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Dept of Orthopedics
Med College, Calicut

 

 

 

 

 

 

ORIGINAL ARTICLE

Biologic Distraction and Maintenance Of Disc Height In Lumbar Disc Disease With A Different Technique: A Clinical and Technical Study.

Gopinathan Patinharayil*, Anwar Marthya*, Chathoth Meethal Kumaran*, Chang Whan Han*, Dinesh SunnyVeliath*, Sibin Surendran*, C V Krishnakumar*

* Department of Orthopedics, Medical College, Calicut,Kerala, India

Address for Correspondence:  

Dr Gopinathan P
Department of Orthopedics, Medical College,
Calicut,Kerala, India

Abstract:

Improvements in spinal instrumentation system has been   the rule of current practice, recently interspinous spacers has been used to treat lumbar disc disease. This sytem relies on the principle of distraction in the interspinous area with indirect decompression of the roots by enlarging the intervertebral neural foramen. 

 We studied the results of a similar principle but using a different system.  We analyzed the role of biologic distraction and global fusion, with maintenance of the disc space using Modified Quasi-Claw technique, in lumbar spine for the treatment of chronic lumbar disc pathology. The modified Quasi-Claw makes use of a distraction claw with supralaminar hooks below and infralaminar hooks above with biologic distraction applied between them. We conducted a prospective study in a series comprising 70 patients (142 segments) with lumbar disc pathology with an average follow up of 2.5yrs. Average preoperative Oswestry disability index was 74.22 and Visual analogue scale(VAS) score was 68.12. Biological distraction was achieved using the principle of Modified Quasi-claw and fusion achieved using posterior lumbar interbody fusion (PLIF) with minced iliac crest graft along with posterolateral fusion (global fusion - 360˚ fusion). Average post operative Oswestry disability index was 26.64 and VAS score was 14.32 respectively which was found to be statistically significant (p<0.01 ). Biological distraction restores disc height, helps in root canal decompression by increasing the size of intervertebral foramen, improves the load bearing ability of anterior ligaments and muscles and helps in maintaining the spinal balance. It also stabilizes the spine by avoiding the abnormal intrinsic instability between the motion segments. The authors consider that biological distraction using the principle of Modified Quasi-Claw with PLIF and posterolateral fusion in the treatment of chronic lumbar disc pathology is a novel concept with a good outcome.

J.Orthopaedics 2008;5(2)e5

 Keywords:
Biologic distraction; Modified Quasi Claw; Posterior lumbar interbody fusion (PLIF); Lumbar segmental instability; functional spinal unit.

Introduction:

The management of chronic disabling low back pain due to lumbar disc disease has always been a controversy in modern orthopedics.  Several treatment methods have been described but none of them have given satisfactory results.  Hence there has always been a quest for newer techniques in this field.   We describe a new technique with good and reproducible outcome in the treatment of Lumbar disc disease.

Crock H V1 described internal disc disruption. The abnormality in the internal architecture of the disc could cause mechanical back pain and referred pain. The outer third of the annulus of the intervertebral disc has nociceptive capability and this could account for discogenic back pain due to internal disc disruption 2, 3, 4. 

Pedicular screws used to achieve posterior lumbar interbody fusion (PLIF) has the disadvantage that the graft should be locked in compression. The compression further narrows the intervertebral neural foramen and the patient may still be symptomatic. So distraction is more biologic in the lumbar spine. The pedicular screw introduction invariably needs radiologic  imaging. In this technique biologic distraction is applied to the posterior complex which is more physiologic since the tension surface of the spine is anterior complex when the spine is considered as a single unit. The Quasi-claw does not need imaging for introduction and is quick with minimum operating time. This study attempts to delineate an easier and more biologic  method of achieving PLIF with out imaging.

Several articles 5,6,7 describe treatments using anterior lumbar interbody fusion (ALIF) and  posterior lumbar inter body fusion(PLIF) with instrumentation.  Posterior lumbar interbody fusion (PLIF) 5,8,9 offers several advantages – it restores disc height, maintains root canal dimensions by increasing the size of the intervertebral neural foramen.   It also restores the load bearing ability of anterior ligaments and muscles, helps in maintaining the spinal balance and in maintaining lumbar lordosis. But with traditional method of compressing the graft in the disc space there is an inherent risk of narrowing of the disc space and the intervertebral foramen especially when the graft collapses.

