Spinal fusion complication: Post-surgical pelvic pain in women and the post-surgical treatment options

Ross Hauser, MD., Danielle R. Steilen-Matias, MMS, PA-C.

Our website contains many articles on the problems of undiagnosed damaged or injured spinal and pelvic ligaments causing lower back and sacroiliac pain. In this article, we will discuss the problems of women who underwent spinal fusion and came home with pelvic pain.

Before we start, let us stress again that many people have great success with spinal fusion. These are not the patients we see at our center. We see the patients who did not have great success or did have moderate success but they wanted to know if there was anything else that can help with a now new pelvic pain or instability.

Let’s also point out that there are many types of spinal fusion. This article deals with spinal fusion that does not involve the fusion of the pelvis or more commonly lumbar spinopelvic fusion. or a fusion that extends into the SI joint. This article is about the simple one or two-segment fusion between L3/L4 and/or L4/L5 that once completed reveals a new pelvic pain.

Here is an example of something we hear:

I had a two-segment spinal fusion. I have the whole cage effect. Rods, screws, and donated cadaver bone “mulch.” I had to have the surgery, nothing I tried up to that point, physical therapy, yoga, chiropractic, and ultimately cortisone and epidurals were helping me. To be honest, I did not have much expectation that the surgery would help me. But I did get some relief. But now that the focus is off my back pain, a deep pelvic pain, which was evidently always there and mistaken for low back pain radiating into my groin became more apparent. This pain is much more pronounced when I try to do simple things like reach low for something or cross my legs which I never do anymore. Shaving my legs is now something I have to “outsource.”

L4-L5 facet osteoarthritis, I have pain all over my pelvis, groin, and hips

The center of my lower back problems was at L4-L5. I have some creeping into the S1. I had an MRI which revealed facet arthropathy. It is limited to my right side. I have degenerative disc disease extending from L4 to S1. The main concern was spondylolisthesis at L4-L5. I was told to have the simple fusion at L4-L5 and that would resolve any possible facet stenosis. The disc would be removed, bone chips would be put in its place and eventually, the bone ends of L4 and L5 would be fused together and everything would be back in its place.

I was also told to prepare for weeks of recovery where I would not be able to do even the simplest of things and it may take up to a year for “full recovery.” Despite being assured that my back surgery was very successful, and I suppose it was, the L4-L5 fused nicely, I have developed a pain in my hips, sacrum, and pelvis, that sometimes radiates down my legs. Now there is an understanding that I have Piriformis Syndrome impinging on my sciatic nerve.

First, the surgical success stories – “Surgeons and patients should discuss potential changes and limitations in the activities of daily living after long spinal fusion including the pelvis.”

A May 2019 study published in the Journal of Orthopaedic Science (1) discussed the realistic assessment of what would be considered a successful lumbar fusion and its impact on the quality of life including pelvic pain relief or pain and function made worse.

In this study, there were 40 patients assessed. Thirty-nine of the patients were women. One patient was male. Their ages ranged from 52-79 years. After the spinal fusion, the patients were asked to evaluate their pain, function, and disability for a period of two years post-op.

For the most part, the patients were satisfied with the surgical results except for the fact that two years later:

  • 65% of patients had difficulty ‘putting on socks or stockings’,
  • 42% had great difficulty ‘bending forward, kneeling, or stooping’,
  • 32% reported improvement in ‘sit to stand’

Conclusions: “Despite restricting lumbar function, spinopelvic fusion improves health-related quality of life. Surgeons and patients should discuss potential changes and limitations in the activities of daily living after long spinal fusion including the pelvis.”

In other words, this surgery can help with some things but you need to be realistic with what happens after the surgery. You will be limited.

How does a woman go in for spinal fusion surgery and come home with pelvic pain?

One answer is that the pelvic pain was there all along, it was mistaken for low back pain because an MRI gave evidence of degenerative disc disease and Sacroiliac joint dysfunction. The fact that the patients came home with pain is an indication that the surgery did not treat what was causing the pain.

The role of spinal fusion in complicating movement for patients with existing hip problems

A February 2021 paper from the Journal of Orthopaedic Case Reports (2) examined the role of spinal fusion in complicating movement for patients with existing hip problems. The researchers noted that in patients with “markedly decreased hip function, patients predominantly utilize spine movement while standing up to compensate for the hip malfunction. However, spinal fusion surgeries might lead to the disruption of this compensatory mechanism, resulting in difficulties in walking and standing up as well as proximal junctional failure (an abnormal bend in the spinal structure) due to the excessive stress on the spine caused by the pendulum-like motion needed for standing up.”

The suggestion these researchers made was that surgeons be aware and cautious about recommending or performing spinal fusion, which inevitably affects spinal mobility in patients with significant enough hip problems.

The doctors then presented a case of a 76-year-old Japanese woman who underwent corrective spinal fusion surgery for spinal scoliosis secondary to hip contracture. The doctors reported that this woman demonstrated post-operative complications, such as unexpected difficulty in walking and standing up and proximal junctional failure (an abnormal bend in the spinal structure).

