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Article: Spinal fusion
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'''Spinal fusion''', also known as ''spondylodesis'' or ''spondylosyndesis'', is a [[Orthopedic surgery|surgical technique]] used to join two or more [[vertebrae]]. Supplementary bone tissue, either from the patient (autograft) or a donor ([[allograft]]), is used in conjunction with the body's natural bone growth ([[osteoblast]]ic) processes to fuse the vertebrae.
 
'''Spinal fusion''', also known as ''spondylodesis'' or ''spondylosyndesis'', is a [[Orthopedic surgery|surgical technique]] used to join two or more [[vertebrae]]. Supplementary bone tissue, either from the patient (autograft) or a donor ([[allograft]]), is used in conjunction with the body's natural bone growth ([[osteoblast]]ic) processes to fuse the vertebrae.
   
Fusing of the spine is used primarily to eliminate the pain caused by abnormal motion of the vertebrae by immobilizing the faulty vertebrae themselves, which is usually caused by degenerative conditions. However, spinal fusion is also the preferred way to treat most spinal deformities, specifically [[scoliosis]] and [[kyphosis]].
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o the preferred way to treat most spinal deformities, specifically [[scoliosis]] and [[kyphosis]].
   
 
==Medical uses==
 
==Medical uses==
Spinal fusion is done most commonly in the [[lumbar]] region of the [[vertebral column|spine]], but it is also used to treat [[cervical vertebrae|cervical]] and [[thoracic vertebrae|thoracic]] problems. The indications for lumbar spinal fusion are controversial.<ref>{{cite book|title=Occupational Medicine Practice Guidelines|publisher=American College of Occupational and Environmental Medicine|edition=2|year=2007|page=210|chapter=Low Back Disorders (revised 2007)}}</ref> People rarely have problems with the thoracic spine because there is little normal motion in the thoracic spine. Spinal fusion in the thoracic region is most often associated with spinal deformities, such as [[scoliosis]] and [[kyphosis]].
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Spinal fusion is done most commonly in the [[lumbar]] region of the [[vertebral column|spine]], but it is also used to treat [[cervical vertebrae|cervical]] and [[thoracic vertebrae|thorms with the thoracic spine because there is little normal motion in the thoracic spine. Spinal fusion in the thoracic region is most often associated with spinal deformities, such as [[scoliosis]] and [[kyphosis]].
   
Cervical spinal fusion can be performed for several reasons. Following injury, this surgery can help stabilize the neck and prevent damage to the spinal cord. It can also be used to treat misaligned vertebrae or as a follow-up for other spinal injuries. Additionally, cervical spinal fusion can be used to remove or reduce pressure on nerve roots caused by bone fragments or ruptured intervertebral disks.
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Cervical spinal fusion can be performed for several reasons. Following injury, this surgery can help stabil reduce pressure on nerve roots caused by bone fragments or ruptured intervertebral disks.
   
 
Patients requiring spinal fusion have either neurological deficits or severe pain which has not responded to conservative treatment. Spinal fusion surgeries are also common in patients who suffer from moderate to severe back deformities that require reconstructive surgery.
 
Patients requiring spinal fusion have either neurological deficits or severe pain which has not responded to conservative treatment. Spinal fusion surgeries are also common in patients who suffer from moderate to severe back deformities that require reconstructive surgery.
   
Bone, metal plates, or screws can be used to make a bridge between adjacent vertebrae. In extreme cases, whole vertebrae can be removed before the fusion occurs. In most cases, however, only the intervertebral disk is removed, and the bone or metal graft is subsequently inserted, allowing for healing of the vertebrae.
 
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Bone,
   
 
Conditions where spinal fusion may be considered include the following:
 
Conditions where spinal fusion may be considered include the following:
 
* [[degenerative disc disease]]
 
* [[degenerative disc disease]]
* [[herniated disc|spinal disc herniation]]
 
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* [[hern
* discogenic [[pain]]
 
* spinal [[tumor]]
 
* vertebral [[fracture (bone)|fracture]]
 
* [[scoliosis]]
 
* [[kyphosis]] (e. g., [[Scheuermann's disease]])
 
* [[spondylolisthesis]]
 
* [[spondylosis]]
 
* [[posterior rami syndrome]]
 
* other degenerative spinal conditions
 
 
* any condition that causes instability of the spine
 
* any condition that causes instability of the spine
   
 
==Contraindications==
 
==Contraindications==
 
[[File:ACDF surgery english.png|thumb|right|[[anterior cervical discectomy and fusion]]]]
 
