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COPYRIGHT 2007 BY THE JOURNAL OF BONE AND JOINT SURGERY, INCORPORATED

Surgical Outcomes of
Posterior Lumbar Interbody Fusion
in Elderly Patients
Surgical Technique
By Shinya Okuda, MD, Takenori Oda, MD, Akira Miyauchi, MD, Takamitsu Haku, MD, Tomio Yamamoto, MD,
and Motoki Iwasaki, MD
tivcsiigalion performed tit the Department of Orthopaedic Surgery, Osaka Rosai Hospital, Osaka, Japan
The original scientific article in which the surgical technique was presented was published in JBJS Vol. 88-A, pp. 274-20, December 2006

ABSTRACT FROM THE ORIGINAL ARTrCLE

BACKGROUND: We are aware of no reports on the surgical results of posterior lumbar interbody fusion in elderly patients.
The purpose of this study was to investigate the clinical and radiographie results of posterior lumbar interbody fusion with
pedicle screws in patients older than seventy years of age and compare them with results in younger patients. We also investigated the association between the clinical and radiographie results.
j
ij
IVIETHODS: The Study included 101 patients who had been followed for at least three years after posterior lumbar interbody fusion with pedicle screws for the treatment of L4-L5 degenerative spondylolisthesis. The average follow-up period
was fifty months. The patients were divided into two groups according to their age at the time of the operation: Group 1
included thirty-one patients who were seventy years of age or older (average age. seventy-four years) at the time of the
operation, and Group 2 included seventy patients who were less than seventy years old (average age. fifty-nine years).
Preoperative and postoperative status (according to the Japanese Orthopaedic Association scoring system) and postoperative complications were compared between the two groups. Postoperative radiographie features, including fusion status and segmental lordosis, were also examined.
RESULTS: No significant differences in preoperative and postoperative scores were observed between the two age groups,
with the numbers available. General eomplications were found in Group 1. However, the prevalence of adjaeent segment
degeneration in Group 1 was lower than that in Group 2. The radiographie results revealed no significant differenee in the
prevalence of segmental lordosis, with the numbers available. There was no nonunion in either group. Although the prevalence of either collapsed union or delayed union in Group 1 was significantly higher than that in Group 2 (p = 0.034), the
fusion results such as union in situ, collapsed union, and delayed union did not appear to affect the postoperative clinical
results in this study.
CONCLUSIONS: No obvious differences in the clinical results were observed between the age groups with the numbers available. Postoperative adjacent segment degeneration was less frequent and collapsed union and delayed union were more
common in the elderly group. The fusion results did not appear to affect the postoperative clinical results in this study.
LEVEL OF EVIDENCE: Prognostic Level II. See Instructions to Authors for a complete description of levels of evidence.
ORIGINAL ABSTRACT CITATION: "Surgical Outcomes of Posterior Lumbar Interbody Fusion in Eiderly Patients"
(2006:88:2714-20).

II
DISCLOSURE: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of
their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial
entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable ot nonprofit
organization with which the authors, or a member of their immediate families, are affiliated or associated.
u

J Bone Joint Surg Am. 2007;89 SuppI 2 (Part 2):310-20 doi:10.21O6/JBJS.G.003O7

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INTRODUCTION

We perform posterior lumbar

interbody fusion with pedicle
screw fixation to treat degenerative lumbar disorders that are
associated with segmental instability. We believe that decompression of all involved
neural elements and stabilization of the affected segment are
essential in the treatment of
such conditions. Although several reports have described the
technique for interbody arthrodesis, we are convinced that
preparation of the fme-bonegraft area and the use of a large
amount of bone graft are of
critical importance for the success of arthrodesis. The procedure involves bilateral total
facetectomies, subtotal discectomy, local bone-grafting with
interbody fusion cages, and
pedicle screw fixation with the
Steffee Variable Spine Plating
System (DePuy Spine,
Raynham, Massachusetts).
SURGICAL TECHNIQUE

Step 1: Total Facetectomy

This report describes L4-L5 posterior lumbar interbody fusion
for L4 degenerative spondylolisthesis. The patient undergoes
general endotracheal anesthesia
and is positioned prone on a
table or frame to decrease abdominal pressure. A routine
posterior approach through a
midline 10-cm incision is employed, thus exposing the L4
and L5 vertebrae. Laminectomy
is performed for almost all of
the caudal two-thirds of the L4
spinous process and laminae,