To correct this problem, her surgeons recommended another surgery where the spinal fusion was expanded to now incorporate proximal junctional failure and muscle release around the hip for hip contracture which resulted in improved walking and standing movements with no reports of pain.

So how did it get to this point? The researchers suggested: “Patients with such risks (for surgical failure and revision surgery) often do not complain of hip symptoms before spinal correction surgery. Surgeons should routinely evaluate hip joints and be cautious about the indication for spinal fusion which inevitably affects spinal mobility.”

The investigation into finding the true source of the woman’s lower back pain – Spinal instability and pelvic instability can look exactly the same.

Spinal instability and pelvic instability are the main causes of most low back and pelvic pain. Various researchers have documented the common symptoms of clinical spinal instability and pelvic instability as:

  • including a sensation of the back ‘giving out’,
  • lower back movements are restricted by catching or locking,
  • standing or sitting in a sustained posture causes pain and spasms
  • and pain that comes and goes in varying degrees of intensity.

Back surgery for pelvic pain is wrong

Dr. Bo Nystrom is a doctor whose research we often cite. In July 2017, he led a study published in the Scandinavian Journal of Pain on the clinical outcome following anterior arthrodesis (spinal fusion) in patients with presumed sacroiliac joint pain. (3) In this study, the problems of continued or worsening pelvic pain in women treated with spinal fusion are what caught our attention.

Here are the findings of that research in 55 women.

  • Over a 6 year period, the researchers treated 55 patients, all women, with an average age of 45, the youngest being 28 and the oldest 65.
  • They suffered pelvic pain for an average of about 9 years, the shortest being 2 years and the longest being 30 years of pelvic pain.
  • The pain started in connection with:
    • minor trauma in seven patients,
    • pregnancy in 20 and
    • unspecified in 28.
  • All patients had undergone long periods of treatment including physiotherapy, manipulation, needling, pelvic belt, massage, and chiropractic without success, and 15 had been operated on for various spinal diagnoses without improvement. (So this was their second surgical attempt to correct their lower back pain.)
  • The patients underwent thorough neurological investigation, plain X-ray and MRI of the spine, and plain X-ray of the pelvis. They were investigated by seven clinical tests aimed at clearly isolating indicating pain was originating from the sacroiliac joints.

At follow-up:

  • 26 patients reported a lower level of pelvic pain than before surgery,
  • 16 had the same level of pelvic pain before the surgery
  • and six had a higher level of pain.
  • Again, 26 had less pelvic pain, 16 had the same pelvic pain, and 6 had worse pelvic pain

A successful spinal fusion causing more pain? Where did all this pain come from? Spinal and Pelvic Ligaments

Here is the researchers’ concluding statement: “We speculate that continued pain despite a healed arthrodesis (fusion) may be due to persistent pain from adjacent ligaments. The next step should be a prospective randomized study comparing posterior fusion and ligament resection with non-surgical treatment.”

As a Prolotherapist, what more can you say? Here we had a successful spinal fusion causing more pain. Why?  Persistent pain from adjacent ligaments, we have seen it here, adjacent segment disease stressing the spinal ligaments and the surgery itself causing damage to the ligaments leading to post-spinal instability, in the research above these problems translated to pelvic pain in 45% or so women who had a spinal fusion.

Causes of Chronic Post-Surgical Spinal Pain and why another surgery is being recommended

In this video, Ross Hauser, MD describes the 5 main reasons that back surgery failed to help the patient’s condition.

  1. The surgery did not address the actual cause of the patient’s pain. The diagnosis is wrong.  In this case, our article focuses on Pelvic Pain as being the primary pain generator. Spinal fusion was performed on the wrong problem.
  2. The surgery made the lower back MORE unstable. Foraminotomy, Laminectomy, Microdiscectomy, and disc surgery, all have to remove parts of the bone in the spine.
  3. The “missed secondary problem.” In the context of this article, this would be Pelvic instability.
  4. Too much sitting after surgery, possibly too much bed rest.
  5. More rare, scar tissue pinches on the nerves.

Summary and contact us. Can we help you?

We hope you found this article informative and that it helped answer many of the questions you may have surrounding your back and pelvic problems.  If you would like to get more information specific to your challenges please email us: Get help and information from our Caring Medical staff

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References:

1 Katayanagi J, Iida T, Hayamizu A, Matsumoto K, Ohyama Y, Mine K, Ozeki S. Effect of long spinal fusion including the pelvis on activities of daily living related to lumbar spinal function in adults with spinal deformity. Journal of Orthopaedic Science. 2019 May 1;24(3):409-14. [Google Scholar]
2 Yoshikawa Y, Toura M, Kudo Y, Okano I, Nishi M, Toyone T, Inagaki K. Unexpected complications after corrective spinal fusion surgery for adult spinal deformity with severe hip contracture. Journal of Orthopaedic Case Reports. 2021 Feb;11(2):37. [Google Scholar]
3 Nyström B, Gregebo B, Taube A, Almgren SO, Schillberg B, Zhu Y. Clinical outcome following anterior arthrodesis in patients with presumed sacroiliac joint pain. Scandinavian Journal of Pain. 2017 Oct 1;17:22-9. [Google Scholar]

This page was last updated November 29, 2023

 

 

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