Confused - what are the reasons for physical restrictions after fusion?

[Pooka1]

I thought the reason was to decrease (considerably) the chance of a pseudoarthrosis somewhere within the fusion.

But now I think I'm wrong about that.

So what are the reasons given for physical restrictions after fusion???

[discombobulated]

Hi

I'm not sure that the post-op restrictions are much to do with preventing pseudo-arthritis, since almost all (if not all) restrictions are lifted within just a year or two of surgery. Post-op, a lot of high impact activities may increase the risk of spinal degeneration in unfused regions, but I think the immediate restrictions are much more to do with ensuring a good result from the surgery.

Perhaps I'm wrong, but my understanding is that you don't want to dislodge or place too much stress on (ie. potentially break) the rods. What keeps the spine really stable post-op is not the rods, but the bone that grows over the rods/spine (ie. the fusion). The process of substantial bone growth takes some months & can continue for up to a couple of years - so by not twisting, lifting heavy things, bending, etc. for a while post-op, you're giving your spine time to fuse solidly before you put too much strain on the rods/spine.

The extra time also allows the muscles & other soft tissues that were sliced through to heal nicely, + ensures that you won't have any major falls, etc. while you're relearning to balance & move differently.

All that said, a little movement & impact is actually good, it promotes bone growth for the fusion, improves blood flow to all levels of the wound, andalso reduces the risk of getting nasties like chest infections from not breathing deeply. Both of these his is why things like walking are very much encouraged from so early post-op.

Hope this makes sense :-)

[Pooka1]

Hi

I'm not sure that the post-op restrictions are much to do with preventing pseudo-arthritis, since almost all (if not all) restrictions are lifted within just a year or two of surgery. Post-op, a lot of high impact activities may increase the risk of spinal degeneration in unfused regions, but I think the immediate restrictions are much more to do with ensuring a good result from the surgery.

Perhaps I'm wrong, but my understanding is that you don't want to dislodge or place too much stress on (ie. potentially break) the rods. What keeps the spine really stable post-op is not the rods, but the bone that grows over the rods/spine (ie. the fusion). The process of substantial bone growth takes some months & can continue for up to a couple of years - so by not twisting, lifting heavy things, bending, etc. for a while post-op, you're giving your spine time to fuse solidly before you put too much strain on the rods/spine.

Thanks for this explanation.

I'm not sure I am following it.

You suggest the reason for restrictions post op is not to avoid pseudoarthrosis but to ensure getting a good result from surgery. What do you mean by a good result if not a solid fusion (i.e., the opposite of pseudoarthrosis)?

You go on to say that the time is required to allow the bone fusion to occur and not to stress the rods. Doesn't that mean to avoid pseudoarthrosis essentially? What are the other possible outcomes of stressing the rods and not allowing bone fusion to occur besides pseudoarthrosis?

Last, the discs above and below the fusion are going to be above and below the fusion for decades. Are you saying it is important to not stress them in the immediate post-op period through physical restrictions but okay to stress them later after being released from restrictions? Is there evidence they hold up better in the long run with a several month period of restricted physical activity immediately post op?

Thanks. Sorry I'm thick but I just have the one daughter who was fused and am looking at one more to go possibly. I'd like to understand this much better.

[The Slice]

Let me see if I can help here. I'm only going by stuff that I've read before. There were posts that I've read about someone's rod(s) bending. What's happening here is very similar to that of a joint replacement therapy. Following the surgery, there needs to be time for any of the cut muscle, tendons, etc. to heal. There also needs to be time for the bone to grow/grow back and get strong. I believe that the rods are primarily for the initial healing phase while the bone is growing. I say that because apparently some people have the rods removed later. I'm also guessing that the reason why the long period is because of the major stresses on the spine and that there's a lot at stake if things fail, like paralysis. j

[discombobulated]

Ahh, Pooka, I do apologise for my earlier ramblings. I still had my got-hardly-no-sleep-last-night brain inserted! When you referred to pseudoarthrosis, I evidently half-[& wrongly!]-read it, & thought you were talking about arthritis/degeneration occurring in unfused regions. Sorry!!

So, with my daytime brain now correctly inserted, I'll try to clarify....

My understanding pretty well gels with Slice's, in that the metal gear is inserted as a way to stabilise/correct the spine in the short term & as a "lattice" for bone graft to fuse over....much like a vine's growing lattice, lol. The rods, especially the titanium (vs. stainless steel), are much less strong than solid bone - so the restrictions are to prevent the rods from dislodging, bending, or breaking before they are reinforced by the solidly fused bone that grows over the top. And also to give the surrounding soft tissues a chance to heal well, etc.. Some light exercise, like walking, may help with blood circulation, bone fusion, & ensuring the lungs are clear. But heavy lifting, twisting, bending, etc., run the risk in early days of shifting the rods/screws, since there's little/no bone fusion covering them well (yet). Later, the solid bone fusion takes most of the impact from such things.

