i

“PROSPECTIVE ANALYSIS OF EARLY SURGICAL OUTCOME IN

PATIENTS UNDERGOING FUSION WITH POSTERIOR

TRANSPEDICULAR SCREW FIXATION IN INTERVERTEBRAL DISC

PROLAPSE” A STUDY

By

Dr. NIRMAL GERALD FURTADO, M.B.B.S.

Dissertation Submitted to the

Rajiv Gandhi University of Health Sciences, Bangalore,

Karnataka,

in partial fulfillment

of the requirement for the degree of

M.S. (Orthopaedics)

Under the guidance of

Dr. PHANEESHA M. S. (PROFESSOR AND HEAD OF

DEPARTMENT)

DEPARTMENT OF ORTHOPAEDICS

ST. JOHN’S MEDICAL COLLEGE & HOSPITAL, BANGALORE- 560 034

2013

ii

DEPARTMENT OF ORTHOPAEDICS

ST.JOHNS MEDICAL COLLEGE HOSPITAL

BANGALORE

CERTIFICATE

This is to certify that the dissertation entitled

“PROSPECTIVE ANALYSIS OF EARLY SURGICAL

OUTCOME IN PATIENTS UNDERGOING FUSION WITH

POSTERIOR TRANSPEDICULAR SCREW FIXATION IN

INTERVERTEBRAL DISC PROLAPSE”is a bonafide research

work done by

DR. NIRMAL GERALD FURTADO ,

under my overall supervision and guidance, in partial fulfilment

of the requirement for the degree of M. S. (Orthopaedics)

examination.

DR. PHANEESHA M. S.,

PROFESSOR AND HEAD OF DEPARTMENT,

DEPT OF ORTHOPAEDICS,

ST.JOHNS MEDICAL COLLEGE HOSPITAL,

BANGALORE.

iii

ST. JOHNS MEDICAL COLLEGE HOSPITAL

BANGALORE

CERTIFICATE

This is to certify that this dissertation entitled “PROSPECTIVE

ANALYSIS OF EARLY SURGICAL OUTCOME IN PATIENTS

UNDERGOING FUSION WITH POSTERIOR TRANSPEDICULAR

SCREW FIXATION IN INTERVERTEBRAL DISC PROLAPSE” is a

bonafide work done by DR. NIRMAL GERALD FURTADO, post

graduate in the Department of Orthopaedics, under the guidance of

DR. PHANEESHA M. S., Professor and Head of Department,

Orthopaedics, St. Johns medical college hospital, Bangalore, in partial

fulfilment of the regulations for the award of M. S. Degree

(Orthopaedics).

I have satisfied myself about the authenticity of his observations noted

in this dissertation and it confirms to the standards of Rajiv Gandhi

University of Health Sciences, Bangalore.

PLACE :

DATE:

Dr.Phaneesha M. S. Dr.Prem Pais

Head Of Department Dean

Orthopaedic St. John’s Medical College

iv

ST.JOHNS MEDICAL COLLEGE HOSPITAL

BANGALORE.

DEPARTMENT OF ORTHOPAEDICS,

DECLARATION

The dissertation work entitled “PROSPECTIVE ANALYSIS OF

EARLY SURGICAL OUTCOME IN PATIENTS UNDERGOING FUSION

WITH POSTERIOR TRANSPEDICULAR SCREW FIXATION IN

INTERVERTEBRAL DISC PROLAPSE” has been carried out by me, under

the guidance of DR. PHANEESHA M. S., Professor and Head of

Department, Department of Orthopaedics, for the award of M. S.

degree (Orthopaedics) examination conducted by the Rajiv Gandhi

University of Health Sciences, Bangalore, Karnataka. This work is

original and has not been submitted for any other Degree or Diploma

of this or any other University.

Place: BANGALORE Dr. NIRMAL GERALD FURTADO

Date:

v

COPYRIGHT

Declaration by the candidate

I hereby declare that the Rajiv Gandhi University of Health Sciences,

Karnataka shall have the rights to preserve, use and disseminate this

dissertation / thesis in print or electronic format for academic/

research purpose.

Place: BANGALORE Dr.NIRMAL GERALD FURTADO

Date:

vi

ACKNOWLEDGEMENT

With proud privilege and deep sense of respect I like to express my gratitude and

indebtedness to my teacher and guide DR. Phaneesha M. S., Professor and Head of

Department, Department of Orthopaedics, St.John’s Medical College Hospital,

Bangalore, for his constant inspiration and support, which he rendered in preparing this

dissertation and in pursuit of my postgraduate studies.

I am grateful to Dr.Issac Thomas (Professor), Dr.Mallikarjuna Swamy (Professor),

Dr. Davy Ollakkengil (Professor), and Dr.Sudhir Pai (Associate Professor) for their

innovativeness, resourcefulness and motivation. I am also thankful to Dr.Rajeesh George

for his valuable help and guidance during my study.

I am grateful to Dr.Prem Pais, Dean, St.Johns Medical College Hospital, Bangalore for

permitting me to utilize resources in completion of this work.

