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CHAPTER 31/POSTERIOR AND POSTEROLATERAL PROCEDURES / 323
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CHAPTER 32
Posterior Lumbar Interbody Fusion
Casey K. Lee and Kenneth J. Kopacz
Degenerative disc disorders are probably the most com-
ural history and the mechanism of pain production of
degenerative disc disorders are poorly understood. Many
different phases of degenerative disc disease (i.e.,
“degenerative cascade”) are described well by KirkaldyWillis et al. (1). The acute onset of low back pain, the first
time or very occasional recurrences, usually becomes
symptom-free after a short duration. Some pathologic
conditions of degenerative disc disease (DDD) are, however, responsible for recurrent or chronic persistent low
back pain that significantly affects a patient’s lifestyle.
These include internal disc derangement which is defined as a derangement of the internal disc structure
(nucleus and annulus) or biochemical alterations without
having any external disc pathology such as disc bulge,
herniation, disc height narrowing, or abnormal displacement. Another subtype of DDD is classified as stable
DDD. This is described as degenerative disc changes
without having gross abnormal displacement such as
degenerative spondylolisthesis.
Spinal fusion for DDD has been a most controversial
subject for many decades. The effectiveness of spinal
fusion for DDD was difficult to prove without knowledge
of the natural history of various degenerative conditions.
Yet, DDD has been the most common pathologic condition for which spinal fusion is indicated. Davis reported
that 51% of spinal fusions performed in the United States
during a 10-year period (1980 to 1990) were for DDD
(2). In a review of English-language literature by Bono
and Lee (3) for spinal fusion for DDD between 1980 and
2000, spinal fusion was indicated for various conditions
of DDD. The most common indication was for stable
DDD (67%) which included internal disc derangement,
DDD without instability, and postdisc excision for disc
herniation. The second most common indication was for
DDD with spondylolisthesis (25%).
Indication for spinal fusion for certain conditions of
DDD such as degenerative spondylolisthesis, progressive
degenerative scoliosis, or hypolordosis (“flat back syn-
as stable DDD and internal disc derangement (IDD) is
still controversial. Spinal fusion for chronic low back
pain caused by DDD has been pro ven more effective than
nonoperative treatments in a recent controlled clinical
study (4). For IDD, there is no controlled clinical study
that conclusivel y proves the effectiv eness of spinal fusion
over the natural history or nonoperative treatments, and it
remains a most controversial subject. There is, however,
some indirect clinical information suggesting that spinal
fusion for IDD may be a more ef fectiv e treatment than the
natural history or nonoperative treatments. In a 5-year
follow-up study of patients with chronic low back pain
caused by IDD (discography-positive) who were treated
with nonoperative treatments, none of the patients
became symptom-free and approximately 50% were
experiencing the same or worse pain (5). In another study,
patients who were candidates for spinal fusion with the
diagnosis of IDD but were denied fusion by insurance
payors were followed for one-and-a-half years. Twothirds of patients were experiencing the same or worse
symptoms at follow-up (6). The published results of
spinal fusion for IDD indicate a high rate of symptom
relief and return to work. In a report on a properly
selected group of patients with IDD, spinal fusion provided better clinical success rates of pain relief (89%) and
return to work (82%) (7).
CHOICE OF SPINAL FUSION TECHNIQUES
Posterolateral Fusion versus Interbody Fusion
Lumbar interbody fusion is preferred to posterior or
posterolateral fusion in patients with discogenic pain (stable DDD and IDD) and in patients with anterior column
weight-bearing deficiency, especially with angular instability in the sagittal or coronal plane. It is also preferred
in patients with failed previous posterior or posterolateral
fusion.
324
CHAPTER 32/POSTERIOR LUMBAR INTERBODY FUSION / 325
FIG. 32-1. Disc degeneration with
anterior column weight-bearing function (“flat-tire syndrome”). Magnetic
resonance imaging of the lumbosacral
spine of a patient with chronic disabling
low back pain shows the L4-5 disc with
diffuse circumferential bulge (arrows)
and with minimally decreased disc
height. The disc has deficient anterior
column weight-bearing function.
