K. Yonenobu· K. Ono· Y. Takemitsu (Eds.)

Lumbar Fusion and Stabilization

With 251 Figures

Springer-Verlag Tokyo Berlin Heidelberg New York London Paris Hong Kong Barcelona Budapest

Kazuo Yonenobu, M.D. Department of Orthopaedic Surgery, Labor Welfare Corporation, Kansai Rosai Hospital, Amagasaki, Hyogo, 660 Japan

Keiro Ono, M.D. Dean of Medical School, Professor and Chairman, Department of Orthopaedic Surgery, Osaka University Medical School, Osaka, 553 Japan

Yoshiharu Takemitsu, M.D. Professor and Chairman, Department of Orthopedic Surgery, Asahikawa Medical College, Asahikawa, Hokkaido, 078 Japan

ISBN-13:978-4-431-68236-3 e-ISBN-13:978-4-43 1-68234-9 DOl: 10.1007/978-4-431-68234-9

Printed on acid-free paper

Library of Congress Cataloging-in-Publication Data Lumbar fusion and stabilization I K. Ono, Y. Takemitsu, K. Yonenobu, (eds.). p. em. Includes bibliographical references and index. ISBN-13:978-4-43 1-68236-3 1. Lumbar vertebrae - Surgery. 2. Spinal fusion. I. Ono, Keiro. II. Takemitsu, Y. (Yoshiharu), 1930-. III. Yonenobu, K. (Kazuo), 1947-. RD768.L843 1993, 617.3'75'059 - dc20, 92-46674

© Springer-Verlag Tokyo 1993 Softcover reprint of the hardcover 1st edition 1993

This work is subject to copyright. All rights are reserved, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in other ways, and storage in data banks. The use of registered names, trademarks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. Product liability: The publisher can give no guarantee for information about drug dosage and application thereof contained in this book. In every individual case the respective user must check its accuracy by consulting other pharmaceutical literature.

Foreword

The hour of departure of this century has brought before us innumerable questions, some of which remain to be resolved. The recent development of image technology and various therapeutic modalities emphasizes the need for orthopedists to address many problems of the lumbar spine. The role of the orthopedic surgeon in the management of lumbar disorders is yet to be ascer­tained. To shoulder the major responsibilities in the management of low back pain, however, we have to assess our ability to identify the causes and the underlying mechanisms of low back pain, sciatica, and intermittent claudication and to realize the limitations of therapeutic modalities in orthopedic surgery. For the surgical elimination of pain, it is essential to identify pain-eliciting lesions by means of careful history taking, physical examination, and image technology. We should be familiar with the sensitivity and specificity of each test and diagnostic modality related to the varying pathology of low back pain. With regard to pain relieving procedures, answers to certain questions should be sought and self assessment in that light should be made on each occasion. These are the questions that must be addressed: What may be the additional procedure or operative intervention that particularly guarantees pain relief and its permanent elimination in each case of low back pain, in the excision of a herniated disc, in the removal of the whole disc and in accomplishing lumbar interbody fusion, in the reduction of severe spondylolisthesis and fusion, in widening the narrow canal, and in stabilizing spinal instability accompanying painful disc, multisegmental degenerated disc with a narrow canal, and nerve tissue irritation?

Although lumbar fusion and stabilization have become more common proce­dures for the treatment of low back pain in routine orthopedic surgery, the identification of pain-eliciting lesions and the identification of essential surgical intervention for the elimination of pain are only occasionally reflected upon by the surgeon before these procedures are carried out. Must lumbar fusion always be indicated for disc herniation in young adults who are often required to do heavy physical work and need a life-long guarantee against pain recur­rence? Must this procedure be indicated for lumbar disc degeneration with instability in elderly persons? How should one localize the dominant pain-

v

VI Foreword

eliciting lesion in multisegmental spondylosis with a narrow spinal canal? Should stabilization with instrumentation be added to secure pain relief in such a condition?

For successful pain eliminating surgery, the significance of technical details should never be overlooked. A master surgeon tends to adhere to routine positioning on the operation table, has well-cared for surgical instruments, and pays due regard to hemostasis. He prefers the existing reliable and well stan­dardized instruments to the newly developed all-round ones. For the prevention of complications due to pedicle screwing, a precise knowledge of anatomy is essential, and careful rechecking of the site and the direction of screwing must be done.

