Pseudarthrosis (Nonunion): A Complete Guide to Causes, Symptoms, and Treatment

Pseudarthrosis, also known as nonunion, is a medical term for a bone fracture that fails to heal correctly. Instead of the broken pieces knitting back together into a solid bone, a fibrous, unstable connection forms, creating a "false joint" (from the Greek pseudo- meaning false, and arthrosis meaning joint). This condition can lead to persistent pain, instability, and a significant impact on quality of life, particularly when it occurs after spinal fusion surgery.

This comprehensive guide synthesizes information from leading medical journals, health institutions, and patient surveys to provide a complete overview of pseudarthrosis, from its underlying causes to the latest treatment options.

What is Pseudarthrosis?

Normally, after a bone breaks, the body initiates a complex healing process to bridge the gap and form new, solid bone. When this process is interrupted or fails, a nonunion or pseudarthrosis occurs. This condition is a significant complication following fractures and is particularly challenging when it happens after a spinal fusion—a surgical procedure intended to permanently connect two or more vertebrae to eliminate motion and relieve pain.

Bone healing is a highly orchestrated biological cascade that occurs in distinct, overlapping stages. It begins with hematoma formation and inflammation, where blood vessels constrict and platelets aggregate to create a temporary fibrin clot. This is rapidly followed by the soft callus phase, where fibrocartilage forms to temporarily stabilize the fracture. Over the next several weeks to months, osteoblasts replace this soft tissue with woven bone during the hard callus phase. Finally, bone remodeling reshapes the newly formed bone into its original cortical and trabecular architecture, a process that can take up to a year or longer. Pseudarthrosis develops when one or more of these stages are disrupted, halting the progression toward mature, weight-bearing bone.

Clinicians classify nonunions into three primary histological and radiographic categories to guide treatment decisions:

• Hypertrophic Nonunion: Characterized by abundant callus formation that fails to consolidate. This type indicates a robust blood supply and viable bone biology, but the failure stems primarily from inadequate mechanical stability.
• Atrophic Nonunion: Presents with minimal to no callus formation and tapered, sclerotic bone ends. This points to a profound biological failure, often due to compromised blood supply, severe trauma, or poor metabolic health.
• Oligotrophic or Synovial Pseudarthrosis: Occurs when the nonunion becomes chronic and develops a synovial-like lining with lubricating fluid. The bone ends appear rounded and avascular, essentially creating a fully functional but pathological false joint.

According to research published in the Journal of the American Academy of Orthopaedic Surgeons, pseudarthrosis is the result of a failed spinal fusion attempt and can manifest months or even years after the initial surgery [1]. While it can happen to any bone, it is most common in long bones like the tibia (shin bone) and in the spine. The overall incidence of spinal nonunion ranges from 5% to 15%, heavily influenced by surgical approach, patient health, and the number of levels fused.

!X-ray showing pseudarthrosis of the tibia

X-ray image demonstrating a clear nonunion (pseudarthrosis) in the tibia.
Source: Radiopaedia.org, rID: 15479

Symptoms: Recognizing the Signs of a Failed Fusion

While some individuals with pseudarthrosis may be asymptomatic, many experience noticeable symptoms. The most common sign is persistent pain at the fracture or surgery site long after it should have healed. Pain typically does not resolve within the expected 3-to-6-month window and may progressively worsen as normal daily activities resume.

Key symptoms include:

• Persistent or Worsening Pain: A deep, aching pain at the site that may be constant or flare up with activity. In spinal pseudarthrosis, this can be neck or back pain that mimics the original symptoms but often feels sharper or more localized over the hardware.
• Radiating Pain: Pain that travels from the spine into the shoulders, arms, or legs (radicular pain). This occurs if the unstable segment allows abnormal movement that irritates or compresses exiting nerve roots.
• Instability: A feeling that the bone or joint is not stable or secure. Patients may describe a sensation of the spine "shifting," "giving way," or a noticeable wobble when transitioning positions.
• Neurological Symptoms: Numbness, tingling, or weakness if the false joint is compressing nearby nerves. In severe cervical cases, myelopathy symptoms such as gait disturbances, loss of fine motor skills in the hands, or bowel/bladder dysfunction may emerge.
• Reduced Mobility: Difficulty moving the affected limb or area of the spine due to pain, mechanical blockage, or protective muscle spasms.
• Clicking or Grinding Sounds: A noticeable sound or sensation with movement. Known clinically as crepitus, this occurs when the unfused bone ends or loose hardware rub against each other.

