Chapter 224 Management of a 45-Year-Old with Mechanical Low Back Pain with or without L4-5 Spondylolisthesis and No Neurologic Findings
Nonoperative Management
Spondylolisthesis is commonly classified as isthmic or degenerative, based on the pathogenesis. Isthmic spondylolisthesis is associated with defects in the pars interarticularis, usually bilateral. Degenerative spondylolisthesis is a consequence of facet joint arthritis, ligamentous laxity, and ineffective muscular stabilization, resulting in ventral displacement of one vertebra over the subadjacent vertebra without disruption of the vertebral ring.1,2 Degenerative spondylolisthesis is most common at L4-5 and has a 3:1 female predominance; isthmic spondylolisthesis is most common at L5-S1 with a 3:1 male predominance.3 In a subset of persons participating in the Framingham Heart Study (mean age, 52.66 years), spondylolysis was identified in 11.5% using CT imaging, with almost 80% of these persons having associated spondylolisthesis.3 In this study the incidence of degenerative spondylolisthesis increased from the fifth through eighth decades of life, and about 20% of patients experienced severe back pain. However, no significant association was identified between spondylolisthesis, isthmic or degenerative, and the occurrence of low back pain.
Is the Spondylolisthesis Responsible for Symptoms?
In evaluating a patient with mechanical, nonradicular back pain without neurologic findings noted to have a spondylolisthesis, an initial question might be whether the slip is responsible for symptoms or is simply an incidental radiographic finding. Most patients with spondylolisthesis are asymptomatic and progression of clinical symptoms does not correlate with progression of the slip.4 The clinical significance of “instability,” characterized by change in listhesis demonstrable on flexion and extension lumbar lateral radiographs, is unknown and not clearly correlated with symptoms. Although patients with spondylolisthesis do experience more daily back pain, they do not report greater disability than individuals without a slip.5 The most common clinical entity associated with spondylolisthesis is symptomatic spinal stenosis (i.e., pseudoclaudication) in older patients with a degenerative slip.
What Is the Natural History of Axial Back Pain without Neurologic Findings in Patients with Spondylolisthesis?
Irrespective of pathogenesis, the natural history of axial low back pain in patients with spondylolisthesis is favorable. Most patients do well with conservative care.2 A prospective cohort study demonstrated that 76% of patients with degenerative spondylolisthesis and no neurologic deficits followed for more than 10 years remained without neurologic findings.4 Patients with neurologic symptoms, however, including pseudoclaudication or cauda equina symptoms, deteriorated without surgery. A meta-analysis of nonoperative treatment results in children and young adults with spondylolysis and isthmic grade 1 spondylolisthesis reported 83.9% of patients had a successful clinical outcome at 1 year.6 Interestingly, a successful treatment outcome was not dependent on healing of the spondylolytic lesion.
What Is the Optimal Medical/Interventional Treatment for Axial Back Pain without Neurologic Findings in a Patient with Spondylolisthesis?
A recent evidence-based review of medical and interventional treatment for degenerative spondylolisthesis found no high-quality studies to adequately address the question of whether nonoperative treatment improves the generally favorable natural history of this condition when neurologic symptoms, particularly pseudoclaudication, are absent.2 Lacking data, treatment of chronic axial back pain in patients with spondylolisthesis should be based on well-established, consensus treatment recommendations for chronic back pain without a slip. Exercise, both general aerobic conditioning and spine specific, is the cornerstone of treatment. Recent systematic reviews of exercise in nonspecific chronic low back pain have confirmed the efficacy of different approaches, including lumbar extensor strengthening, lumbar stabilization, and the McKenzie method.7–9 An older, small retrospective study comparing flexion and extension exercise programs in patients with spondylolisthesis and back pain found significantly better functional outcome and pain relief at 3 years in the flexion exercise group.10 A structured dynamic lumbar stabilization exercise program was more effective than usual care in reducing pain intensity and functional disability in a small randomized trial in younger patients with predominantly isthmic spondylolisthesis.11 Multiple studies have demonstrated that general aerobic conditioning is helpful in patients with nonspecific low back pain, but this approach has not been studied specifically in patients with spondylolisthesis.12–14
In most patients with chronic nonradicular low back pain and spondylolisthesis, the anatomic source of the pain remains ambiguous. A recent evidence-based systematic review strongly recommended against provocative discography as a diagnostic procedure in such patients, primarily because of a high rate of false positive responses.15 This study found no evidence that the use of provocative discography to select patients for fusion improved clinical outcomes. Similarly, the same analysis concluded there was “insufficient evidence” to evaluate the utility or validity of medial branch blocks for identification of facet-mediated pain in patients with axial low back pain. However, a recent randomized, double-blind, small controlled trial found that lumbar facet joint neurotomy using radiofrequency current in patients with chronic low back pain was at least statistically significantly superior to a “sham” procedure in improving pain and function.16 Interestingly, in this trial, only 15% of screened low back pain patients met the stringent diagnostic criteria for facet-mediated pain, suggesting that the facet joint is not commonly the source of chronic low back pain.
There is modest evidence that massage, manipulation, and acupuncture may be helpful adjunctive treatments in management of chronic nonspecific low back pain, but they have not been studied specifically in patients with spondylolisthesis.17–19 Similarly, a systematic review of the literature found no evidence that ancillary treatments, including bracing, traction, and electrical stimulation, are effective in degenerative spondylolisthesis.2
Kalichman L., Hunter D.J. Diagnosis and conservative management of degenerative lumbar spondylolisthesis. Eur Spine J. 2008;17:327-335.
