Dynamic systems in the lumbar spine are believed to reduce main fusion drawbacks such as pseudarthrosis, bone rarefaction, and mechanical failure. Compared to fusion achieved with rigid constructs, biomechanical studies underlined some advantages of dynamic instrumentation including increased load sharing between the instrumentation and interbody bone graft and stresses reduction at bone-to-screw interface. These advantages may result in increased fusion rates, limitation of bone rarefaction, and reduction of mechanical complications with the ultimate objective to reduce reoperations rates. However published clinical evidence for dynamic systems remains limited. In addition to providing biomechanical evaluation of a pedicle-screw-based dynamic system, the present study offers a long-term (average 10.2 years) insight view of the clinical outcomes of 18 patients treated by fusion with dynamic systems for degenerative lumbar spine diseases. The findings outline significant and stable symptoms relief, absence of implant-related complications, no revision surgery, and few adjacent segment degenerative changes. In spite of sample limitations, this is the first long-term report of outcomes of dynamic fusion that opens an interesting perspective for clinical outcomes of dynamic systems that need to be explored at larger scale. 1. Introduction Dynamic instrumentation for fusion has been introduced since the 1990s to address the adverse effects of traditional spinal fusion observed with rigid instrumentation: pseudarthrosis, bone rarefaction, and mechanical failure [1, 2]. Some authors suggested that eliminating mechanical loads on an interbody bone graft may result in negative bone remodeling, pseudarthrosis, and osteoporosis [3–6]. This “stress shielding” phenomenon at the disk space level may result from the excessive stiffness of traditional rigid instrumentation. Reducing the stiffness of the instrumentation, pedicle-screw-based posterior dynamic systems (PDSs) allow for load sharing between the instrumentation and the functional spine unit (FSU) at the instrumented level(s). Using a finite element model of the lumbar spine, several authors demonstrated that posterior dynamic instrumentation, compared to rigid instrumentation, increases the amount of load transmission through the anterior column and the interbody bone graft thus avoiding stress shielding phenomenon. This may favor osteogenesis and enhance interbody fusion in accordance with Wolff’s Law according to which the bone will adapt to the loads it is placed under; that is, the structure and shape of
References
[1]
C. Y. Barrey, “Dynamic instrumentation for fusion with Isobar TTL: biomechanical and clinical aspects,” ArgoSpine News and Journal, vol. 22, no. 2, pp. 62–66, 2010.
[2]
C. Y. Barrey, R. K. Ponnappan, J. Song, and A. R. Vaccaro, “Biomechanical evaluation of pedicle screw-based dynamic stabilization devices for the lumbar spine: a systematic review,” SAS Journal, vol. 2, no. 4, pp. 159–170, 2008.
[3]
R. C. Duffield, W. L. Carson, L. Y. Chen, and B. Voth, “Longitudinal element size effect on load sharing, internal loads, and fatigue life of tri-level spinal implant constructs,” Spine, vol. 18, no. 12, pp. 1695–1703, 1993.
[4]
V. K. Goel, R. J. Konz, H. T. Chang, N. M. Grosland, L. J. Grobler, and K. D. Chesmel, “Hinged-dynamic posterior device permits greater loads on the graft and similar stability as compared with its equivalent rigid device: a three-dimensional finite element assessment,” Journal of Prosthetics and Orthotics, vol. 13, no. 1, pp. 17–20, 2001.
[5]
V. K. Goel and L. G. Gilbertson, “Basic science of spinal instrumentation,” Clinical Orthopaedics and Related Research, no. 335, pp. 10–31, 1997.
[6]
A. Templier, L. Denninger, C. Mazel, F. Lavaste, and W. Skalli, “Comparison between two different concepts of lumbar posterior osteosynthesis implants: a finite-element analysis,” European Journal of Orthopaedic Surgery and Traumatology, vol. 8, no. 1, pp. 27–36, 1998.
[7]
H. M. Frost, “A 2003 update of bone physiology and Wolff s law for clinicians,” Angle Orthodontist, vol. 74, no. 1, pp. 3–15, 2004.