Interestingly, a study noted that around 30% of people with radiographically confirmed pseudarthrosis report no symptoms at all [2]. These "radiographic nonunions" are often discovered incidentally during follow-up imaging. When symptoms are absent and hardware remains intact, some surgeons may adopt a watchful waiting approach, as the fibrous tissue can occasionally provide sufficient stability for low-demand activities. However, symptomatic cases invariably require intervention to prevent long-term joint degeneration, adjacent segment pathology, and chronic pain syndromes.

Uncovering the Causes and Risk Factors

The failure of a bone to heal is often a multifactorial problem, involving a combination of biological, mechanical, and lifestyle-related issues. Understanding these risk factors is crucial for both prevention and treatment. Modern orthopedic literature emphasizes the "diamond concept" of bone healing: a successful union requires osteogenic cells, osteoinductive signals, a stable mechanical environment, and an adequate blood supply. When any corner of this diamond is compromised, pseudarthrosis risk escalates dramatically.

Patient-Related and Lifestyle Factors

Certain personal health conditions and habits can significantly interfere with the body's healing capacity.

• Smoking: This is one of the most significant risk factors. Nicotine constricts blood vessels, reducing blood flow and the delivery of oxygen and nutrients essential for bone healing. It also inhibits the function of osteoblasts, the cells responsible for forming new bone [3]. Carbon monoxide in cigarette smoke further displaces oxygen in hemoglobin, creating a hypoxic environment that starves healing tissues. Vaping and nicotine replacement therapies are not necessarily safe alternatives, as nicotine itself remains a potent vasoconstrictor.
• Age: Older individuals may have slower healing processes and reduced bone quality. Age-related declines in growth hormone, insulin-like growth factor-1 (IGF-1), and stem cell activity diminish the regenerative potential of bone marrow.
• Medical Conditions: Diseases like diabetes, osteoporosis, severe anemia, and metabolic disorders can compromise bone health and repair [4]. Uncontrolled hyperglycemia impairs neutrophil function, increases inflammation, and causes microvascular disease, all of which delay osteogenesis. Rheumatoid arthritis and chronic kidney disease similarly disrupt mineral metabolism and bone turnover rates.
• Obesity: Excess weight places additional stress on healing bones, particularly in the spine, which can hinder fusion. Adipose tissue also secretes pro-inflammatory cytokines like TNF-alpha and IL-6, which can create a chronic low-grade inflammatory state detrimental to bone remodeling.
• Poor Nutrition: Deficiencies in crucial nutrients like calcium, vitamin D, and protein can prevent the body from building strong bone tissue. Protein malnutrition impairs collagen synthesis, while vitamin D deficiency disrupts calcium homeostasis and secondary hyperparathyroidism can lead to bone resorption. Zinc, vitamin C, magnesium, and phosphorus also play critical roles in matrix formation and mineralization.
• Medications: Long-term use of steroids and non-steroidal anti-inflammatory drugs (NSAIDs) can interfere with bone healing. Corticosteroids suppress inflammation (a necessary early healing signal), inhibit osteoblast differentiation, and accelerate osteocyte apoptosis. NSAIDs block cyclooxygenase-2 (COX-2), an enzyme crucial for prostaglandin-mediated bone formation during the early reparative phase. Chemotherapy agents, anticoagulants, and proton pump inhibitors may also impair healing.

Surgical and Mechanical Factors

The nature of the injury and the surgical procedure itself play a vital role.

