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Spinal fusion
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<h2 id="medical-uses">Medical uses</h2> <p>Spinal fusion can be used to treat a variety of conditions affecting any level of the spine—<a href="/facts/Lumbar/tFvq7Kgm">lumbar</a>, <a href="/facts/Cervical_vertebrae/M7Kf14h9">cervical</a> and <a href="/facts/Thoracic_vertebrae/WXBWDkfM">thoracic</a>. In general, spinal fusion is performed to decompress and stabilize the spine.<a class="footnote-ref" id="fnref:7" href="#fn:7"><sup>7</sup></a> The greatest benefit appears to be in <a href="/facts/Spondylolisthesis/FuzTuhkd">spondylolisthesis</a>, while evidence is weaker for <a href="/facts/Spinal_stenosis/VejAI6nL">spinal stenosis</a>.<a class="footnote-ref" id="fnref:8" href="#fn:8"><sup>8</sup></a> </p><p>The most common cause of pressure on the spinal cord/nerves is degenerative disc disease.<a class="footnote-ref" id="fnref:9" href="#fn:9"><sup>9</sup></a> Other common causes include disc herniation, spinal stenosis, trauma, and spinal tumors.<a class="footnote-ref" id="fnref:10" href="#fn:10"><sup>10</sup></a> Spinal stenosis results from bony growths (<a href="/facts/Osteophytes/WP8vVyAr">osteophytes</a>) or thickened ligaments that cause narrowing of the spinal canal over time.<a class="footnote-ref" id="fnref:11" href="#fn:11"><sup>11</sup></a> This causes leg pain with increased activity, a condition called <a href="/facts/Neurogenic_claudication/M4SzI2lK">neurogenic claudication</a>.<a class="footnote-ref" id="fnref:12" href="#fn:12"><sup>12</sup></a> Pressure on the nerves as they exit the spinal cord (<a href="/facts/Radiculopathy/r68AQBDs">radiculopathy</a>) causes pain in the area where the nerves originated (leg for lumbar pathology, arm for cervical pathology).<a class="footnote-ref" id="fnref:13" href="#fn:13"><sup>13</sup></a> In severe cases, this pressure can cause neurologic deficits, like numbness, tingling, bowel/bladder dysfunction, and paralysis.<a class="footnote-ref" id="fnref:14" href="#fn:14"><sup>14</sup></a> </p><p>Lumbar and cervical spinal fusions are more commonly performed than thoracic fusions.<a class="footnote-ref" id="fnref:15" href="#fn:15"><sup>15</sup></a> Degeneration happens more frequently at these levels due to increased motion and stress.<a class="footnote-ref" id="fnref:16" href="#fn:16"><sup>16</sup></a> The thoracic spine is more immobile, so most fusions are performed due to trauma or deformities like <a href="/facts/Scoliosis/SKpqX5lo">scoliosis</a>, <a href="/facts/Kyphosis/ctcRerHJ">kyphosis</a>, and <a href="/facts/Lordosis/6TTUXNm2">lordosis</a>.<a class="footnote-ref" id="fnref:17" href="#fn:17"><sup>17</sup></a> </p><p>Conditions where spinal fusion may be considered include the following: </p> <ul><li><a href="/facts/Degenerative_disc_disease/A9Lu3RK8">Degenerative disc disease</a></li> <li><a href="/facts/Herniated_disc/T4zvLoub">Spinal disc herniation</a></li> <li>Discogenic pain</li> <li>Spinal <a href="/facts/Tumor/K0ytzmPz">tumor</a></li> <li>Vertebral fracture</li> <li><a href="/facts/Scoliosis/SKpqX5lo">Scoliosis</a></li> <li><a href="/facts/Kyphosis/ctcRerHJ">Kyphosis</a> (e. g., <a href="/facts/Scheuermann%2527s_disease/634pbxko">Scheuermann's disease</a>)</li> <li><a href="/facts/Lordosis/6TTUXNm2">Lordosis</a></li> <li><a href="/facts/Spondylolisthesis/FuzTuhkd">Spondylolisthesis</a></li> <li><a