I am extremely thankful to all the patients who were a part of my study for their consent

and cooperation.

I would also like to thank my wife Dr Priyadarshini for being my constant pillar of

strength and my parents Mr Ruben and Mrs Margaret for their support and blessings.

Place: Bangalore Dr.Nirmal Gerald Furtado

Date

vii

ABSTRACT

TITLE: Prospective analysis of early surgical outcome in patients undergoing

fusion with posterior transpedicular screw fixation in intervertebral disc prolapse

AIM :

1) To evaluate and study the early clinical outcome of Fusion and posterior

Transpedicular screw fixation with decompression in patients of intervertebral

disc prolapse .

2) To compare the outcome with other studies done which have assessed the

outcome of other stabilization methods to manage IVDP.

METHODS: A total of 40 patients were enrolled in the study from August 2011

to Jan 2013. The inclusion criteria were patients undergoing decompression

surgery with posterior instrumentation and fusion for IVDP with radiological

confirmation with or without presence of neurological deficits. All selected

patients who qualify the criteria for the study were clinically assessed and relevant

history was taken with the help of the prepared questionnaire. The low back pain

was classified based on the Japanese Orthopaedic Association (JOA) system.

Analysis of the same was done using SPSS and statistical software.

RESULTS: Mean JOA scores for the 40 study subjects was found to be 6.43

which improved to a mean average of 11.68 at 1 month post op and 12.18 after 6

months. On comparing the JOA scores, pre op JOA scores - 1month JOA scores,

1 month JOA scores- 6 month JOA scores as well as pre op JOA-6 months JOA

scores the improvement of JOA scores has been found to be statistically

significant (chi square test) with a p value of <0.001. Good to excellent clinical

outcome with statistical significance has been noted in 80% of study subjects

CONCLUSION:Posterior decompression with posterior transpedicle screw

application with fusion is a safe, effective and reliable method for treating

patients with lumbar disc prolapse who have been carefully scrutinized for

surgery.

viii

LIST OF ABBREVIATIONS USED

A absent

CT computer tomography

CSF cerebrospinal fluid

DTR deep tendon reflex

EHL extensor hallucis longus

EMG electromyogram

FHL flexor hallucis longus

H heavy work

IVDP intervertebral disc prolapse

JOA Japanese orthopaedic association

L light work

MRI magnetic resonance imaging

PLIF postero lateral interbody fusion

SLRT straight leg raising test

TENS transelectrical nerve stimulation

TLIF transforaminal lumbar intebody fusion

ix

TABLE OF CONTENTS PAGE NO:

1. INTRODUCTION 1

2. OBJECTIVE 3

3. REVIEW OF LITERATURE 4

4. METHODOLOGY 38

5. RESULTS 40

6. DISCUSSION 53

7. CONCLUSION 55

8. SUMMARY 56

9. BIBLIOGRAPHY 57

10. ANNEXURES 62

x

LIST OF TABLES

TABLE 1 COMPLICATIONS OF LUMBAR DISC SURGERY

TABLE 2 SEX DISTRIBUTION

TABLE 3 TYPE OF WORK

TABLE 4 BMI DISTRIBUTION

TABLE 5 PRESENCE OF SMOKING

TABLE 6 DISTRIBUTION OF BACK PAIN

TABLE 7 DISTRIBUTION OF RADICULOPATHY

TABLE 8 DISTRIBUTION OF SIDE INVOLVED

TABLE 9 DISTRIBUTION OF SLRT

TABLE 10 DISTRIBUTION OF MUSCLE SPASM/TENDERNESS

TABLE 11 DISTRIBUTION OF SENSORY DEFICIT

TABLE 12 DISTRIBUTION OF LEVEL INVOLVED

TABLE 13 DISTRIBUTION OF MOTOR DEFICIT

TABLE 14 DISTRIBUTION OF BOWEL BLADDER

INVOLVEMENT

TABLE 15 DISTRIBUTION OF MRI FINDINGS

TABLE 16 DISTRIBUTION OF PRE OP PHYSIOTHERAPHY

TABLE 17 DISTRIBUTION OF ESI

TABLE 18 DISTRIBUTION OF LEVELS INSTRUMENTED

TABLE 19 DISTRIBUTION OF COMPLICATIONS

TABLE 20 DISTRIBUTION OF FUSION POST OP

TABLE 21 DISTRIBUTION OF JOA SCORES

TABLE 22 JOA SCORE COMPARISION

xi

LIST OF FIGURES

FIGURE 1 ANATOMY OF LUMBAR SPINE

FIGURE 2 ANATOMY OF SPINAL CORD AND NERVES

FIGURE 3 STAGES OF DISC PROLAPSE

FIGURE 4 TECHNIQUES OF PEDICAL SREW APPLICATION

FIGURE 5 MRI SAGITTAL SECTION LS SPINE

FIGURE 6 MYELOGRAPHY

1

INTRODUCTION

Low back pain due to lumbar disc prolapse is the major cause of morbidity

throughout the world affecting mainly the young adults. Lifetime incidence of low

back pain is 50-70 % with incidence of sciatica more than 40 %. However

clinically significant sciatica due to lumbar disc prolapse occurs in 4-6 % of the

population. The degeneration of the disc results from many factors and can lead to

prolapse into the intervertebral foramen, particularly at L4-L5 & L5-S1 level.

