Adjacent Segment Disease After Fusion: Is It Inevitable?

Have you ever heard this said about spinal fusion surgery: “Once you have one fusion, you’ll inevitably need another. Adjacent segment disease will happen”? As someone four years post-fusion who just had an MRI, I want to challenge this fatalistic view with data, experience, and hope.

A few weeks ago, I had my first back spasm in four years. For any fusion patient, this triggers an immediate, visceral fear: is this it? Is this adjacent segment disease finally catching up with me?

The Numbers Every Fusion Patient Should Know

Let’s start with facts. Adjacent segment disease (ASD)—or as I prefer to call it, adjacent segment deterioration—affects anywhere from 5% to 20% of lumbar fusion patients. That’s a frustratingly wide range, but if we average it out, roughly 10-15% of patients develop symptomatic ASD¹⁾.

This means 85-90% don’t.

Yet somehow, we’ve created a narrative where ASD is inevitable, where every fusion patient is simply waiting for the other shoe to drop. This isn’t just wrong—it’s harmful. The anxiety itself can affect how patients move, exercise, and live their lives post-fusion.

My Fusion Story: Setting the Stage

In 2020, I underwent an L5-S1 fusion for grade 2 isthmic spondylolisthesis. In plain terms, I had fractures at the back of my spine, and the L5 vertebral bone had slipped forward over the S1 bone. I was losing function in my left leg. Surgery wasn’t optional—it was necessary.

My surgeon and I had extensive discussions about ASD before the procedure. My biggest fear was that fixing L5-S1 would simply transfer stress to L4-L5, starting a cascade of failures up my spine. He explained something crucial: the surgery technique and the restoration of proper alignment matter enormously.

We chose an ALIF (anterior lumbar interbody fusion) approach specifically because it allows for excellent lordotic restoration—basically, rebuilding the natural curve of that segment. He didn’t just fuse me; he fully reduced my slippage, restored my alignment, and gave my spine the best possible outcome for long-term health.

The surgery itself became complex—multiple procedures over 12 months to get everything perfect. My surgeon’s commitment to precision wasn’t just admirable; it might be why I’m writing this story today instead of scheduling my next fusion.

Four Years Later: The Spasm That Sparked Fear

Last month, out of nowhere, my back went into spasm. The quadratus lumborum muscle on my side locked up completely. For the first time in four years, I was in significant pain.

The rational part of my brain—the part with decades of spine rehabilitation experience—knew this was muscular. I could account for the accumulation of stresses that week that likely triggered it. There were no red flags: no leg symptoms, no numbness, no loss of function. The pain was localized to the muscle, not radiating along nerve pathways.

But the fusion patient part of my brain? That part was convinced that my L4-L5 level had finally failed.

The Phone Call

I called my surgeon. His response was remarkably confident: “Joel, I’m happy to send you for a scan, but you know what you’re going to see—absolutely nothing.”

He was right, of course. But I needed to see it. As someone who treats fusion patients daily, I needed to know if my “spine hygiene” approach—my careful attention to movement, posture, and load management—had actually protected my adjacent segments.

Inside the MRI Scanner

Lying in that MRI machine, I had an unusual thought: I was excited. If my L4-L5 segment was healthy after four years, I would be living proof that adjacent segment disease isn’t inevitable. That good surgery plus good post-operative care equals good outcomes.

Thirty minutes later, I was walking up to my surgeon’s office. He opened the door with a massive grin. “What are you doing here?” he asked. “Your spine is in pristine condition.”

What “Pristine” Means

We sat down and went through every image. The L4-L5 segment—the one directly above my fusion, the one supposedly doomed to fail—looked perfect. Not just “okay for a fusion patient.” Perfect. No degeneration. No disc bulging. No stenosis. No evidence whatsoever of adjacent segment deterioration.

My latest MRI demonstrating no ASD in the levels above the fusion

Four years post-fusion, my spinal segment above the fusion actually looked better than I could’ve hoped for.

Why This Matters: The Three Pillars of Prevention

My case illustrates three critical factors that influence whether you’ll develop ASD:

1. Surgical Technique and Alignment Restoration

Not all fusions are created equal. My surgeon’s meticulous attention to restoring my natural lordosis and fully reducing my slippage wasn’t just about fixing the immediate problem. It was about ensuring optimal load distribution across my entire spine for years to come.

If a surgeon tells you alignment doesn’t matter, that they “just need to fuse you,” seek a second opinion. Anatomy matters. Alignment matters. The angle of that fused segment affects every level above and below it²⁾.

