Explaining the Most Common Spinal Fusions | Podcast Ep. 148

Foreign hello and welcome to the Evidence Based Chiropractor. I AM your host, Dr. Jeff Langme. Today we are going to break down the most common types of fusions performed on the spine. We're going to break down what the letters mean, how it applies to your practice, and really some of the most common things that you will see or probably already have seen on the patients coming into your practice. But this week's episode we are diving into, as I said at the top, we're gonna talk a little bit about the basics of fusion or stabilization type of procedures, specifically in the cervical and the lumbar spine. So if you've been somebody who's maybe had 50 patients in your practice, or you intend on seeing 50 patients or more in your career, chances are you're gonna find somebody that's been putting post surgical, right? They have had a surgery in the past. So this week's episode we're specifically gonna talk about the stabilization type procedures and then it will save the laminectomies, the laminotomies, foraminotomies, for a separate episode. So we're gonna break down cervical and lumbar, talk about what the letters mean, the approach that the surgeon takes, and also some take home messages for what it means in your practice. And to kick it off, we're gonna start right, right where it counts up in the cervical spine and we're gonna break down ACDFs and disc replacements. Now with this being said, you know, the goal is, you know, to not have patients have to go through these types of aggressive, risky, dangerous procedures. If you've seen me teach continuing education, you've seen that I throw up a slide. That's shocking, that's, you know, somewhat depressing, to be honest with you. Where 20 years ago, I'm gonna rough the numbers up a little bit right now, but 20 years ago, 100,000 fusions were being performed. A couple 500,000 fusions were performed. It's outrageous. They're absolutely overdone. I cannot believe that that many people all of a sudden need more fusions in the last 20 years that our lifestyles have changed that much. I would argue that if anything, our lifestyles have changed to warrant what we do as chiropractors much more than any fusion type procedure. But lo and behold, we're gonna see patients that have had this in their past, hopefully not many going out of our office to have this in the future. So that's why we're gonna break. And as I said, cervical spine ACDFs and disc replacements are what we're gonna talk about. So acdf, anytime you see that, you probably know anterior cervical disectomy and fusion. What's that mean? Well, it means that the surgeon has gone with an anterior approach, they've gone through the front, they've removed a significant portion of a cervical disc, they put in a spacer, they've left behind a plate and some screws to hold it all together. So again, step by step, super simple breakdown. But keep that in mind, anytime a surgeon is going in and doing a fusion based procedure, they never remove all of the disc. That would take an eon to do. Patient would be in surgery so long that they wouldn't come out of surgery. So the goal is to remove a significant portion of the disc, regardless of whether it's lumbar cervical, whether it's a disc replacement or a fusion. Very, very rarely, if ever has an entire disc been removed. It's just a majority of it. Also, with that being said, a spacer is typically placed in that's gonna take the height of the disc and then you're going to have your rods or your screws, or in this case of an acdf, you'll have your screws and your plate holding things together. Now remember, with an acdf, you might see a four screw technique, you might see a two screw technique, you might see a one screw technique. And also the plates can vary on the front from, let's say a millimeter down to a zero profile at this point as well, where it's not supposed to extend any beyond the anterior aspects of the cervical vertebral bodies. So all of those things are to keep in mind. Now, when you also see a cervical disc, what causes that? Well, obviously, if there's drastic instability of the spine, that's one thing. If there's cord damage or myelomalacia, inflammation around the spinal cord, that's another thing that can lead that direction. But here's a lesser known item. A central cervical disc herniation is very, very difficult to approach and be able to perform a laminectomy from the backside. It's difficult to get around the cord and get to a central disc herniation. If you're taking a posterior approach, which would be a laminotomy or a laminectomy. So patients that you see, and they have a central cervical disc herniation causing cord compression, these are people that are going to have an increased likelihood if they go the surgical route to have to undergo a fusion based procedure. It's important to keep in mind in my opinion, with your treatment. Because again, when you know that these people have yellow flags, you should be taking care of everybody to the best of your ability, no questions asked. But these are important things to keep in mind to prepare patients if and when that hard conversation happens, but also to make sure that you're doing everything possible, in my opinion, to keep them out of that direction if they can stay conservative with their care. Now the other thing commonly performed in the cervical spine is a disc replacement. Usually it's a mobi c that also is an anterior approach. So again, a majority of the disc is removed and, and a