• Inadequate Immobilization: If the fractured bone or fusion site is not held perfectly still, the constant micromotion can prevent bone cells from bridging the gap. The mechanical environment dictates healing: stable conditions promote direct bone formation, while excessive strain leads to fibrous tissue differentiation.
• Poor Blood Supply: Certain bones have a naturally limited blood supply (e.g., scaphoid, femoral neck, tibial midshaft). Severe trauma that damages surrounding blood vessels can also lead to nonunion. Open fractures with extensive soft tissue stripping carry a much higher risk due to devascularization.
• Infection: A bacterial infection at the surgical site can overwhelm the body's healing response. Pathogens like Staphylococcus aureus form biofilms on hardware, creating a chronic inflammatory state that degrades bone and prevents fusion.
• Surgical Technique: The success of a fusion can depend on the surgeon's technique, including proper preparation of the bone surfaces and secure placement of hardware (screws and rods). Inadequate decortication (removing the hard outer cortex to expose vascular cancellous bone), insufficient graft volume, or malpositioned screws can all lead to failure.
• Multi-level Fusions: Fusing multiple vertebrae at once increases the mechanical stress and biological demand, raising the risk of pseudarthrosis at one or more levels. Longer constructs create longer lever arms, increasing the bending moments and cyclic fatigue placed on the instrumentation.
• Bone Graft Choice and Preparation: The quality of the graft material, whether autologous or synthetic, and how it is packed into the fusion bed directly impacts osteoinduction. Poor graft handling, excessive drying, or contamination can render the graft biologically inert.

How Pseudarthrosis is Diagnosed

Diagnosing pseudarthrosis involves a combination of a thorough clinical evaluation and advanced imaging. A doctor will first discuss your symptoms and medical history, followed by a physical examination. The evaluation typically includes assessing spinal alignment, palpating for hardware prominence, testing range of motion, and conducting neurological exams to check reflexes, muscle strength, and sensory distribution.

The definitive diagnosis is typically made with imaging studies:

• X-rays: Standard X-rays, particularly flexion-extension views (where you bend forward and backward), can reveal a lack of bone bridging the fracture gap or show motion between vertebrae that were supposed to be fused. Radiologists measure translation greater than 3mm or angular motion exceeding 10 degrees as indicators of instability. Serial imaging over 12-18 months helps confirm whether bridging trabeculae are maturing or if a persistent radiolucent line remains.
• Computed Tomography (CT) Scans: CT scans provide a much more detailed, three-dimensional view of the bone. Thin-cut CT scans are considered the gold standard for assessing whether a solid fusion has formed and can identify even small gaps in the bone [1]. CT allows precise evaluation of graft incorporation, screw purchase, rod continuity, and the presence of bridging bone across the disc space or transverse processes.
• Magnetic Resonance Imaging (MRI): An MRI may be used to evaluate the surrounding soft tissues, such as nerves and discs, to rule out other causes of pain. While metal implants create artifact that can obscure views, newer metal-suppression techniques (SEMAC or MAVRIC) improve visualization of adjacent neural compression, epidural fibrosis, or adjacent segment degeneration.

Additional diagnostic modalities may be employed in complex cases. Single Photon Emission Computed Tomography (SPECT) combined with CT can assess metabolic activity; a "hot" scan may indicate active inflammation, infection, or attempted healing, while a "cold" scan suggests avascular atrophic nonunion. Blood tests including C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), and complete blood count (CBC) are routinely ordered to screen for occult infection, which can masquerade as aseptic pseudarthrosis. In select cases, aspiration of the nonunion site or intraoperative tissue culture is necessary to rule out low-virulence bacterial colonization.

Dr. Alpesh Patel discusses stable pseudarthrosis in athletes. Source: Cervical Spine Research Society on YouTube.

Congenital vs. Acquired Pseudarthrosis

It's important to distinguish between pseudarthrosis that develops after an injury or surgery (acquired) and a rare form that is present at birth (congenital). Understanding this distinction fundamentally alters the treatment paradigm and patient counseling.

Feature	Congenital Pseudarthrosis	Acquired Post-Surgical Nonunion
Onset	Present at birth or develops in early childhood.	Occurs after a fracture or surgery in a previously normal bone.
Common Location	Most often affects the tibia (shin bone).	Can occur in any bone, but common after spinal fusion.
Underlying Cause	A developmental abnormality where bone tissue is inherently dysplastic (abnormal). Often associated with neurofibromatosis type I (NF-I).	Failure of the normal healing process due to various risk factors (e.g., smoking, infection, instability).
Bone Quality	The affected bone segment is weak and has poor healing potential.	The bone is typically healthy before the fracture.
Treatment Focus	Complex reconstructive surgery to excise abnormal tissue and achieve a stable union.	Addressing the specific cause of nonunion and stimulating healing.
Prognosis	Challenging, with a high risk of refracture and persistent nonunion, sometimes requiring multiple surgeries.	Generally favorable with appropriate treatment, leading to high rates of successful union.