[8]
T. H. Lim, V. K. Goel, J. M. Winterbottom et al., “A comparison of stress-induced porosity due to conventional and a modified spinal fixation device,” Journal of Spinal Disorders, vol. 7, no. 1, pp. 1–11, 1994.
[9]
R. C. Huang, F. P. Girardi, M. R. Lim, and F. P. Cammisa, “Advantages and disadvantages of nonfusion technology in spine surgery,” Orthopedic Clinics of North America, vol. 36, no. 3, pp. 263–269, 2005.
[10]
P. Khoueir, K. A. Kim, and M. Y. Wang, “Classification of posterior dynamic stabilization devices,” Neurosurgical Focus, vol. 22, no. 1, article E3, 2007.
[11]
K. Meyers, M. Tauber, Y. Sudin et al., “Use of instrumented pedicle screws to evaluate load sharing in posterior dynamic stabilization systems,” The Spine Journal, vol. 8, no. 6, pp. 926–932, 2008.
[12]
R. C. Mulholland and D. K. Sengupta, “Rationale, principles and experimental evaluation of the concept of soft stabilization,” European Spine Journal, vol. 11, supplement 2, pp. S198–S205, 2002.
[13]
D. K. Sengupta, “Dynamic stabilization devices in the treatment of low back pain,” Orthopedic Clinics of North America, vol. 35, no. 1, pp. 43–56, 2004.
[14]
D. K. Sengupta, “Dynamic stabilization devices in the treatment of low back pain,” Neurology India, vol. 53, no. 4, pp. 466–474, 2005.
[15]
T. Wright, M. Tauber, K. Meyers et al., “P71. The biomechanics of posterior motion preservation systems,” The Spine Journal, vol. 5, no. 4, supplement, pp. 143S–144S, 2005.
[16]
R. Huang, T. M. Wright, M. M. Panjabi, and J. D. Lipman, “Biomechanics of non fusion implants,” Orthopedic Clinics of North America, vol. 36, no. 3, pp. 271–280, 2005.
[17]
D. McNally, “Rationale for dynamic stabilization,” in Dynamic Reconstruction of the Spine, D. H. Kim, F. P. Cammisa Jr., and R. G. Fessler, Eds., pp. 237–243, Thieme, New York, NY, USA, 2006.
[18]
P. Wendsche, “‘Dynamic fusion’ in lumbar spine degenerative disorders mid-term results,” ArgoSpine News and Journal, vol. 22, no. 2, pp. 67–70, 2010.
[19]
A. Castellvi, J. Paraiso, and D. Pienkowski, “The isobar TTL dynamic instrumentation,” in Dynamic Reconstruction of the Spine, D. H. Kim, F. P. Cammisa Jr., and R. G. Fessler, Eds., pp. 86–91, Thieme, New York, NY, USA, 2006.
[20]
A. Castellvi, W. Hudson, and D. Clabeaux, “Evaluation of hybrid posterior dynamic stabilization: a two-year follow-up,” in Proceedings of the 9th Annual Meeting of Spine Arthroplasty Society', London, UK, 2009.
[21]
G. Perrin and A. Cristini, “Long term effect of the intervertebral dynamic stabilization as a protective technique for adjacent levels,” in Proceedings of the Annual Conference of Association of Spine Surgeons of India Congress (ASSICON), Chenai, India, 2009.
[22]
A. Castellvi and D. Clabeaux, “Radiographic and functional outcomes of dynamic stabilization of the lumbar spine: two years follow-up,” in Proceedings of the 4th Interdiciplinary Congress on Spine Care-World Spine Annual, Istanbul, Turkey, 2007.
[23]
G. Perrin, “Circumferential arthrodesis for the treatment of lumbar spondylolisthesis by using cages for PLIF and semi-rigid interpedicular posterior fixation for prevention of adjacent degeneration,” in Proceedings of the EANS Winter Meeting, Luxembourg, 2006.