So...I'm not sure that the restrictions are specifically there to encourage bone fusion growth (ie. prevent poor fusion) - though the extra rest probably does help the body retain more resources to healing the area, growing new bone, etc.; rather, the restrictions are in place so that your spine has the best chance of not "coming undone" whilst it's healing. I sure hope that makes sense!

As for maintaining disc-health in unfused regions...I believe that very high impact activities, injury, etc. would all contribute to later degeneration. But some exercise, especially of low to moderate impact, is important to build and maintain bone density (strength). I think that's a fairly different issue to what you originally asked about, though.

Again - sorry to make such a mess of that first post!! Sure hope this one makes a lot more sense If not...well - what Slice said!

[Pooka1]

Let me see if I can help here. I'm only going by stuff that I've read before. There were posts that I've read about someone's rod(s) bending. What's happening here is very similar to that of a joint replacement therapy.

But what is the big deal if the rods bend? Isn't it that you are likely going to get at least one pseudoarthrosis if they bend enough?

There also needs to be time for the bone to grow/grow back and get strong.

Exactly. And if the bones don't grow back and get strong, isn't the result a pseudoarthrosis?

Am I missing something here?

Are there other issues besides pseudoarthrosis in terms of a failed fusion?

I'm also guessing that the reason why the long period is because of the major stresses on the spine and that there's a lot at stake if things fail, like paralysis. j

Is there ever paralysis in the absence of pseudoarthrosis if there is no paralysis immediately after surgery?

[Pooka1]

so the restrictions are to prevent the rods from dislodging, bending, or breaking before they are reinforced by the solidly fused bone that grows over the top.

And what is a possible/probable result if the rods dislodge, bend, or break before they are reinforced by bone if not a pseudoarthrosis?

I'm missing something here.

[ARN010]

Different Hardware and Different Patients

I suspect that restrictions really depend on the patient, their spinal condition, their age, etc. plus the hardware used (how much, where, etc.). In my daughter's case it was a straightforward right curve no rotation. There are two quite large [and rigid] stainless steel screws at each of ten levels. There are also two rods down each side of her spine (about a foot in length, maybe a little shorter). The doctor says he so confident with the technology (i.e., the techniques used during surgery, like where to place screws, etc.) and the hardware that he does not restrict (at least in my daughter's case). I wouldn't recommend any blanket restrict or don't restrict out there because there are so many different details patient to patient. It should be between the individual and their surgeon (and get a second opinion from the reigning expert in your area; or the closest Medical School Hospital). Of course, time will tell in our case....I'll keep you posted over the years and I guess we'll see how it turns out. Currently, it's a fine piece of medical science [and art]...take care all!

[Carmell]

Sharon,

I think you should stop *thinking* - LOL. We, as parents, start thinking and then worrying about things that are out of our control. If we thought, in depth like this, about everything our kids go through, we wouldn't be accomplishing much in life. Too much time spent thinking...

That said, you are correct, IMHO. The risks of pseudoarthrosis (http://medical-dictionary.thefreedic...pseudarthrosis) literally means "false joint". In a spinal fusion, you NEVER want a joint in the fused area. Ever. Knowing that too much of any activity can contribute to pseudoarthrosis must make every patient highly aware of the risks. I don't know anyone who would knowingly abuse their spine in a way that would risk developing pseudoarthrosis. The rules - no BLTs - are there for a reason - to reduce the risk of developing pseudoarthrosis.

And, we also must understand that each person's body heals differently. Some heal well and quickly. Others take lots of time and TLC to heal. Still, others do not fully heal ever (those with underlying medical issues, usually, like a connective tissue disorder or something). Pseudoarthrosis can be caused by several things, but reducing the risk by being careful about physical activity during the post-op recovery means you'll have a better chance of NOT having this problem. No Bending, Lifting, Twisting should be recommended for ALL fusion patients. The risks are too great, IMHO.

[Pooka1]

Sharon,

I think you should stop *thinking* - LOL. We, as parents, start thinking and then worrying about things that are out of our control. If we thought, in depth like this, about everything our kids go through, we wouldn't be accomplishing much in life. Too much time spent thinking...

I "think" you might be right!

That said, you are correct, IMHO. The risks of pseudoarthrosis (http://medical-dictionary.thefreedic...pseudarthrosis) literally means "false joint". In a spinal fusion, you NEVER want a joint in the fused area. Ever. Knowing that too much of any activity can contribute to pseudoarthrosis must make every patient highly aware of the risks. I don't know anyone who would knowingly abuse their spine in a way that would risk developing pseudoarthrosis. The rules - no BLTs - are there for a reason - to reduce the risk of developing pseudoarthrosis.

