive than you would think, smaller than expected. Changes in sensation, colour and temperature are early signs of infection and should be treated immediately. Ensure you (with a mirror) or a loved one can see and identify any changes around your incision site.
- Nerve damage
As with any surgery the risk of sustaining nerve damage exists. It is normal to experience altered sensation for the first few days after your surgery. This is caused by the inflammatory and immune response. Tell your doctor about any changes you experience in sensation and strength.
- Post-surgical pain
Pain after your back fusion is normal and can last for weeks. It should improve gradually over time. Inflammation and tissue damage caused by the surgery will improve as you heal. You will notice that your pain improves as your back gets stronger.
- Stiffness
Swelling after surgery will contribute to feeling stiff. Depending on the level and amount of vertebrae fused you will lose some freedom of movement, but for the gain of stability and fewer symptoms.
Spinal fusion is only a step on the ladder of your recovery.
How severe is my lumbar fusion?
No two lower back fusion surgeries are exactly the same, because all backs are different. Because fusion surgery is done to fix one level to another, at least two levels will be influenced by your back fusion. In same cases multi-level fusion is done to fixate all the lumbar vertebrae together. Don’t worry, bending your hips will still allow you to pick up objects from the floor!
X-rays
X-rays will show the integrity and alignment of the joints in your spine. This will enable us to see if something is wrong with the structure of the bones in your spine or if there is a loss of disc space. We cannot see the disc tissue or nerve, but may make assumptions as to the available space they have from your Xrays.
Your physiotherapist can refer you to get x-rays taken if necessary.
Nerve conduction
While a MRI can visualise the structure of the nerves, a nerve conduction test can determine the nerve’s function. This is done by a neurologist by inserting needles to check the nerve’s conduction ability, if your nerve is getting information from point A to B. Spinal fusion may be recommended for decreased nerve function to avoid further damage and deterioration.
Why is the pain not going away?
Many people expect lumbar fusion surgery to work like a car service. You go into theatre, get your “new parts” and that’s that. Unfortunately, you are not a car and it’s not that easy. Lower back fusion “fixes” the instability, nerve compression or limited disc space. It does not change how you move or what you believe about your back and healing. Back pain is infamous for worse case scenario stories, like people living with chronic pain, nerve damage or ending up in a wheelchair. Your back fusion can be successful and heal. Get the right support from our physios and avoid getting stuck in a cycle of pain.
Problems we see when patients come to us after back fusion
Not realizing how important it is to see a physio after your spinal fusion
The physiotherapist will give you basic bed exercises to start with in the hospital after your back fusion. These exercises encourage circulation and muscle contraction. These exercises won’t be enough to get you fully mobile again. Some patients don’t follow up with a physiotherapist after leaving the hospital because they think that these exercises will get the job done. As your back heals you will need exercises that challenge and strengthen you to get you back doing the things you love.
How can physiotherapy treatment help me after my back fusion?
Our physiotherapists are experts in rehabilitation and understand the healing process. After your spinal fusion, we can answer any questions you may have and guide you through the process. It’s important to do the right level of exercise at the right time as your back heals. There are no shortcuts to healing. Spinal fusion is only one step of the journey. We can assist you in integrating strength and range of movement drills in your recovery. When you’ve completed the process with us you should understand why you have to avoid certain activities and be able to return to your everyday life.
We will show you what to do every step of the way.
Phases of rehabilitation for lower back fusion
1st Phase of spinal fusion rehabilitation: Hospitalisation (Week 0 – 1)
Rehabilitation begins the day after your lower back fusion. Your physiotherapist will make sure you can breathe comfortably, know how to cough and “brace” your abdominals and pelvic floor. If necessary you will receive chest treatment before/after your surgery. Your physio will teach you how to log roll to get up and back into bed. Circulation exercises and some low load contractions, like basic Pilates mat work start in your hospital bed.
Discharge depends on your vitals and ability to move easily the distances your home necessitates.
2nd Phase of spinal fusion rehabilitation: Low load and co-contraction (Weeks 2 – 4)
During this phase of your rehabilitation, you will be required to do your exercises twice a day. The aim is to get the big muscle groups to contract like a symphony, while keeping your back fairly straight. Bed bound exercises with some resistance bands will be included in your program, while you stick to the “either lying or standing” rule. You should be able to comfortably get in and out of bed and the car (think lazy boy angles with the passenger seat) for short journeys.
3rd Phase of spinal fusion rehabilitation: Initiate paced walking plan (Weeks 5 – 6)
From now on to the end of your rehabilitation, we can launch your paced walking program. This does not replace your exercises but supports your strengthening by getting your heart rate up too. The first aim is to go for accompanied walks from one lamp post to another, slowly increasing the distance and your independence.