Lumbar disc herniation is one of the most common spinal conditions and causes

widespread medical problems. Pain relief after surgical excision for a herniated

disc with radiculopathy is predictably successful in more than 90% of patients 1.

While studies have also reported unsatisfactory results in 38% of patients who

undergo lumbar disc surgery 2. Recurrent disc herniation is one of the most

important reasons for unsatisfactory results and, consequently failed back

syndrome. The surgical treatment of sciatica with discectomy is ineffective in a

sizable percentage and reherniation occurs after 5% to 15% of such procedures 3.

However there was significantly lower rates of recurrent disk disease when

fusion was performed. Concurrent use of instrumentation has been shown to

increase fusion rates by increasing rigidity at the fusion site.

The number of spine fusions undertaken has increased dramatically during the

last few years, but only a limited number of studies on the use of transpedicular

devices for nontraumatic indications have been published4 . There is a laqune with

regard to understanding of outcome of fusion and transpedicular fixation in

Intervertebral disc prolapse.

2

The function of this study is to assess the early clinical outcome of patients

undergoing decompression and fusion with posterior transpedicular screw

fixation in intervertebral disc prolapse.

3

OBJECTIVE

PRIMARY OBJECTIVE

To evaluate and study the early clinical (functional and neurological) outcome of

decompression and posterior transpedicular screw fixation with fusion in patients

of intervertebral disc prolapse .

SECONDARY OBJECTIVE

Significance of pre-operative pain as a determinant of outcome of surgical

outcome.

Significance of neurological deficits as a determinant of outcome of surgical

outcome.

To compare the outcome with other studies done which have assessed the

outcome of other methods to manage IVDP.

4

REVIEW OF LITERATURE

5

HISTORY

Low back and sciatic pain has been one of the most common and disabling spinal

disorders recorded in medical history. The role of the spinal canal’s contents in

extremity function is well demonstrated in the Dying Lioness 650 BC Assyrian

artwork.

In the writings of Hippocrates (460–370 BC) one can find references to the

anatomy of the brain, brachial plexus, and sciatic nerve. He attributed the

development of paresthesia, weakness of the limbs, and fecal and urinary

retention to spinal cord compression.

On the basis of his animal and human dissections, Aristotle (384 BC) described

vertebrate anatomy .

Domenico Cotugno , an eighteenth century Italian physician, introduced the term

sciatica into the medical vocabulary.

In 1868, von Luschka described posterior disc protrusion in cadavers found in the

course of routine autopsy procedures.

Schmorl’s contribution to anatomical structures of the intervertebral disc also

deserves recognition. In 1926, he reported on autopsy findings on 5000

intervertebral discs, 15 of which showed evidence of disc protrusion into the

spinal canal.

6

In 1913, Dr. Elsberg of the New York Neurological Institute reported on his

findings on 60 consecutive laminectomies. However, he did not believe disc

pathology was responsible for the presenting symptomatology in any of the

patients described . In 1928, in a paper entitled a ―Extradural Spinal Tumors,

Primary, Secondary, Metastisis,‖ Dr. Elsberg attributed compression of the cauda

equina to the presence of cartilaginous tumors (chondromas).

In 1927, Putti reported on one of his patients who underwent laminectomy and

facetectomy to decompress the L5 and S1 nerve roots and relieve sciatic pain. He

further elaborated on the contribution of Sicard, who performed laminectomy

from L3 to the sacrum to provide relief from sciatic pain.

Mixter and Barr are credited for establishing a clear causal connection between

the herniated disc and sciatica. They provided a detailed description of disc

herniation and popularized laminectomy and discectomy for surgical management

of herniated lumbar discs . Between the 1930s and 1950s, orthopedic and

neurological surgeons followed the traditional teaching of Mixter and Barr that

consisted of wide exposure, bilateral dissection of the paraspinal muscles,

laminectomy, and extensive epidural hemostasis9.

The first attempts at stabilizing the spine with metalwork date back to the late

nineteenth century. In 1909 Fritz Lange (1864–1952) of Munich was the first to

use rods to stabilize the spine. He reported on the use of steel rods fixed to the

spinous processes with silk and then later with silver wire5.

7

The history of spinal fusion began in New York with Fred H Albee (1876–1945)

and Russel A Hibbs (1869–1932) who, independently of each other, published the

results of their respective techniques in 1911.

In the 1950s, efforts were being made to improve the results of lumbar fusions by

supplementing them with internal fixation. In 1944 Donald King (1903–1987), of

San Francisco, described the technique of screw fusion of the facets, and in 1959

Harold Boucher of Vancouver reported an improvement of King’s technique with

the first description of the use of facet-pedicle screws6.