Various types of spinal fusion produce different biomechanical effects on the fused segment and on adjacent
segments (8,9). In a biochemical study, Rolander reported that posterior fusion did not eliminate motion
across the disc within the fused segment and suggested
that this retained motion across the disc may be the
source of chronic persistent pain after successful posterior fusion. Clinical studies by others further support this
concept (10,11). In these clinical studies, some patients
with discogenic pain had persistent pain after successful
posterior or posterolateral fusion, and their pain symptom
was successfully relieved after subsequent lumbar interbody fusion.
Effects of different types of lumbar fusion on adjacent
segments are primarily caused b y changes in stif fness and
changes in the center of rotation of segmental motion of
adjacent levels to fusion (9). Degeneration of the disc
results in changes in biomechanics of the motion segment. In certain cases, the motion segment may become
unstable in sagittal, coronal, axial or combination
motions due to mechanical incompetence of the disc
(anterior column weight-bearing deficiency) (Fig. 32-1).
Interbody fusion is more effective in cor recting the anterior column deficiency than is posterior or posterolateral
fusion. Posterior or posterolateral fusion for DDD with
anterior column deficiency, especially for angular instability (segmental hypolordosis or disc space wedging),
may produce significant adverse effects on the adjacent
segments (12,13).
rior lumbar interbody fusion (ALIF). The clinical success
rate is comparable for the two, but the “surgeon factor”
(skills and experience) is an important factor (14). Each
procedure has advantages and disadvantages. ALIF has a
wider and easier surgical exposure, but often requires a
second surgeon (vascular or general). It is associated with
inherently more significant and serious complications
than PLIF, such as vascular or visceral injuries, impotence, or retrograde ejaculation. When rigid fixation is
required for ALIF, an additional posterior approach is
required for pedicle screw fixation. PLIF is primarily
indicated for the lower lumbar and lumbosacral spine
(L3-5 and S1). In the upper lumbar spine above the L2
level, the surgical exposure for PLIF is limited by the
presence of conus medullaris and by the short interpedicular distance. The surgical exposure of PLIF is more limited and more difficult to master than ALIF. However,
PLIF has definite advantages over ALIF in other aspects:
all three columns of the motion segment can be addressed
through one exposure—posterior decompression, restoration of anterior column weight-bearing function, correction of degenerative deformities and instability, and rigid
posterior fixation. It has different complications from
ALIF: excessive epidural bleeding, dural tear, or neural
injury . PLIF is preferred to ALIF for patients who require
addressing all three columns at the same time: posterior
decompression, restoration of anterior column weightbearing function, and rigid posterior fixation.
Posterior Lumbar Interbody Fusion versus Anterior
Lumbar Interbody Fusion
Indications for, and the fusion rate of posterior lumbar
interbody fusion (PLIF) are very similar to those of ante-
PLIF Indications
Indications for PLIF are as follows:
1. The preferred indication for PLIF is DDD with ante-
rior column weight-bearing deficiency (Fig. 32-2).
326 /SECTION V/SPECIFIC CLINICAL ENTITIES
FIG. 32-2. Disc degeneration with disc space wedging and
loss of lordosis. A lateral view of the lumbosacral spine of a
female patient shows persistent segmental kyphosis at L4-5
after posterolateral fusion. She has severe persistent low
back pain and was unable to stand up straight.Posterolateral
spinal fusion failed to correct segmental kyphosis and failed
to relieve her symptoms.
roots or severe epidural scarring following previous
surgery. PLIF is not recommended above L2 because of
the very narrow interpedicular distance, narrow spinal
canal, and proximity of the conus medullaris.
PLIF Surgical Techniques
Successful results of PLIF depend on proper patient
selection, indications, and good surgical techniques. The
PLIF procedure requires: (a) adequate exposure; (b) adequate mobilization, retraction, and protection of neural
elements; (c) proper preparation of the vertebral end
plates (graft bed); and (d) placement of an adequate
amount of appropriate bone graft. Basic surgical techniques are described well by others (15–19). Some
selected important points are described here.