PLIF also helps in stabilization of unstable functional spinal unit.  The results of PLIF with instrumentation has been good.7,10,11,12,13,14.The transverse diameter of neural foramen at the disc level of L5-S1 motion segment is around 7 mm.  The diameter of the L5 root is around 7mm 15.  This creates a critical area through which the root escapes. Any reduction in disc height further reduces the transverse diameter and results in compressive radiculopathy.  So the only method to address this problem is by maintaining the disc height and increasing the transverse diameter of the intervertebral neural foramen to decompress the root. This can be achieved by a constant biologic distraction using Quasi-claw.

The currently available segmental instrumentation and bone grafting have helped in achieving posterior intertransverse and posterolateral fusion with results comparable to that of PLIF 16, 17, 18.  But these studies were done on patients with different pathologies and different methods of treatment.  Facetectomy was always a part of PLIF with the use of tricortical grafts. But in this study no facetectomy was done, and minced iliac crest graft were used instead of tricortical iliac crest graft.   The disc space was maintained by posterior biological distraction and instrumentation.

Quasi Claw technique for spinal segmental stabilization is achieved by all hook instrumentation. The supralaminar hook is inserted over the inferior lamina and the infralaminar hook is inserted under the superior lamina of the adjacent vertebra.  This technique stabilizes a single motion segment.  In modified Quasi Claw technique two motion segments are stabilized instead of one.  In modified Quasi Claw technique supralaminar hook is inserted over the inferior lamina and infralaminar hook is inserted under  the superior lamina of the vertebra one level above the adjacent vertebra.

Aim:

To determine the effectiveness and evaluate the outcome of PLIF with biological distraction and posterolateral fusion (global fusion) in the treatment of lumbar disc disease using a different technique.

Material and Methods :

 The study was approved by the institutional ethics committee. Informed consent was obtained from all the patients.

We studied seventy cases of symptomatic Lumbar disc disease operated between June 2000 and December 2005. All the selected cases were in the age group of 30 to 73 years, irrespective of the gender. Average age at the time of operation was 59 ± 7.6yrs. All the cases underwent PLIF with biological distraction using posterior instrumentation and posterolateral fusion. They were followed up for an average period of 2.5 years. A total of 142 segments were fused (Table1,). All the cases were performed by the same  senior surgeon (PGN).

Radiological involvement of intervertebral disc were classified according to Saraste’s classification 19

Stage IA: Normal disc height without dehydration

Stage IB: Normal disc height with dehydration

Stage II: Disc height decrease by less than 50%

Stage III: Disc height decreased by at least 50%

Stage IV: Disc height obliterated (with or without instability)

Potential risk factors for achieving fusion like previous failed fusion, heavy smokers (more than 1 packets of cigarette per day), heavy manual laborers, fusion of more than two  motion segments, instability, listhesis, excess weight (more than 40 Kg in excess of predicted weight) were specifically noted. Patient data about age, sex, walking distance, working capacity, current employment, smoking, VAS(visual analogue scale)  and Oswestry disability index were collected before and after surgery.

Preoperative investigations included plain X-rays, stress X-rays and MRI in all patients. . Lumbar segmental instability was defined as a motion greater than 4 degree of sagittal rotation or angulation and translation of more than 4 mm  15

The inclusion criteria for the patients were:  

  • Patients with grade III and grade IV stages of Saraste19 of symptomatic lumbar disc disease in whom conservative treatment has failed.

  • Only patients  with minimum two adjacent  motion segments are included.

  • Patients with grade I listhesis (degenerative).

  • Patients with symptoms of lumbar segmental instability confirmed radiologically.

  • Previously operated symptomatic patients, who had undergone spinal fusion, decompression and discectomy without significant symptomatic relief.

  •  Patients with symptomatic psuedo-arthrosis, from previous un-instrumented surgery.

Exclusion criteria were,

  • Severe spinal canal stenosis.

  • Single level Disc disease irrespective of grade of disc degeneration.

  • Infection.

  • Trauma.

  • Tumour.

  • Previously instrumented fusion.

