What are the recommendations for surgery to revise a spine fusion?

Recommendations for Spine Fusion Revision Surgery

Revision surgery for spine fusion should be considered only when there is evidence of instability, chronic axial low back pain, or recurrent disc herniations associated with a failed previous fusion, and only after conservative management has failed.

Indications for Revision Spine Fusion Surgery

• Revision surgery with fusion is a treatment option for patients with recurrent disc herniations associated with instability or chronic axial low back pain after previous surgery 1
• Reoperation with fusion should be considered for patients with evidence of pseudarthrosis (failed fusion) from previous attempts, especially in smokers who have a 32% risk of reoperation for pseudarthrosis 1
• Revision surgery should only be pursued after failure of comprehensive conservative management for at least 6 months 2

Patient Selection Factors

• Patients with significant chronic axial back pain, those who work as manual laborers, have severe degenerative changes, or have instability associated with radiculopathy are better candidates for revision fusion surgery 1
• Active smokers should be counseled regarding their increased risk of reoperation and pseudarthrosis before undergoing revision spine fusion 1
• Patients with diabetes should undergo preoperative HbA1c testing, as levels >7.5 mg/dL are associated with increased risk of postoperative infection and reoperation 1

Surgical Approach Considerations

• There is insufficient evidence to recommend a standard approach to achieve solid arthrodesis in revision cases 1

• An individualized surgical approach should be adopted based on:

  • Patient's unique anatomical constraints 1
  • Location of previous fusion and hardware 2
  • Presence of instability (such as retrolisthesis) 3
  • Need to connect to existing fusion constructs 3

• Combined anterior/posterior approaches may be appropriate for cases with significant instability and the need to connect to existing fusion constructs 3

Risks and Benefits

• Fusion increases the complexity of surgery, prolongs surgical time, and potentially increases complication rates 1
• Return to work is slower with fusion procedures (25 weeks) compared to decompression-only procedures (12 weeks) 2
• Despite partial loss of benefits over time, lumbar spine fusion can provide meaningful long-term benefits for up to 10 years, particularly in pain reduction and physical function 4
• Benefits appear more modest with degenerative conditions, reflecting the ongoing nature of spinal degeneration 4

Important Caveats

• Discography is not recommended as a stand-alone test on which to base revision surgery decisions for patients with low-back pain and abnormal imaging studies 1
• Patients should be informed that provocative discography has been associated with acceleration of the degenerative process 1
• Degenerative changes identified on MRI may occur in asymptomatic patients and should not be used as the sole justification for revision surgery 1
• The evidence base for spine fusion effectiveness is limited, with many studies at high risk of bias, and patients should be fully informed about the relative potential benefits and harms compared to non-operative treatments 5