Exposure
Bilateral large laminotomies and medial one-half facetectomies provide a sufficiently large enough exposure
for the basic PLIF technique (Fig. 32-3). Proper control
of epidural bleeding is essential for mobilization and
retraction of the dura and nerve roots. Bipolar coagula-
a. DDD with diffuse circumferential disc bulge with
or without disc space collapse (“flat-tire syndrome”) (12) (Fig. 32-1)
b. DDD with segmental instability such as degener-
ative spondylolisthesis
c. DDD with segmental deformity—hypolordosis or
disc space wedging (Fig. 32-2)
2. PLIF is a good choice for chronic disabling low back
caused by:
a. IDD
b. Stable DDD
c. Post-disc excision DDD
3. Other indications for PLIF are:
a. Failed posterolateral fusion
b. The rare indication of a disc space infection with
epidural abscess resistant to nonoperative treatment that requires surgical intervention for débridement and stabilization
c. Degenerative scoliosis where posterior decom-
pression, correction of deformity, and rigid internal fixation are combined with fusion
PLIF Contraindications
PLIF is contraindicated where the neural elements can-
not be retracted in such conditions as conjoined nerve
FIG. 32-3. The surgical exposure for the basic posterior lumbar interbody fusion (PLIF). Bilateral laminotomies and
medial one-half facetectomies (dotted line) will provide sufficient exposure for the basic PLIF. Most of the lamina, spinous processes, interspinous and supraspinous ligaments,
and lateral one-half of facet joints are sav ed for stability of the
fusion construct.
CHAPTER 32/POSTERIOR LUMBAR INTERBODY FUSION / 327
FIG. 32-4. Control of epidural bleeding and retraction of
neural elements. Epidural vessels have regular anatomic
arrangements, vertically running intraspinal canal vessels and
horizontally running connecting vessels between intraspinal
and extraspinal canal systems. Horizontally running vessels
are coagulated with a bipolar cautery and divided immediately
above the pedicles and near the lower v ertebral end plate.The
traversing nerve root, dura, and intraspinal vertical epidural
vessels are retracted to the midline.
tion and division of cross-linking epidural veins between
the extraspinal canal and intraspinal canal venous system
superior to the pedicles provides a dry surgical field and
allows easier mobilization of the dura and nerve roots
medially to the midline (Fig. 32-4).
Mobilization, Retraction, and Protection of Neural
Elements
The dura and the traversing nerve root ma y be retracted
to the midline (Figs. 32-4, 32-5).A prolonged continuous
retraction of the nerve root should be avoided, especially
for patients who had previous posterior surgery. The exiting nerve root above the disc may occasionally be in the
way at the superior lateral corner of the surgical field
under the facet joint. All of these neural elements should
be retracted and protected all the time during the procedure, especially during insertion of bone graft or any
fusion device into the disc space.
Preparation of the Vertebral End Plates (Graft Bed)
Contact surface area between graft bed and bone graft
is the most important factor for bone healing and subsi-
dence. Exposure of sub–end-plate cancellous bone promotes bone healing. Biomechanical tests indicate that
decortication of the vertebral end plates does not have
any significant effect on the compressive strength at the
interface between bone grafts and vertebral bone (20).
The three most important factors for subsidence of bone
grafts or interbody fusion devices are bone mineral density of the vertebral bone, applied compressive load, and
contact surface area at the interface. To prevent subsidence, a PLIF construct requires a minimum contact
2
surface area of 6.25 cm
for stability at the interface for
a patient with normal bone mineral density under normal postoperative physiologic conditions (21). This
amount of contact surface area can be obtained by
preparing the end plates for 2.5 cm × 2.5 cm for bone
grafts. For the average-size adult Caucasian, laminotomies and medial one-half facetectomies with
retraction of neural elements medially to the midline
provide adequate exposure (1.3 to 1.5 cm on each side)
for decortication of vertebral end plates between pedicles (1.25 cm from each side) and to the depth of 2.8 cm
anteriorly. This contact surface area of 6.25 cm
2
approximately equal to the total contact surface area of
two tricortical iliac crest bone grafts.