Currently, for lumbar fusion, not only autogenous grafts but also allogeneic grafts and biomaterials are applicable. Materials are chosen according to their individual advantageous characteristics and availability. Allogeneic grafts are stored and delivered either in a "freeze and dry" manner or after defatting and gas sterilization. A combination of bone grafting with instrumentation shortens the period of "bed rest", enhances fusion rate, and reduces the risk of instru­mentation' failure.

In the middle of this century, orthopedic researchers overcame certain long­standing problems with regard to many aspects of lumbar disorders. Through the 5th International Conference on Lumbar Fusion and Stabilization, various subjects related to lumbar disorders have been studied. We hope these selected Conference papers will convey a new message of multidisciplinary expertise in current achievements and enable us to widen our perspectives of science and art in spine surgery.

Kazuo Y onenobu Keiro Ono

Y oshiharu Takemitsu

Contents

Foreword....................................................... V List of Contributors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . XI

Part 1 Principles of Lumbar Fusion and Stabilization

1.1 Biomechanics of Lumbar Spine Instability M.M. Panjabi. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

1.2 The Myth of Solid Posterior Lateral Fusion J. Zucherman, S. Brack, K.Y. Hsu, and W. Shea... . . .. . ... . ... . . 10

1.3 Radiological Evidence of Posterior Lumbar Interbody Fusion P.M. Lin.................................................... 16

Part 2 To Fuse or Not To Fuse

SECTION I DETERMINATION OF SEGMENTAL INSTABILITY

2.1 The Role of External Fixation as a Predictor of Fusion Success D.W. Lyon, D.J. Hall, R.C. Mulholland, and J.K. Webb. . . . . . . .. 25

2.2 Assessment of Segmental Spinal Instability Using Magnetic Resonance Imaging T. Toyone, H. Moriya, H. Kitahara, K. Takahashi, M. Yamagata, M. Murakami, and Y. Takahashi . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

2.3 Intraoperative Measurement of Lumbar Spinal Stiffness S. Ebara, M. Tanaka, Y. Morimoto, T. Harada, N. Hosono, K. Yonenobu, and K. Ono ................................... 45

SECTION II THE MERITS AND DEMERITS OF LUMBAR FUSION

2.4 The Long-Term Effect of Lumbar Spine Fusion: Deterioration of Adjacent Motion Segments K.Y. Hsu, J. Zucherman, and A. White. . . . . . . . . . . .. . . . . . . . . . . . 54

VII

VIII Contents

2.5 A Critical Analysis of Motion of the Lumbar Spine Adjacent to an Interbody Fusion: A Clinical Radiological Study and Biomechanical Cadaveric Study K.D.K. Luk, D.H.K. Chow, J.c.Y. Leong, and J. Evans... ...... 65

2.6 Anterior Interbody Fusion for Degenerative Spondylolisthesis: The Long-Term Clinical Results K. Takahashi, H. Kitahara, M. Yamagata, M. Murakami, M. Mimura, and H. Moriya. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72

2.7 Clinical Results of Lumbar Fusion for Heavy Workers with Lumbar Disk Herniation S. Matsunaga, T. Sakou, K. Yone, E. Taketomi, T. Morimoto, and K. Ijiri . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78

SECTION III MULTI-SEGMENTAL SPONDYLOSIS

2.8 Multi-Segmental Spondylosis: An Overview of Presentations at the Fifth International Conference on Lumbar Fusion and Stabilization J. Kostuik . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86

2.9 Patien.t Selection for Stabilization of Multisegmental Spondylosis W. Dick, H. Widmer, and V.J. Leone......................... 92

2.10 A Clinical Study of Degenerative Lumbar Scoliosis M.-S. Moon, K.-S. Lee, C.-I. Lim, Y.-B. Kim, and H.-S. Lee. . . . . 98

2.11 Surgical Management of Degenerative Lumbar Scoliosis Y. Toyama ....... '. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113

2.12 Treatment of Multilevel Anterior and Retrolisthesis of the Lumbosacral Spine P. Enker, A.D. Steffee, L. Keppler, R.S. Biscup, and S.D. Miller. . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . 126

2.13 Posterior Stabilization for Lumbar Degenerative Kyphosis: In Situ Fusion in Maximum Extension on Hall's Frame O. Nakai, I. Yamaura, Y. Kurosa, H. Komori, A. Ookawa, H. Sakai, and M. Abe ....................................... 135