2. Spine Hygiene: Living Consciously Post-Fusion

For four years, I’ve practiced what I call “spine hygiene.” This isn’t about being paranoid or overly restricted. It’s about awareness:

• Standing every 10-15 minutes during prolonged sitting
• Using optimal mechanics (for my spine) when lifting (letting hips and knees share the load)
• Being mindful of spinal position before applying any load
• Maintaining strong supporting musculature
• Respecting my spine’s new reality without fearing it

This isn’t living in a bubble—I exercise, I work, I live fully. But I do so with awareness of what my spine needs to stay healthy.

3. Realistic Expectations and Genetic Reality

Here’s an uncomfortable truth: genetics play a role we can’t control. Some people’s discs are simply more prone to degeneration. But we can control surgical technique and post-operative behavior, and these factors appear to matter more than we’ve been led to believe.

Another truth: you might not be able to return to everything you did pre-fusion. That’s not defeatism; it’s wisdom. If the longevity of your spine is the priority, some activities might need to go. I’d rather skip certain movements than need another fusion in five years.

The Degeneration Myth

Here’s something interesting from my MRI: while some people show degeneration throughout their spine as they age, others show it only at specific levels. You might see terrible degeneration at L4-L5 and L5-S1, but pristine discs at L1-L2 and L2-L3.

Why? Because degeneration isn’t just “aging.” It’s load and stress concentrated at particular segments. If you don’t overload a segment, it doesn’t have to degenerate. This is evident in my scan—despite being four years older, my segment above the fusion looks excellent because it hasn’t been subjected to excessive stress.

Challenging the Narrative

We need to stop telling fusion patients they’re doomed to progressive failures. Yes, adjacent segment disease exists. Yes, some patients will need additional surgeries. But it’s not inevitable, and the fear of it might actually cause more problems than ASD itself.

When patients believe ASD is unavoidable, they either:

• Become so fearful they stop moving, leading to weakness and actual problems
• Adopt a fatalistic “nothing matters” approach and ignore proper spine care
• Live in constant anxiety, which affects their quality of life

None of these responses are helpful or necessary.

The First Three Months: Critical but Misunderstood

One of the biggest mistakes I see is patients doing too much in the first three months post-fusion because they feel good. Feeling good doesn’t mean you’re healed. The fusion needs time to solidify, and those early months set the stage for long-term success or failure.

This is where platforms like Vertera Health become invaluable—guiding patients through those critical months with appropriate progression, not just generic timelines.

My Message to Fusion Patients

If you’re facing fusion surgery or living with a fusion, here’s what I want you to know:

• Adjacent segment disease is not inevitable. With good surgical technique and proper post-operative care, you can protect your adjacent segments for years, possibly decades.

• The quality of your fusion matters. Don’t just accept any fusion. Understand the approach, the alignment goals, and why your surgeon is choosing specific techniques.

• Your behavior post-fusion matters enormously. Spine hygiene isn’t about living in fear; it’s about living intelligently.

• One muscle spasm doesn’t mean failure. Sometimes a spasm is just a spasm, even in fusion patients.

• Regular monitoring without paranoia. I hadn’t had an MRI in years. This one was prompted by symptoms, not routine surveillance.

The Bottom Line

Four years post-fusion, my adjacent segments are pristine. Not “good for a fusion patient”—pristine. This isn’t luck. It’s the result of excellent surgery, careful rehabilitation, and conscious living.

For many of us, a fusion can be what it was meant to be: a solution, not the beginning of a cascade of problems.

We’re all outliving our spines these days. The question isn’t whether you’ll need a fusion—many of us will. The question is whether that fusion condemns you to progressive deterioration or gives you decades of good function.

The answer, I’m learning, is largely up to us.

For evidence-based guidance on preparing for and recovering from spine fusion surgery, visit Vertera Health or download the app for comprehensive, expert-guided protocols.

References

1. Park P, Garton HJ, Gala VC, Hoff JT, McGillicuddy JE. Adjacent segment disease after lumbar or lumbosacral fusion: review of the literature. Spine. 2004 Sep 1;29(17):1938-44. doi: 10.1097/01.brs.0000137069.88904.03. PMID: 15534420.

2. Barrey C, Darnis A. Current strategies for the restoration of adequate lordosis during lumbar fusion. World J Orthop. 2015 Jan 18;6(1):117-26. doi: 10.5312/wjo.v6.i1.117. PMID: 25621216; PMCID: PMC4303780.