Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Job Classification

In most duration tables, five job classifications are displayed. These job classifications are based on the amount of physical effort required to perform the work. The classifications correspond to the Strength Factor classifications described in the United States Department of Labor's Dictionary of Occupational Titles. The following definitions are quoted directly from that publication.

Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Spinal Fusion


Related Terms

  • Anterior Spinal Fusion
  • Arthrodesis
  • Harrington Rod Insertion
  • Luque Rod Insertion
  • Posterior Spinal Fusion
  • Spinal Arthrodesis
  • Spine Arthrodesis
  • Spondylosyndesis
  • Vertebral Fusion

Specialists

  • Neurosurgeon
  • Occupational Therapist
  • Orthopedic (Orthopaedic) Surgeon
  • Physical Therapist

Comorbid Conditions

Factors Influencing Duration

The region of the spine involved, the surgical technique used, the underlying disease or condition for which the fusion was performed, the presence of complications, and an individual's job requirements may influence the length of disability. The individual's preoperative level of physical fitness and response to surgical treatment also influences the length of disability.

Cigarette smoking decreases the chances of successful spinal fusion as does the use of nonsteroidal anti-inflammatory drugs (NSAIDs) in the early postoperative period.

Medical Codes

ICD-9-CM:
81.0 - Spinal Fusion
81.00 - Spinal Fusion, Not Otherwise Specified
81.01 - Atlas-axis Spinal Fusion; Craniocervical Fusion by Anterior, Transoral, or Posterior Technique; C1-C2 Fusion by Anterior, Transoral, or Posterior Technique; Occiput C2 Fusion by Anterior, Transoral, or Posterior Technique
81.02 - Other Cervical Fusion of the Anterior Column, Anterior Technique; Arthrodesis of C2 Level or Below: Anterior Interbody Fusion
81.03 - Other Cervical Fusion of the Posterior Column, Posterior Technique; Arthrodesis of C2 Level or Below, Posterolateral Technique
81.04 - Dorsal and Dorsolumbar Fusion of the Anterior Column, Anterior Technique; Arthrodesis of Thoracic or Thoracolumbar Region: Anterior Interbody Fusion; Extracavitary Technique
81.05 - Dorsal and Dorsolumbar Fusion of the Posterior Column, Posterior Technique; Arthrodesis of Thoracic or Thoracolumbar Region, Posterolateral Technique
81.06 - Lumbar and Lumbosacral Fusion of The Anterior Column, Anterior Technique; Anterior Lumbar Interbody Fusion (ALIF); Arthrodesis of Lumbar or Lumbosacral Region: Anterior Interbody Fusion; Anterolateral Technique; Retroperitoneal; Transperitoneal; Direct Lateral Interbody Fusion [DLIF]; Extreme Lateral Interbody Fusion [XLIF]
81.07 - Lumbar and Lumbosacral Fusion of the Posterior Column, Posterior Technique; Facet Fusion; Posterolateral Technique; Transverse Process Technique; Facet Fusion; Posterolateral Technique; Transverse Process Technique
81.08 - Lumbar and Lumbosacral Fusion of The Anterior Column, Posterior Technique; Arthrodesis of Lumbar or Lumbosacral Region, Posterior Interbody Fusion; Axial Lumbar Interbody Fusion [Axialif] ; Posterior Lumbar Interbody Fusion (PLIF); Transforaminal Lumbar Interbody Fusion (TLIF)

Overview

Spinal fusion is the surgical immobilization of two or more adjacent bones of the spinal column (vertebra). Multiple bones are fused or made to grow together to become one solid bone. Spinal fusion is often associated with removal of a part or all of the intervertebral discs (discectomy) and/or removal of the lamina (laminectomy), a portion of vertebral bone. (See Spinal Stenosis for an overview of conditions.)

Source: Medical Disability Advisor



Reason for Procedure

When excess or abnormal motion of the vertebrae (spinal instability) causes neurologic deficit such as numbness or paralysis or the individual is experiencing pain or other symptoms from certain spinal disorders, fusion of the vertebrae may be indicated. The purpose is to increase spinal stability, reduce irritation of the affected nerve roots, or reduce compression on the spinal cord. Spinal fusion is also used to correct deformity. Some other conditions of the spine, including degenerative disc disease, are often treated with fusion.

Spinal fusion is an option in the treatment of vertebral inflammation (spondylitis); fracture of the pars interarticularis, or the arch of the posterior segment of the vertebra (spondylolysis); vertebral displacement (spondylolisthesis or dislocation); spinal fractures; scoliosis; stenosis; or combinations of these conditions. When discs between the vertebrae either slip out of place (herniation) or collapse due to degeneration, the vertebrae in that part of the spine are not supported, increasing motion of the spine and causing instability. Nearly all spinal fusion procedures are done to treat degenerative disease of the spine (Pakzaban).