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including both inferior facets,

with use of an osteotome (Fig.
1, A). We use the cut-line of the
laminectomy as a landmark for
the cranial end of the superior
facet, as the superior facet is
usually hypertrophie in patients
with degenerative spondylolisthesis. The cranial attachment
of the ligamentum flavum is
then resected by undercutting of
the L4 lamina. Next, the medial
edge of the superior facets of L5
and the cranial portion of the L5
lamina are excised with use of
an osteotome (Fig. 1, B). After
confirming the location of the
cranial edge of the L5 pedicle,
we then make a cut at the cranial
edge of the L5 superior facet
above the L5 pedicle with use of
an osteotome. These procedures enable total resection of
the ligamentum flavum and exposure of the neural elements
(Fig. 1, C). The resected bone is
used for bone graft as blocks or
chips. Meticulous hemostatic
control of the extradural venous
plexus with use of a bipolar cautery is necessary for fme exposure of the intervertebral disc.
The extradural venous plexus is
comprised of three components: the cranial (L4) nerve
root, the caudal (L5) nerve root,
and the thecal sac. At first, the
scar and epidural veins are electrocoagulated with a bipolar
cautery with cauterization ending at the cranial wall of the L5
pedicle, which serves as a safety
zone. Next, after the medial wall
of the L5 pedicle is identified,
the epidural veins around the L5
nerve root and the thecal sac are

electrocoagulated and cut and

the L4 nerve root is identified
and protected while the epidural
veins around the L4 nerve root
are electrocoagulated. The thecal sac and the L5 nerve root are
then retracted with a nerve-root
retractor to identify the posterior wall of the intervertebral
disc and the vertebral body. If
bleeding from epidural vessels
cannot be controlled with bipolar electrocautery, control is best
achieved with use of a topical
hemostatic agent and packing
with cottonoids.
Step 2: Total Discectomy
To achieve an effective interbody
arthrodesis, we are convinced
that preparation of the finebone-graft area is one of the
most important parts of the
procedure' '. The fine-bone-graft
area is defined as a wide and flat
area with preservation of the osseous end plate. Subtotal discectomy consists of excision of as
much of the anulus and the perimeter of the end plate as necessary to achieve an extensive
bone-graft area yet allow preservation of the osseous end plate.
We believe that total facetectomy
facilitates identification of the
lateral border of the intervertbral disc and achievement of the
widest bone-graft area possible.
After the posterior aspects of the
disc are exposed, the intervertebral disc space is enlarged with a
lamina spreader that is placed in
the space between the laminae at
L4 and L5. Discectomy is then
performed centrally, with use of
a scalpel, at the junction of the

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L5 pedicle-..

L4 nerve root-.

L5 nerve root - ^

Total facetectomy. A: The caudal two-thirds of the L4 spinous process and laminae, including the inferior facets, are excised. B: The superior facets of L5 around the pedicle and the cranial portion of the L5 laminae are then resected. C: These procedures enable total resection
of the ligamentum flavum and exposure of the neural elements (dashed lines point to the L4 and L5 nerve roots). D: The corresponding
surgical exposure is demonstrated (1 = L4 nerve root; 2 ^ L5 nerve root).

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anulus and the end plate, leaving

the peripheral border ofthe disc
intact while retracting the neural
elements (Fig. 2, A). After subto-

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tal resection ofthe anulus with

rongeurs, a small Cobb elevator
is used to separate the cartilaginous end plate from the osseous

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end plate. This maneuver must

be performed with care to preserve the integrity ofthe subchondral osseous end plate. If the

- - L4/5 intervertebral
disc

A: Subtotal discectomy is performed centraily, with the peripheral border of the disc left untouched and with retraction of the neurai
elements. B; Contours of the end plates are flattened with use of a chisel. C; The corresponding surgical exposure shows the disc space
after Iaminectomy (1 = L4 nerve root; 2 = disc space).

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B
Insertion of the cage and bone graft. A: First, one cage is inserted while protecting the neural elements. 6; The cage is then moved
centrally with the use of two chisels, keeping one chisel in a fixed position while twisting the other (arrow). C: Next, autologous bone blocks
(arrow) are inserted lateral to the cage. D: The process is repeated on the contraiaterai side of the vertebra. E: The cages (1) and the bone
blacks (2) are in place.

end plates are excessively concave, a chisel may be used to flatten the contour of the end plates

slightly, taking care to preserve as

much of the osseous end plate as
possible (Fig. 2, B). Whenever

the anterior portion of the intervertebral disc is manipulated, it

is important to confirm the ex-

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Bone block

FIG. 3 (CONTINUED)

act location ofthe anterior edge

ofthe disc. The anulus and cortical end plate at the anterior portion ofthe disc space are raked
out with a curet and excised. Finally, the irregLilar surface ofthe
osseous end plate is flattened

with use of an appropriately

sized disc shaver. In these steps,
excessive retraction ofthe neural
elements is unnecessary, as the
total facetectomy provides more
working space and a wide-angle
approach to the neural elements

and intervertebral disc'. We believe that preservation ofthe osseous end plate and provision of
a large amount of bone graft are
important to the prevention of
subsidence and essential to good
fusion' \

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Preparation of the cage and graft bone. A and B: Excised laminae with the spinous process and inferior facets. C and D; Trimmed bone
blocks and cages. The height of the bone block is made even to that of the cage.