href="/facts/Spondylosis/aLoVa3Rm">Spondylosis</a></li> <li><a href="/facts/Posterior_rami_syndrome/x4P2pys8">Posterior rami syndrome</a></li> <li>Other degenerative spinal conditions<a class="footnote-ref" id="fnref:18" href="#fn:18"><sup>18</sup></a></li> <li>Any condition that causes instability of the spine<a class="footnote-ref" id="fnref:19" href="#fn:19"><sup>19</sup></a></li></ul> <h2 id="contraindications">Contraindications</h2> <p><a href="/facts/Bone_morphogenetic_protein/VpwFr7Ih">Bone morphogenetic protein</a> (rhBMP) should not be routinely used in any type of anterior cervical spine fusion, such as with <a href="/facts/Anterior_cervical_discectomy_and_fusion/UYhcYEpJ">anterior cervical discectomy and fusion</a>.<a class="footnote-ref" id="fnref:20" href="#fn:20"><sup>20</sup></a> There are reports of this therapy causing <a href="/facts/Soft_tissue/cHBwqLpP">soft tissue</a> swelling, which in turn can cause life-threatening complications due to <a href="/facts/Difficulty_swallowing/vgfd6FpV">difficulty swallowing</a> and pressure on the <a href="/facts/Respiratory_tract/nnG9UEmr">respiratory tract</a>.<a class="footnote-ref" id="fnref:21" href="#fn:21"><sup>21</sup></a> </p> <h2 id="epidemiology">Epidemiology</h2> <p>According to a report by the <a href="/facts/Agency_for_Healthcare_Research_and_Quality/r3QXI6H1">Agency for Healthcare Research and Quality (AHRQ)</a>, approximately 488,000 spinal fusions were performed during U.S. hospital stays in 2011 (a rate of 15.7 stays per 10,000 population), which accounted for 3.1% of all operating room procedures.<a class="footnote-ref" id="fnref:22" href="#fn:22"><sup>22</sup></a> This was a 70 percent growth in procedures from 2001.<a class="footnote-ref" id="fnref:23" href="#fn:23"><sup>23</sup></a> Lumbar fusions are the most common type of fusion performed ~ 210,000 per year. 24,000 thoracic fusions and 157,000 cervical fusions are performed each year.<a class="footnote-ref" id="fnref:24" href="#fn:24"><sup>24</sup></a> </p><p>A 2008 analysis of spinal fusions in the United States reported the following characteristics: </p> <ul><li>Average age for someone undergoing a spinal fusion was 54.2 years – 53.3 years for primary cervical fusions, 42.7 years for primary thoracic fusions, and 56.3 years for primary lumbar fusions <a class="footnote-ref" id="fnref:25" href="#fn:25"><sup>25</sup></a></li> <li>45.5% of all spinal fusions were on men <a class="footnote-ref" id="fnref:26" href="#fn:26"><sup>26</sup></a></li> <li>83.8% were white, 7.5% black, 5.1% Hispanic, 1.6% Asian or Pacific Islander, 0.4% Native American <a class="footnote-ref" id="fnref:27" href="#fn:27"><sup>27</sup></a></li> <li>Average length of hospital stay was 3.7 days – 2.7 days for primary cervical fusion, 8.5 days for primary thoracic fusion, and 3.9 days for primary lumbar fusion <a class="footnote-ref" id="fnref:28" href="#fn:28"><sup>28</sup></a></li> <li>In-hospital mortality was 0.25% <a class="footnote-ref" id="fnref:29" href="#fn:29"><sup>29</sup></a></li></ul> <h2 id="effectiveness">Effectiveness</h2> <p>Although spinal fusion surgery is widely performed, there is limited evidence for its effectiveness for several common medical conditions. For example, in a <a href="/facts/Randomized_controlled_trial/LG9lkyVx">randomized controlled trial</a> of Swedish adults with <a href="/facts/Spinal_stenosis/VejAI6nL">spinal stenosis</a>, after 2 and 5 years, there were no significant clinical benefits of lumbar fusion in combination with <a href="/facts/Spinal_decompression/Rc9wEv4p">decompression surgery</a> in comparison to decompression surgery alone. The study enrolled 247 patients from 2006 to 2012 and further found increased medical costs for those who received fusion surgery as a result of increased surgery time, hospital stay duration, and cost of the implant.