Clinical studies have reported increased rates of disc degeneration at levels adjacent to fusion. It is believed that eliminating motion through fusion shifts the load to the adjacent levels, causing earlier disc degeneration. This study has shown that significant increases in intradiscal pressure and segmental motion occur at levels adjacent to fusion during normal range of motion. These results may partially explain the mechanism of early disc degeneration at levels adjacent to cervical spine fusion.

In this comparison of patients receiving transforaminal lumbar interbody fusion versus posterior lumbar interbody fusion, no complications occurred with the transforaminal approach, whereas multiple complications were associated with the posterior approach. Similar operative times, blood loss, and duration of hospital stay were obtained in single-level fusions, but significantly less blood loss occurred with the transforaminal lumbar interbody approach in two-level fusions. The transforaminal procedure preserves the interspinous ligaments of the lumbar spine and preserves the contralateral laminar surface as an additional surface for bone graft. It may be performed at all lumbar levels because it avoids significant retraction of the dura and conus medullaris.

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Incidence of C5 nerve palsy after cervical spine decompression was 6.7%. This is consistent with previously published studies and represents the largest series of North American patients to date. There is no statistically significant difference in incidence of C5 palsy based on surgical procedure, although there was a trend toward higher rates with laminectomy and fusion.

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Patients presenting with stenosis associated with a spondylolisthesis will often describe signs and symptoms consistent with neurogenic claudication, radiculopathy, and/or low-back pain. The primary objective of surgery, when deemed appropriate, is to decompress the neural elements. As a result of the decompression, the inherent instability associated with the spondylolisthesis may progress and lead to further misalignment that results in pain or recurrence of neurological complaints. Under these circumstances, lumbar fusion is considered appropriate to stabilize the spine and prevent delayed deterioration. Since publication of the original guidelines there have been a significant number of studies published that continue to support the utility of lumbar fusion for patients presenting with stenosis and spondylolisthesis. Several recently published trials, including the Spine Patient Outcomes Research Trial, are among the largest prospective randomized investigations of this issue. Despite limitations of study design or execution, these trials have consistently demonstrated superior outcomes when patients undergo surgery, with the majority undergoing some type of lumbar fusion procedure. There is insufficient evidence, however, to recommend a standard approach to achieve a solid arthrodesis. When formulating the most appropriate surgical strategy, it is recommended that an individualized approach be adopted, one that takes into consideration the patient's unique anatomical constraints and desires, as well as surgeon's experience.

Minimally invasive techniques for lumbar spine fusion have been developed in an attempt to decrease the complications related to traditional open exposures (eg, infection, wound healing problems). Anterior minimally invasive procedures include laparoscopic and mini-open anterior lumbar interbody fusion as well as the lateral transpsoas and percutaneous presacral approaches. Posterior techniques typically use a tubular retractor system that avoids the muscle stripping associated with open procedures. These techniques can be applied to both posterior and transforaminal lumbar interbody fusion procedures. Many initial reports have shown similar clinical results in terms of spinal fusion rates for both traditional open and minimally invasive posterior approaches. However, the anterior minimally invasive procedures are often associated with significantly greater incidence of complications and technical difficulty than their associated open approaches. There is a steep learning curve associated with minimally invasive techniques, and surgeons should not expect to master them in the first several cases.

This study has shown that the majority of patients with incidental durotomy can be treated effectively with dural stitches and fibrin glue. Patients can be permitted to ambulate immediately after surgery but should be cautioned to lay flat if they develop symptoms. This will reduce the costs related to the hospital stay and missed work.