The union was probable when bony trabecular continuity was not clear, and there was less than 4-degree mobility between adjacent fused segments. Nonunion was defined as clear gap and motion greater than 4 degree of sagital rotation or angulations and translation of more than 4 mm  15. But the presence of instruments will definitely hinder this interpretation. The preoperative and postoperative disc height was measured in all cases in lateral view midway between the anterior and posterior longitudinal ligaments.

Patient data about age, sex, walking distance, working capacity, current employment, smoking, VAS and Oswestry disability index were collected before and after surgery.

Clinical improvements were noted on the basis of improvement of back pain and working capacity. Follow up was done at 3 months and there after at regular intervals of 6 months

Clinical improvements were noted on the basis of improvement of back pain and working capacity. Follow up was done at 3 months and thereafter at regular intervals of 6 months.

Out of 142 segments fused, 100 segments had grade IV and remainder had grade III degeneration. Disc involvement according to the spinal levels is shown in Table2. 68 patients had adjacent one level disc disease and two had three level disc disease. Single level disc diseases were not selected.

Adjacent segments, which were abnormal in the form of Grade III or IV disc disease,

were included in the fusion mass to prevent post fusion symptoms. Four patients had Grade IV disc degeneration with grade I listhesis, all were at L4-L5.In all these patients reduction could be achieved with the method described. Two patients were previously operated cases for grade IV disc degeneration at L4-L5. Thirty two patients had paraesthesia or sensory deficit.  Radiculopathy was present in 10 patients in the form of L5 or S1 root lesion. Tone and reflexes were normal. The average follow up period was two and half years (between two to three years).  Out of 142 segments, 132 levels had clinico-radiological correlation. 10 segments (in the double level group) had atypical pain, which had grade IV disc degeneration changes at adjacent segments and so adjacent levels were included in the fusion mass. All segments with grade IV degeneration had radiological signs of Lumbar segmental instability (LSI).

Table:1

 

L3-L4

L4-L5

L5-S1

Total

Grade III

0

27

15

42

Grade IV

2

36

62

100

Total

2

63

77

142

On doing the Chi square test, a significant relationship (at 5% level) was seen between grade IV disc degeneration and L5-S1 level.

Table 2:

 Statistical analysis

 Statistical analysis was performed by using Paired t-test with using SPSS for Windows (version 12.0, SPSS, Chicago, IL). Comparisons between preoperative and postoperative disc height,VAS, Oswestry score  and grade of degeneration and spinal level measurements were made using the Paired t-test. The values were summarized as mean ± standard deviation. A p value of < 0.05 was considered significant. 

Surgical Technique:

Posterior lumbar interbody fusion (PLIF) was done through a midline posterior approach under general anaesthesia in the lateral decubitus position. Laminectomy was performed, but facetectomy was not done in any case.  Discectomy was done in all cases and end plates prepared till bleeding subchondral bone was exposed.  The nerve roots were retracted and protected. All hook system was used in all the patients. Posterior instrumentation with Modified Quasi Claw with short segment stabilization was done using indigenously made supralaminar and infralaminar claw.. The instrumentation consisted of supralaminar and infralaminar narrow hooks, positioned in the superior and inferior laminae after decompression.. The rods were contoured to maintain the lumbar lordosis.   Instead of tricortical iliac crest grafts, minced iliac crest grafts were packed through the hole made for removal of the disc. Disc height was maintained by biological distraction and packing the disc space with bone grafts.  Autologous iliac crest grafts were used in all patients.  Maintenance of the disc space increased the size of the intervertebral foramen and this indirectly decompresses the nerve root (Fig1,2). Posterolateral fusion was done through subperiosteal approach, and the bed of the graft, prepared by subperiosteal dissection through the transverse process and through the remaining lamina and spinous processes.  Inter facetal fusion was achieved without facetectomy, by exposing the subperiosteal region of superior and inferior facets and bridging them with autologous iliac crest graft.     

Radiologic assessment for integrity and placement on the implants were done on the table before closure of the wound. Postoperatively all patients were mobilized on the 3rd day on a Knight Taylor’s brace.  Postoperative stress x-rays where taken in all patients after 8 weeks. The criteria for fusion was trabecular continuity8.All the levels fused when there was less than 4 degree mobility as measured by sagittal rotation angle or less than 4 mm translation as measured as sagittal translation distance.

Fig1 and Fig2 :Diagrammatic representation of biologic distraction with maintenance of disc height and indirect decompression of the nerve root by the enlargement of the intevertebral  neural foramen.