<a class="footnote-ref" id="fnref:30" href="#fn:30"><sup>30</sup></a> </p> <h2 id="technique">Technique</h2> <p>There are many types of spinal fusion techniques. Each technique varies depending on the level of the spine and the location of the compressed spinal cord/nerves.<a class="footnote-ref" id="fnref:31" href="#fn:31"><sup>31</sup></a> After the spine is <a href="/facts/Spinal_decompression/Rc9wEv4p">decompressed</a>, <a href="/facts/Bone_grafting/4kK5tXfv">bone graft</a> or artificial bone substitute is packed between the vertebrae to help them heal together.<a class="footnote-ref" id="fnref:32" href="#fn:32"><sup>32</sup></a> In general, fusions are done either on the anterior (stomach), posterior (back), or both sides of the spine.<a class="footnote-ref" id="fnref:33" href="#fn:33"><sup>33</sup></a> Today, most fusions are supplemented with hardware (screws, plates, rods) because they have been shown to have higher union rates than non-instrumented fusions.<a class="footnote-ref" id="fnref:34" href="#fn:34"><sup>34</sup></a> <a href="/facts/Invasiveness_of_surgical_procedures/Lm4xbpYG">Minimally invasive</a> techniques are also becoming more popular.<a class="footnote-ref" id="fnref:35" href="#fn:35"><sup>35</sup></a> These techniques use advanced image guidance systems to insert rods/screws into the spine through smaller incisions, allowing for less muscle damage, blood loss, infections, pain, and length of stay in the hospital.<a class="footnote-ref" id="fnref:36" href="#fn:36"><sup>36</sup></a> The following list gives examples of common types of fusion techniques performed at each level of the spine: </p> <h3>Cervical spine</h3> <ul><li><a href="/facts/Anterior_cervical_discectomy_and_fusion/UYhcYEpJ">Anterior cervical discectomy and fusion</a> (ACDF)<a class="footnote-ref" id="fnref:37" href="#fn:37"><sup>37</sup></a></li> <li>Anterior cervical <a href="/facts/Corpectomy/SYGxUVlf">corpectomy</a> and fusion<a class="footnote-ref" id="fnref:38" href="#fn:38"><sup>38</sup></a></li> <li>Posterior cervical decompression and fusion<a class="footnote-ref" id="fnref:39" href="#fn:39"><sup>39</sup></a></li></ul> <h3>Thoracic spine</h3> <ul><li>Anterior decompression and fusion<a class="footnote-ref" id="fnref:40" href="#fn:40"><sup>40</sup></a></li> <li>Posterior instrumentation and fusion – many different types of hardware can be used to help fuse the thoracic spine including sublaminar wiring, pedicle and transverse process hooks, pedicle screw-rod systems, vertebral body plate systems.<a class="footnote-ref" id="fnref:41" href="#fn:41"><sup>41</sup></a></li></ul> <h3>Lumbar spine</h3> <ul><li>Posterolateral fusion is a bone graft between the <a href="/facts/Transverse_process/qAdLhD5H">transverse processes</a> in the back of the spine. These vertebrae are then fixed in place with screws or wire through the <a href="/facts/Pedicle_of_vertebral_arch/qAdLhD5H">pedicles</a> of each vertebra, attaching to a metal rod on each side of the vertebrae.