[24]
S. Champain, C. Mazel, A. Mitulescu, and W. Skalli, “Quantitative analysis in outcome assessment of instrumented lumbosacral arthrodesis,” European Spine Journal, vol. 16, no. 8, pp. 1241–1249, 2007.
[25]
Y. S. Kim, H. Y. Zhang, B. J. Moon et al., “Nitinol spring rod dynamic stabilization system and Nitinol memory loops in surgical treatment for lumbar disc disorders: short-term follow up,” Neurosurgical Focus, vol. 22, no. 1,article E10, 2007.
[26]
C. E. Mandigo, P. Sampath, and M. G. Kaiser, “Posterior dynamic stabilization of the lumbar spine: pedicle based stabilization with the AccuFlex rod system,” Neurosurgical Focus, vol. 22, no. 1, article E9, 2007.
[27]
M. Bothmann, E. Kast, G. J. Boldt, and J. Oberle, “Dynesys fixation for lumbar spine degeneration,” Neurosurgical Review, vol. 31, no. 2, pp. 189–196, 2008.
[28]
S. Agazzi, A. Reverdin, and D. May, “Posterior lumbar interbody fusion with cages: an independent review of 71 cases,” Journal of Neurosurgery, vol. 91, no. 2, supplement, pp. 186–192, 1999.
[29]
P. M. Arnold, S. Robbins, W. Paullus, S. Faust, R. Holt, and R. McGuire, “Clinical outcomes of lumbar degenerative disc disease treated with posterior lumbar interbody fusion allograft spacer: a prospective, multicenter trial with 2-year follow-up,” American Journal of Orthopedics, vol. 38, no. 7, pp. E115–E122, 2009.
[30]
T. Asazuma, M. Yamugishi, M. Sato, S. Ichimura, K. Fujikawa, and H. V. Crock, “Posterior spinal fusion for lumbar degenerative diseases using the Crock-Yamagishi (C-Y) spinal fixation system,” Journal of Spinal Disorders and Techniques, vol. 17, no. 3, pp. 174–177, 2004.
[31]
D. A. Bednar, “Surgical management of lumbar degenerative spinal stenosis with spondylolisthesis via posterior reduction with minimal laminectomy,” Journal of Spinal Disorders, vol. 15, no. 2, pp. 105–109, 2002.
[32]
I. T. Benli, H. ？i？ek, and A. Kaya, “Comparison of sagittal plane realignment and reduction with posterior instrumentation in developmental low or high dysplastic spondylolisthesis,” Kobe Journal of Medical Sciences, vol. 52, no. 6, pp. 151–169, 2006.
[33]
A. G. Brotis, K. N. Paterakis, P. M. Tsiamalou, K. N. Fountas, G. M. Hahjigeorgiou, and A. Karavelis, “Instrumented posterior lumbar fusion outcomes for lumbar degenerative disorders in a Southern European, semirural population,” Journal of Spinal Disorders and Techniques, vol. 23, no. 7, pp. 444–450, 2010.
[34]
G. Cheh, K. H. Bridwell, L. G. Lenke et al., “Adjacent segment disease followinglumbar/thoracolumbar fusion with pedicle screw instrumentation: a minimum 5-year follow-up,” Spine, vol. 32, no. 20, pp. 2253–2257, 2007.
[35]
F. B. Christensen, E. S. Hansen, S. P. Eiskjaer et al., “Circumferential lumbar spinal fusion with brantigan cage versus posterolateral fusion with titanium cotrel-dubousset instrumentation: a prospective, randomized clinical study of 146 patients,” Spine, vol. 27, no. 23, pp. 2674–2683, 2002.
[36]
S. Dai, Z. Zhang, Y. Li, Z. Yang, Y. Zhang, and Q. Wang, “Treatment of lumbar spondylolisthesis with spondylolisthesis reduction system internal fixation and decompression, posterior alone interbody cage fusion and bone grafting,” Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi, vol. 22, no. 12, pp. 1445–1447, 2008.