In 1960 Paul Harrington (1911–1980) in Houston, Texas, introduced his hook and

rod fixation system,first used for deformities, later also applied to fractures. The

combination of effective instrumentation and bony fusion dramatically reduced

the incidence of pseudarthroses and greatly improved the results, making this the

standard method for scoliosis correction and fusion throughout the world for more

than a quarter of a century5.

The earliest forms of segmental fixation for spinal deformity with the help of

wiring were developed in the 1950s in Spain and Portugal and perfected by

Eduardo Luque in Mexico. In 1963 Raymond Roy-Camille in Paris started to fix

vertebral fractures by using posterior plates with pedicle screws. It was not until

1970 that Roy-Camille published his method. From the mid-1980s, pedicle screws

gained widespread use and numerous analogous systems have since been

developed7.

8

The first operation with the fixateur interne took place in 1982 in Basel. This

innovation enhanced the practicability of the system. Both these fixators had an

advantage; they enabled the fixation of a shorter portion of the spine than other

techniques leaving more flexibility for the patient.

9

EMBRYOLOGY

The vertebral column defines the species of the subphylum Vertebrata. Vertebral

column development depends on development of the notochord and somites.

While the mesoderm is forming during gastrulation, a mass of ectodermal cells

proliferates and forms the archenteron, a tube that migrates cranially in the

midline between the ectoderm and the endoderm. The floor of the archenteron

forms the notochordal plate.

The notochord arises from cells in the primitive streak that come from the ingress

of cells from the epiblast during gastrulation and, later, from the caudal eminence.

This ingress of cells forms the endoderm as well as the notochord and the paraxial

mesoderm (segmental plate). The notochord develops from cranial to caudal end

by adding cells as it develops. It is initially a solid rod in which a small central

canal develops. The notochord induces the formation of the neural groove, which

gradually closes to form a tube with a central canal. The somites also develop

from cells that are internalized through the primitive streak. These cells form the

paraxial mesoderm, which will become the somites and will ultimately become

the vertebrae.

Four occipital, 8 cervical, 12 thoracic, 5 lumbar, 5 sacral, and 4 or 5 coccygeal

pairs of somites will develop. The somite begins as a ball of pseudostratified

epithelium surrounding a central cavity, the somitocoele. The central cavity

becomes filled with mesenchymal cells. Some of these cells, along with cells in

the medioventral portion of the somite, become the sclerotome. Cells from the

sclerotome will form the vertebral bodies and vertebral arches and emerge

10

without the epithelial portion of the sclerotome to surround the neural tube. In

addition to contributing to the sclerotome, cells from the central cavity migrate to

become the intervertebral discs and contribute to rib formation.

The dense caudal portion of each sclerotome unites with the cranial, less-

condensed part of the next sclerotome to form the primordium of the vertebra.

Therefore, the skeletal portions of the somites no longer correspond to the original

segmentation. The segmental spinal nerves that originally were in midsomite now

lie at the level of the disc. The intersegmental arteries located between somites

come to lie at the midportion of the vertebral bodies, and the myotomes bridge the

vertebrae. The initially continuous notochordal sheath segments into loosely

cellular cranial and densely cellular caudal portions. The cranial portion becomes

the vertebral centrum and the dense, caudal portion becomes the intervertebral

disc. The vertebral centrum surrounds the notochord and forms the vertebral

body.

11

ANATOMY

ANATOMY OF THE VERTEBRAL COLUMN

The vertebral column comprises 33 vertebrae divided into five sections (7

cervical, 12 thoracic, 5 lumbar, 5 sacral, and 4 coccygeal). The sacral and

coccygeal vertebrae are fused, which typically allows for 24 mobile segments.

The cervical and lumbar segments develop lordosis as an erect posture is

acquired. The thoracic and sacral segments maintain kyphotic postures, which are

found in utero. In general, each mobile vertebral body increases in size when

moving from cranial to caudal. A typical vertebra comprises an anterior body and

a posterior arch that enclose the vertebral canal. The neural arch is composed of

two pedicles laterally and two laminae posteriorly that are united to form the

spinous process. To either side of the arch of the vertebral body is a transverse

process and superior and inferior articular processes. The articular processes

articulate with adjacent vertebrae to form synovial joints. The relative orientation

of the articular processes accounts for the degree of flexion, extension, or rotation

possible in each segment of the vertebral column. The spinous and transverse

processes serve as levers for the numerous muscles attached to them. The

vertebral canal extends throughout the length of the column and provides

protection for the spinal cord, conus medullaris, and cauda equine10

.

12

ANATOMY OF THE SPINAL JOINTS

The individual vertebrae are connected by joints between the neural arches and

between the bodies. The joints between the neural arches are the zygapophyseal

joints or facet joints. They exist between the inferior articular process of one

vertebra and the superior articular process of the vertebra immediately caudal.

These are synovial joints with surfaces covered by articular cartilage, a synovial

membrane bridging the margins of the articular cartilage, and a joint capsule

enclosing them. The branches of the posterior primary rami innervate these joints.