Kalichman L., Kim D.H., Ling L., et al. Spondylolysis and spondylolisthesis. Prevalence and association with low back pain in the adult community-based population. Spine (Phila Pa 1976). 2009;34:199-205.
Matsunaga S., Ijiri K., Hayashi K. Nonsurgically managed patients with degenerative spondylolisthesis: a 10 to 18-year follow-up study. J Neurosurg. 2000;93:194-198.
Watters W.C., Bono C.M., Gilbert T.J., et al. An evidence-based clinical guideline for the diagnosis and treatment of degenerative lumbar spondylolisthesis. Spine J. 2009;9:609-614.
1. Kalichman L., Hunter D.J. Diagnosis and conservative management of degenerative lumbar spondylolisthesis. Eur Spine J. 2008;17:327-335.
2. Watters W.C., Bono C.M., Gilbert T.J., et al. An evidence-based clinical guideline for the diagnosis and treatment of degenerative lumbar spondylolisthesis. Spine J. 2009;9:609-614.
3. Kalichman L., Kim D.H., Ling L., et al. Spondylolysis and spondylolisthesis. Prevalence and association with low back pain in the adult community-based population. Spine (Phila Pa 1976). 2009;34:199-205.
4. Matsunaga S., Ijiri K., Hayashi K. Nonsurgically managed patients with degenerative spondylolisthesis: a 10- to 18-year follow-up study. J Neurosurg. 2000;93:194-198.
5. Kauppila L.I., Eustace S., Kiel D.P., et al. Degenerative displacement of lumbar vertebrae: a 25-year follow-up study in Framingham. Spine (Phila Pa 1976). 1998;23:1868-1873.
6. Klein G., Mehlman C.T., McCarty M. Nonoperative treatment of spondylolysis and grade 1 spondylolisthesis in children and young adults. J Pediatr Orthop. 2009;29:146-–156.
7. Mayer J., Mooney V., Dagenais S. Evidence-informed management of chronic low back pain with lumbar extensor strengthening exercises. Spine J. 2008;8:96-113.
8. Standaert C.J., Weinstein S.M., Rumpeltes J. Evidence-informed management of chronic low back pain with lumbar stabilization exercises. Spine J. 2008;8:114-120.
9. May S., Donelson R. Evidence-informed management of chronic low back pain with the McKenzie method. Spine J. 2008;8:134-141.
10. Sinaki M., Lutness M.P., Hstrup D.M., et al. Lumbar spondylolisthesis: retrospective comparison and 3-year follow up of two conservative treatment programs. Arch Phys Med Rehabil. 1989;70:594-598.
11. O’Sullivan P.B., Phyty G.D., Twomey L.T., Allison G.T. Evaluation of specific stabilizing exercise in the treatment of chronic low back pain with radiologic diagnosis of spondylolysis or spondylolisthesis. Spine (Phila Pa 1976). 1997;22:2959-2967.
12. Frost H., Lamb S.E., Moffett J.A.K., et al. A fitness program for patients with chronic low back pain: 2-year follow up of a randomized controlled trial. Pain. 1998:273-279.
13. Moffett J.K., Torgerson D., Bell-Byer S. Randomized controlled trial of exercise for low back pain: clinical outcomes, costs, and preferences. BMJ. 1999;319:279-283.
14. Van der Velde G., Mierau D. The effect of exercise on percentile rank aerobic capacity and self-rated disability in patient with chronic low back pain: a retrospective chart review. Arch Phys Med Rehabil. 2000;81:1457-1463.
15. Chou R., Loeser J.D., Owens D.K., et al. Interventional therapies, surgery and interdisciplinary rehabilitation for low back pain. An evidence-based clinical practice guideline from the American Pain Society. Spine (Phila Pa 1976). 2009;34:1066-1077.
16. Nath S., Nath C.A., Pettersson K. Percutaneous lumbar zygapophysial (facet) joint neurotomy using radiofrequency current, in management of chronic low back pain. Spine (Phila Pa 1976). 2008;33:1291-1297.
17. Assendelft W.J., Morton S.C., Yu E.L., et al. Spinal manipulative therapy for low back pain. A meta-analysis of effectiveness relative to other therapies. Ann Intern Med. 2003;138:871-881.
18. Furlan A.D., Brosseau L., Inamura M., et al. Massage for low back pain: a systematic review within the framework of the Cochrane Collaboration Back Review Group. Spine (Phila Pa 1976). 2002;27:1896-1910.
19. Furlan A.D., van Tulder M.W., Cherkin D.C., et al. Acupuncture and dry-needling for low back pain. Cochrane Database Syst Rev. 2005:CD001351.
