Abstract The Results & Affecting Factors of Posterior Lumbar Interbody Fusion with TPM Cages in Spondylolisthesis Jae Yoon Chung, M.D., Hyoung Yeon Se

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1 Abstract The Results & Affecting Factors of Posterior Lumbar Interbody Fusion with TPM Cages in Spondylolisthesis Jae Yoon Chung, MD, Hyoung Yeon Seo, MD, Jong Seon Kim, MD Department of Orthopedic Surgery, Chonnam National University Hospital, Gwangju, Korea Study Design : This is a retrospective study analyzing the results of posterior lumbar interbody fusion(plif with TPM cages in spondylolisthesis Objectives : The purpose of this study was to evaluate the clinical, radiologic results & affecting factors of PLIF with TPM cages in spondylolisthesis Summary of Literature Review : The ordinary PLIF has 86-98% of radiologic union rate and clinical satisfactory rate The problems of ordinary PLIF were graft breakage, donor site morbidity, limited bone resources, high failure rate using only transpedicular screw fixation Materials and Methods : From October 1995 to January 1999, 108 consecutive patients with spondylolisthesis were treated by PLIF with TPM cages, in which morcellized bone chips salvaged from posterior neural arch applied, and pedicle screw fixation Results : Preoperative Low Back Pain score(total 100 points was improved from 474 points to 887 points at last follow-up 10 point visual analogue scale was reduced to 15 point at last follow-up In the end results, Ninty-two percent of patients rated as excellent or good The preoperative value of slippage, 186% was achieved to 55% at last follow-up The anterior intervertebral disc space height was increased from 100 to 162mm postoperatively Fusion occurred in all patients except one Groups below 60-year-old patient at the time of surgery showed better clinical results than those above 60 (P<005 No clear correlations were noted between sex, the types of spondylolisthesis, bone mineral density, smoking habits and obesity in clinical, radiologic results Conclusion : PLIF with TPM cages is appeared to be a recommended procedure of choice to treat lumbar spondylolisthesis and this operation should be performed with a caution in aged patients Key Words : Lumbar spine, Spondylolisthesis, TPM cage, Posterior lumbar interbody fusion, Affecting factor Address reprint requests to Jae Yoon Chung, MD Department of Orthopaedic Surgery, College of Medicine, Chonnam National University #8 Hak-dong, Dong-ku, Gwangju, , Korea Tel : , Fax : , jychung@chonnamchonnamackr

2 ,, 23, 25, C l o w a r d 10, 11, 1, M e y e r d i n g method, 1 86, 2, 2 1, 3 1 L , (63%, L5-S120(19%, L3-4-57(6%, L4-5-S1 1 3( 12 % (Table 1 DEXA(Dual energy 2, 10, 11, 13, 17, 35, 42, 44, X-ray Absorptiometry, Lunar DPX-,,,, L (Lunar Radiation Corp, Widconsin, USA, 2, 3, 4,,, 109g/( g/ 19% 1, 3, 25, 44 (body mass index, BMI, K g /( 12, m 2, 27, 25, 32% 14, 16, 20, 30,,, 80~90Hg, 3, 10, 11,,,, (epidural fat Trapezoidal PLIF Mesh(TPM cage(depuy Acromed,, Moss M i a m i Leeds, England polyaxial screw(depuy Acromed, Raynham Ma, USA,, TPM, (12 ~62, 34(315%, 74(685% , (70%,, 105( 97 %, 102(95%, 92(86% 48, 59 Table 1 Levels of fusion Levels of fusion No of case L (63% L5-S1 20 (19% L (06% L4-5-S1 13 (12%