</li> <li>Interbody Fusion is a graft where the entire <a href="/facts/Intervertebral_disc/RTj5SrMo">intervertebral disc</a> between vertebrae is removed and a bone graft is placed in the space between the <a href="/facts/Vertebra/qAdLhD5H">vertebra</a>. A plastic or titanium device may be placed between the vertebra to maintain spine alignment and disc height. The types of interbody fusion are: <ol><li>Anterior lumbar interbody fusion (ALIF) – the disc is accessed from an anterior abdominal incision</li> <li>Posterior lumbar interbody fusion (PLIF) – the disc is accessed from a posterior incision</li> <li>Transforaminal lumbar interbody fusion (TLIF) – the disc is accessed from a posterior incision on one side of the spine</li> <li>Transpsoas interbody fusion (DLIF or XLIF) – the disc is accessed from an incision through the psoas muscle on one side of the spine</li> <li>Oblique lateral lumbar interbody fusion (OLLIF) – the disc is accessed from an incision through the psoas muscle obliquely</li></ol></li></ul> <h2 id="risks">Risks</h2> <p>Spinal fusion is a high risk surgery and complications can be serious, including death. In general, there is a higher risk of complications in older people with elevated body mass index (BMI), other medical problems, poor nutrition and nerve symptoms (numbness, weakness, bowel/bladder issues) before surgery.<a class="footnote-ref" id="fnref:42" href="#fn:42"><sup>42</sup></a> Complications also depend on the type/extent of spinal fusion surgery performed. Smokers and people who are Vitamin D deficient are at a higher risk of spinal fusion failure.<a class="footnote-ref" id="fnref:43" href="#fn:43"><sup>43</sup></a> There are three main time periods where complications typically occur: </p> <h3>During surgery</h3> <ul><li>Patient positioning on operating table<a class="footnote-ref" id="fnref:44" href="#fn:44"><sup>44</sup></a></li> <li>Blood loss<a class="footnote-ref" id="fnref:45" href="#fn:45"><sup>45</sup></a></li> <li>Damage to nerves and surrounding structures during procedure<a class="footnote-ref" id="fnref:46" href="#fn:46"><sup>46</sup></a></li> <li>Insertion of spinal hardware<a class="footnote-ref" id="fnref:47" href="#fn:47"><sup>47</sup></a> <ul><li>Conventional Pedicle screws increased the risk of failure compared to Expandable Pedicle screws<a class="footnote-ref" id="fnref:48" href="#fn:48"><sup>48</sup></a></li></ul></li> <li>Harvesting of bone graft (if autograft is used)<a class="footnote-ref" id="fnref:49" href="#fn:49"><sup>49</sup></a></li> <li>Patients who used the allograft were at a higher risk of fusion failure.<a class="footnote-ref" id="fnref:50" href="#fn:50"><sup>50</sup></a></li></ul> <h3>Within a few days</h3> <ul><li>Moderate to severe postoperative pain<a class="footnote-ref" id="fnref:51" href="#fn:51"><sup>51</sup></a></li> <li>Wound infections - risk factors include old age, obesity, diabetes, smoking, prior surgery<a class="footnote-ref" id="fnref:52" href="#fn:52"><sup>52</sup></a></li> <li><a href="/facts/Deep_vein_thrombosis/vX7cGv8J">Deep vein thrombosis</a> (DVT)<a class="footnote-ref" id="fnref:53" href="#fn:53"><sup>53</sup></a></li> <li><a href="/facts/Pulmonary_embolism/LPjKCPba">Pulmonary embolism</a> (PE)<a class="footnote-ref" id="fnref:54" href="#fn:54"><sup>54</sup></a></li> <li><a href="/facts/Urinary_retention/YvTCprKk">Urinary retention</a><a