Spinal Fusion: Ventral Approach
The ventral approach is a valuable tool for treatment of many pathologic processes in the lumbar spine. In this section we consider the role of ventral surgical options in the treatment of a 45-year-old male with mechanical back pain due to degeneration at L4-5 with or without instability. As with any surgical option ventral approaches, though versatile, are not amenable to all pathologies. In some indications there are clear benefits to the ventral approach, but it has limitations.1,2 This discussion concentrates on the anterior mini-open retroperitoneal approach because this is the most common approach to L4-5. Transperitoneal approaches are an option but are not widely used currently.3 The laparoscopic transperitoneal approach has now been mostly abandoned because it did not lead to better outcomes than the retroperitoneal approach and had higher rates of complications.4–7 In recent years there has been increased interest in the direct lateral access corridor to the ventral aspect of the spine.8 The use of newer retractor systems has facilitated this approach. It is of more use higher in the lumbar spine due to anatomic constraints from the iliac wing and from the lumbosacral plexus.9,10
Establish the Diagnosis
In deciding treatment options the key is to establish the diagnosis. In a patient with low back pain in the absence of neurologic symptoms, this is often the most difficult and important piece of information. The causes of back pain and the workup are addressed in other chapters. The AANS Guidelines on Surgery for Axial Back Pain indicate that surgery for axial back pain may be an option in those patients with a clear symptomatic level or levels who have failed an appropriate course of active nonoperative treatment.11 Surgical treatment for significant instability in the spine is less controversial, though there is no uniform definition of instability.12
In the context of this case the establishment of instability may alter the treatment options selected. Biomechanical studies of stand-alone anterior interbody constructs show that the absence of an intact posterior tension band makes these implants much less stable and that supplemental fixation may be indicated.13 In the setting of isthmic spondylolisthesis ventral stand-alone constructs have been used without supplemental fixation in low-grade slips with reasonable results.14,15 In degenerative spondylolisthesis there has been little written.16
Disc collapse may also be an important factor in choosing an approach. Stand-alone constructs rely on tension of the fibers of the disc anulus for stability.17,18 Discs with collapse have shortened fibers and may be more stable. In clinical terms post hoc analysis of patients in FDA trials of a tapered threaded interbody device showed improved outcomes with increasing loss of disc height preoperatively.19
Why a Ventral Approach?
In the lumbar spine, the majority of the axial load passes through the disc space. Bone forms better under compressive loads. As a result interbody constructs place the fusion mass in the area of highest load and under the best loading conditions for fusion. Surface area for fusion is also larger in interbody constructs. Predominant loads in the intertransverse region of the spine are tension or shear and the area for fusion is smaller. As a result of the wide anular opening in the ventral approach, disc removal and endplate preparation are easier and more complete than with posterior interbody techniques.20
Fusion rates with anterior interbody fusion are high. In prospective studies fusion rates in the 90% range are common.21–24 In one large study the radiographic rate of fusion on reconstructed CT imaging was 100%.22 In comparative studies fusion rates with ventral stand-alone constructs are equal to or better than with dorsal fusion or dorsal interbody constructs.2,14,25 In conjunction with dorsal instrumentation, anterior interbody fusions probably have the most consistently high fusion rates and, in comparison studies against dorsal and dorsal interbody constructs, have shown equivalent or better fusion rates and equivalent or better clinical outcomes.26–28
The ventral approach in the lumbar spine is technically demanding but with experience can be done quickly and safely.1,29–31 Vascular injury rates range from 0% to 11% and decrease as experience increases.29,31,32 Ureteric and enteric injuries are rare.1,33,34 Retrograde ejaculation rates have been highly variable, but in large series from experienced centers this rate can be reduced to the 1% to 3% range. Shorter hospital stays are reported for ventral-only procedures when compared to open dorsal fusions. Blood loss and operative time are also lower. Though the use of an access surgeon is common, at least two studies have shown that operative times and complications are not decreased through use of an access surgeon.35,36 Surgical volume and experience with the approach may be more important than the surgical background of the surgeon doing the approach.
Numerous studies have shown that dorsal open surgical approaches lead to histochemical radiographic and pathologic changes to the dorsal musculature.37–43 Muscle strength is compromised.37 Placement of pedicle screws leads to increased loads on the suprajacent facet.44 This constellation of pathology has been termed fusion disease by Zdeblick. The anterior perirectus approach and the minimal access lateral muscle splitting approach avoid these problems. Some authors have suggested that anterior interbody fusion decreases the risk of adjacent segment degeneration as a result.45–48
Not all patients or pathologic processes are amenable to a ventral approach and in some cases dorsal options alone or combined approaches are a better option. There is limited ability to directly decompress the spinal canal through the ventral approach. Ventral compression by bulging or herniated discs can be dealt with through ventral-only approaches. Dorsal pathology, such as facet or ligamentous hypertrophy, cannot be directly addressed. Indirect decompression is possible. Restoration of disc height can increase foraminal height and volume, thus indirectly decompressing foraminal stenosis.49–53 Reduction of a spondylolisthesis will also improve foraminal stenosis and in the case of a degenerative spondylolisthesis will also improve central canal diameter.49,54 In this case, in which no neurogenic symptoms are present, decompression is not a major goal of surgery.
To perform the discectomy and place an interbody graft, it is necessary to have linear access to the disc space. In patients with high slip angles it may not be possible to access the disc; therefore, it may not be possible to do an anterior interbody fusion. When considering a ventral approach, a standing lateral radiograph with the pelvic symphysis visible on the film will allow assessment of the trajectory. As seen in Figure 224-1A, a line drawn along the superior endplate of S1 passes above the symphysis and a ventral approach is possible. In Figure 224-1B the line goes below the symphysis and a ventral approach would not be possible. In general the L4-5 level is more horizontal, so in this case it is unlikely that a ventral approach would not be possible due to approach angle.
The bifurcation of the inferior vena cava to the common iliac veins generally occurs at or near the L4-5 disc. It is generally visible on the preoperative MRI,55 although some advocate a preoperative CT angiogram to assess its position.56 It is generally possible to mobilize the vessels off the disc, but in rare cases it is impossible and a ventral approach must be aborted. Extensive vascular calcification and aneurysm of the aorta and common iliac vessels are also relative contraindications to a ventral approach to the lumbar spine due to the possibility of compromising the circulation of the lower extremities. In patients who have had previous retroperitoneal surgery, it is very difficult to access and mobilize the vessels; a ventral approach should be avoided.