[[File:ACDF surgery english.png|thumb|right|[[anterior cervical discectomy and fusion]]]]
[[Bone morphogenetic protein]] (rhBMP) should not be routinely used in any type of anterior cervical spine fusion, such as with [[anterior cervical discectomy and fusion]].<ref name="NASSfive">{{Citation |author1 = North American Spine Society |author1-link = North American Spine Society |date = February 2013 |title = Five Things Physicians and Patients Should Question |publisher = North American Spine Society |work = [[Choosing Wisely]]: an initiative of the [[ABIM Foundation]] |page = |url = http://www.choosingwisely.org/doctor-patient-lists/north-american-spine-society/ |accessdate = 25 March 2013}}, which cites
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[[Bone morphogenetic protein]] (rhBMP) should not be routinely used in any type of anterior cervical Associated with Recombinant Human Bone Morphogenetic Protein in Cervical Spine Fusion |first=Daniel G. |last=Schultz |work=[[Food and Drug Administration|fda.gov]] |date=July 1, 2008 |accessdate=25 March 2014}}
*{{cite web |url= http://www.fda.gov/MedicalDevices/Safety/AlertsandNotices/PublicHealthNotifications/ucm062000.htm |title=Public Health Notifications (Medical Devices) - FDA Public Health Notification: Life-threatening Complications Associated with Recombinant Human Bone Morphogenetic Protein in Cervical Spine Fusion |first=Daniel G. |last=Schultz |work=[[Food and Drug Administration|fda.gov]] |date=July 1, 2008 |accessdate=25 March 2014}}
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*{{cite journal|last=Woo|first=EJ|title=Recombinant human bone morphogenetic protein-2: adverse events reported to the Manufacturer and User Facility Device Experience databasen, which may be used in conjunction with each other:
*{{cite journal|last=Woo|first=EJ|title=Recombinant human bone morphogenetic protein-2: adverse events reported to the Manufacturer and User Facility Device Experience database.|journal=The spine journal : official journal of the North American Spine Society|date=Oct 2012|volume=12|issue=10|pages=894–9|pmid=23098616}}</ref> There are reports of this therapy causing swelling of [[soft tissue]] which in turn can cause life-threatening complications due to [[difficulty swallowing]] and pressure on the [[respiratory tract]].<ref name="NASSfive"/>
 
 
==Technique==
 
 
=== Types of spinal fusion ===
 
There are two main types of lumbar spinal fusion, which may be used in conjunction with each other:
 
   
 
'''Posterolateral fusion''' places the bone graft between the [[transverse process]]es in the back of the spine. These vertebrae are then fixed in place with screws and/or wire through the [[pedicle of vertebral arch|pedicles]] of each vertebra attaching to a metal rod on each side of the vertebrae.
 
'''Posterolateral fusion''' places the bone graft between the [[transverse process]]es in the back of the spine. These vertebrae are then fixed in place with screws and/or wire through the [[pedicle of vertebral arch|pedicles]] of each vertebra attaching to a metal rod on each side of the vertebrae.
   
'''Interbody fusion''' places the bone graft between the [[vertebra]] in the area usually occupied by the [[intervertebral disc]]. In preparation for the spinal fusion, the disc is removed entirely, for example in [[Anterior cervical discectomy and fusion|ACDF]]. A device may be placed between the vertebra to maintain spine alignment and disc height. The intervertebral device may be made from either plastic or titanium. The fusion then occurs between the [[endplates]] of the vertebrae. Using both types of fusion is known as 360-degree fusion. Fusion rates are higher with interbody fusion.
 
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'''Interbody fusion''' places the bone graft between the [[vertebra]] in the area usually occupfrom a posterior incision
Three types of interbody fusion are:
 
* Anterior lumbar interbody fusion (ALIF)- the disc is accessed from an anterior abdominal incision
 
* Posterior lumbar interbody fusion (PLIF) – the disc is accessed from a posterior incision
 
 
* Transforaminal lumbar interbody fusion (TLIF) – the disc is accessed from a posterior incision on one side of the spine
 
* Transforaminal lumbar interbody fusion (TLIF) – the disc is accessed from a posterior incision on one side of the spine
 
*Transpsoas interbody fusion (DLIF or XLIF) – the disc is accessed from an incision through the psoas muscle on one side of the spine
 
*Transpsoas interbody fusion (DLIF or XLIF) – the disc is accessed from an incision through the psoas muscle on one side of the spine
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===Procedure===
 
===Procedure===
 
[[File:Blausen 0446 HarringtonRods.png|thumb|right|Stabilization rods used after spinal fusion surgery.]]
 
[[File:Blausen 0446 HarringtonRods.png|thumb|right|Stabilization rods used after spinal fusion surgery.]]
In most cases, the fusion is augmented by a process called fixation, involving the placement of metallic screws (pedicle screws often made from titanium), rods, plates, or cages to stabilize the vertebrae and facilitate bone fusion. The fusion process typically takes 6 to 12 months after surgery. During this time external bracing ([[orthotics]]) may be required. External factors such as smoking, osteoporosis, certain medications, and heavy activity can prolong or even prevent the fusion process. If fusion does not occur, patients may require reoperation.
 