Congenital pseudarthrosis of the tibia (CPT) is particularly daunting due to its aggressive biological behavior. The affected bone exhibits hamartomatous fibroosseous tissue, severe periosteal thickening, and medullary canal obliteration. Standard fracture fixation often fails, necessitating advanced techniques like free vascularized fibular grafting, intramedullary rodding, or the Ilizarov circular external fixator. A 2025 study in the Journal of Orthopaedic Surgery and Research highlights the complexities of treating congenital pseudarthrosis of the tibia (CPT), noting that even necessary corrective osteotomies (bone cuts) are controversial due to healing concerns [5]. Gene therapy and targeted molecular interventions targeting NF-1 pathway dysregulation represent emerging frontiers in congenital nonunion management.

A Spectrum of Treatment Options

Treatment for pseudarthrosis is tailored to the individual, depending on the location of the nonunion, the severity of symptoms, and the patient's overall health. The overarching goal remains consistent: restore biological potential, establish absolute mechanical stability, and address any modifiable systemic risk factors.

Preoperative Optimization

Before proceeding with revision surgery, surgeons often recommend a 4-to-6-week optimization window. This includes strict smoking cessation verified by cotinine urine testing, aggressive nutritional supplementation (ensuring protein intake of 1.5g/kg/day, 2000-4000 IU vitamin D, and calcium), glycemic control targeting HbA1c <7.5%, and medication adjustments. Temporarily discontinuing NSAIDs and transitioning to acetaminophen or neuropathic pain agents can remove pharmacological barriers to osteogenesis.

Non-Surgical Management

For patients who are asymptomatic or poor surgical candidates, conservative treatment may be the first choice.

• Bone Stimulators: These external devices use low-level ultrasonic or pulsed electromagnetic waves to encourage bone growth at the nonunion site. Pulsed electromagnetic field (PEMF) therapy alters cell membrane ion channels, upregulating calcium uptake and increasing transforming growth factor-beta (TGF-β) production. Ultrasound devices deliver low-intensity pulsed ultrasound (LIPUS) for 20 minutes daily, creating micro-mechanical strains that stimulate osteoblast proliferation. Consistent compliance is critical; studies show significantly higher union rates with daily, uninterrupted use over 3-9 months.
• Bracing: A custom brace can be used to immobilize the area, reducing motion and pain while giving the bone another chance to heal. Spinal orthoses like TLSO (thoracolumbosacral orthosis) or rigid cervical collars limit flexion, extension, and rotation, offloading stress from the nonunion site. Bracing protocols typically span 8-12 weeks, accompanied by gradual weaning to prevent muscle atrophy.
• Physical Therapy: Strengthening the muscles around the affected area can improve stability and function. Targeted rehabilitation focuses on isometric strengthening, proprioceptive training, core stabilization, and postural correction. Aquatic therapy may be introduced early to promote movement in a low-gravity, hydrostatic environment.
• Lifestyle Modifications: Quitting smoking, optimizing nutrition, and managing underlying conditions like diabetes are essential steps. Weight management programs, stress reduction techniques, and sleep optimization also contribute to systemic recovery and hormonal balance conducive to bone healing.

Surgical Intervention

When conservative treatments fail or symptoms are severe, surgery is often necessary. The goal of surgery is to establish stability and stimulate a robust biological healing response. Revision procedures are inherently more complex due to scar tissue, distorted anatomy, and potential hardware complications.