[37]
F. L. R. Dantas, M. N. Prandini, and M. A. T. Ferreira, “Comparison between posterior lumbar fusion with pedicle screws and posterior lumbar interbody fusion with pedicle screws in adult spondylolisthesis,” Arquivos de Neuro-Psiquiatria, vol. 65, no. 3 B, pp. 764–770, 2007.
[38]
E. Dehoux, E. Fourati, K. Madi, B. Reddy, and P. Segal, “Posterolateral versus interbody fusion in isthmic spondylolisthesis: functional results in 52 cases with a minimum follow-up of 6 years,” Acta Orthopaedica Belgica, vol. 70, no. 6, pp. 578–582, 2004.
[39]
J. S. Fischgrund, M. Mackay, H. N. Herkowitz, R. Brower, D. M. Montgomery, and L. T. Kurz, “1997 Volvo award winner in clinical studies: degenerative lumbar spondylolisthesis with spinal stenosis: a prospective, randomized study comparing decompressive laminectomy and arthrodesis with and without spinal instrumentation,” Spine, vol. 22, no. 24, pp. 2807–2812, 1997.
[40]
J. C. France, M. J. Yaszemski, W. C. Lauerman et al., “A randomized prospective study of posterolateral lumbar fusion outcomes with and without pedicle screw instrumentation,” Spine, vol. 24, no. 6, pp. 553–560, 1999.
[41]
B. J. C. Freeman, P. Licina, and S. H. Mehdian, “Posterior lumbar interbody fusion combined with instrumented postero-lateral fusion: 5-year results in 60 patients,” European Spine Journal, vol. 9, no. 1, pp. 42–46, 2000.
[42]
P. Fritzell, O. H？gg, P. Wessberg, and A. Nordwall, “Chronic low back pain and fusion: a comparison of three surgical techniques: a prospective multicenter randomized study from the Swedish lumbar spine study group,” Spine, vol. 27, no. 11, pp. 1131–1141, 2002.
[43]
S. D. Gertzbein, R. Betz, D. Clements et al., “Semirigid instrumentation in the management of lumbar spinal conditions combined with circumferential fusion: a multicenter study,” Spine, vol. 21, no. 16, pp. 1918–1926, 1996.
[44]
P. Gillet, “The fate of the adjacent motion segments after lumbar fusion,” Journal of Spinal Disorders and Techniques, vol. 16, no. 4, pp. 338–345, 2003.
[45]
K. Gong, Z. Wang, and Z. Lou, “Reduction and transforaminal lumbar interbody fusion with posterior fixation versus transsacral cage fusion in situ with posterior fixation in the treatment of grade 2 adult isthmic spondylolisthesis in the lumbosacral spine,” Journal of Neurosurgery: Spine, vol. 13, no. 3, pp. 394–400, 2010.
[46]
N. Goyal, D. W. Wimberley, A. Hyatt et al., “Radiographic and clinical outcomes after instrumented reduction and transforaminal lumbar interbody fusion of mid and high-grade isthmic spondylolisthesis,” Journal of Spinal Disorders and Techniques, vol. 22, no. 5, pp. 321–327, 2009.
[47]
K. Y. Ha, K. H. Na, J. H. Shin, and K. W. Kim, “Comparison of posterolateral fusion with and without additional posterior lumbar interbody fusion for degenerative lumbar spondylolisthesis,” Journal of Spinal Disorders and Techniques, vol. 21, no. 4, pp. 229–234, 2008.
[48]
M. K. Hsieh, L. H. Chen, C. C. Niu, T. S. Fu, P. L. Lai, and W. J. Chen, “Postoperative anterior spondylodiscitis after posterior pedicle screw instrumentation,” The Spine Journal, vol. 11, no. 1, pp. 24–29, 2011.
[49]
W. C. H. Jacobs, A. Vreeling, and M. de Kleuver, “Fusion for low-grade adult isthmic spondylolisthesis: a systematic review of the literature,” European Spine Journal, vol. 15, no. 4, pp. 391–402, 2006.