And, we also must understand that each person's body heals differently. Some heal well and quickly. Others take lots of time and TLC to heal. Still, others do not fully heal ever (those with underlying medical issues, usually, like a connective tissue disorder or something). Pseudoarthrosis can be caused by several things, but reducing the risk by being careful about physical activity during the post-op recovery means you'll have a better chance of NOT having this problem. No Bending, Lifting, Twisting should be recommended for ALL fusion patients. The risks are too great, IMHO.

Okay that makes sense. I thought I was on Candid Camera with some of those responses.

But I don't think it is completely out to lunch to suggest that the hardware is overkill in terms of stabilization and that kids will be appropriately self-limited.

I think the definitive study has yet to be done.

I'm going to run this by my daughter's surgeon to see what, if any, evidence is out there on the outcomes of restricted vice non-restricted kids. These last seven months haven't been a huge burden but if there is no evidence of decreased pseudoarthrosis from restrictions then I want to know about it if/when my other daughter is fused.

Thanks.

[ARN010]

Pseudoarthrosis

I believe pseudoarthrosis in scoliosis fusion patients means failure to fuse?

[Pooka1]

Yes. Here are a few things I found...

http://www.spineuniverse.com/article...gery-4444.html

http://www.jbjs.org.uk/cgi/content/abstract/58-B/3/305

http://www.taiwanspinecenter.com/tsc...entation_f.htm

[txmarinemom]

But I don't think it is completely out to lunch to suggest that the hardware is overkill in terms of stabilization and that kids will be appropriately self-limited.

I think the definitive study has yet to be done.

I'm going to run this by my daughter's surgeon to see what, if any, evidence is out there on the outcomes of restricted vice non-restricted kids.

I doubt you'll ever see that study - or even semi-accurate data ... really. Few doctors advise little or no restrictions - especially for kids - and I think it would be irresponsible to do so on a broad basis.

How would you ever determine a non-restricted kid failed to fuse/pulled out a screw because they twisted to play all 88 keys on the piano or because they were kickboxing at 3 weeks? "No restrictions" is too broad, kids are too different, and "self-limiting" for kids is a little dangerous because ... well - LOL ... some have not one whit of common sense. "Be prudent" isn't in their job description.

In my personal opinion, I (mostly ) agree with Carmell in that I believe all KIDS should be restricted. And if restrictions haven't bothered Savannah, what's the big deal?

For the record, yeah ... Hanson turned me loose soon - but I can't say how he restricts adolescent and juvenile patients. No idea. I also have idea why he's more liberal about restrictions than some other adult surgeons. Does it really matter?

I certainly don't agree the hardware is overkill: It holds the spine in place until it's fused. Today's pedicle screws allow for better correction than ever - and certainly better than the days when a post-op cast held a fusion ... and patients often only fused partially - or lost ALL correction.

Hardware serves a very definite purpose.

Regards,
Pam

[Carmell]

Sharon,

Pam beat me to my thoughts... Hardware is NOT overkill. Simply put, the surgeon can NOT get any correction of the curve without hardware. None. I know this because my Braydon was fused (NO instrumentation) at age 11 months old. They did the fusion to prevent further curve of his 70 degree scoliosis. The fusion did it's job. His thoracic spine (T5-L1) is fused solid at a 70 degree curve. It can't get better. For teens with typical idiopathic scoliosis, they need to get as much correction to re-balance and stabilize the spine in as close to natural position as possible. Hardware MUST be used to achieve this. Without hardware, there is no possibility for correction.

Then, the rest of the story is what you already know. The hardware remains along the spine, just hanging out. In a nicely healed scoli patient, they don't need their hardware, but they don't have removal surgery because there is no need. It would require major surgery and a recovery process to remove something that isn't causing a problem at all.

Pam - When Braydon had his fusion as an infant, aside from wearing a post-op TLSO brace (which was standard post-fusion at the time) he had no restrictions. The surgeon told us when Braydon was in the PICU still that "short of dropping him from a 3-story building, the fusion material is not going to be disrupted". Yes, we were careful during his post-op recovery, but, we didn't limit him in his toddler stages. He learned to walk independently at 16 months, which involved lots of "plopping" on his bottom (he was in his TLSO brace and a foot brace (AFO) at the time. I believe that most kids need oral instructions to be careful, but most families are going to use caution with their kids as they heal. Pain is a good indicator of overdoing things. If it hurts, don't do it. Some kids (like Braydon) are naturally cautious. These kids would likely do fine with a fusion surgery and little or no restrictions. But, most kids aren't. They need a gentle reminder that their body will take months to heal. Each patient is so very different. No one can cookie-stamp any part of the process... as we all know so well.

[Pooka1]

Well, I think there is a difference between saying on the one hand that the hardware is required for the fusion and on the other hand that the hardware is so efficient that a pseudoarthrosis is very unlikely if you simply avoid pain with no other restrictions.

In other words, acknowledging the hardware is necessary for a fusion doesn't rule out that it is strong enough to avoid pseudoarthrosis unless you fall out of a three story building.

Those two things are not orthogonal but they are not mutually exclusive either on their face.