Fig 3 : Preoperative radiogram showing Grade 1 lumbar spondylolisthesis at L4-L5 with unequal and also reduced disc height at L4-L5.
 

Fig 4 :Post operative radiogram showing normal disc height and parallel end plates with reduction of spondylolisthesis.
 

Results :

Mean VAS was improved from 68.12 to 14.33 in this study. The range of VAS was 15-80 preoperatively , while post operatively it was 10-20. The average reduction in VAS was 48.5 % (Table 3).

Average preoperative Oswestry disability index was 74.22 and post operatively was

 26.64 (Table 4). The range was from 60-88 preoperative and 20-36 post operative so the reduction in disability was 49%. Since the intervention involved a single variable with paired measurements in each subject the paired students t test was used as the test of statistical significance. This was statistically significant with the p-value <0.01 .So there was significant statistical improvement in Oswestry score (p<0.05%). There was 4-fold increase in walking distance. Age at the time of operation was 59 ± 7.6 yrs. The range being 30 to 73 yrs. The average operation time was 101.8 ± 50 mts and the average blood loss was 633 ± 25.4 gms.

Excellent correction of disc height could be achieved post-operatively (Fig3,4). Average preoperative disc height was 4.72 ± 1.49mm and post operative was 9.81 ± 2.19mm with an average increase of 5.12mm.(Table 5)

Table 3:   VAS Score (n=70)

 

 Preoperative

   Postoperative

Mean

          68.12

              14.33

Std. Deviation

           9.89

                2.49

    p value  < 0.01

Table 4    :  Oswestry Score(n=70)

 

  Preoperative

          Postoperative

Mean

              74.22

               26.64

p value  < 0.01

Table5 : Disc Height (n=142)

 

   Preoperative(mm)

     Postoperative(mm)

Mean

  4.72 ± 1.49mm

      9.81 ± 2.19mm

Twelve patients were symptomatic even after surgery. Of these twelve, eight patients had low back pain, 4 patients had leg pain at latest follow up. Out of these 12 patients,10 patients said their symptoms improved after surgery, but 2 patients had same symptoms even after surgery.

None of the patients had nonunion. 4 patients had doubtful interbody fusion but had demonstrable posterolateral union and the sagital translation less than 4mm, sagital angulation less 4 degree. 32 patients returned to their original duties. Twenty two patients returned to light duties after surgery. There was an improvement of 77% in working ability according to Oswestry scale.

 Four patients developed urinary tract infection, treated successfully with antibiotics. Two patients had delayed wound healing and persistent iliac crest pain for six months, both were known diabetic patients. Two cases had paralytic ileus, which responded to treatment.

Discussion: 

It is always desired that a comprehensive approach is a must in the management of chronic disc disease with low backache (LBA). But the complexity of the problem puts the  treating surgeon in a difficult situation. Morgan FP et al 20 drew attention to the association between annular tears, radiographic instability and LBA and the use of flexion extension views in  diagnosing lumbar segmental instability. Kirkady Willis21 et al  defined stages of instability and focused on anteroposterior and lateral bending radiographs in chronic lumbar disc disease. They described three stages of disc degeneration.  

  • Stage I: circumferential and radial tears in the disc annulus and localized synovitis with hypermobility of facet joints. 

  • Stage II:  characterized by internal disruption of disc, progressive disc resorption, degeneration of facet joints with capsular laxity, subluxation and joint erosion leading to instability. 

  • Stage III : marked by osteophytosis and spinal stenosis, where the body tries for stabilization.

 Frymoyer JW22  et al defined the basis of mechanical instability in chronic lumbar disc disease and  described that the disc degeneration can result due to aging.

Leufven 23 et al reported 93% fusion and 73 % satisfactory outcome using circumferential fusion and 62% patients had returned to original work. Some other authors 5,6,7,8,10 have reported 70% satisfactory outcome when PLIF was combined with posterolateral fusion and instrumentation. Degenerative lumbar segmental instability is a concern for spinal surgeons even today. Accurate pre operative identification of each component of the problem, which produces a particular symptom, should be addressed individually for the complete relief. PLIF is commonly advocated as a method of treating mechanical low back pain including LSI (Lumbar Segmental instability) with 70-80 % fusion rate and patient satisfaction are reported in literature 1,5,24 and 75 – 90% return to work is also reported.  Accelerated degeneration of the adjacent segments was described in literature.25,26,27,28 Once a particular functional spinal unit is fused, more stress occurs at the adjacent spinal unit, accelerating degeneration and Lumbar Segmental Instability.27 Instability in a particular functional spinal unit starts as sclerosis of the end plates with disk space narrowing, (Figure 1).             