In some patients, a minimal access lateral approach allows ventral access to the L4-5 level without mobilizing the vessels. This approach is limited by the height of the iliac wing and there is a risk to the lumbosacral plexus even with EMG monitoring.8,9
What Conditions Are Amenable to a Ventral Approach?
The ventral approach can be used for most lumbar pathologies. The treatment of intractable low back pain with disc degeneration has been the main indication for stand-alone interbody fusion and has had good short- and long-term results.21–23,47,57 Other authors have reported much poorer results.58–60 The use in both isthmic and degenerative spondylolisthesis has also been established.14–16,27,28,61 Anterior interbody fusion has been used in the treatment of herniated discs in those patients in whom fusion is indicated.62,63
Interbody Fusion Options
Interbody fusions typically involve a structural component to increase and maintain disc height and a biological component to ensure fusion. The early descriptions of anterior interbody fusion used iliac crest bone graft as a tricortical strut.63 Iliac crest bone provides structural support and is osteogenic. Allograft femoral rings have also been widely and successfully used.21,45,47,64,65 They provide a strong strut and some osteoconductive properties. Cancellous autograft is typically placed inside the ring, although recent studies have used recombinant human bone morphogenetic protein-2 (rhBMP-2).66,67 Studies with BMP have shown a higher failure rate when used as a stand alone.67,68
Numerous interbody implants have been developed using multiple materials. The intitial implants were threaded interbody devices, typically metallic.20,21,24 Threaded cortical allograft dowels were used in the past, although they are no longer widely used.22 Impacted metallic cages were developed to provide a broader footprint to lessen subsidence.69 Metallic interbody implants make imaging to assess fusion difficult and have a modulus of elasticity much higher than cancellous bone. As a result, carbon fiber70 and PEEK71 implants have been developed. Multiple studies have compared the biomechanics of these implants, but there has been little written on clinical outcome differences between them.70,72
Cages can either be used as a stand-alone device or augmented with other stabilizers. Dorsal instrumentation with pedicle screws through a traditional open approach with or without dorsal fusion is commonly used.13,15,25,27 Transfacet screws have also been widely used to augment interior interbody fusion.73,74 In one study translaminar screws were associated with a higher pseudarthrosis rate.75 In recent years anterior tension band plates and cages with screw augmentation have also been developed. Although biomechanical studies have compared these implants, there is a lack of comparative clinical studies.76–80
Motion Preservation Options
In recent years there has been a lot of interest in motion preservation implants using the ventral approach. The best data to date is likely from the FDA trials of the implants that have come to market in the United States. The Charité81 and ProDisc82 trials show short-term results comparable to fusion at 2 years and with limited follow-up at 5 years.83 It is unclear how this technology will fit into our armamentarium in the future.
Brau S.A. Mini-open approach to the spine for anterior lumbar interbody fusion: description of the procedure, results and complications. Spine J. 2002;2(3):216-223.
Burkus J.K., Gornet M.F., Schuler T.C., et al. Six-year outcomes of anterior interbody arthodesis with use of interbody fusion cages and recombinant human bone morphogenetic protein-2. J Bone Joint Surg [Am]. 2009;91(5):1181-1189.
Kwon B.K., Hilibrand A.S. A critical analysis of the literature regarding surgical approach and outcome for adult low-grade isthmic spondylolisthesis. J Spinal Disord Tech. 2005;18(Suppl):S30-S40.
Pradham B.B., Bae H.W., Dawson E.G., et al. Graft reabsorption with the use of bone morphogenetic protein: lessons from anterior lumbar interbody fusion using femoral ring allografts and recombinant human bone morphogenetic protein-2. Spine (Phila Pa 1976). 2006;31(10):E277-E284.
Resnick D.K., Choudhri T.F., Dailey A.T., et al. Guidelines for the performance of fusion procedures for degenerative disease of the lumbar spine. Part 7: Intractable low back pain without stenosis or spondylolisthesis. J Neurosurgery Spine. 2005;2(6):670-672.
Schuler T.C., Burkus J.K. The correlation between preoperative disc height and clinical outcomes after anterior lumbar interbody fusion. J Spinal Disord Tech. 2005;18(5):396-410.
Swan J., Hurwitz E., Malek F., et al. Surgical treatment for unstable low-grade isthmic spondylolisthesis in adults: a prospective controlled study of posterior instrumented fusion compared with combined anterior-posterior fusion. Spine J. 2006;6(6):606-614.
Wai E.K., Santos E.R., Morcom R.A., Fraser R.D. Magnetic resonance imaging 20 years after anterior lumbar interbody fusion. Spine (Phila Pa 1976). 2006;31(17):1952-1956.
1. Brau S.A. Mini-open approach to the spine for anterior lumbar interbody fusion: description of the procedure, results and complications. Spine J. 2002;2(3):216-223.
2. Pradham B.B., Nassar J.A., Delamarter R.B., Wang J.C. Single level lumbar spine fusions: a comparison of anterior and posterior approaches. J Spinal Disord Tech. 2002;15(5):355-361.
3. Gumbs A.A., Bloom N.D., Bitan F.D., Hanan S.H. Open anterior approaches for lumbar spine procedures. Am J Surg. 2007;194(1):98-102.
4. Rodriguez H.E., Connolly M.M., Dracopoulos H., et al. Anterior access to the lumbar spine: laparoscopic versus open. Am Surg. 2002;68(11):978-982.