Bone Graft Insertion
Stand-alone PLIF construct (PLIF construct without
internal f ixation systems such as pedicle screw fixation
or facet screw fixation) requires bone g rafts that provide
sufficient compressive strength to prevent graft collapse,
that provide a suff iciently large contact surface area to
prevent subsidence, and that have good bone healing
potential. Two autologous tricortical iliac crest bone
grafts meet all of the requirements. Each tricortical iliac
crest bone graft may be harvested and split in half and
inserted in four blocks of split grafts (Fig. 32-5). An alternative graft is to remove the outer wall of the iliac crest,
obtaining four corticocancellous blocks. These modifications allow easy placement of graft into the disc space
without excessive retraction of neural elements, and save
the inner cortical table of the iliac crest. Patients treated
with stand-alone PLIF with four blocks of autologous
one-half iliac crest bone grafts show no significant graft
subsidence or graft collapse. Furthermore, there is no significant difference in graft subsidence or fusion rate
between stand-alone PLIF and PLIF with pedicle screw
fixation. This strongly suggests that stand-alone PLIF
provides a high rate of fusion without subsidence or graft
collapse when the basic principles of PLIF techniques are
diligently followed. These include: (a) saving posterior
structures of interspinous and supraspinous ligaments
and lateral one-half facet joints; (b) adequate size of vertebral end-plate preparation for contact surface area with
bone graft; and (c) proper choice of bone graft in quantity and quality.
is
328 /SECTION V/SPECIFIC CLINICAL ENTITIES
FIG. 32-5. Preparation of the vertebral end plates and insertion of bone grafts. The vertebral end plates
are decorticated between the pedicles (about 2.5 cm) and to the depth of approximately 2.8 cm toward
the anterior aspect of the spinal column. Four blocks of bicortical corticocancellous graft (each with 0.7
cm width, 2.5 cm depth, and with an appropriate height) are impacted into the disc space. The space
available for bone graft inser tion is limited to approximately 1.25 to 1.3 cm when the neural elements
are retracted to the midline. A bone graft wider than 1.3 cm is very difficult and requires further retraction of neural elements or total facetectomy.
Modifications of the Basic PLIF Technique
Many different types of modification of PLIF surgical
techniques have been described in the literature (22–31).
Some advocate bilateral total facetectomies and laminotomies for a larger surgical exposure and for easier
insertion of bone grafts or interbody fusion devices. This
surgical exposure, however, produces an unstable PLIF
construct and requires additional rigid internal f ixation
systems such as pedicle screw fixation or facet screw fixation. One other similar variation is unilateral approach:
laminotomy and facetectomy, insertion of bone graft or
interbody fusion devices and pedicle screw fixation are
performed on one side only. Little information is available in the literature about the success rate of the unilateral PLIF.
Facet screw fixation or other posterior tension band
devices have been used with PLIF for additional stability
of the fusion construct. PLIF with pedicle screw fixation
provides a marginally better fusion rate than stand-alone
PLIF. A good stand-alone PLIF construct provides sufficient enough stability for prevention of subsidence or
bone graft collapse. A clinical comparison study of standalone PLIF versus PLIF with pedicle screw fixation
demonstrated no significant difference in subsidence and
graft failure (32). Patients with stand-alone PLIF do not
require any external brace postoperatively. Patients with
PLIF and pedicle screw fixation appear to have easier and
faster mobilization during the immediate postoperative
period.
Although autologous iliac crest corticocancellous bone
graft has been the standard for basic PLIF procedure,
many other alternatives have been used. These include
local bone graft from spinous process or lamina removed
during the operation, cortical or corticocancellous allograft, graft substitutes, or various types of interbody
fusion devices. In recent years, the use of ready made cortical or corticocancellous interbody fusion grafts or interbody fusion cages have become popular. Most of these
products require facetectomies to provide a large exposure for insertion, and therefore require supplemental
pedicle screw fixation. Some of these devices are poorly
designed and do not satisfy the basic principles of interbody fusion techniques (Fig. 32-6).
The average interpedicular (right to left) distance of
the lower lumbar spine of an adult Caucasian is about 2.5
cm, and the average disc height in the lower lumbar spine
is 1.2 to 1.3 cm. In order to have a cylindric cage suff iciently contact the vertebral end plates, the diameter of
the cage has to be greater than 1.6 cm. A smaller cage
will result in gradual subsidence or failure of bony union.