 It causes hypertrophy of the ligamentum  flavum and posterior longitudinal ligament. Later on there is translation listhesis and angulations that  indirectly narrows the intervertebral foramen and compresses the root. This will result in spinal canal stenosis, facet joint arthritis, capsular ligament laxity of the facet joint with facetal instability resulting in facet induced pain and discogenic pain.  It can also lead to claudication and neurological deficit (Table 1) from global spinal instability in a particular functional spinal unit.It is the surgeon’s duty to intervene at any of these stages to reverse this cascade of processes, so that the symptoms can be reversed. Instability should be addressed by instrumentation, which later on should be taken over by  interbody and posterolateral fusion . Otherwise, the implant will fail in the long run. Canal compromise should be addressed by decompression.In this study, stress is given to maintain the disk height by the technique of jacking up the disk space so that this will indirectly increase the size of the intervertebral foramen and decompressing the root, thus relieving the radiculopathy. Adjacent functional spinal units are usually abnormal and should be included in the fusion mass to avoid re operation for LSI at the adjacent functional spinal unit.The etiology of low backache is often  multifactorial, including organic and nonorganic causes. This study was not intended to address all of the manifestations of low back pain, but it was directed at evaluating the efficacy and safety of the technique of fusion and instrumentations. Chronic low backache cause prolonged disability, anxiety and discomfort. It is often difficult to treat such patients because of difficulties in diagnosis and interpretations of investigations. There is also an important factor of psychosomatic elements. Clinicoradiological correlation revealed high intensity zone in MRI, loss of disc height, end plate changes and grade one listhesis, which were addressed during treatment14. Fusion rate was 100%. The assessment was prospective. The work ability out come was good probably because of better restoration of disc height, maintenance of lumbar lordosis and better load distribution through the spine. Nachemson et al 30 discussed the psychological factors in this particular condition. In this study no attempt was made to assess the psychological status of patients. Psychological factors do affect pain, hence patient selection is important. 83% patients had good outcome in this study. Usually posterolateral fusion has been advocated for this condition to avoid morbidity associated with PLIF.17. In this study 100% fusion rate could be achieved by disc excision and instrumented PLIF and posterolateral fusion. This eliminates chemical and mechanical sources of pain associated with internal disc disruption. If the disc is not removed, it remains as a source of continuous pain. Correction of instability and removal of biological substances from degenerated disc eliminates the nociceptive stimulation of outer annulus 2,3,4        

The motion segment is a three joint structure with two facet joints and the intervertebral disc 30. PLIF should be supported by posterior instrumentation. PL fusion will enhance fusion at PLIF. The current study shows 4 patients with doubtful PLIF, but had good PL fusion.

This novel technique has the advantage of extreme technical simplicity, it does not need imaging for placement. In degenerative lumbar disc disease, the traditional method of pedicular screw fixation carries risk of implant failure due to osteoporosis and lack of adequate screw purchase. The severity of osteoporosis is most marked initially in the vertebral bodies. The posterior complex is spared from osteoporosis. This technique makes use of posterior complex for implant fixation  which is more biomechanical stable. The traditional method of pedicular screw involved compression using pedicular screws .This will result in narrowing  of intervertebral foramen and results in radicular pain. This technique uses the technique of biologic distraction which widens intervertebral foramen and reduces the chances of radicular pains. If the lumbar spine is considered as a single unit, the anterior complexes form the tension surface and the posterior complex  forms the compression surface. Compression of the tension surface is the well accepted method of stabilization of any bone. So compression of the posterior complex with pedicular screws is biomechanically incorrect. Biologic distraction of the posterior complex indirectly leads to compression of the tension surface i.e the anterior complexes and is more physiologic. Screw  breakage is a known complication with the traditional method but not a problem with this technique. The disadvantage of this technique is that over distraction and  lack of proper contouring of the rod leads to flat back syndrome but adherence of the correct technique negates this problem. Hook dislodgement could be a problem but correct selection of hooks and their perfect placement avoids such complication. 

