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      Comparison of the early results of transforaminal lumbar interbody fusion and posterior lumbar interbody fusion in symptomatic lumbar instability

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          Transforaminal lumbar interbody fusion (TLIF) has been preferred to posterior lumbar interbody fusion (PLIF) for different spinal disorders but there had been no study comparing their outcome in lumbar instability. A comparative retrospective analysis of the early results of TLIF and PLIF in symptomatic lumbar instability was conducted between 2005 and 2011.

          Materials and Methods:

          Review of the records of 102 operated cases of lumbar instability with minimum 1 year followup was done. A total of 52 cases (11 men and 41 women, mean age 46 years SD 05.88, range 40-59 years) underwent PLIF and 50 cases (14 men and 36 women, mean age 49 years SD 06.88, range 40-59 years) underwent TLIF. The surgical time, duration of hospital stay, intraoperative blood loss were compared. Self-evaluated low back pain and leg pain status (using Visual Analog Score), disability outcome (using Oswestry disability questionnaire) was analyzed. Radiological structural restoration (e.g., disc height, foraminal height, lordotic angle, and slip reduction), stability (using Posner criteria), fusion (using Hackenberg criteria), and overall functional outcome (using MacNab's criteria) were compared.


          Pain, disability, neurology, and overall functional status were significantly improved in both groups but PLIF required more operative time and caused more blood loss. Postoperative hospital stay, structural restoration, stability, and fusion had no significant difference but neural complications were relatively more with PLIF.


          Both methods were effective in relieving symptoms, achieving structural restoration, stability, and fusion, but TLIF had been associated with shorter operative time, less blood loss, and lesser complication rates for which it can be preferred for symptomatic lumbar instability.

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          Most cited references 50

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          Clinical spinal instability and low back pain.

          Clinical instability is an important cause of low back pain. Although there is some controversy concerning its definition, it is most widely believed that the loss of normal pattern of spinal motion causes pain and/or neurologic dysfunction. The stabilizing system of the spine may be divided into three subsystems: (1) the spinal column; (2) the spinal muscles; and (3) the neural control unit. A large number of biomechanical studies of the spinal column have provided insight into the role of the various components of the spinal column in providing spinal stability. The neutral zone was found to be a more sensitive parameter than the range of motion in documenting the effects of mechanical destabilization of the spine caused by injury and restabilization of the spine by osteophyle formation, fusion or muscle stabilization. Clinical studies indicate that the application of an external fixator to the painful segment of the spine can significantly reduce the pain. Results of an in vitro simulation of the study found that it was most probably the decrease in the neutral zone, which was responsible for pain reduction. A hypothesis relating the neutral zone to pain has been presented. The spinal muscles provide significant stability to the spine as shown by both in vitro experiments and mathematical models. Concerning the role of neuromuscular control system, increased body sway has been found in patients with low back pain, indicating a less efficient muscle control system with decreased ability to provide the needed spinal stability.
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            Negative disc exploration. An analysis of the causes of nerve-root involvement in sixty-eight patients.

             I Macnab (1971)
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              An analysis of sagittal spinal alignment in 100 asymptomatic middle and older aged volunteers.

              A radiographic evaluation of 100 adult volunteers over age 40 and without a history of significant spinal abnormality was done to determine indices of sagittal spinal alignment. To determine the sagittal contours of the spine in a population of adults older than previously reported in the literature and to correlate age and overall sagittal balance to other measures of segmental spinal alignment. Previous studies of sagittal alignment have focused on adolescent and young adult populations before the onset of degenerative changes that may affect sagittal alignment. Radiographic measurements were collected and subjected to statistical analysis. Mean sagittal vertical axis fell 3.2 +/- 3.2 cm behind the front of the sacrum. Total lumbar lordosis (T12-S1) averaged -64 degrees +/- 10 degrees. Lordosis increased incrementally with distal progression through the lumbar spine. Lordosis at L5-S1 and the position of the apices of the thoracic and lumbar curves were most closely correlated to sagittal vertical axis. Increasing age correlated to a more forward sagittal vertical axis with loss of distal lumbar lordosis but without an increase in thoracic or thoracolumbar kyphosis. The majority of asymptomatic individuals are able to maintain their sagittal alignment despite advancing age. Loss of distal lumbar lordosis is most responsible for sagittal imbalance in those individuals who do not maintain sagittal alignment. Spinal fusion for deformity should take into account the anticipated loss of lordosis that may occur with age.

                Author and article information

                Indian J Orthop
                Indian J Orthop
                Indian Journal of Orthopaedics
                Medknow Publications & Media Pvt Ltd (India )
                May-Jun 2013
                : 47
                : 3
                : 255-263
                Department of Orthopaedic Surgery, Islami Bank Central Hospital, Anjuman Mufidul Islam Road, Kakrail, Bangladesh
                [1 ]Department of Orthopaedic Surgery, Bangabandhu Sheikh Mujib Medical University, Shahbag, Dhaka, Bangladesh
                Author notes
                Address for correspondence: Dr. Najmus Sakeb, Room No 605, Islami Bank Central Hospital, 30, Anjuman Mufidul Islam Road, Kakrail, Dhaka - 1000, Bangladesh. E-mail: sakibortho999@ 123456yahoo.com
                Copyright: © Indian Journal of Orthopaedics

                This is an open-access article distributed under the terms of the Creative Commons Attribution-Noncommercial-Share Alike 3.0 Unported, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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