  +
In most c
 
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In spinal fusion, the accuracy with which screws are inserted in the [[Pedicle of vertebral arch|pedicles]] has a direct effect on the surgical outcome. Accurate placement generally involves considerable judgmental skills that have been developed through a lengthy training process. Because
Some newer technologies are being introduced which avoid fusion and preserve spinal motion. Such procedures, such as [[artificial disc replacement]], are being offered as alternatives to fusion in the cervical spine. Their advantage over fusion has not been well established. [[Invasiveness of surgical procedures|Minimally invasive]] techniques have also been introduced to reduce complications and recovery time for lumbar spinal fusion.
 
 
In spinal fusion, the accuracy with which screws are inserted in the [[Pedicle of vertebral arch|pedicles]] has a direct effect on the surgical outcome. Accurate placement generally involves considerable judgmental skills that have been developed through a lengthy training process. Because the impact of misaligning one or more pedicle screws can directly affect patient safety, a number of navigational and trajectory verification approaches have been described and evaluated in the literature to provide some degree of guidance to surgeons. For example, Manbachi ''et. al'' (2013) presented an overview of the need and the current status of the guidance methods available for improving the surgical outcomes in spinal fusion. They also describe educational aids that have the potential for reducing the training process.<ref name=man>Manbachi, A., et al. (2013). [http://www.academia.edu/3432245/Guided_pedicle_screw_insertion_techniques_and_training Guided pedicle screw insertion: Techniques and training.] ''The Spine Journal'' 13(4) 1–15.</ref> Accurate guidance systems, such as the [[Mazor Robotics]] "Renaissance", have been developed to assist with spinal fusion procedures.
 
 
==Society==
 
   
 
===Frequency of use===
 
===Frequency of use===
According to a report by the Agency for Healthcare Research and Quality (AHRQ), approximately 488,000 spinal fusions were performed during U.S. hospital stays in 2011 (a rate of 15.7 stays per 10,000 population), which accounted for 3.1% of all operating room procedures.<ref>{{cite web | author = Weiss AJ, Elixhauser A, Andrews RM. | title = Characteristics of Operating Room Procedures in U.S. Hospitals, 2011. | work = HCUP Statistical Brief #170 | publisher = Agency for Healthcare Research and Quality | location = Rockville, MD | date = February 2014 | url = http://hcup-us.ahrq.gov/reports/statbriefs/sb170-Operating-Room-Procedures-United-States-2011.jsp }}</ref>
 
  +
According to a report by the Agency for Healthcare Research and Quality (AHRQ), approximately 488,000 spinal fu=Mcgair |first=Brendan |url=http://www.pawtuckettimes.com/content/red-sox-kalish-hopes-latest-surgery-does-trick |title=Red Sox OF Kalish hopes latest surgery does the trick |publ-finley-excited-play-again-spinal-fusion-surgery-171659287--nfl.html |title=Jermichael Finley excited to play again after spinal fusion surgery &#124; Shutdown Corner |publisher=Sports.yahoo.com |date=February 31, 2014 |accessdate=March 28, 2014}}</ref>
 
===Notable persons who underwent spinal fusion===
 
*[[Phil Jackson]], NBA basketball player<ref>{{cite web|url=http://www.nba.com/coachfile/phil_jackson/ |title=Phil Jackson |publisher=Nba.com |date= |accessdate=November 9, 2013}}</ref>
 
*[[Ryan Kalish]], major league baseball player<ref>{{cite web|last=Mcgair |first=Brendan |url=http://www.pawtuckettimes.com/content/red-sox-kalish-hopes-latest-surgery-does-trick |title=Red Sox OF Kalish hopes latest surgery does the trick |publisher=The Pawtucket Times |date= |accessdate=November 9, 2013}}</ref>
 
*[[Orland Kurtenbach]], NHL hockey player<ref>{{cite web|url=http://www.arcticicehockey.com/2011/10/26/2508850/the-nhls-most-interesting-name-1960s-part-ii |title=The NHL's Most Interesting Name: 1960s Part II |publisher=Arctic Ice Hockey |date= |accessdate=November 9, 2013}}</ref>
 
*[[Peyton Manning]], NFL football quarterback<ref>{{cite web|url=http://news.medill.northwestern.edu/chicago/news.aspx?id=199809 |title=Spinal fusion surgery: The science behind Manning's life changing operation |publisher=News.medill.northwestern.edu |date=February 2, 2012 |accessdate=November 9, 2013}}</ref>
 