Spinal fusion has been used increasingly to treat low back pain without associated leg pain (sciatica or radiculopathy). Radiographic findings of degenerative disc disease are commonly identified on imaging studies in this condition. However, the use of spinal fusion to treat "discogenic pain without proven radiculopathy" is controversial.

Spinal fusion is not generally performed in individuals who have metastatic or terminal cancer, severe osteoporosis, or infection of soft tissue adjacent to the spine, whether or not it has spread to the spine. Severe cardiopulmonary disease, anemia, malnutrition, or systemic infection may also rule out performing spinal fusion procedures.

Source: Medical Disability Advisor



How Procedure is Performed

Spinal fusion can be performed from an anterior approach, a posterior approach, or both. Regardless of the approach, bone graft and instrumentation are generally used to supplement the fusion and provide support while the fusion heals.

The anterior approach to the lumbar spine is through the abdomen and may be through the abdominal cavity or retroperitoneal (behind the cavity), to gain access to the spine. The anterior approach through the front of the neck is the most common approach for cervical spine fusion to treat disc disease and many other conditions of the cervical spine.

The posterior approach gains access to the spine through the muscles in the back. Posterior fusions are a common procedure in the lumbar spine and are often accompanied by the use of instrumentation (see below in this section). Anterior and posterior fusions may be used in combination. This combination is used most often for degenerative disease, especially when three or more vertebrae will be fused. Posterior cervical fusions, which are used less frequently than anterior fusions, are performed for anterior fusion failure (nonunion, pseudarthrosis) and as an alternate approach for stabilization of the cervical spine after decompression. Posterior cervical approaches more commonly result in postoperative neck pain.

For all types of spinal fusion, the segment of the spine is ultimately immobilized with a bone graft, which serves as a scaffold for new bone growth to create a bony union (ankylosis) between two or more adjacent vertebrae. For fusion to succeed, bone cells (osteoprogenitor cells) must differentiate into mature cells that reproduce and grow throughout the fusion matrix until new bone forms, fusing the vertebrae together.

Bone grafts are most commonly obtained from the pelvis or the portions of the spine that have been removed (spinous process and lamina) at the time of the operation (autograft); however, structural grafts may be obtained from a donor or bone bank (allograft). New products that augment bone graft and enhance the rate of fusion are frequently added to the fusion site.

Instrumentation, including plates and screws, rods and screws or hooks, cables, and cages, is also used. It rigidly holds the segments while the bone graft establishes a solid union to the vertebrae. The devices may become encased within the fusion mass. In some cervical spine fusions, temporary stability or immobilization is achieved by using a metal halo, which is affixed to the skull by metal pins. This halo is then attached by rods to a well-fitting plaster or plastic body jacket. If metal implants are used, external support is not always needed.

After surgery, pain is aggressively controlled with opioid medications for 12 to 36 hours, followed by oral analgesics. Muscle relaxants may also be used. Early mobilization of the patient helps prevent complications and facilitates rehabilitation.

The individual’s general health status is important to the success of fusion surgery and will be evaluated thoroughly prior to surgery. The presence of chronic disease such as diabetes or osteoporosis or the presence of local infection may contribute to poor results. Immobilization of the fused section of spine has been shown to increase the chances of successful fusion. Autografts have also shown greater capacity to reproduce bone cells than allografts, enhancing the result of spinal fusion.

Source: Medical Disability Advisor



Prognosis

Spinal fusion has variable outcomes, with some individuals experiencing a good to excellent outcome and others experiencing a poor outcome. Cervical spine fusions have a high success rate, both in terms of patient outcome and in terms of radiographic fusion status. Even with successful lumbar fusion, back symptoms are not relieved (clinical failure) in many cases. Nonunion may occur, although new technology has contributed to its decreased frequency. Serious complications can have lifelong, debilitating effects.

Source: Medical Disability Advisor



Rehabilitation

Rehabilitation for individuals who undergo spinal fusion will depend on the level of the spinal involvement, the number of segments fused, the type of instrumentation used, the individual's bone quality (normal or osteoporotic), and the preoperative status of the individual. Throughout rehabilitation, special attention must be paid to protect the integrity of the fusion until imaging establishes that solid fusion has in fact occurred. All rehabilitation must progress based on the recommendations of the surgeon.

The immediate focus after surgery is to promote independent transfers and ambulation in order to allow the individual to reach independence in activities of daily living. Assistive devices may be used, with a rolling walker on level surfaces often recommended. Proper transfer techniques must be taught, emphasizing log rolling for all bed transfers. Occupational therapy may be useful for training in activities of daily living and providing assistive devices that may be useful during recovery (Christensen).