5. Zdeblick T.A., David S.M. A prospective comparison of surgical approach for anterior L4-L5 fusion: laparoscopic versus mini anterior lumbar interbody fusion. Spine (Phila Pa 1976). 2000;25(20):2682-2687.
6. Kaiser M.G., Haid R.W., Subach B.R., et al. Comparison of the mini-open versus laparoscopic approach for anterior lumbar interbody fusion: a retrospective review. Neurosurgery. 2002;51(1):97-103.
7. Liu J.C., Ondra S.L., Angelos P., et al. Is laparoscopic anterior lumbar interbody fusion a useful minimally invasive procedure? Neurosurgery. 2002;51(Suppl 5):S155-S158.
8. Ozgur B.M., Aryan H.E., Pimenta L., Taylor W.R. Extreme Lateral Interbody Fusion (XLIF): a novel surgical technique for anterior lumbar interbody fusion. Spine J. 2006;6(4):435-443.
9. Knight R.Q., Schwaegler P., Hanscom D., Roh J. Direct lateral lumbar interbody fusion for degenerative conditions; early complication profile. J Spinal Disord Tech. 2009;22(1):34-37.
10. Benglis D.N., Vanni S., Levi A.D. An anatomical study of the lumbosacral plexus as related to minimally invasive transpsoas approach to the lumbar spine. J Neurosurg Spine. 2009;10(2):139-144.
11. Resnick D.K., Choudhri T.F., Dailey A.T., et al. Guidelines for the performance of fusion procedures for degenerative disease of the lumbar spine. Part 7: intractable low back pain without stenosis or spondylolisthesis. J Neurosurg Spine. 2005;2(6):670-672.
12. Resnick D.K. Evidenced based guidelines for the performance of lumbar fusions. Clin Neurosurg. 2006;53:279-284.
13. Oxland T.R., Lund T. Biomechanics of stand alone cages and cages in combination with posterior fixation: a literature review. Eur Spine J. 2000;9(Suppl 1):S95-S101.
14. Min J.H., Jang J.S., Lee S.H. Comparison of anterior and posterior approach instrumented lumbar interbody fusion for spondylolisthesis. J Neurosurg Spine. 2007;7(1):21-26.
15. Kim J.S., Lee K.Y., Lee S.H., Lee H.Y. Which lumbar interbody fusion technique is better in terms of level for the treatment of unstable isthmic spondylolisthesis. J Neurosurg Spine. 2010;12(2):171-177.
16. Takahasi K., Kitahara H., Yamagata M., et al. Long term results of anterior interbody fusion for treatment of degenerative spondylolisthesis. Spine (Phila Pa 1976). 1990;15(11):1211-1215.
17. Tencer A.F., Hampton D., Eddy S. Biomechanical properties of threaded inserts for lumbar interbody spinal fusion. Spine (Phila Pa 1976). 1995;20(22):2408-2414.
18. Patwardhan A.G., Carandang G., Ghanayem A.J., et al. Compressive preload improves the stability of anterior lumbar interbody fusion cage constructs. J Bone Joint Surg [Am]. 2003;85(9):1749-1756.
19. Schuler T.C., Burkus J.K. The correlation between preoperative disc height and clinical outcomes after anterior lumbar interbody fusion. J Spinal Disord Tech. 2005;18(5):396-410.
20. Burkus J.K. Intervertebral fixation: clinical results with anterior cages. Orthop Clin North Am. 2002;33(2):349-357.
21. Sasso R.C., Kitchel S.H., Dawson E.G. A prospective, randomized controlled clinical trial of anterior lumbar interbody fusion using a titanium cylindrical threaded fusion device. Spine (Phila Pa 1976). 2004;29(2):113-122.
22. Burkus J.K., Transfeldt E.E., Kitchel S.H., et al. Clinical and radiographic outcomes of anterior lumbar interbody fusion using recombinant human bone morphogenetic protein-2. Spine (Phila Pa 1976). 2002;27(21):2396-2408.
23. Burkus J.K., Gornet M.F., Dickman C.A., Zdeblick T.A. Anterior lumbar interbody fusion using rhBMP-2 with tapered interbody cages. J Spinal Disord Tech. 2002;15(5):337-349.
24. McAfee P.C., Lee G.A. Anterior BAK instrumentation and fusion: complete versus partial discectomy. Clin Orthop Relat Res. 2002;394:55-63.
25. Maden S.S., Boeree N.R. Comparison of instrumented anterior interbody fusion with instrumented circumferential lumbar fusion. Eur Spine J. 2003;12(6):567-575.
26. Faundez A.A., Schwender J.D., Safriel Y., et al. Clinical and radiographic outcomes of anterior posterior fusion versus transforaminal lumbar interbody fusion for symptomatic disc degeneration: a retrospective comparative study of 133 patients. Eur Spine J. 2009;18(2):203-211.
27. Kim J.S., Choi W.G., Lee S.H. Minimally invasive anterior lumbar interbody fusion followed by percutaneous pedicle screw fixation for isthmic spondylolisthesis: minimum 5-year follow-up. Spine J. 2010;10(5):404-409.
28. Swan J., Hurwitz E., Malek F., et al. Surgical treatment for unstable low-grade isthmic spondylolisthesis in adults: a prospective controlled study of posterior instrumented fusion compared with combined anterior-posterior fusion. Spine J. 2006;6(6):606-614.
29. Bianchi C., Ballard J.L., Abou-Zamzam A.M., et al. Anterior retroperitoneal lumbosacral spine exposure: operative techniques and results. Ann Vasc Surg. 2003;17(2):137-142.