ANATOMY OF THE SPINAL CORD AND NERVES

The spinal cord is shorter than the vertebral column and terminates as the conus

medullaris at the second lumbar vertebra in adults and the third lumbar vertebra in

neonates. From the conus, a fibrous cord called the filum terminale extends to the

dorsum of the first coccygeal segment. The spinal cord is enclosed in three

protective membranes—the pia, arachnoid, and dura mater. The pia and arachnoid

membranes are separated by the subarachnoid space, which contains the

cerebrospinal fluid. The spinal cord has enlargements in the cervical and lumbar

regions that correlate with the brachial plexus and lumbar plexus. Within the

spinal cord are tracts of ascending (sensory) and descending (motor) nerve fibers.

These pathways typically are arranged with cervical tracts located centrally and

thoracic, lumbar, and sacral tracts located progressively peripheral10

.

13

FIGURE-1

FIGURE-2

14

DISC ANATOMY

The interbody joints contain specialized structures called intervertebral discs.

These discs are found throughout the vertebral column except between the first

and second cervical vertebrae. The intervertebral disc has a complex structure;

The central gelatinous nucleus is contained around the periphery by the

collagenous anulus, the cartilaginous anulus, and the cartilage end plates cephalad

and caudad. The nucleus pulposus is a semifluid mass of mucoid material, 70% to

90% water, with proteoglycan constituting 65% and collagen constituting 15% to

20% of the dry weight .

The anulus fibrosus consists of 12 concentric lamellae, with alternating

orientation of collagen fibers in successive lamellae to withstand multidirectional

strain. The anulus has interconnections between adjacent layers of collagen fibrils.

The fibers of the annulus can be divided into three main groups:

1) the outermost fibers attaching between the vertebral bodies and the

undersurface of the epiphysial ring;

2) the middle fibers passing from the epiphysial ring on one vertebral body to the

epiphysial ring of the vertebral body below;

3) the innermost fibers passing from one cartilage endplate to the other. The

anterior fibers are strengthened by the powerful anterior longitudinal ligament.

The posterior longitudinal ligament affords only weak reinforcement, especially at

L4-5 and L5-S1. The anterior and middle fibers of the annulus are most numerous

anteriorly and laterally but are deficient posteriorly, where most of the fibers are

attached to the cartilage plate .

15

The anulus cells produce predominantly type I collagen, whereas nucleus cells

synthesize type II collagen. The cells within the disc are sustained by diffusion of

nutrients into the disc through the porous central concavity of the vertebral end

plate. Motion and weight bearing are believed to be helpful in maintaining this

diffusion. The discs are the largest avascular structures in the body12

.

NATURAL HISTORY OF DISC DISEASE

The natural history of degenerative disc disease is one of recurrent episodes of

pain followed by periods of significant or complete relief. Kirkaldy-Willis et al

has provided us with the framework for understanding the natural history of

spondylogenic low back pain. They divided the spectrum of degenerative

disc/facet joint disease into three phases.

Phase I: Dysfunction

Minor pathology causes limited abnormal function in the disc and/or facet joints,

which leads to pain.

Phase II: Instability

This is the intermediate phase in which continuing microtrauma leads to further

degeneration in the disc and facet joints, producing laxity of the annulus and facet

joint capsules. The resulting instability leads to more prolonged episodes of back

pain.

Phase III: Stabilization

This is the final stage that not all patients reach. Fibrosis of the nuclear-annular

complex and the facet joint capsule, along with osteophyte formation, represents

the body's attempt to stabilize the motion segment. Narrowing of the disc and

16

settling of the facet joints probably adds further mechanical stability to the

segment13

.

FIGURE-3

SEQUESTRATED DISC

17

BIOMECHANICS

Between 70% and 90% of static axial load is carried by the cancellous vertebral

body. The role of the shell and core in providing mechanical strength varies with

age.

Processes serve as lever arms to provide mechanical advantage for muscles

inserting along their surfaces. Vertebrae are loaded in series. Caudal vertebrae

must support a greater share of the body weight and this accounts for an

increasing cross-sectional area of the vertebral bodies. In healthy adults the bone

density remains reasonably constant throughout the entire spine. Facet joints

carry, in an upright standing posture, between 10% and 20% of the axial body

load. In hyperextension, the joint load increases up to 30%. In a flexed posture,

the facet joints carry up to 50% of the anterior shear load (compressive loads

transmitted by surface contact and tensile loads resisted by joint capsule). Facet

joint capsules are highly innervated and have been shown to be a source of low

back pain.

In a healthy disc, with the annular fibers cyclically loaded in circumferential

directions, the endurance limit for such hoop stresses is around 1.5 MPa, but it

can drop quickly for degenerated discs. The annulus is weakest in a radial

direction, with tensile strength values consistently below 0.5 MPa. The annulus is

poorly designed to resist tensile radial forces which tend to separate the laminar

layers. When the annular band is being compressed on the side of bending (eg,

anteriorly during flexion), inner fiber layers are bulging inward and outer

layers are bulging outward, in effect separating annular fiber layers21

.