3 (thecal sac ( r o o t r e t r a c t o r 10 box chisel 10 point visual analogue scale (,concave shape SPSS(statistical package for social science (cortical bony plate TPM, compressor,, ( L o r d o s i s, 1997R a y 36,,,,,,,,,,, Lin 27 (Table 2, Inoue 22 (Low back pain score, LBP score LBP Score 100,,,,,,,, (Table , Meyerding grade, 1 2, 1 0 g /,,,, LBP score,,,,,, Table 2 Clinical results (Lin et al, 1983 Exellent result Good result Fair Poor complete recovery resumption of normal activity no medication returned to work took occasional mild analgesis enjoyed work & recreation activities worked with discomfort improved after surgery medication in a dependent fashion unable to return to work denied any improvement Table 3 Radiologic criteria of bony union (Ray et al, 1997 (1 lack of any visible motion or less than 3 degree of intersegmental change, as seen on flexion-extension radiograph (2 lack of dark halo around the implant (3 minimum loss of disc-space height indicating a resistance to collapse of the cancellous vertebral bone (4 lack of visible fracture of the cage, graft, vertebra (5 lack of substantial sclerotic changes in the recipient bone bed or graft (6 visible bone within the hollow Ray titanium fusion cages as seen on anterior,posterior or Feguson radiographs

4 , 887 (Table 6 105( 97 %, 27 6(6%, 102(95%, 6(6% (Table 7 ( 25 %, (neurologic claudication 92( 85 % 30( 28 %,, 10 point visual analogue 25(87%, 5(13% s c a l e ( 55 % 4 2, 1 5, 44( 72 %, (Table 6 16(28% (Table 4 L i n 80( 74 %, 20(18%, 5(5%, 3(3% (Table 5 92%, 3, 18 6 % 5 3 % 72%, 55% (pseudoarthrosis 1 (Table 6, 2 (p<005 I n o u e (LBP score 474( Table 4 Objective Clinical Results %, 153 Preoperative Complete Partial recovery recovery *SLRT 27 (25% 27 (100% 00 (00% Muscle weakness 30 (28% 25 (087% 05 (13% Sensory deficit 60 (55% 44 (072% 16 (28% *SLRT= positive to straight leg raising test Table 5 Clinical Results ( Lin et al, 1983 No of cases Exellent 80 (74% Good 20 (18% Fair 05 (05% Poor 03 (03% (Table 6, (P< ( 99 0 % 13( 10 40, 2 (Table 8 Table 7 Subjective Clinical results Preoperative Final Low back pain 105 (97% 6 (6% Leg pain 102 (95% 6 (6% Neurologic claudication 192 (86% 0 (0% Table 6 Mean LBP score, 10 point Visual Analogue Scale, Slippage Percent and Anterior Intervertebral Disc Height Change Preoperative Immediately Postoperative Final LBP score(point point scale(point %-Slip(% Anterior disc height(mm

5 2 Meyerding grade I, 19 grade II, 1 grade III,, 4, 2, (Table 10 2, 1, (Table 9,,,,,,, 1 4, (Table 11, 2, 6, 1 8, Mardjetko , 60, LBP score (P<005, (P<005 =( LBP score- LBP score/(100- LBP score 1 00, 60 79%, % 75 % Table 8 Fusion rates cases Fused (interbody fusion 107 Delayed union 002 Pseudoarthrosis 001 Table 10 Comparison of slippage percent between degenerative & spondylolytic spondylolisthesis Table 9 Complication Case Profiles No Age Sex Diagnosis Operation Cx 1 24 M LytSp L5-S1 PLIF L5-S1 distal screw breakage 2 40 M TraumaticSp L5-S1 LytSp L4-5 PLIF L4-5-S1 distal screw breakage 3 54 M LytSp L3-4-5 PLIF L3-4-5 distal screw breakage 4 56 M DSp L4-5 PLIF L4-5 distal screw breakage 5 65 F DSp L4-5 PLIF L4-5 & PL L2-3-4 L5 screw loosening 6 69 F DSp L4-5 PLIF L4-5 L5 screw loosening 7 53 M DSp L4-5 PLIF L4-5-S1 deep infection 8 66 F DSp L4-5-S1 SS L3-4 PLIF L4-5-S1 & PL L3-4 deep infection 9 71 F DSp L5-S1, SS L3-4 PLIF L4-5-S1 & PL L3-4 Pseudoarthrosis L5-S1 LytSp = spondylolytic spondylolisthesis, DSp= degenerative spondylolisthesis, SS= spinal stenosis, PL = posterolateral fusion