2.14 Operative Treatment of Lumbar Degenerative Kyphosis Y. Takemitsu, Y. Atsuta, Y. Kamo, T. Iwahara, O. Sugawara, Y. Harada, and Y. Miyatake . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150

2.15 Non-Instrumentation Stabilization/Decompression Procedure for Lumbar Spinal Stenosis: Significance of Expansive Laminoplasty H. Tsuji, H. Matsui, M. Kanamori, N. Hirano, and Y. Katoh ..... 160

Part 3 Stabllization Methods

3.1 How to Stabilize the Lumbar Spine: An Overview K. Hirabayashi. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169

Contents IX

3.2 Results of Posterior Lumbar Interbody Fusion for Lytic and Degenerative Spondylolisthesis R.B. Cloward................................................ 178

3.3 Posterior Lumbar Interbody Fusion: With and Without Pedicle Screw Fixation S. Nakai, H. Yoshizawa, K. Kenmotsu, S. Nishimoto, and T. Morita. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 188

3.4 Posterior Lumbar Interbody Fusion Combined Auto- and Allograft Technique P.S. Ramani. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 197

3.5 Posterior Lumbar Interbody Fusion with Allograft and Plates T. Ohwada, T. Yamamoto, K. Nose, M. Inaoka, arid M. Kakiuchi .. 208

3.6 Effects of Ceramic Interspinous Block on Anterior Lumbar Interbody Fusion H. Tsuji, N. Hirano, H. Matsui, H. Ohshima, H. Ishihara, and Y. Katoh . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 220

3.7 Boucher Screw Fixation of the Spine: A Translaminar Pedicle Screw Technique C.E. Graham. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 227

3.8 Reduction and Stabilization of High Grade Spondylolisthesis: A Study of 29 Patients Using a Posterior Approach R. Roy-Camille, J.Y. Lazennec, C.H. Garreau, G. Saillant, and J.P. Benazet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 241

3.9 Lumbar Diskectomy, Facetectomy, and Laminectomy of L4-L5 and L5-S1 Levels: Experimental Approach and Biomechanical Consequences of Practical Application J.Y. Lazennec, R. Desjardins, R. Roy-Camille, C.G. Laudet, A. Lazennec, and B. Roger. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 249

Part 4 Spinal Instrumentation

SECTION I BIOMECHANICS

4.1 Biomechanical Analysis of Lumbosacral Fixation D.H. McCord, B.W. Cunningham, Y. Shono, J.J. Myers, and P.C. McAfee. ... . ... . . . .. .. . .... . . . . . . .. . ... .. . .. . .... .. 259

4.2 Comparative Study of Three Pedicle Screw Devices R. Steffen, L.-P. Nolte, and J. Kramer. . . . . . . . . . . . . . . . . . . . . . . . .. 278

4.3 Biomechanical Study of Pedicle Screw Fixation Systems for the Lumbar Spine M. Yamagata, H. Kitahara, S. Minami, K. Takahashi, H. Moriya, and T. Tamaki . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 288

X Contents

SECTION II PEDICLE SCREW SYSTEMS

4.4 Lumbosacral Fusion with Pedicular Screw Plating Instrumentation: lO-year Follow-up Results R. Roy-Camille, J.-P. Desauge, and J.-P. Benazet ................ 297

4.5 Simmons Plating System for Spinal Fusion Surgery J. W. Simmons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 303

4.6 Stabilization of Spondylolisthesis: The Hartshill System J. Dove..................................................... 312

4.7 Lumbar Spinal Stabilization by the MOSS System M.-S. Moon, K.-S. Lee, S.-S. Kim, and D.-H. Sun. . . . . . . . . . . . . . .. 316

4.8 Internal Fixation of the Lumbar Spine: Further Clinical Experience Using Computer Assisted Design and Manufacture of a Precise System D.C. Hemmy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 332

4.9 Complications of Lumbar Spinal Surgery with Transpedicular Fixation S.H. D,avne and D.L. Myers................................... 338

Part 5 Bank Bone and Bone Graft Substitutes

5.1 Recent Trends in the Use of Bank Bone in Spinal Surgery: Replies to Questionnaires from the United States M. Kakiuchi and K. Ono . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 349