18

BIOMECHANICS OF INSTRUMENTATION

The stabilizing potential of posterior spinal fixation systems has been

demonstrated in many biomechanical studies. A comparison of the internal fixator

and the uss has shown that motion of the stabilized spinal segment is reduced by

up to 85% in flexion, 52% in extension, 81% in Lateral bending, and 51% in axial

rotation. Additional stability can be achieved by adding cross-links. Posterior

systems derive their stability from a solid anchorage in the pedicle and the

inherent rigidity of the connecting Instrumentation. The pullout strength of

pedicle screws is directly related to the bone density . It is possible to achieve an

increase in pullout strength by choosing convergent screw trajectories and by the

addition of cross-links.

Furthermore, it has been shown that with parallel pedicle screws in short-segment

constructs, an unstable ―four-bar‖ mechanism can result in the absence of

adequate anterior column support ; therefore, triangulation of Pedicle screws is

recommended for better stability. The same rationale applies for cross-linking the

rods. Diagonal Cross- linking is preferable to the horizontal configuration in terms

of rotational stability. The stiffness of the fixator construct depends heavily on the

diameter of the connecting rods. Compared with a system using 7 mm rods, a 10

mm Rod has a 4.1 times higher bending stiffness. An increase in rod diameter

provides a more stable construct, but at the same time it produces higher internal

loads in the implant, on the clamping device, and on the pedicle screws, and thus

a higher risk of screw breakage. Therefore, a compromise between an absolutely

rigid fixation and a minimal risk of implant failure must be achieved22,23

.

19

TECHNIQUE OF PEDICAL SCREW APPLICATION

Lumbar pedicles are conical, oval-shaped structures with diameters ranging from

7 mm at the thoraco-lumbar junction to 15 mm at the lumbo-sacral junction.

Lumbar pedicles angulate medially, from 0° in the upper lumbar spine increasing

to 30° at L5. The average postero-anterior distance is 45 - 50 mm. Imaging, in

each case, will allow selection of the maximum possible screw size and

appropriate trajectory for a given pedicle. Classically, the entry point is located at

the intersection of a horizontal line passing through the mid-line of the transverse

processes and a vertical line that would pass through the infero-lateral margin of

the facet joint.

Sacral Pedicle Screws The sacral pedicle is much larger than the largest lumbar

pedicle. Larger bi-cortical screws are typically required. Typical S1 screws

medially directed towards the sacral promontory are adequate for most (short)

constructs. The entry for S1 medially directed promontory screw is located at the

intersection of a vertical line tangential to the lateral border of the S1 facet and a

horizontal line tangential to its inferior border. Using the same point of entry, the

S1 lateral screw, directed 35° laterally, parallel to the end-plate and the S2 lateral

screw, directed 40° laterally, towards the corner of the S1-2 Ala, can be used in

exceptional situations.

20

FIGURE-4

21

CLINICAL SIGNS AND SYMPTOMS

Although back pain is common from the second decade of life on, intervertebral

disc disease and disc herniation are most prominent in the third and fourth

decades of life. Most people relate their back and leg pain to a traumatic incident,

but close questioning frequently reveals that the patient has had intermittent

episodes of back pain for many months or even years before the onset of severe

leg pain. In many instances, the back pain is relatively fleeting and is relieved by

rest. This pain often is brought on by heavy exertion, repetitive bending, twisting,

or heavy lifting. The pain usually begins in the lower back, radiating to the

sacroiliac region and buttocks. The pain can radiate down the posterior thigh.

Radicular pain usually extends below the knee and follows the dermatome of the

involved nerve root .

The usual history of lumbar disc herniation is of repetitive lower back and buttock

pain, relieved by a short period of rest. This pain is suddenly exacerbated, often

by a flexion episode, with the appearance of leg pain. Most radicular pain from

nerve root compression caused by a herniated nucleus pulposus is evidenced by

leg pain equal to, or in many cases greater than, the degree of back pain. The pain

from disc herniation usually varies, increasing with activity, especially sitting,

straining, sneezing, or coughing. The pain can be decreased by rest, especially in

the semi-Fowler position.

Other symptoms of disc herniation include weakness and paresthesias. In most

patients, the weakness is intermittent, varies with activity, and is localized to the

neurological level. If a fragment is large, or the herniation is high, symptoms of

pressure on the entire cauda equina can occur with development of cauda equina

syndrome. These symptoms include numbness and weakness in both legs, rectal

22

pain, numbness in the perineum, and paralysis of the sphincters. This diagnosis

should be the primary consideration in patients who complain of sudden loss of

bowel or bladder control.

The physical findings with disc disease vary because of the time intervals

involved. Usually patients with acute pain show evidence of marked paraspinal

spasm that is sustained during walking or motion. A scoliosis or a list in the

lumbar spine may be present, and in many patients the normal lumbar lordosis is

lost. Point tenderness may be present over the spinous process at the level of the

disc involved, and pain may extend laterally in some patients.

