In the fall of 2020, I recorded an I Have a Client Who . . . podcast about a massage therapist whose client had spinal fusion surgery, along with some other health challenges. In pulling together information for that project, I found lots and lots of material about spinal fusions—and almost nothing about massage therapy for these patients. This surprised me because spinal fusions and similar surgeries are among the most common operations conducted in the United States. Also, as evidenced by the person who contributed the story to my podcast, it is a sure bet that many massage therapists have clients who have been through this process. But what do we know about the procedure and where massage therapy fits in this context?
Definition
Spinal fusion surgery is a procedure that joins connecting vertebrae by fusing them together. According to the American Academy of Orthopedic Surgeons, “It is essentially a ‘welding’ process. The basic idea is to fuse together two or more vertebrae so that they heal into a single, solid bone. This is done to eliminate painful motion or to restore stability in the spine.”1
So, spinal fusion surgery is recommended when a surgeon believes too much movement between vertebrae leads to severe pain that cannot be managed any other way. Read that carefully: too much movement between vertebrae leads to severe pain. This is a surprisingly complicated concept, given what we know (and don’t know) about how the spine works, and how pain is generated. It is an assumption that turns out to be true in many—but not all—cases.
Spinal Fusion Surgery Statistics
It’s difficult to gather statistics on exactly how many spinal fusion surgeries are conducted, but an organization that tracks device sales suggests that about 352,000 interbody fusions are conducted each year. However, this does not account for all cervical fixations or disk replacement surgeries and other spine-stabilizing procedures. Also, a person may have multiple fusions in a single surgery, which further muddies the numbers. What we do know is that in the United States we spend over $6 billion per year on spinal implant devices.2
The number of surgeries conducted in this country has risen substantially in the last two decades. This is partly because a large number of baby boomers are now candidates for this procedure, and also because new technologies have reduced many of the risks associated with fusions. Spinal fusion surgery is considered a more feasible option than living with chronic, intractable pain that does not respond to less invasive treatments.
Who Needs Spinal Fusion Surgery?
Obviously, with a surgery as common, complex, and fraught with possible complications as spinal fusion therapy, you would think we must have a well-established rubric for when, why, and for whom these surgeries should take place. You’d be wrong.
The reasons spinal fusion surgery is often controversial are fascinating but not central to this discussion. Still, I couldn’t resist exploring this topic a bit, and I will share what I learned, along with an interview with massage therapist, past Massage & Bodywork columnist, and spinal fusion surgery veteran Diana Thompson in the video that accompanies this article.
When considering spinal fusion surgery, the decision-making process theoretically involves trying to quantify a person’s spinal instability, and we don’t have a great way to do that. In addition, surgeons must try to analyze the multiple contributors to pain responses in order to predict whether surgery is likely to improve the situation, and this is not always clear.
But the short answer to who might need spinal fusion surgery is this: anyone who has signs of bone or disk deformation or instability, along with severe pain that persists for six months or more, in spite of less invasive management strategies. Those strategies typically include physical therapy, spinal injections (with painkillers and/or anti-inflammatories), and medication. It is interesting that massage doesn’t appear on this list, but it may be included as part of physical therapy in some cases.
The conditions most resources list as correctable by spinal fusion surgery include degenerative disk disease, spondylolisthesis, spinal stenosis, scoliosis, fractured vertebrae, infection, and tumors. Each of these is worth its own discussion, but for now we’ll just say they all involve combinations of bone and disk damage that can endanger nerve roots and the spinal cord.
What Happens in the Spinal Fusion Procedure?
As one might imagine, spinal fusion procedures can be extremely complex. Beyond fusing two or more vertebral bodies together, surgery can also involve a laminectomy (cutting through the lamina to relieve pressure from a damaged disk, bone spurs, or other obstructions), and they often work to create more space between the vertebrae that are being treated; this is called decompression surgery.