[50]
M. B. Kornblum, J. S. Fischgrund, H. N. Herkowitz, D. A. Abraham, D. L. Berkower, and J. S. Ditkoff, “Degenerative lumbar spondylolisthesis with spinal stenosis: a prospective long-term study comparing fusion and pseudarthrosis,” Spine, vol. 29, no. 7, pp. 726–733, 2004.
[51]
P. Korovessis, T. Repantis, G. Petsinis, P. Iliopoulos, and A. Hadjipavlou, “Direct reduction of thoracolumbar burst fractures by means of balloon kyphoplasty with calcium phosphate and stabilization with pedicle-screw instrumentation and fusion,” Spine, vol. 33, no. 4, pp. E100–E108, 2008.
[52]
R. Masferrer, C. H. Gomez, D. G. Karahalios, and V. K. H. Sonntag, “Efficacy of pedicle screw fixation in the treatment of spinal instability and failed back surgery: a 5-year review,” Journal of Neurosurgery, vol. 89, no. 3, pp. 371–377, 1998.
[53]
K. Matsudaira, T. Yamazaki, A. Seichi et al., “Spinal stenosis in grade I degenerative lumbar spondylolisthesis: a comparative study of outcomes following laminoplasty and laminectomy with instrumented spinal fusion,” Journal of Orthopaedic Science, vol. 10, no. 3, pp. 270–276, 2005.
[54]
K. R. Moore, M. R. Pinto, and L. M. Butler, “Degenerative disc disease treated with combined anterior and posterior arthrodesis and posterior instrumentation,” Spine, vol. 27, no. 15, pp. 1680–1686, 2002.
[55]
D. B. Moreland, H. L. Asch, G. A. Czajka, J. A. Overkamp, and D. M. Sitzman, “Posterior lumbar interbody fusion: comparison of single intervertebral cage and single side pedicle screw fixation versus bilateral cages and screw fixation,” Minimally Invasive Neurosurgery, vol. 52, no. 3, pp. 132–136, 2009.
[56]
A. M. Müslüman, A. Yilmaz, T. Cansever et al., “Posterior lumbar interbody fusion versus posterolateral fusion with instrumentation in the treatment of low-grade isthmic spondylolisthesis: midterm clinical outcomes,” Journal of Neurosurgery: Spine, vol. 14, no. 4, pp. 488–496, 2011.
[57]
T. H. Nguyen, D. C. Randolph, J. Talmage, P. Succop, and R. Travis, “Long-term outcomes of lumbar fusion among workers' compensation subjects: a historical cohort study,” Spine, vol. 36, no. 4, pp. 320–331, 2011.
[58]
S. E. Nork, S. S. Hu, K. L. Workman, P. A. Glazer, and D. S. Bradford, “Patient outcomes after decompression and instrumented posterior spinal fusion for degenerative spondylolisthesis,” Spine, vol. 24, no. 6, pp. 561–569, 1999.
[59]
D. K. Resnick, T. F. Choudhri, A. T. Dailey et al., “Guidelines for the performance of fusion procedures for degenerative disease of the lumbar spine. Part 11: interbody techniques for lumbar fusion,” Journal of Neurosurgery: Spine, vol. 2, no. 6, pp. 692–699, 2005.
[60]
D. J. Rivet, D. Jeck, J. Brennan, A. Epstein, and C. Lauryssen, “Clinical outcomes and complications associated with pedicle screw fixation-augmented lumbar interbody fusion,” Journal of Neurosurgery: Spine, vol. 1, no. 3, pp. 261–266, 2004.
[61]
J. D. Rompe, P. Eysel, and C. Hopf, “Clinical efficacy of pedicle instrumentation and posterolateral fusion in the symptomatic degenerative lumbar spine,” European Spine Journal, vol. 4, no. 4, pp. 231–237, 1995.
[62]
M. A. Rousseau, J. Y. Lazennec, E. C. Bass, and G. Saillant, “Predictors of outcomes after posterior decompression and fusion in degenerative spondylolisthesis,” European Spine Journal, vol. 14, no. 1, pp. 55–60, 2005.
