I saw a 73 year-old woman who came to me for a second opinion. She had undergone a spine surgical consultation and had been told that she needed to undergo an eight level fusion of her spine from the tenth thoracic vertebra to her pelvis. She was understandably apprehensive.
She was moderately physically active but not in great physical shape. Her career had been in the National Guard and she had been able to retire early. Golf was her passion. Two years earlier, she had developed pain down her right leg and weakness of the muscles that elevated her foot. The term commonly used to describe this condition is “foot drop.” A surgery was performed between her lumbar 3-4 and 4-5 to take the pressure off of the nerves. After this surgery, which is called a laminectomy, the patient’s leg pain quickly resolved. However, the damage to the nerves in her foot was permanent and she wore a brace to keep her foot from flopping. Usually foot drop does not resolve with any surgical procedure, as the damage has occurred within the nerve.
Her symptoms were now just a persistent foot drop. She had no back pain or leg pain. Her spine was completely straight. She was able to walk easily with the brace on her lower leg. I looked at her new MRI scan and it showed that the surgeon had successfully taken the pressure off of the nerves to her foot. There was generalized arthritis, but there is no correlation with spinal arthritis and back pain. But this is besides the point: she had no back pain!
You must be asking yourself, “Why does she need another surgery? The nerve is permanently damaged (surgery will not help) and she’s not in any pain.”
You are correct. My recommendation was that no further surgery should be performed.
These are the implications of going forward with a T10 to pelvis fusion:
- This is an operation that can take up to 10 hours to perform
- You are in the hospital for a week
- The fusion takes about four months to heal
- Your strength does not return for at least six months
- The complication rate is over 70% with a significant chance of major problems. They include: infection, paralysis, hardware failure, blindness, screws damaging nerves, blood clots to the lungs with the potential for death, etc.
- The cost of this operation for society is over $100,000.
- With her spine fused from her lower thoracic spine to the pelvis, the patient will lose much of her ability to twist (her golf game is finished), and it will be more difficult to bend over. With a fusion, you lose all flexibility in that area of the spine.
- There is a chance that a fusion of this magnitude will cause long-term back pain.
Pros and Cons
I could go on for a while about the downside of this operation. I know a lot about it, as this is an operation that I frequently perform. There is hardly anything more satisfying than giving back a person the ability to be completely upright. However, over my 25-year career, I have gone through every possible complication with my patients. Eventually, we usually end up with a good result, but it always feels like we are waging a battle.
Surgery is Risky
I am very clear about the risks of surgery, not for medical legal reasons, but because patients need to understand the degree of commitment required to undergo it. The benefit has to be worth the risk. The only reason I perform an operation like this is for tumor, infection, fracture, or if a patient is bent over and cannot stand up.
In this patient’s situation the risk is high and the benefit is zero.