30. Brewster L., Trueger N., Schermer C., et al. Infraumbilical anterior retroperitoneal exposure of the lumbar spine in 128 consecutive patients. World J Surg. 32(7), 2008. 1414–1149
31. Sasso R.C., Best N.M., Mummaneni P.V., et al. Analysis of operative complications in a series of 471 anterior lumbar interbody fusion procedures. Spine (Phila Pa 1976). 2005;30(6):670-674.
32 Hamdan A.D., Malek J.Y. Vascular injury during anterior exposure of the spine. J Vasc Surg. 2008;48(3):650-654.
33. Tiusanen H., Seitsalo S., Osterman K., Soini J. Retrograde ejaculation after anterior interbody lumbar fusion. Eur Spine J. 1995;4(6):339-342.
34. Sasso R.C., Burkus J.K., LeHuec J.C. Retrograde ejaculation after anterior lumbar interbody fusion: transperitoneal versus retroperitoneal approach. Spine (Phila Pa 1976). 2003;28(10):1023-1026.
35. Jarrett C.D., Heller J.G., Tsai L. Anterior exposure of the lumbar spine with and without an “access surgeon”: morbidity analysis of 265 consecutive cases. J Spinal Disord Tech. 2009;22(8):559-564.
36. Holt R.T., Majd M.E., Vadhava M., Castro F.P. The efficacy of anterior spine exposure by an orthopedic surgeon. J Spinal Disord Tech. 2003;16(5):477-486.
37. Gejo R., Matsui H., Kawaguchi Y., et al. Serial changes in trunk muscle performance after posterior lumbar surgery. Spine (Phila Pa 1976). 1999;24(10):1023-1028.
38. Kawaguchi Y., Matsui H., Tsuji H. Changes in serum creatine phosphokinase MM isoenzyme after lumbar spine surgery. Spine (Phila Pa 1976). 1997;22(9):1018-1023.
39. Kawaguchi Y., Yabuki S., Styf J., et al. Back muscle injury after posterior lumbar spine surgery. Topographic evaluation of intramuscular pressure and blood flow in the porcine back muscle during surgery. Spine (Phila Pa 1976). 1996;21(22):2683-2688.
40. Kawaguchi Y., Matsui H., Tsuji H. Back muscle injury after posterior lumbar spine surgery. A histologic and enzymatic analysis. Spine (Phila Pa 1976). 1996;21(8):941-944.
41. Kawaguchi Y., Matsui H., Tsuji H. Back muscle injury after posterior lumbar spine surgery. Part 2: Histologic and histochemical analyses in humans. Spine (Phila Pa 1976). 1994;19(22):2598-2602.
42. Styf J.R., Willén J. The effects of external compression by three different retractors on pressure in the erector spine muscles during and after posterior lumbar spine surgery in humans. Spine (Phila Pa 1976). 1998;23(3):354-358.
43. Weber B.R., Grob D., Dvorak J., Muntener M. Posterior surgical approach to the lumbar spine and its effect on the multifidus muscle. Spine (Phila Pa 1976). 1997;22(15):1765-1772.
44. Chen S.H., Tai C.L., Lin C.Y., et al. Biomechanical comparison of a new stand-alone anterior lumbar interbody fusion cage with established fixation techniques—a three-dimensional finite element analysis. BMC Musculoskelet Disord. 2008;9:88.
45. Van Horn J.R., Bohnen L.M. The development of discopathy in lumbar discs adjacent to a lumbar anterior interbody spondylodesis. A retrospective matched pair study with a postoperative follow-up of 16 years. Acta Orthop Belg. 1992;58(3):280-286.
46. Rao R.D., David K.S., Wang M. Biomechanical changes at adjacent segments following anterior lumbar interbody fusion using tapered cages. Spine (Phila Pa 1976). 2005;30(24):2772-2776.
47. Wai E.K., Santos E.R., Morcom R.A., Fraser R.D. Magnetic resonance imaging 20 years after anterior lumbar interbody fusion. Spine (Phila Pa 1976). 2006;31(17):1952-1956.
48. Min J.H., Jang J.S. The clinical characteristics and risk factors for adjacent segment degeneration in instrumented lumbar fusion. J Spinal Disord Tech. 2008;21(5):305-309.
49. Vamvanij V., Ferrara L.A., Hai Y., et al. Quantitative changes in spinal canal dimensions using interbody distraction for spondylolisthesis. Spine (Phila Pa 1976). 2001;26(3):E13-E18.
50. Motosuneya T., Asazuma T., Nobuta M., et al. Anterior lumbar interbody fusion: changes in area of the dural tube, disc height, and prevalence of cauda equine adhesions on magnetic resonance imaging. J Spinal Disord Tech. 2005;18(1):18-22.
51. Wang M., Delai S. Changes in the lumbar foramen following anterior interbody fusion with tapered cylindrical cages. Spine J. 2007;7(5):563-569.
52. Nibu K., Panjabi M.M., Oxland T., Cholewicki J. Intervertebral disc distraction with a laparoscopic anterior spinal fusion system. Eur Spine J. 1998;7(2):142-147.
53. Chen D., Fay L.A., Lok J., et al. Increasing neuroforaminal volume by anterior interbody distraction in degenerative lumbar spine. Spine (Phila Pa 1976). 1995;20(1):74-79.
54. Kim N.H., Kim H.K., Suh J.S. A computed tomographic analysis of changes in the spinal canal after anterior lumbar interbody fusion. Clin Orthop Relat Res. 1993;286:180-191.