If there is nerve root irritation, stretch of the sciatic nerve should reproduce

buttock, thigh, and leg pain (i.e., pain distal to the knee). A Lasègue sign usually

is positive on the involved side. A positive Lasègue sign or straight leg raising

should elicit buttock and leg pain. Occasionally, if leg pain is significant, the

patient leans back from an upright sitting position and assumes the tripod position

to relieve the pain. This is referred to as the ―flip sign.‖ Contralateral leg pain

produced by straight leg raising should be regarded as pathognomonic of a

herniated intervertebral disc. The absence of a positive Lasègue sign should make

one skeptical of the diagnosis, although older individuals may not have a positive

Lasègue sign. If the leg pain has persisted for any length of time, atrophy of the

involved limb may be present, as shown by asymmetrical girth of the thigh or

calf. The neurological examination varies as determined by the level of root

involvement11

.

23

Differential Diagnosis

The differential diagnosis of back and leg pain is extremely lengthy and complex.

It includes diseases intrinsic to the spine and diseases involving adjacent organs,

but causing pain referred to the back or leg. For simplicity, lesions can be

categorized as being extrinsic or intrinsic to the spine. Extrinsic lesions include

diseases of the urogenital system, gastrointestinal system, vascular system,

endocrine system, nervous system not localized to the spine, and extrinsic

musculoskeletal system. These lesions include infections, tumors, metabolic

disturbances, congenital abnormalities, and associated diseases of aging. Intrinsic

lesions involve diseases that arise primarily in the spine. They include diseases of

the spinal musculoskeletal system, the local hematopoietic system, and the local

neurological system. These conditions include trauma, tumors, infections,

degenerative and immune diseases affecting the spine or spinal nerves.

DIAGNOSTIC STUDIES

Radiography

The simplest and most readily available diagnostic tests for lumbar or cervical

pain are anteroposterior and lateral radiographs of the involved spinal region.

These simple radiographs show a relatively high incidence of abnormal findings.

There is insignificant correlation between back pain and the radiographic findings

24

of lumbar lordosis, transitional vertebra, disc space narrowing, disc vacuum sign,

and claw spurs. In addition, the entity of disc space narrowing is extremely

difficult to quantify in all but the operated backs or in obviously abnormal

circumstances. Frymoyer et al. in a study of 321 patients found that only when

traction spurs or obvious disc space narrowing or both were present did the

incidence of severe back and leg pain, leg weakness, and numbness increase.

Special radiographic views can be helpful in defining further or disproving the

initial clinical radiographic impression. Oblique views are useful in defining

further spondylolisthesis and spondylolysis, but are of limited use in facet

syndrome and hypertrophic arthritis of the lumbar spine. Lateral flexion and

extension radiographs may reveal segmental instability14

.

Myelography

The value of myelography is the ability to check all spinal regions for abnormality

and to define intraspinal lesions; it may be unnecessary if clinical and CT or MRI

findings are in complete agreement. The primary indications for myelography are

suspicion of an intraspinal lesion, patients with spinal instrumentation, or

questionable diagnosis resulting from conflicting clinical findings and other

studies. In addition, myelography is valuable in a previously operated spine and in

patients with marked bony degenerative change that may be underestimated on

MRI. Myelography is improved by the use of postmyelography CT. Bell et al.

found myelography to be more accurate than CT scanning for identifying

herniated nucleus pulposus and only slightly more accurate than CT scanning in

the detection of spinal stenosis14

.

25

Computed Tomography

CT revolutionized the diagnosis of spinal disease. Most clinicians now agree that

CT is an extremely useful diagnostic tool in the evaluation of spinal disease.

Software is available to evaluate the density of a selected vertebra and compare

the images so that exact measurements of various structures it with vertebrae of

the normal population to give a numerically reproducible estimate of vertebral

density to quantitate osteopenia. This noninvasive, painless, outpatient procedure

can supply more information about spinal disease than was previously available

with a battery of invasive and noninvasive tests usually requiring hospitalization.

CT does not show intraspinal tumors or arachnoiditis and is unable to differentiate

scar from recurrent disc herniation14

.

Magnetic Resonance Imaging

MRI is currently the standard for advanced imaging of the spine. MRI is superior

to CT in most circumstances, in particular, identification of infections, tumors,

and degenerative changes within the discs. More importantly, MRI is superior for

imaging the disc and directly images neural structures. Of particular value is the

ability to image the nerve root in the foramen, which is difficult even with

postmyelography CT because the subarachnoid space and the contrast agent do

not extend fully through the foramen14

.

ELECTROMYOGRAPHY

Electromyography is the most notable of these tests. One advantage of

electromyography is in the identification of peripheral neuropathy and diffuse

neurological involvement indicating higher or lower lesions. Electromyography

and nerve conduction velocity can be helpful if a patient has a history and

26

physical examination suggestive of radiculopathy at either the cervical or the

lumbar level with inconclusive imaging studies

BONE SCANS

Bone scans are another procedure in which positive findings usually are not

indicative of intervertebral disc disease, but they can confirm neoplastic,

traumatic, and arthritic problems in the spine.