6 Table 11 Comparison of the clinical & radiological results between age, sex, the types of spondylolisthesis, Meyerding grade, bone mineral density, smoking habits, obesity LBP score %-slip Intervertebral disc height preop last pre Imm last pre imm last age below60(n= * * age above60(n= * * male (n= * * female (n= * * deg (n= * * lyt (n= * * Grade I (n= * * Grade II (n= * * BMD1 (n= * * BMD<1 (n= * * Smoker (n= * * Non-smok(n= * * obesity (n= * * non-obesity(n= * * * Preoperative P=0012, Last follow-up P=0022 Preoperative P=0000, Immediate postoperative P=0002, Last follow-up P=0007 Preoperative P=0017 Preoperative P=0030, Immediate postoperative P=0001, Last follow-up P=0023 Preoperative P= % 93%,, 90% 86% 45, Blumenthal 5 K a n t 24 2, ( 42 % (29%, ( 68 % R a y 36 69% 31% (Table 3-3,13,14,33,44 29,,, 26, C T 3,13,14,33, Meyerding grade,, 1,6,39, 1,3,14,42, Kuslich 19,26 86~98% 1,3,13-15,18,25,33,34,44, 99% 1, Yahiro %, 17 ~ 40 % 2 6,14,39,43 McGuire A m u n d- s o n 31, Thomsen 45,, 1,2,17,20,27,35,44 Watts

A B C Fig 1-A Lateral radiograph of a 54-year-old woman with spondylolytic spondylolisthesis Fig 1-B Lateral radiograph at the immediate postoperation shows PLIF L4-5 with TPM

fusion A B C Fig 1-A Lateral radiograph at 70-year-old male with degenerative spondylolisthesis Fig 1-B Lateral radiograph at seven-month follow-up examination shows distal

7 A B C Fig 1-A Lateral radiograph of a 54-year-old woman with spondylolytic spondylolisthesis Fig 1-B Lateral radiograph at the immediate postoperation shows PLIF L4-5 with TPM cages and Moss -Miami system Fig 1-C Lateral radiograph at three-year follow-up examination shows restoration of lumbar lordosis, wide foraminal patency, and solid interbody fusion A B C Fig 1-A Lateral radiograph at 70-year-old male with degenerative spondylolisthesis Fig 1-B Lateral radiograph at seven-month follow-up examination shows distal screw breakage Fig 1-C Lateral radiograph at two years seven months follow-up examination shows no further slippage, maintenance of lumbar lordosis, foraminal patency,, 170%,,,, 2,

8 17%, 71%, (rod 02%, 1 25% TPM,,,,, 40, 28, Roca 3,35,39,41 Nakai 2, 16, 26, Rish 38,, Brown 9, 31 TPM 44% 10, Ricciardi 37, K u s l i c h 26 Gill , 4 4,, 382 c c,,, 138, 1 4, g /,,,, Dennis %,, 46% 60 6, 1, 60 3, 14,16,20,30, 1 30,47 TPM (flattened teeth-like,,, 29, Brantigan 8,14,47,,,,,, 3, TPM,, TPM 7,19,34 Y a h i r o %,,,

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11 : : , ,,,,,,,, : ( , 887 (P<005, 100(92% 10 point Visual analogue scale 15 (P< % 53%, 55% (P< , 152mm 1, 13(8-24,,,,,,, 60 : TPM,, :,, TPM,,

Lumbar spine

Lumbar spine CT 32 111 DOI : 10.3831/KPI.2010.13.2.111 Lumbar Spine CT 32 Received : 10. 05. 23 Revised : 10. 06. 04 Accepted : 10. 06. 11 Key Words: Disc herniation, CT scan, Clinical analysis The Clinical