A cage with a 1.5 cm diameter or greater will be very difficult to inser t posteriorly because of the anatomic limitations described herein. It requires total facetectomy or
CHAPTER 32/POSTERIOR LUMBAR INTERBODY FUSION / 329
FIG. 32-6. Interbody fusion devises. For a lower lumbar disc with disc space height of 1.2 cm, the
diameter of a cylindric cage should be more than 1.6 cm for adequate contact surface area.To insert
this through the posterior approach, the surgical exposure requires total laminectomies and facetectomies and requires retraction of the neural elements far beyond the midline.
excessive retraction of the dura and the nerve root be yond
the midline for insertion of such a large cage. The interpedicular distance in the Asian population is smaller than
that of Caucasians, and the procedure becomes even more
difficult and riskier for excessive bleeding and neural
injury (33). Any interbody device or prepared bone graft
in excess of 1 cm wide is difficult to insert posteriorly
into the disc space, and it requires an excessive amount of
retraction even with total facetectomies. The design of
interbody fusion devices for PLIF should be different
from that for ALIF because of these anatomic limitations.
Surgeons must be familiar with these limitations and
choose a proper device to avoid serious complications.
Complications of PLIF
PLIF has a steep learning curve and it carries the risk
of various complications (34–41). Most complications
during PLIF are related to inadequate exposure, excessiv e
epidural bleeding, and poor understanding of anatomic
and biomechanical principles of the procedure.
Excessive epidural bleeding can be a problem during
the PLIF procedure. This ma y cause not onl y an excessi ve
amount of blood loss but also poor visualization of the
surgical field leading to dural tear or neural injury. Adequate bleeding control with a dry surgical field must be
obtained before mobilization of neural elements and
work within the disc space.
The incidence of neuropraxia is reported in the range
of 1.5% to 4% (34,41). Okuyama et al. reported a high
rate (8%) of neuropraxia, but all had transient neuropraxia with no permanent neural palsy (40). This is primarily due to excessive and prolonged retraction of the
nerve root. To avoid this complication, one must have
constant visualization and adequate mobilization of the
dura and nerve roots, and must avoid prolonged retraction
of neural elements. When PLIF procedure is performed
on a patient who had previous posterior disc surgery with
perineural scar, one must pay extra attention to mobilize
the neural elements and release them more frequently
from retraction. The incidence of dural laceration is
reported in 1.5% (34). This is primarily due to poor visualization of the dura either by an inadequate size of exposure or by excessive bleeding. Over-sized bone graft or
interbody fusion device is another cause for dural laceration during insertion.
The incidence of bone graft migration into the spinal
canal is reported in the range of 0.3% to 2.4% (34,35,
41). The common causes for this complication are misfit of bone graft or interbody fusion device in the disc
space or an unstable fusion construct. Proper preparation of the vertebral end plates and adequate size of bone
graft are essential for a stable fusion construct. When
posterior spinal structures are removed during the PLIF
procedure, especially the facet joints, the fusion construct
must be adequately stabilized with a rigid internal fixation system.
Excessive epidural fibrosis has been blamed to be a
cause of failed PLIF procedure, although it has not been
proven b y an y credib le study. Excessive epidural bleeding
330 /SECTION V/SPECIFIC CLINICAL ENTITIES
and rough handling of the neural elements during the
procedure may result in excessive scarring that may
adversely af fect the outcome. Adequate control of epidural
bleeding, as described earlier, will minimize any signif icant epidural fibrosis.
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CHAPTER 33
Operative Treatment of Anterior Procedures
Kambiz Hannani and Rick Delamarter
Low back pain has been a significant cause of disability.
Disc pathology, such as degenerative disc disease and instability, is believed to contribute to chronic low back pain.
Anterior lumbar interbody fusion (ALIF) addresses this
issue by removal of the disc and stabilization of the vertebrae via bone graft or substitutes, including autograft or
allograft bone or bone morphogenic protein. In the past 5
years, cages ha ve been introduced in addition to bone grafting to improve anatomic alignment and provide stability.
More recently, artif icial disc replacement has been investigated for the anterior treatment of degenerative disc disease.
Axial pain caused by degenerative disc disease continues to be the main indication for stand alone ALIF. Multiple studies have demonstrated the presence of nociceptors in the anulus of the disc. The innervation of the disc
is found to increase in discogenic disease (1). Therefore,
the removal of the pain generator (disc) is a logical
approach to improve patients’symptoms.
