Clinical Outcomes of Posterolateral Fusion Versus Posterior Lumbar Interbody Fusion in Patients with Lumbar Spinal Stenosis and Degenerative Instability

Abstract

Background: Degenerative lumbar spine disease can lead to lumbar spine instability. Lumbar spine instability is defined as an abnormal response to applied loads characterized kinematically by abnormal movement in the motion segment beyond normal constraints. Patients with lumbar spinal stenosis (LSS) typically present with low back pain (LBP), cramping, cauda equine syndrome, and signs of nerve root compression associated by weakness, numbness and tingling in their legs that are worsened with standing and walking. This degenerative condition severely restricts function, walking ability, and quality of life (QOL). Objectives: This study aims to compare clinical and radiological outcomes of posterolateral fusion (PLF) with posterior lumbar interbody fusion (PLIF) with posterior instrumentation in the treatment of LSS and degenerative instability. Study Design: A randomized, prospective, controlled clinical study. Methods: In this prospective study, 88 patients with LSS and degenerative instability were randomly allocated to one of 2 groups: PLF (Group I) or PLIF (Group II). Primary outcomes were the control of LBP and radicular pain, evaluated with visual analog scale (VAS), the improvement of QOL assessed by the Oswestry disability index (ODI) scale, and measurement of fusion rate, Cobb angle, spinal sagittal balance, and modic changes in the 2 groups. Results: At 24 months postoperatively, the mean reduction in VAS scores in Group I was more than in Group II (5.67 vs. 5.48, respectively) and the patients in Group I had more improvement in the ODI score than the patients in Group II (42.75 vs. 40.94, respectively). There was a statistically significant difference between the preoperative and postoperative sagittal balance in the 2 groups. The mean Cobb angle changed significantly in the 2 groups. Limitations: There are few prospective studies of PLIF or PLF in patients with LSS and degenerative lumbar spine instability, and a limited number of studies which exists have examined the safety and outcome of each procedure without comparing it with other fusion techniques. Because most of the studies in the literature have been conducted in the patients with IS, we could not compare and contrast our findings with studies in patients with LSS and degenerative lumbar spine instability. In addition, although in our study the findings at a 24-month follow-up period showed that PLF was better than PLIF in these patients, there were some studies in which the authors reported that PLIF showed better clinical results than PLF at a 48-month followup period. So we suggest that rigorous controlled trials at longer follow-up periods should be undertaken in groups of patients with LSS and degenerative lumbar spine instability who undergo posterior decompression and instrumented fusion to help to determine the ultimate best fusion technique for these patients. Conclusion: PLF with posterior instrumentation provides better clinical outcomes and improvement in the LBP, radicular pain, and functional QOL, more correction of the Cobb angle, more restoration of sagittal alignment, more decrease in Modic type 1, and more increase in Modic type 0, despite the low fusion rate compared to PLIF. Key words: Lumbar spinal stenosis, degenerative instability, posterolateral fusion, posterior lumbar interbody fusion, low back pain, quality of life, cobb angle, fusion rate, mobic changes, sagittal balance

Analysis of Spinopelvic Sagittal Balance and Persistent Low Back Pain (PLBP) for Degenerative Spondylolisthesis (DS) following Posterior Lumbar Interbody Fusion (PLIF)

“…A negative correlation between PT and PLBP in spondylolisthesis patients has also been found, indicating that lumbar degeneration accompanies sagittal balance deterioration [9]. For most DS patients, PLIF can dramatically improve sagittal balance via the fixation of pedicle screws and distraction of the inserted cage [10]. However, few studies have been published about correlation between spinopelvic sagittal balance and clinical outcomes, especially the impact of spinopelvic sagittal balance on PLBP.…”

A Letter to the Editor Regarding “Fusion or Not for Degenerative Lumbar Spinal Stenosis: A Meta-Analysis and Systematic Review”

“…Our recent findings suggest that decompression and posterior fusion and using methylene blue on the soft tissue around fusion site during spinal surgeries are effective surgical methods which are associated with satisfying clinical results in terms of improvement of postoperative low back pain (LBP), radicular pain, and quality of life (QOL) (14-16). Our 2018 randomized prospective controlled clinical study (17), which has been recently accepted for publication in PAIN PHYSICIAN, compared the clinical outcomes of posterolateral fusion (PLF) with posterior lumbar interbody fusion (PLIF) with posterior instrumentation after lumbar decompression surgery for lumbar spinal stenosis (LSS) and degenerative lumbar spine instability. Our findings showed that compared with PLIF, PLF with posterior instrumentation in patients with LSS and degenerative lumbar spine instability provides better clinical outcomes and improvement in the LBP, radicular pain, and functional QOL (Table 1).…”

Superiority of Lumbar Fusion Surgery with ISOBAR Devices over Posterior Lumbar Interbody Fusion Surgery in Patients with Lumbar Degenerative Diseases: An Invited Brief Commentary

“…Their findings are important as they provide a better cure for back pain without predisposing patients to future spinal problems. Meanwhile, however, the fact that there are many studies in the literature which show that posterolateral fusion (PLF) provides better clinical outcomes and more improvement in low back pain than PLIF [2,3] raises this question that if according to Su et al [1], ISOBAR device use is superior to standard approaches such as PLIF, then we can take a step forward and hypothesize that ISOBAR device may also be more effective than PLF, but this should be investigated. Regarding different findings of various studies, we cannot reach a consensus on the superiority of ISOBAR devices over PLF.…”

“…One of the major issues after lumbar spinal fusion is the development of adjacent segment disease (ASD), resulting in clinical symptoms and detectable imaging study abnormalities [4]. Degeneration that develops at mobile segments above or below a fused spinal segment is known as ASD [2]. The increase of adjacent segment compensatory activity after rigid internal fixation is one of the most important causes of adjacent segment degeneration [5].…”

“…The PLIF technique is more invasive, technically more demanding, and results in a longer operating time and a larger blood loss, factors all increasing the risk of complication [13]. Many studies have reported that some complications associated with the PLIF procedure are permanent neurological deficit, cerebrospinal fluid leakage, radicular pain, and deep wound infection [2,13]. In addition to sagittal balance, clinical outcomes of instrumented PLIF in patients with LDDs may be influenced by a variety of pathophysiologic factors [14], including residual compression of the neural tissues, recurrence of spinal canal stenosis, irreversible changes to the nerve root, or cauda equine.…”