5.2 Defatted, Gas-Sterilized Bone Allograft as Bank Bone: Preparation, Safety, and Utility for Lumbar Spine Surgery M. Kakiuchi, K. Ono, and K. Shinka ........................... 354

5.3 A Titanium Implant for Interbody Fusion in Degenerative Lumbar Disk Disease J.W. Chang and A.C.M.C. Yau . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 364

5.4 Use of Hydroxyapatite Blocks in Posterior Interbody Fusion N. Suzuki and Y. Iwamoto.............. ...................... 371

5.5 A Carbon Fiber Implant to Aid Interbody Lumbar Fusion: I-year Clinical Results in the First 26 Patients J.W. Brantigan and A.D. Steffee ........................ ....... 379

Keyword Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 397

List of Contributors

Abe, M. 135 Atsuta, Y. 150 Benazet, J.-P. 241,297 Biscup, R.S. 126 Brack, S. ·10 Brantigan, J.W. 379 Chang, J.W. 364 Chow, D.H.K. 65 Cloward, R.B. 178 Cunningham, B.W. 259 Davne, S.H. 338 Desauge, J.-P. 297 Desjardins, R. 249 Dick, W. 92 Dove, J. 312 Ebara, S. 45 Enker, P. 126 Evans, J. 65 Garreau, e.H. Graham, e.E. Hall, D.J. 25 Harada, T. 45

241 227

Harada, Y. 150 Hemmy, D. e. 332 Hirabayashi, K. 169 Hirano, N. 160,220 Hosono, N. 45 Hsu, K.Y. 10,54 Ijiri, K. 78 Inaoka, M. 208 Ishihara, H. 220 Iwahara, T. 150

Iwamoto, Y. 371 Kakiuchi, M. 208,349, 354 Kamo, Y. 150 Kanamori, M. 160 Katoh, Y. 160, 220 Kenmotsu, K. 188 Keppler, L. 126 Kim, S.-S. 316 Kim, Y.-B. 98 Kitahara, H. 35, 72, 288 Komori, H. 135 Kostuik, J. 86 Kramer, J. 278 Kurosa, Y. 135 Laudet, e.G. 249 Lazennec, A. 249 Lazennec, J.Y. 241,249 Lee, H.-S. 98 Lee, K.-S. 98, 316 Leone, V.J. 92 Leong, J.e.Y. 65 Lim, C.-I. 98 Lin, P.M. 16 Luk, K.D.K. 65 Lyon, D.W. 25 McAfee, P.C. 259 McCord, D.H. 259 Matsui, H. 160, 220 Matsunaga, S. 78 Miller, S.D. 126 Mimura, M. 72 Minami, S. 288

XI

XII List of Contributors

Miyatake, Y. 150 Shono, Y. 259 Moon, M.-S. 98,316 Simmons, J.W. 303 Morimoto, Y. 45 Steffee, A.D. 126,379 Morimoto, T. 78 Steffen, R. 278 Morita, T. 188 Sugawara, O. 150 Moriya, H. 35,72,288 Sun, D.-H. 316 Mulholland, R.C. 25 Suzuki, N. 371 Murakami, M. 35,72 Takahashi, K. 35,72,288 Myers, D.L. 338 Takahashi, Y. 35 Myers, J.J. 259 Takemitsu, Y. 150 Nakai, O. 135 Taketomi, E. 78 Nakai, S. 188 Tamaki, T. 288 Nishimoto, S. 188 Tanaka, M. 45 Nolte, L.-P. 278 Toyama, Y. 113 Nose, K. 208 Toyone, T. 35 Ohshima, H. 220 Tsuji, H. 160,220 Ohwada, T. 208 Webb, J.K. 25 Ono, K. 45,349, 354 White, A. 54 Ookawa, A. 135 Widmer, H. 92 Panjabi, M.M. 3 Yamagata, M. 35,72,288 Ramani, P.S. 197 Yamamoto, T. 208 Roger, B. 249 Yamaura, I. 135 Roy-Camille, R. 241, 249, 297 Yau, A.C.M.C. 364 Saillant, G. 241 Yone, K. 78 Sakai, H. 135 Yonenobu, K. 45 Sakou, T. 78 Yoshizawa, H. 188 Shea, W. to Zucherman, J. to,54 Shinka, K. 354