In 1988 the Editor contributed Chapter 19 to the Cauthen textbook on Lumbar Spine Surgery devoted to the subject of avoiding future back surgery failures. It is interesting to note that there is little evidence as the 21st century begins that the observations made in 1988 have been taken to heart by the majority the spine surgery community. The incidence of failed back surgery cases remains unacceptably high. Reprinted below is the section on the subject of “Fusion.” The conclusion that: The future belongs to flexible nonmetallic stabilization devices, continues to be most valid.
The continuing use of multilevel rigid fusion for the primary treatment of low back pain is in great need for change. The advent of modern imaging has continually documented the fact that many patients who had multi-level fusions in past years are now presenting with secondary adjacent level degeneration of the discs and facet joints (the “transitional” syndrome“). Chronic local stress to adjacent motion segments, as well as the pelvis, is created in rigid fusion.
The requirement for both instrumentation and bony fusion represents a long and costly surgical procedure for the patient, often involving significant blood loss and replacement, with lengthy hospitalization. Another disadvantage of metallic fusion devices is subsequent reduction in quality of postoperative imaging techniques. These liabilities represent a persuasive argument for reexamination of the concept of fusion as a treatment modality.
Evidence suggests that a more logical approach would be that of flexible (energy absorbing) stabilization rather than multilevel rigid fusion. By basing future instrumentation design on the principle of stabilization rather than fusion, improved clinical success, decrease in FBSS, and improved economics appear possible. The future still belongs to flexible nonmetallic stabilization devices.