class="footnote-ref" id="fnref:55" href="#fn:55"><sup>55</sup></a></li> <li><a href="/facts/Malnutrition/KasQy5MR">Malnutrition</a><a class="footnote-ref" id="fnref:56" href="#fn:56"><sup>56</sup></a></li> <li>Neurologic deficit<a class="footnote-ref" id="fnref:57" href="#fn:57"><sup>57</sup></a></li> <li>Shock, sepsis and cerebrovascular infarction<a class="footnote-ref" id="fnref:58" href="#fn:58"><sup>58</sup></a></li></ul> <h3>Weeks to years following surgery</h3> <ul><li>Infection – sources of bacterial bioburden that infiltrate the wound site are several, but the latest research highlights repeated reprocessing of implants before surgery and exposure of implants (such as pedicle screws) to bacterial contaminants in the "sterile-field" during surgery as major risk factors.<a class="footnote-ref" id="fnref:59" href="#fn:59"><sup>59</sup></a><a class="footnote-ref" id="fnref:60" href="#fn:60"><sup>60</sup></a><a class="footnote-ref" id="fnref:61" href="#fn:61"><sup>61</sup></a><a class="footnote-ref" id="fnref:62" href="#fn:62"><sup>62</sup></a><a class="footnote-ref" id="fnref:63" href="#fn:63"><sup>63</sup></a><a class="footnote-ref" id="fnref:64" href="#fn:64"><sup>64</sup></a></li> <li>Deformity – loss of height, alignment, and failure of fusion<a class="footnote-ref" id="fnref:65" href="#fn:65"><sup>65</sup></a></li> <li><a href="/facts/Pseudarthrosis/AthlSHkm">Pseudarthrosis</a> – nonunion between fused bone segments. Risk factors include tobacco use, <a href="/facts/Nonsteroidal_anti-inflammatory_drug/coIkzl4s">nonsteroidal anti-inflammatory drug</a> use, osteoporosis, revision procedures, decreased immune system.<a class="footnote-ref" id="fnref:66" href="#fn:66"><sup>66</sup></a></li> <li>Adjacent segment disease – degeneration of vertebrae above/below the fused segments due altered biomechanical stresses or patient propensity to develop progressive degenerative change.<a class="footnote-ref" id="fnref:67" href="#fn:67"><sup>67</sup></a></li> <li>Epidural fibrosis – scarring of the tissue that surrounds the spinal cord<a class="footnote-ref" id="fnref:68" href="#fn:68"><sup>68</sup></a></li> <li><a href="/facts/Arachnoiditis/8eIT0Qe9">Arachnoiditis</a> – inflammation of the thin membrane surrounding the spinal cord, usually caused by infection or contrast dye.<a class="footnote-ref" id="fnref:69" href="#fn:69"><sup>69</sup></a></li></ul> <h2 id="recovery">Recovery</h2> <p>Recovery following spinal fusion is extremely variable, depending on individual surgeon's preference and the type of procedure performed.<a class="footnote-ref" id="fnref:70" href="#fn:70"><sup>70</sup></a> The average length of hospital stay for spinal fusions is 3.7 days.<a class="footnote-ref" id="fnref:71" href="#fn:71"><sup>71</sup></a> Some patients can go home the same day if they undergo a simple cervical spinal fusion at an outpatient surgery center.<a class="footnote-ref" id="fnref:72" href="#fn:72"><sup>72</sup></a> <a href="/facts/Minimally_invasive_thoracic_spinal_fusion/osJLVwG8">Minimally invasive surgeries</a> are also significantly reducing the amount of time spent in the hospital.<a class="footnote-ref" id="fnref:73" href="#fn:73"><sup>73</sup></a> Recovery typically involves both restriction of certain activities and rehabilitation training.