Failure to Fuse - What Does It Mean?

[Tina_R]

What does it mean when a surgeon tells you that part of your back might have failed to fuse? Does that mean the area of the spine operated on never hardened? Could that be due to osteopenia?

I asked what could be done for something like this and the answer was "fuse it again". What exactly does this mean? Another operation to do what exactly?

The surgeon told me this could possibly be the reason for the back pain I've been left with. This is a second opinion surgeon.

How do you diagnose failure to fuse, with imaging?

[LindaRacine]

What does it mean when a surgeon tells you that part of your back might have failed to fuse? Does that mean the area of the spine operated on never hardened? Could that be due to osteopenia?

I asked what could be done for something like this and the answer was "fuse it again". What exactly does this mean? Another operation to do what exactly?

The surgeon told me this could possibly be the reason for the back pain I've been left with. This is a second opinion surgeon. My own surgeon never tells me anything.

How do you diagnose failure to fuse, with imaging?

It means that, at one or more levels, the vertebrae that were meant to fuse together, didn't do that. In the image link below, the dark like between L5 and S1 probably means there was a failure to fuse. (Bone appears as smoky white. The bright white is a cage that was placed during surgery, to aid in fusion.)

https://www.researchgate.net/figure/...fig1_255975924

There are some types of images (e.g., CT scans) that CAN show non-unions, but there are probably more false negatives and positives than accurate results.

--Linda

[Tina_R]

It means that, at one or more levels, the vertebrae that were meant to fuse together, didn't do that. In the image link below, the dark like between L5 and S1 probably means there was a failure to fuse. (Bone appears as smoky white. The bright white is a cage that was placed during surgery, to aid in fusion.)

https://www.researchgate.net/figure/...fig1_255975924

There are some types of images (e.g., CT scans) that CAN show non-unions, but there are probably more false negatives and positives than accurate results.

If images tend to show false positives and negatives what does the surgeon do? Does he cut open and probe to see if there's really non-fusion?
--Linda

What causes vertebrae to fuse together? Isn't it a combination of cadaver bone and some kind of glue that is used? And does your own bone grow and merge with it as well? I wear an electromagnetic vest that is supposed to aid in that, a bone growth stimulator made by Orthofix.

[titaniumed]

Tina, Some of us fuse and some of us do not, and they are not completely sure why this happens. It's our ability to grow bone.

I am having problems growing bone in my face or mouth these days, (Mandible and Maxilla) Jaw and upper facial bone. I have been infected, that's why this happened. They don't know exactly why we get infected....but staph is EVERYWHERE. It's our immune systems....The battle can get harder as we age.

We had a 25 year old member that did not fuse years ago, it took 2 attempts and they finally got it. They used BMP, which is a protein. Not glue. This protein is made in our body, and some of us need more to promote or speed up the fusion process.

Dr Lenke has found pseudarthrosis or non unions in patients 8 years post surgery.

If you ask your surgeon about this, the short answer will be "chemistry" If you don't have a biochem background, this ends the discussion with one word they are not about to explain it because we are not medically trained. I had this happen to me with my vascular surgeon talking about stone formation in the gall bladder.

Bone cells....
https://en.wikipedia.org/wiki/Ossification

https://en.wikipedia.org/wiki/Bone_remodeling

Ed

[Tina_R]

Tina, Some of us fuse and some of us do not, and they are not completely sure why this happens. It's our ability to grow bone.

I am having problems growing bone in my face or mouth these days, (Mandible and Maxilla) Jaw and upper facial bone. I have been infected, that's why this happened. They don't know exactly why we get infected....but staph is EVERYWHERE. It's our immune systems....The battle can get harder as we age.

We had a 25 year old member that did not fuse years ago, it took 2 attempts and they finally got it. They used BMP, which is a protein. Not glue. This protein is made in our body, and some of us need more to promote or speed up the fusion process.

Dr Lenke has found pseudarthrosis or non unions in patients 8 years post surgery.

If you ask your surgeon about this, the short answer will be "chemistry" If you don't have a biochem background, this ends the discussion with one word they are not about to explain it because we are not medically trained. I had this happen to me with my vascular surgeon talking about stone formation in the gall bladder.

Bone cells....
https://en.wikipedia.org/wiki/Ossification

https://en.wikipedia.org/wiki/Bone_remodeling

Ed

Your vascular surgeon gave you an explanation that proved too much, huh? I can see that happening. The surgeon yesterday told me an angle in my spine post-surgery isn't ideal. It was hard for me to even see what angle he was drawing over the x-ray and I didn't want to get too close due to COVID distancing. And I usually feel comfortable discussing angles.

I wonder how these non-fusions are usually discovered. Why did one escape notice for 8 years. I guess that's partly why they keep taking x-rays on your return visits though Linda says the x-rays can be deceptive.

I hope your tooth and jaw problems resolve. I knew they're treating infection there, are they trying to regrow bone as part of that?