At approximately 4 to 6 weeks postoperatively, or when recommended by the surgeon, isometric training of the trunk muscles can be initiated. General conditioning exercises of the upper and lower extremities, and aerobic training are initiated and progressed as indicated. Activities that promote trunk flexion should be avoided until approved by the surgeon. A short course of cognitive pain management as a part of a multidisciplinary intervention may be beneficial for individuals who underwent this type of surgery (Mayer).

Once trunk flexion is advised, then general trunk flexibility, strengthening, and endurance exercises can be taught and progressed as tolerated.

An ergonomic assessment may be beneficial to modify the workplace as needed and ensure the work status of the individual.

Controversy exists in the literature regarding the benefits of conservative management versus a surgical approach (Brox).

FREQUENCY OF REHABILITATION VISITS
Surgical
SpecialistSpinal Fusion
Physical TherapistUp to 12 visits within 6 weeks
Note on Surgical Guidelines: Rehab usually begins after soft tissue healing, about 6 to 8 weeks after surgery.
The table above represents a range of the usual acceptable number of visits for uncomplicated cases. It provides a framework based on the duration of tissue healing time and standard clinical practice.

Source: Medical Disability Advisor



Complications

Complications of spinal fusion vary with the surgical approach and the region of the spine. Complications associated with the anterior approach include post-thoracotomy pain syndrome associated with the surgical approach, swallowing difficulties related to cervical spine surgery, laceration of the aorta, laceration of the tube that conveys urine from the kidney to the bladder (ureter), backward (retrograde) ejaculation, and abdominal hernias associated with anterior lumbar surgery. Complications associated with a posterior approach include injury to the vertebral artery and nerves in the cervical spine, severe spinal muscle pain, high blood loss, and nerve injury in the lumbar spine. Complications associated with retrieval of the bone autograft include chronic pain at the donor site, deep or superficial infection, pelvic fracture (when the bone graft is obtained from the pelvis), vascular injury, collection of blood (hematoma) within tissues, nerve damage, and increased blood loss. All spinal fusion procedures carry the additional complications of laceration of the outermost membrane of the spinal cord (dura mater), spinal cord or nerve root injury (including paraplegia and quadriplegia), injuries caused by the instrumentation, loosening and failure of the instrumentation, infection, extrusion of the bone graft, fusion failure (pseudarthrosis), and instability.

Source: Medical Disability Advisor



Ability to Work (Return to Work Considerations)

To reduce the risk of complications, the individual may not be allowed to work during the early recovery period after a fusion or repair of a fusion. Prolonged sitting, standing, heavy lifting, bending, doing overhead (spine extension) work, and climbing long flights of stairs may be temporarily restricted. Use of a soft or rigid cervical collar, upper body traction, or halo traction devices may be required for several weeks after a cervical fusion. These traction devices may severely limit dexterity and mobility. Adjusting worktable height and chair height and using footrests are all beneficial for individuals with back problems, including failed fusion of the lumbar spine. The individual may require frequent breaks. Temporarily working reduced hours may be necessary. Permanent restrictions may include heavy lifting, carrying moderate to heavy loads, and overhead work.

Source: Medical Disability Advisor



References

Cited

Brox, Ivar J., et al. "Randomized Clinical Trial of Lumbar Instrumented Fusion and Cognitive Intervention and Exercises in Patients with Chronic Low Back Pain and Disc Degeneration." Spine 28 17 (2003): 1913-1921. National Center for Biotechnology Information. National Library of Medicine. 3 Mar. 2009 <PMID: 12973134>.

Christensen, F. B., et al. "Importance of the Back-café Concept to Rehabilitation after Lumbar Spinal Fusion: A Randomized Clinical Study with a 2-year Follow-up." Spine 28 23 (2003): 2561-2569. National Center for Biotechnology Information. National Library of Medicine. 3 Mar. 2009 <PMID: 14652472>.

Mayer, T. G., et al. "Impact of Functional Restoration after Anterior Cervical Fusion on Chronic Disability in Work-Related Neck Pain." European Spine Journal 2 4 (2002): 267-273. National Center for Biotechnology Information. National Library of Medicine. 3 Mar. 2009 <PMID: 14589478>.

Pakzaban, Peyman. "Spinal Instability and Spinal Fusion Surgery." eMedicine. Eds. Paul L. Penar, et al. 20 Mar. 2008. Medscape. 3 Mar. 2009 <www.emedicine.com/med/topic1343720.htm>.

Source: Medical Disability Advisor






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