55. Kang B.U., Lee S.H., Jeon S.H., et al. An evaluation of vascular anatomy for minilaparotomic anterior L4-5 procedures. J Neurosurg Spine (Phila Pa 1976). 2006;5(6):508-513.
56. Inamasu J., Kim D.H., Logan L. Three dimensional computed tomographic anatomy of the abdominal great vessels pertinent to L4-L5 anterior lumbar interbody fusion. Minim Invasive Neurosurg. 2005;48(3):127-131.
57. Burkus J.K., Gornet M.F., Schuler T.C., et al. Six-year outcomes of anterior interbody arthodesis with use of interbody fusion cages and recombinant human bone morphogenetic protein-2. J Bone Joint Surg [Am]. 2009;91(5):1181-1189.
58. Pellise F., Puig O., Rivas A., et al. Low fusion rate after laparoscopic anterior lumbar interbody fusion using twin stand-alone carbon fiber cages. Spine (Phila Pa 1976). 2002;27(15):1665-1669.
59. Choi J.Y., Sung K.H. Subsidence after anterior lumbar interbody fusion using paired stand-alone rectangular cages. Eur Spine J. 2006;15(1):16-22.
60. Buttton G., Gupta M. Three- to six-year follow-up of stand-alone BAK cages implanted by a single surgeon. Spine J. 2005;5(2):155-160.
61. Kwon B.K., Hilibrand A.S. A critical analysis of the literature regarding surgical approach and outcome for adult low-grade isthmic spondylolisthesis. J Spinal Disord Tech. 2005;18(Suppl):S30-S40.
62. Vishteh A.G., Dickman C.A. Anterior lumbar microdiscectomy and interbody fusion for the treatment of recurrent disc herniation. Neurosurgery. 2001;48(2):334-337.
63. Inoue S., Watanabe T. Anterior discectomy and interbody fusion for lumbar disc herniation. A review of 350 cases. Clin Orthop Relat Res (183). 1984:22-31.
64. Sacks S. Anterior interbody fusion of the lumbar spine. J Bone Joint Surg [Br]. 1965;47:211-223.
65. Penta M.R.D., Fraser R.D. Anterior lumbar interbody fusion. A minimum 10-year follow-up. Spine (Phila Pa 1976). 1997;22(20):2429-2434.
66. Burkus J.K., Sandhu H.S., Gornet M.F., Longley M.C. Use of rh-BMP-2 in combination with structural cortical allografts: clinical and radiographic outcomes in anterior lumbar spinal surgery. J Bone Joint Surg [Am]. 2005;87(6):1205-1212.
67. Pradhan B.B., Bae H.W., Dawson E.G., et al. Graft reabsorption with the use of bone morphogenetic protein: lessons from anterior lumbar interbody fusion using femoral ring allografts and recombinant human bone morphogenetic protein-2. Spine (Phila Pa 1976). 2006;31(10):E277-E284.
68. Vaidya R., Weir R., Sethi A., et al. Interbody fusion with allograft and rhBMP-2 leads to consistent fusion but early subsidence. J Bone Joint Surg [Br]. 2007;89(3):342-345.
69. Oxland T.R., Hoffer Z., Nydegger T., et al. A comparative biomechanical investigation of anterior lumbar interbody cages: central and bilateral approaches. J Bone Joint Surg [Am]. 2000;82(3):383-393.
70. Jost B., Cripton P.A., Lund T., et al. Compressive strength of interbody cages in the lumbar spine: the effect of cage shape, posterior instrumentation and bone density. Eur Spine J. 1998;7(2):132-141.
71. Vadapalli S., Sairyear K., Goel V.K., et al. Biomechanical rationale for using polyetheretherketone (PEEK) spacers for lumbar interbody fusion—A finite element study. Spine (Phila Pa 1976). 2006;31(26):E992-E998.
72. Tsantrizos A., Andreu A., Aebi M., et al. Biomechanical stability of five stand alone anterior lumbar interbody fusion constructs. Eur Spine J. 2000;9(1):14-22.
73. Best N.M., Sasso R.C. Efficacy of translaminar facet screw fixation in circumferential interbody fusions as compared to pedicle screw fixation. J Spinal Disord Tech. 2006;19(2):98-103.
74. Marchesi D.G., Boos N. Translaminar facet joint screws to enhance segmental fusion of the lumbar spine. Eur Spine J. 1992;1(2):125-130.
75. Anjarwalla N.K., Morcom R.K., Fraser R.D. Supplementary stabilization with anterior lumbar intervertebral fusion—a radiologic review. Spine (Phila Pa 1976). 2006;31(11):1281-1287.
76. Johnson W.M., Nichols T.A., Jethwani D., Guiot B.H. In vitro biomechanical comparison of an anterior and anterolateral lumbar plate with posterior fixation following single level anterior lumbar interbody fusion. J Neurosurg Spine. 2007;7(3):332-335.
77. Tzermiadianos M.N., Mekhail A., Vorono L.I., et al. Enhancing stability of anterior lumbar interbody fusion: a biomechanical comparison of anterior plate versus posterior transpedicular instrumentation. Spine (Phila Pa 1976). 2008;33(2):E38-E43.
78. Beaubien B.P., Derincek A., Lew W.D., et al. In vitro, biomechanical comparison of an anterior lumbar interbody fusion with an anteriorly placed low profile lumbar plate and posteriorly placed pedicle screws or translaminar screws. Spine (Phila Pa 1976). 2005;30(6):1846-1851.