[LindaRacine]

What causes vertebrae to fuse together? Isn't it a combination of cadaver bone and some kind of glue that is used? And does your own bone grow and merge with it as well? I wear an electromagnetic vest that is supposed to aid in that, a bone growth stimulator made by Orthofix.

When the surgery is done, the surface of the vertebrae is usually roughed up a bit before bone (usually bone removed from your vertebrae during surgery and morselized), is applied to the surface. I've heard this described as a process similar to a scab forming on a skin wound. Additionally, older patients frequently have one of the many bio-medical materials available (like BMP) to aid in fusion. The hardware placed during surgery is meant to keep the vertebrae from moving during the early postop period. Over time, the bone will "scab" over, and bridge the vertebrae together. If there's a lot of movement, especially in the first 6-12 weeks, it's harder for the area to fuse. That's thought to be the most frequent reason why a non-fusion takes place.

As to why you didn't fuse (if that's the problem), there's no way of knowing. In the end, it doesn't really make any difference. The problem just needs to be resolved. The good news is that, if the problem is a non-union, the fix is usually pretty easy compared to the original surgery, and recovery is typically fast.

[Tina_R]

When the surgery is done, the surface of the vertebrae is usually roughed up a bit before bone (usually bone removed from your vertebrae during surgery and morselized), is applied to the surface. I've heard this described as a process similar to a scab forming on a skin wound. Additionally, older patients frequently have one of the many bio-medical materials available (like BMP) to aid in fusion.

Bio-medical materials including cadaver bone?
Are you not supposed to grow new bone of your own, and isn't that what the bone stimulator helps with?
If you fail to fuse, does this mean the bone never hardens?

The hardware placed during surgery is meant to keep the vertebrae from moving during the early postop period. Over time, the bone will "scab" over, and bridge the vertebrae together. If there's a lot of movement, especially in the first 6-12 weeks, it's harder for the area to fuse. That's thought to be the most frequent reason why a non-fusion takes place.

Yet you swam without a brace in your first 6-12 weeks, didn't you?

As to why you didn't fuse (if that's the problem), there's no way of knowing. In the end, it doesn't really make any difference. The problem just needs to be resolved. The good news is that, if the problem is a non-union, the fix is usually pretty easy compared to the original surgery, and recovery is typically fast.

If it's not resolved, what problems can you have?

[jackieg412]

I just went through another fusion surgery. My thoracic was first fused in Feb. 2011. Apparently it never fused. I had part of the hardware removed last January, due to a non healing wound.I
After that, in about 7 weeks the pain in one area of the spine was insane. We started looking at why.
When the doctor did a myelogram he found a nonunion, during the surgery in October, he found that the entire thoracic had not healed. So he removed the hardware and refused with my bone, cadaver bone and BMP. Without the fusion, I was going into a very fast moving kyphosis.

[Tina_R]

I just went through another fusion surgery. My thoracic was first fused in Feb. 2011. Apparently it never fused. I had part of the hardware removed last January, due to a non healing wound.I
After that, in about 7 weeks the pain in one area of the spine was insane. We started looking at why.
When the doctor did a myelogram he found a nonunion, during the surgery in October, he found that the entire thoracic had not healed. So he removed the hardware and refused with my bone, cadaver bone and BMP. Without the fusion, I was going into a very fast moving kyphosis.

Did you have the same surgeon from 2011 do all this recent stuff?
I'm just wondering why they couldn't thoroughly check for non-union years ago, why they didn't do a myelogram then? Seems like it should be a routine part of the treatment. It should be important to make sure people fuse, not have them find out by accident years later. I know a myelogram has certain risks, but maybe there are other ways to diagnose non-fusion?

[LindaRacine]

Bio-medical materials including cadaver bone?

I'm unsure whether cadaver bone would be considered bio-medical.

Are you not supposed to grow new bone of your own, and isn't that what the bone stimulator helps with?

Yes, fusion involves growing bone. And, the theory of bone stimulators is that it helps. Like anything else, it doesn't always work.

If you fail to fuse, does this mean the bone never hardens?

It means that the fusion mass never completely bridged. I believe it's that the bone bridge never completes attachment to the vertebra.

Yet you swam without a brace in your first 6-12 weeks, didn't you?

After my first surgeries, I didn't swim until about 3 months postop. After the second surgeries, I didn't swim, I water walked. The theory is that the implants will hold the spine in place while fusion takes place. For whatever reason, that doesn't work for everyone. If you think about the natural movement of the spine, especially with pedicle screws and rods, you'll notice that movement toward the posterior is nearly impossible, so swimming isn't necessarily risky. On the other hand, bending over to tie one's shoe, probably allows for some amount of micro movement, even with implants.

If it's not resolved, what problems can you have?

Pain and eventually, broken implants.

[Tina_R]

I'm unsure whether cadaver bone would be considered bio-medical.



Yes, fusion involves growing bone. And, the theory of bone stimulators is that it helps. Like anything else, it doesn't always work.