Step 3: Cage and Bone Graft

(Figs. 3 and 4)
A large amount of bone graft
also appears to be important to
the success of the interbody arthrodesis procedure. The bonegrafting procedure involves the
insertion of autologous bone
blocks, autologous bone chips,
and Brantigan interbody fusion
cages (DePuy Spine) in the
manner of a sandwich (a minimum of two autologous bone
blocks, then two chip-filled fu-

sion cages, then a minimum of

two more autologous bone
blocks). Thus, with bilateral discectomy, one cage is inserted on
either side of the vertebral midhne, followed by insertion of
bone blocks laterally. The two
rectangular cages are used to
prevent collapse of the graft and
to avoid subsidence. In our series, the same size cage (height,
10 mm; width, 10 mm; length,
25 mm) was used for 97% of the
patients. First, the cage (filled as I

tightly as possible with autologous bone chips) is inserted

while the neural elements are
protected(Fig. 3,v4). As with the
discectomy, excessive nerve retraction is unnecessary. The
cage is then moved centrally,
with the use of two chisels, by
keeping one chisel in a fixed
position while twisting the other
(Fig. 3, B). Next, autologous
bone blocks are inserted lateral
to the cage (Fig. 3, C and 3, D).
After one cage and bone blocks

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Pedicle screw fixation. A: The starting point of the L4 pedicle screw is at the vertex of a triangular ravine between the lateral edge of the
lamina and the accessory process (arrow). B: To avoid injuring the adjacent facet joint, the plate is first connected with the cranial pedicle
screw at the upper end of the plate nest. The caudal end is then connected. C; As the screw nut is tightened, the spondylolisthesis is
gradually reduced (arrow).

have been inserted on one side,

another cage and bone blocks
are inserted in a similar manner
on the contralateral side. Bone
blocks are harvested from the
excised spinous process, the
laminae, the interior facets, and
the superior facets (Fig. 4, A and

4, B). Usually, three bone blocks

of almost the same size as the
cage can be obtained from excised spinous processes and inferior facets, and smaller bone
blocks can be obtained from the
excised laminae and superior
facets. The height ofthe bone

block is made even to that ofthe

cage. Surplus bone is tben broken into small chips with use of
a bone mill and packed into tbe
cage (Fig. 4, Cand4, D), No
posterior iliac crest bone is used.
Cages and autologous bone
blocks should be placed 3 to 5-

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h. tx IOINT SURGF.RY SURGICAL T E C H N I Q U E S

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B
A and B: Postoperative radiographs. C: Postoperative computed tomograph.

mm deep to the posterior vertebral margin. In addition, the

upper edge ofthe grafted bone
should be examined to be certain that it does not impinge on
the exiting L4 nerve root.
Step 4: Pedicle Screw Eixation
We usually place pedicle screws
after completion ofthe bone
graft. To avoid loosening or decreased fixation force, the pedicle screws must be aimed
carefully so that tbey are placed
accurately on the first try. The
starting point for placement of
tbe pedicle screw is important.
We start tbe L4 pedicle screw at
the vertex of a triangular ravine
between the lateral edge ofthe
lamina and tbe accessory process (Fig. 5, A). Tbe L4 pedicle
screw is inserted in an upward
direction to avoid injury to tbe
adjacent cranial facet joint by
the screw head. The L5 pedicle
can be seen extending from the
cranial to tbe medial wall. We

start by exposing tbe posterior

tip ofthe L5 superior facet,
which will be used as the starting point for the L5 pedicle
screw. Careful identification of
landmarks and sounding ofthe
cavity are needed to prevent canal penetration; however, we
have not used fluoroscopic
guidance or computer navigation during insertion ofthe
pedicle screw. Pedicle screw size
is determined by measuring the
size ofthe pedicle on the preoperative computed tomographic
images; we have found that this
measurement often reveals tbat
a screw ofthe same size as the
L4 pedicle screw (width, 6.25
mm; length, 45 mm) may be
used. Intraoperative radiography is used to confirm that the
pedicle screw is in the proper
position. A plate as short as possible is then selected and bent to
accommodate the inclination of
the pedicle screw. First, the plate
I is connected with the cranial

pedicle screw at the upper (cranial) end ofthe plate nest to

avoid injuring the adjacent facet
joint (Fig. 5, B). As the screw
nut is tightened, the spondylolisthesis is gradually reduced
(Fig. 5, C). It is important to
confirm the location ofthe neural elements during the reduction procedure because the
cages or bone blocks often bulge
posteriorly as the reduction
takes place. The caudal end of
the plate is then connected, and
the screw head is cut. We have
found that injury to tbe facet
joint can be avoided by making
the starting point for placement of tbe pedicle screw less
medial and less cranial. In fact,
we have confirmed the integrity
ofthe L3-L4 facet joint at revision surgery in patients with adjacent segment degeneration,
and we have found tbat none of
these patients had L3-L4 facetjoint injury as a result of tbe
plate system.

