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Spinal Pseudoarthrosis

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I’m a 77 year old retired physician. For 1 year I had severe sciatic pain radiating from my right lower back to my right lower leg. I couldn’t walk more than 50 feet before the pain became severe. Dr. Georgiy Brusovanik performed surgery at Doctors hospital in Coral Gables replacing all the disk in my lumbar spine because the degeneration was severe.Procedure was done in two stages.The surgery was very successful.My recovery each time was shorter than i expected.I am now able to walk my dogs up to 12 city blocks per day.I am very pleased with the care i received and feel that Dr. Brusovanik expertise and kind manor helped me to achieve the success i had.

Dr. Burton Silver, MD
Dermatologic Surgeon
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Spinal Non-Union

Spinal non-union is a common cause of failed back surgery syndrome. Specifically, it’s the fusion surgery that is the culprit in this diagnosis. There’s a long history of improvement in the technology of fusion. Many patients had the old style of fusion that had an extremely high rate of failure. A common mode of failure is non-union or Pseudoarthrosis. This results in severe pain and dysfunction in patients about 6 months to a year after their original fusion surgery. These patients have a characteristic set of symptoms that is common. This diagnosis is associated with severe dysfunction and frequent failure of conservative care such as injections and physical therapy. There’s a strong emotional component to failed back surgery, as many patients and, unfortunately, many doctors tend to blame the patients. It is often extremely rewarding to heal the patient’s back pain, as well as their emotional state with corrective minimally invasive spinal surgery for pseudoarthrosis or nonunion.


Scoliosis | About two percent of people are affected by this deformation of the spine, which causes the normally straight spine to curve.

Background | Pseudoarthrosis is failure to unite. When fusion surgery is undertaken, the goal of the operation is to restructure a deformed spine and hold it in place. That is the definition of fusion surgery. Fusion is usually accomplished with screws. Historically, fusions were done without screws. Placement of screws makes a big difference and the type of exposure makes a big difference. It also matters whether it was an ALIF, a TLIF, or a PLIF, if disc work was done. Once fusion surgery is undertaken, the patient is in a “race”. The race is between the ability of the spinal bones to mend together versus time for loosening of hardware. Imagine placing hardware into a living tree. Imagine placing a screw into a branch. With time, that screw may loosen.

Another example is placing a screw into dry wall, and without any additional support, the screw will core out a large hole around and then loosen. The same happens to screws placed into the human body, unless within about 6 months or a year, the bones connect and motion between those segments effectively stops. At that point, hardware makes no difference and will never loosen again. In case of a non-union, the hardware loosens before bone is able to mend together. That results in pain related to micro fractures, that occur around the screws or, loosening of other hardware such as the disc replacing cage. Micro motion between the 2 bones either results in fracture of the hardware with catastrophic failures such as breakage of screws or rods, or conversely, creation of a large cavitary defect within the bone that’s associated with severe pain.


XLIF: Lateral Lumbar Interbody FusionUnlike traditional back surgery, XLIF is performed through the patient’s side. By entering this way, major muscles of the back are avoided. This minimally-invasive procedure is generally used to treat leg or back pain caused by degenerative disc disease. It can be performed on an outpatient basis.
Lumbar pedicle screw fixation (CD HORIZONS Sextant)This minimally-invasive procedure uses special guides and fluoroscopic imaging to allow a surgeon to precisely implant stabilizing screws and rods in the spine while minimizing damage to muscles, tendons and other soft tissue in the back.

The Symptoms | These patients are in a lot of pain and there are a lot of reasons for that. When screw loosens, they’re literally creating micro fractures and that hurts as any other fracture would. Second, if a cage backs up due to micro motion, it may start compressing a nerve, and that would cause pain going down the buttocks or the legs. The instability at the same level will produce micro motion that produces a significant background noise of constant pain. Patients will report that they’re never free from pain, and they frequently have to tense their core to an extreme extent doing any kind of transitional movements such as standing up from siting or changing from a laying position to siting down. These patients will also complain of severe pain that spikes and makes them unable to function due to back spasms. These spasms may actually occur due to nerve compression as the body tries to immobilize the painful segment. Whether it’s nerve irritation or actual instability, your muscles are trying to protect your bones from shearing and moving in a way that is traumatic.

Patients with pseudoarthrosis or non-union will complain of severe night time pain, as the inflammation is usually the cause for night time pain. They will also complain of pain with any transitions. Getting in the car is terrible. Standing up at the sink and brushing their teeth is terrible. Standing in the kitchen next to a sink is terrible. Cooking is impossible. We see many moms who say that they just can’t take the pain. And I ask her, “What about before the severe pain began, how was it then”. If she has a non-union for a previous operation. She’ll usually start to cry and say that the pain is there all the time.

Treatment | Conservative treatment for non-union usually does not work. There’s one exception, which is what is called the locked non-union, where a fixation that was placed years back does not show a solid fusion on the scan, but there’s no loosening of the screws. This implies that the hardware is stable enough not to loosen, and that’s usually not the cause of patient’s pain. On the other hand, a typical pseudoarthrosis or a non-union is supremely symptomatic and injections or physical therapy may provide only temporary relief. Bone growth stimulators, or chemical means of making bone heal; like taking calcium have not been shown to make any difference. Long term, patients with pseudoarthrosis or a non-union usually end up with surgery.

Nowadays, minimally invasive technology has created ways to fix patients’ backs who have had a failed back surgery. The techniques involve tiny incisions and fixation that allows a surgeon to use the previous hardware for new fixation. This allows minimizing trauma from surgery. And a lot of times, for big, wide, open operations, revision can be done in a minimal invasive way. A common issue associated with pseudoarthrosis is a lack of disc preparation. And operations such as TLIF or PLIF are associated with a high risk of retained disc fragments, since the entrance into the disc via the back incision is minimal. There’s a high—as much as 25% risk in some studies—risk of a non-union. The good news, however, is that all the operations are very much amenable to what’s called an anterior approach or lateral approach. This allows a surgeon to enter a disc through virgin territory and avoid the issues associated with operating through scar tissue.

Furthermore, going from the side (XLIF), or from the front (ALIF) allows you to remove the loose cage and often times, restabilize the spine without revising the screws at all. Operating for pseudoarthrosis or spinal non-union is very rewarding. These patients usually wake up and say that their pre-operative pain is gone. A lot of these patients have been placed on narcotics, and that makes their recovery much more difficult, however, not impossible. Mostly the patients, who are willing to go through a period of diminution of narcotics usage, are able to see a much better recovery than their counterparts who have maintained a high does narcotic usage. However, it is difficult to take narcotics off the table when a patient has severe pain. Same goes with weight loss. Weight loss makes surgery and recovery better. But when a patient has severe pain, it’s very difficult to just go out and exercise. Often times, these patients are faced with the difficult decision of operating in less than optimal conditions. However, I’m usually excited about helping patients with pseudoarthrosis of the spine or a non-union after a failed fusion, because helping these patients is so rewarding. A lot of them become long term friends.