• Revision Surgery with Bone Grafting: This is the most common approach. The surgeon removes any failed hardware, excises the fibrous tissue from the "false joint," and prepares the bone ends to create a fresh surface for healing. Decortication is meticulously performed to expose bleeding cancellous bone. A bone graft—either an autograft (bone taken from the patient's own body, often the iliac crest), allograft (processed donor bone), or synthetic substitutes (calcium phosphate, hydroxyapatite, or demineralized bone matrix)—is packed into the gap to provide a scaffold and cells that promote new bone formation. Autografts remain the gold standard due to their osteogenic, osteoinductive, and osteoconductive properties.
• Improved Fixation: New, more rigid hardware such as plates, screws, or rods are used to provide absolute stability. Surgeons often employ supplemental fixation strategies, such as adding anterior column support (cages or structural grafts) in conjunction with posterior pedicle screws, utilizing multi-axial screws for better trajectory alignment, or employing transforaminal lumbar interbody fusion (TLIF) or extreme lateral interbody fusion (XLIF) techniques to maximize graft surface area and load sharing.
• Biologics: In some cases, substances like Bone Morphogenetic Proteins (BMPs), specifically recombinant human BMP-2 or BMP-7, may be used to powerfully stimulate bone growth. BMPs act as potent osteoinductive signals, recruiting mesenchymal stem cells and directing their differentiation into osteoblasts. Other biologics include concentrated bone marrow aspirate (BMA) rich in mesenchymal stem cells and platelet-rich plasma (PRP), which deliver high concentrations of growth factors like PDGF and VEGF.
• Electrical Stimulation: Studies have found that electrical stimulation devices, sometimes implanted internally, can significantly increase fusion rates after spinal surgery [6]. Capacitive coupling, direct current (DC), and inductive stimulation methods have all demonstrated efficacy in recalcitrant nonunions by creating electric fields that mimic the body's endogenous piezoelectric signals generated during normal mechanical loading.
• Postoperative Rehabilitation: Recovery requires a carefully phased protocol. Patients typically avoid heavy lifting, twisting, and high-impact activities for 3-6 months. Serial imaging monitors graft incorporation, and physical therapy progressively introduces mobility, strength, and functional training once radiographic bridging is confirmed.

!Surgical fixation of a nonunion fracture

Surgical repair of a femoral nonunion using a plate and screws to provide stability.
Source: Wikimedia Commons, user Bone_and_joint

Prognosis and Life After Treatment

The outlook for patients with pseudarthrosis has improved with modern surgical techniques. With appropriate treatment, success rates for achieving a solid fusion can be as high as 80-90%. However, the journey can be challenging. Revision surgery is often more complex than the initial procedure, with longer operative times, increased blood loss, and higher complication rates including nerve injury, dural tears, and surgical site infections. Even after a successful fusion, some patients may experience persistent symptoms. Adjacent segment disease, where the levels above or below the fusion compensate for lost mobility and degenerate over time, remains a long-term consideration.

The long-term impact on quality of life can be significant, particularly concerning mental health. Chronic pain and disability can lead to depression and anxiety, which may not fully resolve even after the physical issue is corrected. Central sensitization can cause the nervous system to amplify pain signals even after structural stability is restored. Addressing these psychological components through cognitive behavioral therapy (CBT), mindfulness-based stress reduction, and, when necessary, pharmacological intervention, is an integral part of comprehensive care. Patient support groups and peer mentorship programs have also shown remarkable efficacy in improving adherence to rehabilitation protocols and overall coping strategies.

A comprehensive approach that addresses both the physical and psychological aspects of the condition is crucial for achieving the best possible long-term outcome. If you are experiencing persistent pain after a fracture or fusion surgery, it is essential to consult with an orthopedic surgeon or spine specialist for a thorough evaluation. Early recognition of pseudarthrosis, meticulous preoperative optimization, and a personalized, multidisciplinary treatment plan offer the highest likelihood of restoring function, alleviating pain, and returning to an active, fulfilling life.

Frequently Asked Questions

How long does it typically take for a bone to heal, and when should I suspect pseudarthrosis?

Normal bone healing generally progresses significantly within 3 to 6 months, with full remodeling continuing for up to 18 months depending on the bone and fracture severity. If pain, swelling, or functional limitation persists beyond the 6-month mark, or if serial X-rays show no progressive bone bridging over a 3-to-6-month interval, pseudarthrosis should be suspected. Your surgeon will typically wait until at least 6 to 9 months post-operation or post-injury before formally diagnosing a nonunion, unless clear hardware failure or gross instability is evident earlier.

Can pseudarthrosis heal on its own without surgery?

While the body retains some innate healing capacity, true established pseudarthrosis rarely resolves spontaneously once the fibrous tissue has matured into a synovial-like lining or the bone ends have become sclerotic. However, early delayed unions or asymptomatic fibrous unions with excellent mechanical stability may continue to consolidate with time, immobilization, and the use of bone stimulators. Smoking cessation, nutritional optimization, and offloading can sometimes tip the balance toward natural healing, but persistent symptomatic cases usually require surgical revision to disrupt the fibrous barrier and restore a conducive biological and mechanical environment.

What is the difference between a bone graft and bone morphogenetic proteins (BMPs)?