Depending on what part of the spine is affected, surgery may be conducted through an anterior approach (this is common for cervical fusions), a posterolateral approach, or a fully posterior approach to the spine. The central goal is to link two or more vertebrae in some way that they will heal as a single bone.
Grafts are typically inserted between the vertebral bodies to start the fusion process. They can be autografts with bone harvested from the patient’s iliac crest or other areas, or allografts with bits of cadaver bone. Various types of synthetic grafts are also used. These can consist of a putty made from demineralized cadaver bone, bone morphogenetic proteins, or synthetic bone made from calcium and phosphate. Exactly which grafts are used depends on the circumstances, and it is common to use multiple types to create appropriate space and to initiate a healing process that will bind the bones together. Then metal plates, screws, and rods are inserted to stabilize the bones as they heal.
The recovery process from spinal fusion surgery is predictably slow. Most patients stay in the hospital for about two days, and then return home with instructions for wound care, pain management, and how to safely get in and out of bed. Physical therapy to rebuild strength and flexibility begins a few weeks after surgery and often goes for 3–6 months. Patients are advised not to do any heavy lifting for several weeks and to wear a neck brace if their surgery was for a cervical fusion. Above all, patients are counseled not to smoke, as it has been demonstrated that smokers have poorer success rates with bone grafts.
Alternatives for Spinal Fusion Surgery
Traditional spinal fusion surgery has been used since the early 20th century. It was originally developed to help correct bone loss related to tuberculosis infections, but those surgeons found it also helped reduce severe low-back pain.
By definition, spinal fusion surgery leads to loss of function and range of motion in the spine, but this is considered by patients and surgeons to be an acceptable trade-off for the relief it often provides from severe, intractable pain. And the loss of motion at a single spinal segment is so minimal for most people that it doesn’t impact their activities of daily living at all.
Several options that work to preserve spinal function have been developed, and they are possible choices for people who are worried about full fusions. The two main alternatives to fusion surgery are disk arthroplasty and posterior dynamic stabilization devices.
Disk Arthroplasty
This is a procedure approved by the US Food and Drug Administration (FDA) in 2004. Debris from a damaged disk is removed, and a prosthetic disk made of metal and plastic is inserted. It is not suitable for all patients, though. People with multiple level dysfunction, who are obese or who have scoliosis, problems at the facet joints, or previous surgeries are not good candidates for disk replacement surgery. For patients who are good candidates, we see some advantages: less analgesic use and fewer repeat surgeries than for traditional fusion surgery for at least two years out from the initial procedure.3
Posterior Dynamic Stabilization Devices
This describes several pieces of hardware that can be used to help reduce hypermobility. They function as an internal brace, using combinations of screws, cords, flexible rods, and spacers. So far, posterior dynamic stabilization devices have been used in addition to traditional fusion surgery and are now being tried as a freestanding intervention.4
Possible Complications from Spinal Fusion Surgery
As one might imagine, the possible complications from spinal fusion surgery are serious. The same risks seen with any open surgery are present, including blood clots, excessive bleeding, and infection. But these surgeries also carry the chance of nerve damage, pain at the graft site, broken hardware, and failure of the graft to take hold. Equipment failure and poor grafting can require follow-up surgeries, which of course carry further risks.
But the most common risk associated with spinal fusions is that pain may not be relieved. About 80 percent of patients get some pain relief (although most do not report being completely pain-free). But around 20 percent of patients find that the surgery did not solve their problem, even without surgical complications. This is especially true when multiple levels are fused.
Advances in technology have indeed made spinal fusion surgery safer and more effective than ever before. It would be even better, though, if we could identify who is less likely to derive benefit from this very invasive and risky procedure before they go through this ordeal.
Role for Massage Therapy
The number of spinal fusion surgeries conducted in the United States has doubled in the past 20 years, but even with all that work being done, there is a remarkable lack of consensus on best practices for rehabilitation. This is frustrating on many levels, including the fact that highly customizable massage therapy seems like a natural fit for the recovery process from a surgery of this nature.