The traditional method of pedicular screw fixation with compression to lock the interbody graft has the disadvantage of narrowing the disc space and intervertebral foramen especially when there is graft collapse 31.  The primary concern of LSI is radicular pain and pain due to instability.  Radicular pain can be addressed to a certain extent by foraminotomy but the basic disease process is not corrected.  So maintaining the disc height is of great importance which can be achieved by biologic distraction and PLIF.

The transverse diameter (from the ligamentum flavum to the vertebral body and disc) of intervertebral foramen at L4 disc level is around 7mm. Diameter of L4 root is around 7mm 15,31. So there is a critical area through which root escapes 12,32. Measuring the cross sectional area of the canal seems pointless unless only the minimal area is considered 32   Narrowing of the intervertebral foramen will further reduce this transverse diameter and result in radiculopathy.

Tandon etal 13 reported mean reduction in Oswestry disability index from 51 preoperative to 39-post operative so there is reduction of disability by 12%. This series shows an improvement by 25%.

Biologic distraction with instrumentation helps to maintain the disc height resulting in prevention of compression of nerve roots in the intervertebral foramen. By maintaining the disc space transverse diameter can be increased and the root can be indirectly decompressed.  The traditional 31 method of pedicular screws used to compress the vertebrae together may reduce the disc height especially when there is tricortical graft collapse. This will lead to foraminal narrowing and radiculopathy resulting in radicular pain even after solid fusion. The good outcome in this study could also be either due to decompression of the roots or dural sac, or could be due to short-term nature of this study.

The current study shows that maintenance of disc height (Figure 2) and PLIF along with posterolateral fusion had produced good clinical outcome. More patients returned to their original work. PLIF improved the dynamics of lumbar spine and restores lordosis, reduces biochemical and mechanical factors of pain (Table 2).  PLIF also restores the disc height, which is critical in achieving good outcome. Thus stability achieved at the end of fusion aids in good outcome. The facet joints and the annulus fibrosus, which are the main stabilizers in the axial plane1,14 are only disturbed to the minimum.

Suk et al 33 reported a mean pre-op disc height  of 7.4 ± 5.6 mm which was improved to 9.8 ± 2.6mm. We obtained a comparable result of average preoperative disc height as 4.72 ± 1.49mm and post operative as 9.81 ± 2.19mm with an average increase of 5.12mm.                                         

The global fusion of 100% in this study does not correlate with the 80% recovery by Oswestry (Table 3) probably due to the psychosomatic status and multifactorial 30 nature of the particular problem. Appropriate patient selection after psychosomatic assessment could further improve the result. Posterior distraction and instrumentation apply distraction to the posterior lordotic (concave) side of the lumbar spine, which is more physiologic than compression of the posterior aspect of the lumbar spine.  Since the rods are contoured to the exact lumbar lordosis, there is less chance of flat back syndrome.    As long as the amount of distraction is just to maintain the disc height and within physiological limits it does not seem to affect the biomechanics of the spine. To the best of our knowledge, there are no reported studies with use of such an instrumentation technique to treat the particular group of patients. But considering the short term nature of the study, further studies with long term follow up are needed to have for a more clear-cut analysis.

Conclusion:

The present study has demonstrated that rigid instrumentation with biologic distraction, using the principle of Modified Quasi claw; with a short segment stabilization produces good clinical results in the type of patients with chronic lumbar disc lesions as detailed in this study. This is achieved by maintenance of disc height, with indirect decompression of roots along with global fusion.  PLIF, posterior instrumentation and posterolateral fusion (global fusion) is effective in producing solid satisfactory fusion rate.  Good clinical outcome is obtained is based on reduction in pain, return to work or comparable activities. There was significant improvement in Oswestry score (p < 0.01). The maintenance of disc height is probably the single most important factor in improving outcome in such patients.

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This is a peer reviewed paper 

Please cite as : Gopinathan Patinharayil: Biologic Distraction and Maintenance Of Disc Height In Lumbar Disc Disease With A Different Technique: A Clinical and Technical Study.

J.Orthopaedics 2008;5(2)e5

URL: http://www.jortho.org/2008/5/2/e5

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Ph:+91 9961303044

E-Mail:
anwarmh@gmail.com

 

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