4th Phase of spinal fusion rehabilitation: Range of motion (Weeks 7 – 12)
Once cleared by your surgeon we can incorporate back-specific movements into your rehabilitation, increase sitting duration and incorporate weights into your exercises. To move on to the next phase of your rehabilitation you should be able to carry light grocery bags, and do light household chores like dusting and sweeping.
5th Phase of spinal fusion rehabilitation: Functional training (Weeks 13 – 18)
Your life will determine how we progress this phase of your rehabilitation. Combined movement with weights are needed to get back on the golf course or caring and lifting grandchildren. You should be able to lift and carry 5 kg comfortably, squat with good form, climb a flight of stairs and walk 2 km to return to realistic daily living.
6th Phase of spinal fusion rehabilitation: Final clearance (Week 18 onwards)
To receive your final clearance we check specific stress tests. These tests are predetermined by what your goals are at the start of your rehabilitation, so that we can sign off on your recovery, knowing you’re safe. We make sure that you feel comfortable with what to expect onwards, know when to contact us, and will stay away from contact sports. Graduating from your spinal fusion rehabilitation we hope that you will share your knowledge and encourage others on the same journey.
Healing time after lumbar fusion surgery
Healing is different from returning to your strenuous activities and healing is, unfortunately never a perfect linear acceleration.
Physiologically, healing is a staircase, with the following steps:
Inflammatory phase (1 week after fusion surgery)
The inflammatory phase is marked by the inflammation caused by the fusion surgery, when your back feels warm to touch, appears swollen, and feels painful. It is important to use your medication as prescribed by your doctor during this phase. This will enable you to move as comfortably as possible.
Proliferation phase (+/- 3 weeks)
The second phase of healing starts about 48 hours after your operation and lasts about 2-3 weeks. During this phase of healing scar tissue forms in and around your spinal fusion. This is your body’s way of accepting the screws, nails and rods used during your spinal fusion and is crucial to regaining your mobility.
Guidance from your physiotherapist is vital during this phase, to ensure the correct exercise dose. Movement and muscle contraction supports the physiological changes around the surgical site. Doing too much or too little will result in stiffness and can interfere with how much movement you eventually regain. By now you should be able to get in and out of bed with confidence, walk and climb steps.
Remodelling phase (+/- 6 weeks)
The scar tissue formed during the proliferation phase matures now. This means that it isn’t as fragile and can tolerate more than during the early phases of healing.
The process described above takes about 6 weeks, but there will be overlap from one phase to the next. During the first 6 weeks after your spinal fusion it is advisable to see your physiotherapist once a week. As you get stronger your physiotherapist will see you every second week and finally once a month until you reach the 6 month mark.
At 12 weeks
Throughout your rehabilitation we will check on your progress, muscle strength and endurance. By this stage you should be able to do everyday activities like driving, getting into and out of a car, brisk walking, climbing stairs and strolling around in a shopping mall. Even picking up small objects, like a shoe, will be easy.
Full recovery after lumbar fusion can take up to two years after surgery. How long your recovery takes will depend on many different factors including your pre operative fitness, mobility and strength. After 18 months you should be back on the tennis court of golf course, hopping off the sidewalk.
Other forms of spinal fusion rehabilitation treatment
- Your doctor will prescribe medication to decrease swelling, ease pain and assist with bowel movements. Make sure that you understand how and when to take your medication and when to stop.
- Wearing a back brace may be recommended by your doctor for the first month of your recovery. Make sure you know when you can start weaning the wear of your back brace as this is never intended to be worn indefinitely.
- DVT or pressure stockings can be prescribed in hospital to limit the risk of developing blood clots.
- A biokineticist will be able to help you in the final stages of your rehabilitation and get you back to gym training or non-contact sport participation.
- Getting your back ‘aligned’ or ‘clicked’ is NOT INDICATED after spinal fusion surgery.
- Aquarobics or swimming is a great alternative to cardiovascular exercise.
- Pilates or yoga can be considered as a way to maintain core stability as a form low load exercise.
What else could it be?
The following list is of diagnoses that may require spinal fusion if neglected:
- Lumbar stenosis
Stenosis is characterised by pain in standing that is eased by leaning forward.
Disc pathology that causes radiculopathy (pain down the leg) may require surgical intervention to decrease nerve damage.
- Scoliosis
Curvatures that influence breathing pattern, organ function and mobility may require lower back fusion.
Instability from antero- or retrolisthesis can be fixated with a lower back fusion.
Spinal fusion is also known as
- back fusion
- spondylosyndesis
- lumbar fusion
- spondylodesis
- lower back fusion