79. Gerber M., Crawford N.R., Chamberlain R.H., et al. Biomechanical assessment of anterior lumbar interbody fusion with an anterior lumbosacral fixation screw-plate: comparison to stand-alone anterior lumbar interbody fusion and anterior lumbar interbody fusion with pedicle screws in an unstable human cadaver model. Spine (Phila Pa 1976). 2006;31(7):762-768.
80. Nichols T.A., Yantzer B.K., Alameda S., et al. Augmentation of an anterior lumbar interbody fusion with an anterior plate or pedicle screw fixation: a comparative biomechanical in vitro study. J Neurosurg Spine (Phila Pa 1976). 2007;6(3):267-271.
81. Blumenthal S., McAfee P.C., Guyer R.D., et al. A prospective, randomized, multicenter Food and Drug Administration investigational device exemptions study of lumbar total disc replacement with the CHARITE artificial disc versus lumbar fusion: part I: evaluation of clinical outcomes. Spine (Phila Pa 1976). 2005;30(14):1565-1575.
82. Zigler J., Delamarter R., Spivak J.M., et al. Results of the prospective, randomized, multicenter Food and Drug Administration investigational device exemption study of the ProDisc-L total disc replacement versus circumferential fusion for the treatment of 1-level degenerative disc disease. 32(11):1155–1162, 200783.Guyer RD, McAfee PC, Banco RJ, et al. Prospective, randomized, multicenter Food and Drug Administration investigational device exemption study of lumbar total disc replacement with the CHARITE artificial disc versus lumbar fusion: five-year follow-up. Spine (Phila Pa 1976). 2007;32(11):1155-1162.
83. Guyer R.D., McAfee P.C., Banco R.J., et al. Prospective, randomized, multicenter Food and Drug Administration investigational device exemption study of lumbar total disc replacement with the CHARITE artificial disc versus lumbar fusion: five-year follow-up. Spine J. 2009;9(5):374-386.
Spinal Fusion: Dorsal Approach
Mechanical low back pain is an extremely common entity in the United States, affecting 15% to 85% of all adults at some point in their lives.1,2 It is the second most common diagnosis-linked cause for a physician visit and has a point prevalence of approximately 30%. Despite the expenditure of nearly $100 billion annually in the United States for the diagnosis and treatment of low back pain–related disorders, low back pain continues to be poorly understood, and a discrete anatomic cause for the pain can be found in only 20% of cases.3 Although the majority of patients experience improvement of their symptoms within 2 to 4 weeks and 90% are improved within 3 months, a small percentage have symptoms persistent and severe enough to warrant surgical intervention.
Although a myriad of surgical procedures have been proposed for the treatment of low back pain secondary to either degenerative disc disease or spondylolisthesis, arthrodesis to stabilize the painful motion segment has been the mainstay of surgical treatment since its introduction in the 1920s.4 Broadly speaking, surgical alternatives for fusion include dorsal, ventral, and combined techniques. The latter can be performed through either an all-dorsal approach (posterior lumbar interbody fusion [PLIF], and transforaminal lumbar interbody fusion [TLIF]), or can be done through separate ventral and dorsal incisions. Within the spectrum of dorsal fusion procedures, dorsolateral intertransverse fusion with or without pedicle screw instrumentation is commonly performed, although other procedures, such as facet fusion, have been more recently developed.5
Mechanical Low Back Pain without Spondylolisthesis
In this chapter, a 45-year-old male patient with mechanical low back pain is discussed. In the patient with degenerative disc disease and low back pain without spondylolisthesis, fusion surgery is still considered controversial but has been successfully performed when using strict operative indications.6,7 Anterior lumbar interbody fusion (ALIF) has been reported as an alternative to posterior fusion and has the benefit of decreased blood loss and operative time, as well as avoiding the morbidity associated with the muscle dissection necessary for posterior fusion. However, concerns with the ventral approach include the risk of visceral or potentially life-threatening vascular injury and deep venous thrombosis. In addition, pseudarthrosis rates after ALIF have been reported to be as high as 31%, and retrograde ejaculation can be a significant issue in young males who wish to reproduce.8 In addition, graft extrusion requiring high-risk anterior revision surgery is a rare but potentially catastrophic complication of this procedure and of lumbar total disc arthroplasty.9 TLIF and PLIF-type procedures are theoretically desirable because they increase the surface area for fusion compared to posterior-alone techniques, but the longer operative times, potential for neurologic injury, and the more recently described potential for postoperative radiculitis and heterotopic bone formation within the spinal canal with the use of bone morphogenetic protein (BMP) are cause for concern.10,11
Dorsolateral intertransverse fusion, in the appropriately selected patient, can avoid the complications described previously and has been shown to provide acceptable clinical results at mid- and long-term follow-up. Glassman et al. studied 224 patients undergoing single-level dorsolateral arthrodesis with iliac crest autograft for lumbar degenerative disease and found significant improvements in both the Short Form-36 and Oswestry Disability Index scores at up to 2-year follow-up.12 They observed a fusion rate of 88% to 95% at 2-year follow-up (in younger and older patients, respectively) and reported modest improvements in back pain, leg pain, and return to work. Dimar et al. performed dorsolateral instrumented fusions on 463 patients with lumbar degenerative disease and up to grade I degenerative spondylolisthesis.13 They reported fusion rates of 96% with use of rhBMP-2 and 89% with iliac crest and had significant improvements in back pain, leg pain, and return to work status at 2-year follow-up. In conclusion, dorsolateral instrumented fusion can result in significant improvements in pain score and health-related quality of life as well as obtaining a high fusion rate in the appropriately selected patient with mechanical low back pain.
