Fusion for spinal stenosis: a personal view.

Decompression of the lumbar spine for spinal stenosis is a gratifying procedure, improving the quality of life for many otherwise fit elderly and middle-aged patients who are prematurely disabled. There is much debate as to whether or not fusion of the decompressed segments should be part of the surgical procedure. Failure to fuse may leave a patient with good legs but intractable back pain. Fusion is a much more debilitating procedure than decompression, carrying its own risk of complications in those patients who are likely to have all the conditions associated with advanced years. Vitaz et al 1 noted that 10% of patients over the age of 75 years who had surgery for spinal stenosis suffered one or more serious postoperative complications. There is little guidance from the literature. The conclusions of the few papers on the subject are evenly divided between the three obvious options: never fuse; always fuse; fuse sometimes. One is therefore left to develop a personal view on the subject, preferably based on experience, sometimes bitter, or to adopt the views of others. Intuitively, in a world of few absolutes, the most appropriate approach is likely to be one which recommends fusion sometimes. All that remains is to establish a set of indications which satisfies the demands of one's own practice. Advising against fusion, Silvers, Lewis and Asch 2