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CRITICAL CONCEPTS

INDICATIONS;
All patients considered for surgery have severe, disabling low back pain accompanied by lower extremity pain that is
unresponsive to conservative treatment, including epidurai steroid injection. Indications for posterior lumbar interbody
fusion are as follows:
Spondylolistnesis witn slippage in excess of 3 mm and a posterior opening of >5 on a lateral flexion radiograph
Lumbar canal stenosis or disc herniation requiring wide decompression and discectomy

CONTRAINDICATIONS:
Active infection
Metastatic spinal tumor
A massive defect of the vertebral end plates or bodies due to osteoporosis, fracture, or intraspinal neoplasm

PITFALLS:
Bleeding can be extensive with this procedure; preoperatively. we strive to have the patient donate 400 to 800 mL
of autologous blood for transfusion.
Forcible reduction of the spondylolisthesrs or distraction of the intervertebral disc space by pedicle screws carries a
risk of vertebral fracture or loosening of the pedicle screw, particularly in elderly patients.
Vascular injury. We have not encountered any major vascular injuries intraoperatively. Nonetheless, the aorta and
Inferior vena cava lie anterior to the spinal column, so whenever the anterior portion of the intervertebral disc is
manipulated, confirmation of the anterior edge of the vertebral body is warranted.
Excessive distraction of the intervertebral disc space. We usually install the lamina spreader between the caudal edge
of the remnant L4 lamina and the superior edge of the L5 lamina. Excessive distraction with the lamina spreader can
cause slippage of the device or collapse of the lamina.
Identification of the cranial (L4) nerve root. While excising as much as possible along the peripheral border of the
intervertebral disc, protection of the cranial nerve root is necessary. When cranial nerve root exposure is insufficient,
manipulation at the penphera! border of the disc should be undertaken with great care during disc excision and when
inserting bone-graft material. We are convinced that our low rate of neurological complications is due to generous
exposure of the neural elements (Fig. 6).

AUTHOR UPDATE:
The principles of the procedure used today (and reported herein) resemble those used in the originally reported series.
However, slight modifications have been made to the surgical technique. Specific changes include the following:
The improved procedure now permits less invasive access through smaller incisions.
If patients are elderly or have osteoporosis, we are more circumspect in excising the cartilaginous end plate so as to
avoid breaking the osseous end plate. In addition, we try to graft a larger amount of bone, particularly in elderly
patients and/or patients with osteoporosis. A minimum of four autologous bone blocks {two on each side) are placed
around the cages.

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Shinya Okuda. MD
Takenori Oda, MD
Akira Miyauchi, MD
Takamitsu Haku. MD
Department of Orthopaedic Surgery, Osaka Rosai
Hospital, 1179-3
Nagasone-cho, Sakai, Osaka 591-8025, Japan.
E-mail address for S. Okuda: okuda-s@uinin.ac.jp
Tomio Yamamoto, MD
Department of Orthopaedic Surgery, Amagasaki
Chuo Hospitai, 1-12-1 Shioe, Amagasaki, Hyogo
661-0976, Japan

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Motoki Iwasaki, MD
Department of Orthopaedic Surgery. Osaka University Graduate School of Medicine, 2-2 Yamadaoka,
Suita, Osaka 565-0871, Japan
The iine drawings in this article are the wor1< of
Joanne Haderer Mller of Haderer & MiJIier
(biomedart@hadererniuller.com),

REFERENCES
1. Okuda S, Miyauchi A, Oda T, Haku T, Vamamoto T, Iwasaki M. Surgicai compiications of

posterior lumbar interbody fusion with total

facetectomy in 251 patients, J Neurosurg
Spine. 2006:4:304-9.
2. Okuda S, Iwasaki M, Miyauchi A, Aono H,
Morita M, Yamamoto I Risk factors for adjacent segment degeneration after PUR Spine.
2004:29:1535-40.
3. Yamamoto I Ohkohchi T. Ohwada T. Kotoku
H, Harada N. Ciinicai and radiological results
of PLIF for degenerative spondyiolisthesis.
J Musculoskeletal Res. 1998:2:181 95.

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