*[[Lolo Jones]], Olympic hurdler<ref>{{cite web|url=http://www.wbez.org/blogs/cheryl-raye-stout/2012-08/after-torch-goes-out-olympics-recap-101606 |title=Cheryl Raye-Stout reviews some key moments from the 2012 Summer Olympic Games in London |publisher=Wbez.org |date=August 13, 2012 |accessdate=November 9, 2013}}</ref>
 
*[[Hulk Hogan]], WWF/WWE professional wrestler
 
*[[Jermichael Finley]], NFL football tight end<ref>{{cite web|last=Schwab |first=Frank |url=http://sports.yahoo.com/blogs/nfl-shutdown-corner/jermichael-finley-excited-play-again-spinal-fusion-surgery-171659287--nfl.html |title=Jermichael Finley excited to play again after spinal fusion surgery &#124; Shutdown Corner |publisher=Sports.yahoo.com |date=February 31, 2014 |accessdate=March 28, 2014}}</ref>
 
   
 
== References ==
 
== References ==
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== Further reading ==
 
== Further reading ==
 
*[http://www.webmd.com/back-pain/cervical-spinal-fusion Cervical Spinal Fusion.] WebMD.
 
*[http://www.webmd.com/back-pain/cervical-spinal-fusion Cervical Spinal Fusion.] WebMD.
*[http://www.umm.edu/spinecenter/education/anterior_cervical_fusion.htm A Patient's Guide to Anterior Cervical Fusion.] University of Maryland Medical Center.
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*[http://www.umm.edu/spinecenter/education/anterior_cervical_fusion.htm A Patient's Guide to Anteriments/surgery/what-spinal-instrumentation-spinal-fusion What is Spinal Instrumentation and Spinal Fusion?] SpineUniverse. September 2012. Accessed 1 June 2013.
*Boatright, K. C. and S. D. Boden. Chapter 12: Biology of Spine Fusion. In: Lieberman, J., et al., Eds. ''Bone Regeneration and Repair''. [[Totowa, New Jersey]]: [[Humana Press]]. 2005. pp.&nbsp;225–239. ISBN 978-0-89603-847-9.
 
*Holmes, C. F., et al. Chapter 9: Cervical Spine Injuries. In: Schenck, R. F., [[American Academy of Orthopedic Surgeons|AAOS]]. ''Athletic Training in Sports Medicine.'' Jones & Bartlett Publishers. 2005. pp.&nbsp;197–218. ISBN 0-89203-172-7
 
*Camillo, F. X. Chapter 36: Arthrodesis of the Spine. In: Canale, S. T. and J. H. Beaty. ''Campbell's Operative Orthopaedics 2''. (11th Ed.). Philadelphia: Mosby. 2007. pp.&nbsp;1851–1874. ISBN 978-0-323-03329-9.
 
*Williams, K. D. and A. L. Park. Chapter 39: Lower Back Pain and Disorders of Intervertebral Discs. In: Canale, S. T. and J. H. Beaty. ''Campbell's Operative Orthopaedics 2''. (11th Ed.). Philadelphia: Mosby. 2007. pp.&nbsp;2159–2224. ISBN 978-0-323-03329-9.
 
*Weyreuther, M., et al., Eds. Chapter 7: The Postoperative Spine. ''MRI Atlas: Orthopedics and Neurosurgery – The Spine''. trans. B. Herwig. Berlin: Springer-Verlag. 2006. pp.&nbsp;273–288. ISBN 978-3-540-33533-7.
 
*Tehranzadehlow, J., et al. (2005). Advances in spinal fusion. ''Seminars in Ultrasound, CT, and MRI'' 26(2): 103–113.
 
*Resnick, D. K., et al. ''Surgical Management of Low Back Pain'' (2nd Ed.). Rolling Meadows, Illinois: American Association of Neurosurgeons. 2008. ISBN 978-1-60406-035-5.
 
 
==External links==
 
*Wheeless, C. R., et al., Eds. [http://www.wheelessonline.com/ortho/fusion_of_the_spine Fusion of the Spine.] ''Wheeless' Textbook of Orthopaedics''. Division of Orthopedic Surgery. Duke University Medical Center.
 
*[http://orthoinfo.aaos.org/topic.cfm?topic=A00348 Spinal Fusion.] American Academy of Orthopaedic Surgeons. June 2010. Accessed 1 June 2013.
 
*Spinasanta, S. [http://www.spineuniverse.com/treatments/surgery/what-spinal-instrumentation-spinal-fusion What is Spinal Instrumentation and Spinal Fusion?] SpineUniverse. September 2012. Accessed 1 June 2013.
 
 
*[http://www.surgeryencyclopedia.com/Pa-St/Spinal-Fusion.html Spinal fusion.] Encyclopedia of Surgery. Accesses 1 June 2013.
 
*[http://www.surgeryencyclopedia.com/Pa-St/Spinal-Fusion.html Spinal fusion.] Encyclopedia of Surgery. Accesses 1 June 2013.
   
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