A bone graft acts primarily as a physical scaffold (osteoconductive matrix) that new bone cells can grow across, and it may provide living cells (osteogenic) and natural growth factors (osteoinductive) if autologous. In contrast, BMPs are highly concentrated, laboratory-synthesized signaling proteins that actively trigger the cellular machinery to form new bone. They are strictly osteoinductive. BMPs are often used as potent adjuncts to bone grafts in difficult nonunions, spinal fusions, or patients with compromised healing biology, but their use is carefully weighed against potential side effects like postoperative swelling, heterotopic ossification, and cost.

Does insurance typically cover revision surgery for pseudarthrosis?

Yes, revision surgery for symptomatic pseudarthrosis is generally considered medically necessary and is covered by most major health insurance plans, including Medicare. Coverage typically requires comprehensive documentation of failed conservative treatment, radiographic confirmation of nonunion, correlation with persistent symptoms, and proof of preoperative optimization attempts (like smoking cessation). Prior authorization may be required for specific high-cost biologics like BMPs or implanted bone stimulators. Patients should always verify coverage details with their insurer and surgical team before proceeding.

Can I return to sports or heavy labor after successful pseudarthrosis treatment?

Many patients successfully return to athletic and occupational activities after solid fusion is confirmed radiographically and clinically, but the timeline and extent depend heavily on the surgical site, bone quality, and individual recovery. Generally, low-impact activities can resume at 3 to 4 months, while high-impact sports or heavy manual labor typically require 9 to 12 months of dedicated rehabilitation and surgeon clearance. Even after successful healing, the fused segment will no longer move, potentially placing increased stress on adjacent joints. Long-term conditioning, ergonomic modifications, and cross-training are essential for sustaining active lifestyles and preventing adjacent segment degeneration.

Conclusion

Pseudarthrosis represents a complex orthopedic challenge where the intricate balance between biological potential and mechanical stability is disrupted. Whether arising as a complication of spinal fusion, a stubborn long bone fracture, or a rare congenital anomaly, the formation of a false joint can profoundly disrupt daily function and diminish quality of life. Recognizing the signs—persistent pain, instability, and neurological symptoms—alongside understanding the modifiable risk factors like smoking, nutritional deficits, and mechanical overload, empowers both patients and clinicians to intervene proactively.

Modern diagnostic tools, particularly advanced CT imaging and dynamic studies, allow for precise identification of nonunion type and severity, guiding targeted interventions. Treatment has evolved from simple immobilization to sophisticated revision strategies combining meticulous debridement, optimized fixation, advanced bone grafting, and targeted biologics. When paired with strict lifestyle modifications, physical rehabilitation, and psychological support, the prognosis for achieving solid bony union is highly favorable.

Ultimately, successful management of pseudarthrosis hinges on a patient-centered, multidisciplinary approach. By prioritizing preoperative optimization, leveraging cutting-edge surgical techniques, and maintaining realistic, long-term rehabilitation goals, individuals can overcome this formidable complication and return to a stable, active, and pain-managed life. If you suspect a nonunion or are navigating the recovery process post-surgery, partnering closely with an experienced orthopedic or spine specialist remains the most critical step toward a successful outcome.

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References

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3. Cuellar Spine. Pseudarthrosis After Fusion Treatment & Symptoms. https://cuellarspine.com/insights/pseudarthrosis-after-fusion/
4. MedicalNewsToday. Pseudarthrosis: Definition, symptoms, and treatments. https://www.medicalnewstoday.com/articles/pseudoarthrosis
5. Liu, Y., Zhu, G., Liao, S. et al. Does an osteotomy performed in congenital pseudarthrosis of the tibia accompanied by tibial angular deformity heal?. J Orthop Surg Res 20, 397 (2025). https://josr-online.biomedcentral.com/articles/10.1186/s13018-025-05806-z
6. Marquez-Lara A, D'Agostino R, Medda S, Ricciardi L, Ramhmdani S. Electrical stimulation therapy in spinal fusion: a cross-sectional analysis of indications and outcomes. J Neurosurg Spine. 2020 Jan 1;32(1):106-112. https://thejns.org/spine/view/journals/j-neurosurg-spine/32/1/article-p106.xml

Disclaimer: This article is for informational purposes only and does not constitute medical advice. Always consult with a qualified healthcare professional for any health concerns or before making any decisions related to your health or treatment.