implant is placed in that does allow some motion. Now a couple things. With a disc replacement, sometimes people can look that up and they think it's gonna be a miracle. Like the disc replacements. Wow, it's even better than what I'm born with. Not true. So disc replacements are meant to mimic the best of their ability, the motion in the cervical spine. But the motion in our spines is so complex, no disc replacement to date has been able to mirror it. So it's supposed to allow some motion, but the amount of motion does not nearly compensate compared to what would be norma in terms of a normal range of motion in the fluid motion between the segments of a region as well. So it is not necessarily an upgrade if somebody gets a cervical disc replacement. But believe me, I certainly have heard it all as far as that's concerned. Now, cervical disc replacements, one of the things to keep in mind with them is they're not applicable in every level of the cervical spine. So you can only do that at certain levels. You can't obviously do a disc replacement. Typically you don't see them at like C2, C3 or anything like that. So you have to keep in mind that they are most frequently performed. C4, C5, C5, C6. But as you start to get towards the outer extensions of that cervical spine region, it starts to become more challenging to use a cervical disc replacement. The other thing to keep in mind is you can't stack them. So if somebody has multi level cord compression and they're going to have it all addressed, that usually takes the disc replacements out of the equation. You can't just start stacking them. It starts to become a house of cards. So those are the most common things you're going to see in the cervical spine and the lumbar spine. I want you to keep, keep three letters in mind. Lif. Anytime you see lif, that means lumbar inner body fusion. You've probably seen that a Lot on reports now, the wild card is going to be the first letter. And I don't mean the L, but I mean you may see alif, xlif, tlif, dlif. You can see a variety of different letters before the lif. All that first letter means is the direction that the surgeon took. Axial, you know, transforaminal, lateral, extreme lateral. Those are all indicated by the first letter. And then the LIF is lumbar interbody fusion. So all that means to you is rods and screws in the lumbar spine. The surgeon might have taken various approaches, but ultimately they have left behind rods and screws, your prototypical fusion, that is an lif. The surgeon might take, again, a varying. They might take a varying angle to get in there and do the work. Similar to the cervical spine. Usually you're removing a majority of the disc, an implant or a spacer is placed in, and then the rods and screws and cage sort of surround it to keep everything stabilized as the bony fusion takes place over the next six to 12 months. So it's a process. The other thing to keep in mind, in the lumbar spine, you may see a Coflex or an X stop. I wanna break down the two differences, the differences between those two items quickly before we wrap up this episode, we. Coflex is an intralaminar device. It slides in posteriorly in between the lamina. An X stop is an intraspinous device. It slides in between the spinous processes. They can be. If you don't look at them every day, they can be tricky to identify one versus the other on an image. So if you ever have a question about that, ask, and here's why, in X dot. Because it's pretty superficial between the spinous processes, it can be removed relatively easily and. And nothing has to go in its place. So you could have a failed X stop and have it removed and the patient moves along with their life with the Coflex because it's deeper, it's intralaminar every time a Coflex is removed. I've never seen an instance where a Coflux hasn't been removed, that it didn't resort instantaneously to effusion. So the removal of the Coflex was basically at the same time they removed it and they installed rods and screws. So people have to understand Coflex is farther down the road, so to speak, than an AX stop. In X stop, you still have a couple outs in terms of your treatment. But if you have a Coflex that fails or needs to be removed, it's exceptionally likely that that is going to trickle to a fusion based procedure. Also in the lumbar spine, of course there are disc replacements. They were done overseas forever. They were sort of not approved in the US but now they are usually that's going to again be a 4.5L. 4L 5 is a common place for a disc replacement. You don't see them very often at 5:1 and as you go up in the lumbar spine I've seen them less frequently as but that's breaking down some of the basic nomenclature on stabilization or fusion based procedures that you're gonna see in the cervical or the lumbar spine. We'll do a follow up episode where we break down the decompressive type procedures and hopefully that was informing for you. Shoot me some feedback. I'd love to know what you thought of this episode. It's kind of got a little technical there for a little while, but I'd love to know what you think. Jeff the evidencebasedchiropractor.com Shoot me a message and I hope you have a great week in practice and I will talk to you soon.

We appreciate you joining us for this episode of the Evidence Chiropractor. Learn more tips for explosive practice development at the evidence basedchiropractor.com youm can also join the Premier MD monthly membership, enabling you to use what you just heard to maximize results in your office.