It means that the fusion mass never completely bridged. I believe it's that the bone bridge never completes attachment to the vertebra.


After my first surgeries, I didn't swim until about 3 months postop. After the second surgeries, I didn't swim, I water walked. The theory is that the implants will hold the spine in place while fusion takes place. For whatever reason, that doesn't work for everyone. If you think about the natural movement of the spine, especially with pedicle screws and rods, you'll notice that movement toward the posterior is nearly impossible, so swimming isn't necessarily risky. On the other hand, bending over to tie one's shoe, probably allows for some amount of micro movement, even with implants.


Pain and eventually, broken implants.

Implants being the rods? Which were never meant to support the spine forever, were they, only until the spine fuses. So if the spine never hardens and the rods are taking all the forces, the rods eventually break. Is that right?

"If you think about the natural movement of the spine, especially with pedicle screws and rods, you'll notice that movement toward the posterior is nearly impossible, so swimming isn't necessarily risky. "

This I don't understand. What do you mean movement toward the posterior? Why impossible?

[jackieg412]

No it was as different surgeon than the Dr that did the 2011 fusion. It was checked multiple times by xrays and CT scans. The doctors from 2011 are orthopaedic and the recent doctor is a neurosurgeon. According to the neurosurgeon, there isn't anyway to know if a fusion occurs for sure until you look during surgery. Most people find out when something happens. Once the rod was taken out last January, my spine moved and caused so much pain.
Now I have 4 rods from the thoracic attaching to the lumber.

[Tina_R]

No it was as different surgeon than the Dr that did the 2011 fusion. It was checked multiple times by xrays and CT scans. The doctors from 2011 are orthopaedic and the recent doctor is a neurosurgeon. According to the neurosurgeon, there isn't anyway to know if a fusion occurs for sure until you look during surgery. Most people find out when something happens. Once the rod was taken out last January, my spine moved and caused so much pain.
Now I have 4 rods from the thoracic attaching to the lumber.

Is there a reason you changed from orthopedic surgeons to a neurosurgeon?

[jackieg412]

The reason I changed is difficult to understand. But in 2016 I started having some leg problems and the orthopaedic tried to figure it out but couldn't do he asked me to see a neurosurgeon. So I picked one from Rush University in Chicago. He diagnosed arachnoiditis and 6 months of so later I had a pain pump placed by an anesthesiologist at the same university. I continued see the orthopaedic. In September of 2018 I broke my neck in an auto accident. At the first hospital that the paramedics took me to, no one was on staff that could help me so the emergency room doctor asked where I wanted to go because I was going to need a neurosurgeon. So I was transferred to the neurosurgeon at Rush that night. There was a piece of bone partially severing the nerve to my right arm. To give it the best chance we needed a neurosurgeon to try to repair it.
After that, I messaged my orthopaedic and saw him at about 4 months later. He got angry or appeared angry at me for even coming to tell him about it. It was an arranged appointment from the year before.
I was still upset from the accident and felt I could not take anyone getting angry at me for something I wished with my whole being did not happen. But it did and I have to live with it the best I can without anyone taking it out on me. The whole accident was a very difficult time for me and not in my control.

[Tina_R]

The reason I changed is difficult to understand. But in 2016 I started having some leg problems and the orthopaedic tried to figure it out but couldn't do he asked me to see a neurosurgeon. So I picked one from Rush University in Chicago. He diagnosed arachnoiditis and 6 months of so later I had a pain pump placed by an anesthesiologist at the same university. I continued see the orthopaedic.

And Dr. Orthopedic knew you were seeing a neurosurgeon at the same time? And knew about the diagnosis of arachnoiditis?

In September of 2018 I broke my neck in an auto accident. At the first hospital that the paramedics took me to, no one was on staff that could help me so the emergency room doctor asked where I wanted to go because I was going to need a neurosurgeon. So I was transferred to the neurosurgeon at Rush that night. There was a piece of bone partially severing the nerve to my right arm. To give it the best chance we needed a neurosurgeon to try to repair it.
After that, I messaged my orthopaedic and saw him at about 4 months later. He got angry or appeared angry at me for even coming to tell him about it. It was an arranged appointment from the year before.
I was still upset from the accident and felt I could not take anyone getting angry at me for something I wished with my whole being did not happen. But it did and I have to live with it the best I can without anyone taking it out on me. The whole accident was a very difficult time for me and not in my control.

The orthopedic guy was angry at you because you saw someone other than him for the accident? You did what you had to do. You did what was best for you by listening to the emergency room physician. It was an emergency situation.

I don't have a good relationship with my doctor anymore either. I don't think anyone gets the best medical treatment from a doctor who is angry at them. So I'm shopping for another doctor and a diagnosis for my post-surgical problems, which I have mentioned elsewhere.

Once for fun I typed "arrogant s" into google and one of the first things google filled in was "arrogant surgeon". Many of them are arrogant and some to the point where I think they are unbalanced. Don't think I don't respect their immense talents, but this is the truth.