<a class="footnote-ref" id="fnref:74" href="#fn:74"><sup>74</sup></a><a class="footnote-ref" id="fnref:75" href="#fn:75"><sup>75</sup></a> Restrictions following surgery largely depend on surgeon preference. A typical timeline for common restrictions after a lumbar fusion surgery are listed below: </p> <ul><li>Walking – most people are out of bed and walking the day after surgery<a class="footnote-ref" id="fnref:76" href="#fn:76"><sup>76</sup></a></li> <li>Sitting – can begin at 1–6 weeks following surgery<a class="footnote-ref" id="fnref:77" href="#fn:77"><sup>77</sup></a></li> <li>Lifting – it is generally recommended to avoid lifting until 12 weeks<a class="footnote-ref" id="fnref:78" href="#fn:78"><sup>78</sup></a></li> <li>Driving – usually can begin at 3–6 weeks<a class="footnote-ref" id="fnref:79" href="#fn:79"><sup>79</sup></a></li> <li>Return to sedentary work – usually between 3–6 weeks<a class="footnote-ref" id="fnref:80" href="#fn:80"><sup>80</sup></a></li> <li>Return to manual work – between 7–12 weeks<a class="footnote-ref" id="fnref:81" href="#fn:81"><sup>81</sup></a></li></ul> <p>Rehabilitation after spinal fusion is not mandatory. There is some evidence that it improves functional status and low back pain so some surgeons may recommend it.<a class="footnote-ref" id="fnref:82" href="#fn:82"><sup>82</sup></a> </p> <h2 id="usage">Usage</h2> <p>According to a report by the Agency for Healthcare Research and Quality (AHRQ), approximately 488,000 spinal fusions were performed during U.S. hospital stays in 2011, a rate of 15.7 stays per 10,000 population, which accounted for 3.1% of all operating room procedures.<a class="footnote-ref" id="fnref:83" href="#fn:83"><sup>83</sup></a> </p> <h2 id="public-health-hazard">Public health hazard</h2> <p>In 2019, the news channel <a href="/facts/WTOL-TV/n6vn5jzx">WTOL-TV</a> broadcast an investigation, "Surgical implants raising contamination concerns", uncovering a dossier of scientific evidences that current methods of processing and handling spinal implants are extremely unhygienic and lacks quality control. This lack of quality control is exposing patients to high risk of infection, which themselves are underreported given the long time frame (0–7 years) and reportedly lack follow up data on the patients undergoing spine surgery. A petition was filed by the lead investigator, Aakash Agarwal, to rectify this global public health hazard of implanting contaminated spinal devices in patients.<a class="footnote-ref" id="fnref:84" href="#fn:84"><sup>84</sup></a><a class="footnote-ref" id="fnref:85" href="#fn:85"><sup>85</sup></a><a class="footnote-ref" id="fnref:86" href="#fn:86"><sup>86</sup></a><a class="footnote-ref" id="fnref:87" href="#fn:87"><sup>87</sup></a><a class="footnote-ref" id="fnref:88" href="#fn:88"><sup>88</sup></a> </p> <h2 id="see-also">See also</h2> <ul><li><a href="/facts/TOPS_System/l9G2jWJH">TOPS System</a>, an alternative approach to Spinal fusion</li></ul> <h2 id="further-reading">Further reading</h2> <ul><li><a href="http://www.webmd.com/back-pain/cervical-spinal-fusion">Cervical Spinal Fusion.</a> WebMD.</li> <li><a href="http://www.umm.edu/spinecenter/education/anterior_cervical_fusion.htm">A Patient's Guide to Anterior Cervical Fusion.</a> University of Maryland Medical Center.</li> <li>Boatright, K. C. and S. D. Boden. Chapter 12: Biology of Spine Fusion. In: Lieberman, J., et al., Eds. <i>Bone Regeneration and Repair</i>. <a href="/facts/Totowa%2c_New_Jersey/9IKqC7EC">Totowa, New Jersey</a>: <a href="/facts/Humana_Press/hIweL3at">Humana Press</a>. 