Indications, techniques, and outcomes of posterior surgery for chronic low back pain
Section snippets
Etiologic considerations in patients with low back pain
Though low back pain may be caused by a wide spectrum of conditions, a specific etiology cannot be firmly established in the majority of patients for whom the diagnosis of idiopathic or nonspecific low back pain is assigned [1]. Unfortunately, neither our understanding of the pathophysiology nor our current level of diagnostic sophistication are sufficient to determine convincingly the exact pathoanatomic etiology in most cases of low back pain. The consequences of age-related intervertebral
Diagnostic modalities—a surgical perspective
For the surgeon attempting to delineate which chronic low back pain patients are appropriate candidates for a fusion operation and determining what levels actually warrant fusion, the primary diagnostic tools include plain radiographs with flexion and extension views, MRI, and provocative diskography. Plain radiographs provide a great deal of information in terms of the presence of intraosseous pathology, intervertebral disk height, and overall sagittal and coronal plane alignment. Flexion and
Indications for surgical intervention
This brief discussion of the diagnostic tools used to investigate low back pain should make it fairly obvious that our ability to delineate the exact cause of lumbar symptoms and then predict the outcome of surgical fusion based on these findings is far from perfect. A rational approach to the diagnosis of low back pain, and a reasonable perspective on the ability of surgery to improve on its natural history, is therefore necessary. In this regard, low back pain patients are generally
Outcomes of surgical treatment
Overall, despite the enormous attention paid to low back pain and its treatment, the role of surgical management is remarkably poorly defined. A Cochrane review of surgical treatment for degenerative spondylosis published in 1999 concluded that there was a “serious lack” of current evidence to support surgical intervention for chronic low back pain, pointing out the nonexistence of prospective randomized controlled comparisons of surgery to nonoperative care of chronic low back pain and other
Posterior surgical fusion procedures
A number of well-accepted options exist for performing lumbar arthrodesis from a posterior approach. These include posterolateral intertransverse fusion, with or without pedicle screw instrumentation, posterior lumbar interbody fusion, and transforaminal lumbar interbody fusion. Both interbody procedures usually are, and should be, supported with an additional instrumented procedure. An intertransverse approach to performing lumbar interbody fusion has recently been described, but experience
Posterolateral intertransverse fusion (with or without pedicle screw instrumentation)
Posterolateral fusion in which autologous bone graft is laid along the decorticated transverse processes and posterolateral surfaces of the facet joints and pars interarticularis is the most common method of promoting fusion in the lumbar spine (Fig. 3). With the explosion of interest in spinal instrumentation over the past 2 decades, it has been common to supplement posterolateral intertransverse fusions with pedicle screw fixation. Considering that one of the goals of lumbar arthrodesis for
Posterior lumbar interbody fusion
The technique of posterior lumbar interbody fusion (PLIF) was introduced over half a century ago by Ralph Cloward. In its original form, the PLIF involved a laminectomy, subtotal diskectomy, and then insertion of bone graft into the disk space to promote anterior interbody fusion. The contemporary iterations of this procedure now include an attempt to excise as much of the disk as possible through a wide laminectomy and the insertion of a large interbody spacer device with autogenous bone graft
Transforaminal lumbar interbody fusion
The transforaminal approach to the intervertebral disk was developed by Harms as a means of approaching the intervertebral disk in a more lateral fashion to reduce the amount of medial neural retraction necessary to achieve adequate access [59] (Fig. 5). The technique, transforaminal lumbar interbody fusion (TLIF), involves distraction across pedicle screws and a unilateral facetectomy to gain access to the disk space. TLIF facilitates direct decompression of the nerve roots on that side but,
Summary
This article summarizes a number of issues surrounding the diagnosis, indications, and techniques of posterior lumbar spine surgery for chronic low back pain. It would not be entirely unjustified for a spine surgeon to adhere to a totally avoidant approach to chronic low back pain, rationalized by a reasonably legitimate nihilism regarding the presently available means of diagnosing and surgically managing low back pain [64]. Judging by the number of lumbar fusions performed in North America
References (64)
Instability of the lumbar spine. Pathology, treatment, and clinical evaluation
Neurosurg Clin N Am
(1991)Diagnostic evaluation of LBP: reaching a specific diagnosis is often impossible
Arch Intern Med
(2002)- et al.
Abnormal magnetic-resonance scans of the lumbar spine in asymptomatic subjects. A prospective investigation
J Bone Joint Surg [Am]
(1990) - et al.
Lumbar spine fusion in the treatment of degenerative conditions: current indications and recommendations
J Am Acad Orthop Surg
(1995) - et al.
Efficacy of flexion and extension treatments incorporating braces for low-back pain patients with retrodisplacement, spondylolisthesis, or normal sagittal translation
Spine
(1993) - et al.
Degenerative lumbar spondylolisthesis with spinal stenosis. A prospective study comparing decompression with decompression and intertransverse process arthrodesis
J Bone Joint Surg [Am]
(1991) - et al.
1997 Volvo Award winner in clinical studies. Degenerative lumbar spondylolisthesis with spinal stenosis: a prospective, randomized study comparing decompressive laminectomy and arthrodesis with and without spinal instrumentation
Spine
(1997) - et al.
Posterolateral lumbar fusion. Outcome of 71 consecutive operations after 4 (2–7) years
Acta Orthop Scand
(1994) - et al.
Anterior lumbar fusion: results, assessment techniques and prognostic factors
Eur Spine J
(1994) - et al.
The natural history of radiographic instability of the lumbar spine
Spine
(1993)