Determining which patients with low back discomfort
have discogenic pain is challenging. Multiple factors,
including the patient’s signs and symptoms, radiographic
findings, and pro v ocative tests need to be combined to mak e
an accurate diagnosis and treatment plan. Patients with
discogenic disease tend to complain mainly of low back
pain with minimal leg radicular symptoms. The pain usually
worsens with flexion and on the return to the erect posture.
Radiographic findings may be subtle on X-ray films.
Degenerative disc disease (DDD) can be identified radiographically by a decrease in disc space height and the
presence of osteophytes. Magnetic resonance imaging
(MRI) is helpful in identifying DDD . Magnetic resonance
imaging findings of DDD include decreased signal of the
disc on the T2-weighted images. A high-intensity zone
(HIZ) may be identified, which is thought by some to be
associated with positive discography and annular tears.
Discography, although controversial, is helpful in identifying symptomatic DDD. Concordant pain during disco graphy may respond to surgical fusion (2).
Multiple surgical options are available for the surgical
treatment of symptomatic DDD. Anterior lumbar interbody fusion alone, combined ALIF and posterior fusion
with instrumentation, posterior fusion alone or combined
with posterior lumbar interbody fusion (PLIF) are all
potential options availab le to the sur geon. Although many
patients having fusion do well, the removal of the disc
appears to improve the surgical outcome for DDD (3–6).
The two approaches that allow for removal of the disc are
ALIF and PLIF.
Cloward f irst reported on posterior interbody fusion in
1943 (7). In 1956, he described an anterior cervical interbody fusion (8). However, anterior lumbar interbody
fusion was first reported by Paul Harmon in 1963, and
Crock described a bilateral Dowel technique in 1982
(9,10). Although multiple options are available for the surgical treatment of DDD, ALIF has many advantages compared to other procedures. In contrast to posterolateral
intertransverse fusions (PLIF), ALIF restores the disk
height thereby allowing decompression of neuroforaminal
stenosis. Anterior column support fav ors load transmission
and places the bone graft volume under compression.
Finally, ALIF removes the disc, which may be the painful
structure (11). Compared to PLIF, ALIF affords a more
complete discectomy and a v oids dissection of the posterior
paraspinal muscles. The operati v e time is significantly less
with ALIF compared to PLIF, and it can be performed
using minimally invasive procedures (11).
Allograft or autograft can be used for ALIF procedures. Historically, autograft has been the gold standard
with excellent incorporation and high fusion rates. Good
clinical outcomes with ALIF autograft have been reported. Penta reviewed 125 patients who underwent
ALIF with iliac crest bone graft (ICBG) over a 10-year
period (12). Sixty-eight percent of the patients were satisfied. The overall fusion rate was 72.4%, and varied
from 91% for single level fusions to 51% for multilevel
fusions. However, one drawback of ICBG is the risk of
331
332 /SECTION V/SPECIFIC CLINICAL ENTITIES
graft subsidence and collapse, which is less common with
allograft struts (13,14). Furthermore, the iliac crest donor
site is a significant source of morbidity.
Allograft bone has also been used as a stand-alone
device with ALIF. Kozak reported excellent results with a
combination of cortical and cancellous allograft with
97% fusion rate at 1-year follow-up. Recently, however,
unfavorable results with this procedure were reported by
Dawson et al. (15). Seven of 16 patients in that study
developed a pseudarthrosis that required posterior fusion.
Additionally, all patients showed subsidence of their
grafts within the first year, with the pseudarthrosis group
having a threefold increase in subsidence compared to the
fused group (Fig. 33-1).
The fusion rate increases when ALIF using autograft is
combined with posterior instrumentation (16,17). Sarwat
reviewed 43 patients undergoing combined antero-posterior fusions using femoral allograft rings packed with
A
C
FIG. 33-1. A: Lateral X-ray of a lumbar spine illustrating instability and grade I spondylolisthesis at L45 with moderate disc space loss and degenerative disc disease at L5-S1 interspace.B: T2 sagittal magnetic resonance image confirming the degenerative disc disease at the lower two levels with decrease
T2 signal and end plate changes at L4-5. C: Lateral X-ray of the lumbar spine following anterior lumbar
interbody fusion using femoral ring allografts at the L4-5 and L5-S1 interspaces; the disc spaces have
been restored with anatomic reduction of the spondylolisthesis at L4-5. D: Antero-posterior X-ray following anterior lumbar interbody fusion.
B
D