2005. pp. 225–239. <a href="/facts/ISBN_(identifier)/15AdSPa9">ISBN</a> 978-0-89603-847-9.</li> <li>Holmes, C. F., et al. Chapter 9: Cervical Spine Injuries. In: Schenck, R. F., <a href="/facts/American_Academy_of_Orthopedic_Surgeons/sluGr5ou">AAOS</a>. <i>Athletic Training in Sports Medicine.</i> Jones & Bartlett Publishers. 2005. pp. 197–218. <a href="/facts/ISBN_(identifier)/15AdSPa9">ISBN</a> 0-89203-172-7</li> <li>Camillo, F. X. Chapter 36: Arthrodesis of the Spine. In: Canale, S. T. and J. H. Beaty. <i>Campbell's Operative Orthopaedics 2</i>. (11th Ed.). Philadelphia: Mosby. 2007. pp. 1851–1874. <a href="/facts/ISBN_(identifier)/15AdSPa9">ISBN</a> 978-0-323-03329-9.</li> <li>Williams, K. D. and A. L. Park. Chapter 39: Lower Back Pain and Disorders of Intervertebral Discs. In: Canale, S. T. and J. H. Beaty. <i>Campbell's Operative Orthopaedics 2</i>. (11th Ed.). Philadelphia: Mosby. 2007. pp. 2159–2224. <a href="/facts/ISBN_(identifier)/15AdSPa9">ISBN</a> 978-0-323-03329-9.</li> <li>Weyreuther, M., et al., Eds. Chapter 7: The Postoperative Spine. <i>MRI Atlas: Orthopedics and Neurosurgery – The Spine</i>. trans. B. Herwig. Berlin: Springer-Verlag. 2006. pp. 273–288. <a href="/facts/ISBN_(identifier)/15AdSPa9">ISBN</a> 978-3-540-33533-7.</li> <li>Tehranzadehlow J.; et al. (2005). "Advances in spinal fusion". <i>Seminars in Ultrasound, CT and MRI</i>. 26 (2): 103–113. <a href="/facts/Doi_(identifier)/muM9Etpq">doi</a>:<a href="https://doi.org/10.1053%2Fj.sult.2005.02.007">10.1053/j.sult.2005.02.007</a>. <a href="/facts/PMID_(identifier)/JlHAvMHt">PMID</a> <a href="https://pubmed.ncbi.nlm.nih.gov/15856812">15856812</a>.</li> <li>Resnick, D. K., et al. <i>Surgical Management of Low Back Pain</i> (2nd Ed.). Rolling Meadows, Illinois: American Association of Neurosurgeons. 2008. <a href="/facts/ISBN_(identifier)/15AdSPa9">ISBN</a> 978-1-60406-035-5.</li> <li><a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4652919">Oblique Lateral Lumbar Interbody Fusion (OLLIF): Technical Notes and Early Results of a Single Surgeon Comparative Study.</a> NIH.</li></ul> <h2 id="external-links">External links</h2> <ul><li>Wheeless, C. R., et al., Eds. <a href="http://www.wheelessonline.com/ortho/fusion_of_the_spine">Fusion of the Spine.</a> <i>Wheeless' Textbook of Orthopaedics</i>. Division of Orthopedic Surgery. Duke University Medical Center.</li> <li><a href="http://orthoinfo.aaos.org/topic.cfm?topic=A00348">Spinal Fusion.</a> American Academy of Orthopaedic Surgeons. June 2010. Accessed 1 June 2013.</li> <li>Spinasanta, S. <a href="http://www.spineuniverse.com/treatments/surgery/what-spinal-instrumentation-spinal-fusion">What is Spinal Instrumentation and Spinal Fusion?</a> SpineUniverse. September 2012. Accessed 1 June 2013.</li> <li><a href="http://www.surgeryencyclopedia.com/Pa-St/Spinal-Fusion.html">Spinal fusion.</a> Encyclopedia of Surgery. Accessed 1 June 2013.</li></ul> <h2 id="references">References</h2> <ol> <li id="fn:1"><p>Meyer, Bernhard; Rauschmann, Michael (4 March 2019). Spine Surgery: A Case-Based Approach. Springer. ISBN 9783319988757. <a href="9783319988757" target="_blank">9783319988757</a> <a href="#fnref:1" class="footnote-back-ref">↩</a></p></li> <li id="fn:2"><p>Chou, Roger (March 11, 2016). "Subacute and Chronic Low Back Pain: Surgical Treatment". 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