After extensive searching, I was surprised to find only one published research project that looked at massage therapy for a person who had recently had spinal fusion surgery. It was published in 2012 by the International Journal of Therapeutic Massage and Bodywork. It was also the subject of a Massage Therapy Foundation Research Perch podcast with me and Niki Munk, PhD.5
The study found that massage therapy offered considerable benefits for the client, with some limitations based on circumstances outside of anyone’s control (the client had to return to work earlier than expected).6 The benefits for pain and disability appeared to be relatively short-lived, but they were substantial. We hoped this report would spark interest in the use of massage therapy as part of the rehabilitation process for spinal fusion surgery patients, but to my knowledge, no further research on this topic has been published.
That said, it seems clear that most patients who want to regain safe flexibility and movement capacity after a spinal fusion, disk replacement, or any other kind of spine repair intervention could benefit from skilled bodywork. It was especially notable that in this case report, the hands-on techniques used were not highly specialized, and they are within the capabilities of most massage therapists.
Cautions for working with this population are the same as for all postsurgical situations, including the risk of infection, incomplete wound healing, and any reactions to medications. Additionally, people in recovery from spine surgeries are taught careful procedures for certain activities, like getting in and out of bed—these would apply for getting on and off a massage table as well.
But the benefits we can offer are many and varied. If we coordinate with the client’s health-care team, then skilled massage therapy can conceivably help manage pain, improve safe range of motion, minimize the negative repercussions of scar tissue, and otherwise support the healing process while adding to the client’s general quality of life. This is a situation where our hands-on work is only part of what we bring to the table; our communication skills can support a sense of self-efficacy and self-empowerment that are central to the healing process.
The fact that almost no data has been recorded about massage therapy for people recovering from spinal fusion surgery does not mean this work isn’t happening. I’m positive that many massage therapists are working with clients in this population. I encourage you to report on your work so we can get your results into the hands of doctors and patients who need to know what massage can add to the healing process of this common but complex intervention.
Resources
Vaccaro, Alexander R. “3 Things You Need to Know About Spinal Fusion Recovery.” Rothman Orthopaedic Institute Blog. October 10, 2014. Accessed January 2021. www.rothmanortho.com/stories/blog/3-things-you-need-to-know-about-spinal-fusion-recovery.
Notes
1. American Academy of Orthopaedic Surgeons, “Spinal Fusion,” OrthoInfo 2020, accessed January 2021, www.orthoinfo.org/en/treatment/spinal-fusion.
2. iData Research, “How Many Spinal Fusions are Performed Each Year in the United States?” May 25, 2018, www.idataresearch.com/how-many-instrumented-spinal-fusions-are-performed-each-year-in-the-united-states.
3. Peyman Pakzaban, “Spinal Instability and Spinal Fusion Surgery” Medscape, March 6, 2020, https://emedicine.medscape.com/article/1343720-overview#showall.
4. Stephen Hochschuler, “Posterior Dynamic Stabilization Systems,” SPINE-health, updated March 26, 2007, www.spine-health.com/treatment/back-surgery/posterior-dynamic-stabilization-systems.
5. MassageNerd, “Massage Therapy and Fusion Surgery of the Lumbar Spine—Research Perch,” YouTube Video, 28:59, December 17, 2015, www.youtube.com/watch?v=BxCZbXIrzes.
6. Glenda Keller, “The Effects of Massage Therapy after Decompression and Fusion Surgery of the Lumbar Spine: A Case Study,” International Journal of Therapeutic Massage & Bodywork 5, no. 4 (December 2012): 3–8, https://doi.org/10.3822/ijtmb.v5i4.189.
Ruth Werner is a former massage therapist, a writer, and an NCBTMB-approved continuing education provider. She wrote A Massage Therapist’s Guide to Pathology (available at booksofdiscovery.com), now in its seventh edition, which is used in massage schools worldwide. Werner is available at ruthwerner.com or wernerworkshops@ruthwerner.com.