[63]
M. A. Rousseau, J. Y. Lazennec, and G. Saillant, “Circumferential arthrodesis using PEEK cages at the lumbar spine,” Journal of Spinal Disorders and Techniques, vol. 20, no. 4, pp. 278–281, 2007.
[64]
W. Sears, “Posterior lumbar interbody fusion for degenerative spondylolisthesis: restoration of sagittal balance using insert-and-rotate interbody spacers,” The Spine Journal, vol. 5, no. 2, pp. 170–179, 2005.
[65]
S. I. Suk, C. K. Lee, W. J. Kim, J. H. Lee, K. J. Cho, and H. G. Kim, “Addding posterior lumbar interbody fusion to pedicle screw fixation and posterolateral fusion after decompression in spondylolytic spondylolisthesis,” Spine, vol. 22, no. 2, pp. 210–220, 1997.
[66]
Y. Tokuhashi, Y. Ajiro, and N. Umezawa, “Outcomes of posterior fusion using pedicle screw fixation in patients？≥？70 years with lumbar spinal canal stenosis,” Orthopedics, vol. 31, no. 11, article 1096, 2008.
[67]
D. L. Yan, F. X. Pei, J. Li, and C. L. Soo, “Comparative study of PILF and TLIF treatment in adult degenerative spondylolisthesis,” European Spine Journal, vol. 17, no. 10, pp. 1311–1316, 2008.
[68]
C. H. Yu, C. T. Wang, and P. Q. Chen, “Instrumented posterior lumbar interbody fusion in adult spondylolisthesis,” Clinical Orthopaedics and Related Research, vol. 466, no. 12, pp. 3034–3043, 2008.
[69]
D. K. Palmer, S. Inceoglu, and W. K. Cheng, “Stem fracture after total facet replacement in the lumbar spine: a report of two cases and review of the literature,” The Spine Journal, vol. 11, no. 7, pp. e15–e19, 2011.
[70]
P. Korovessis, Z. Papazisis, G. Koureas, and E. Lambiris, “Rigid, semirigid versus dynamic instrumentation for degenerative lumbar spinal stenosis: a correlative radiological and clinical analysis of short-term results,” Spine, vol. 29, no. 7, pp. 735–742, 2004.
[71]
D. Grob, A. Benini, A. Junge, and A. F. Mannion, “Clinical experience with the dynesys semirigid fixation system for the lumbar spine: surgical and patient-oriented outcome in 50 cases after an average of 2 years,” Spine, vol. 30, no. 3, pp. 324–331, 2005.
[72]
M. Di Silvestre, F. Lolli, G. Bakaloudis, and P. Parisini, “Dynamic stabilization for degenerative lumbar scoliosis in elderly patients,” Spine, vol. 35, no. 2, pp. 227–234, 2010.
[73]
T. M. Stoll, G. Dubois, and O. Schwarzenbach, “The dynamic neutralization system for the spine: a multi-center study of a novel non-fusion system,” European Spine Journal, vol. 11, supplement 2, pp. S170–S178, 2002.
[74]
K. H. Kim, S. H. Lee, C. S. Shim et al., “Adjacent segment disease after interbody fusion and pedicle screw fixations for isolated L4-L5 Spondylolisthesis: a minimum five-year follow-up,” Spine, vol. 35, no. 6, pp. 625–634, 2010.
[75]
P. Park, H. J. Garton, V. C. Gala, J. T. Hoff, and J. E. McGillicuddy, “Adjacent segment disease after lumbar or lumbosacral fusion: review of the literature,” Spine, vol. 29, no. 17, pp. 1938–1944, 2004.
[76]
J. Stulik, T. R. Pitzen, J. Chrobok et al., “Fusion and failure following anterior cervical plating with dynamic or rigid plates: 6-months results of a multi-centric, prospective, randomized, controlled study,” European Spine Journal, vol. 16, no. 10, pp. 1689–1694, 2007.