Various laboratory tests, such as a complete blood count, differential white blood

cell count, C-reactive protein, biochemical profile, urinalysis, serum protein

electrophoresis, and erythrocyte sedimentation rate, are extremely good screening

procedures for other causes of pain in the spine. Rheumatoid screening studies,

such as rheumatoid arthritis, antinuclear antibody, lupus erythematosus cell

preparation, and HLA-B27, also are useful when indicated by the clinical picture.

27

FIGURE-5-MRI LS SPINE

FIGURE-6-MYELOGRAPHY

28

Nonoperative Treatment

The number and variety of nonoperative therapies for back and leg pain are

diverse and overwhelming. The simplest treatment for acute back pain is rest.

Biomechanical studies indicate that lying in a semi-Fowler position. Muscle

spasm can be controlled by the application of ice, preferably with a massage over

the muscles in spasm. Pain relief and antiinflammatory effect can be achieved

with nonsteroidal antiinflammatory drugs (NSAIDs). As the pain diminishes, the

patient should be encouraged to begin isometric abdominal and lower extremity

exercises. Walking within the limits of comfort also is encouraged. Malmivaara et

al. compared the efficacy of bed rest alone, back extension exercises, and

continuation of ordinary activities as tolerated in the treatment of acute back pain.

They concluded that continuation of ordinary activities within the limits permitted

by pain led to a quicker recovery.

Education in proper posture and body mechanics is helpful in returning the patient

to the usual level of activity after the acute exacerbation has improved. Oral

steroids used briefly can be beneficial as potent antiinflammatory agents. When

depression is prominent, mood elevators such as nortriptyline can be beneficial in

reducing sleep disturbance and anxiety without increasing depression.

Nortriptyline also decreases the need for narcotic medication.

Physical therapy should be used judiciously. The exercises should be fitted to the

symptoms and not forced as an absolute group of activities. The true benefit of

such treatments may be in the promotion of good posture and body mechanics

rather than of strength.

29

Numerous treatment methods have been advanced for the treatment of back pain.

Some patients respond to the use of transcutaneous electrical nerve stimulation.

Others do well with traction varying from skin traction in bed with 5 to 8 lb to

body inversion with forces of more than 100 lb. Back braces or corsets may be

helpful to other patients. Ultrasound and diathermy are other treatments used in

acute back pain. The scientific efficacy of many of these treatments has not been

proved.

Operative Treatment

If nonoperative treatment for lumbar disc disease fails, the next consideration is

operative treatment. Before this step is taken, the surgeon must be sure of the

diagnosis. The patient must be certain that the degree of pain and impairment

warrants such a step. The surgeon and the patient must realize that disc surgery is

not a cure, but may provide symptomatic relief. It neither stops the pathological

processes that allowed the herniation to occur nor restores the disc to a normal

state. The patient still must practice good posture and body mechanics after

surgery. The key to good results in disc surgery is appropriate patient selection.

The optimal patient is one with predominant (if not only) unilateral leg pain

extending below the knee that has been present for at least 6 weeks. The pain

should have been decreased by rest, antiinflammatory medication, or even

epidural steroids, but should have returned to the initial levels after a minimum of

6 to 8 weeks of conservative care. Some managed care plans now insist on a trial

of physiotherapy. Physical examination should reveal signs of sciatic irritation

and possibly objective evidence of localizing neurological impairment. CT,

30

lumbar MRI, or myelography should confirm the level of involvement consistent

with the patient's examination.

Surgical disc removal is mandatory and urgent only in cauda equina syndrome.

All other disc excisions should be considered elective. The elective status of

surgery should allow a thorough evaluation to confirm the diagnosis, level of

involvement, and physical and psychological status of the patient.

Regardless of the method chosen to treat a disc rupture surgically, the patient

should be aware that the procedure is predominantly for the symptomatic relief of

leg pain. Patients with predominantly back pain may not be relieved of their major

complaint—back pain.

Table -1 -- Complications of Lumbar Disc Surgery

Complication

Incidence

(%)

1. Cauda equina syndrome

0.2

2. Thrombophlebitis

1

3. Pulmonary embolism

0.4

4. Wound infection

2.2

5. Pyogenic spondylitis

0.07

31

Complication

Incidence

(%)

6. Postoperative discitis

2

7. Dural tears

1.6

8. Nerve root injury

0.5

32

REVIEW OF LITERATURE

It was in 1934 that mixter and Barr published their classic paper on ruptured

intervertebral disc in 58 cases, in the New England Journal Of medicine. The

Procedure used was laminectomy and discectomy by a transdural approach and

thus demonstrated the effectiveness of the operative treatment9.

Lumbar disc herniation is one of the most common spinal conditions and causes

widespread medical problems. Pain relief after surgical excision for a herniated

disc with radiculopathy is predictably successful in more than 90% of patients15

.

Low back pain, segmental instability, with sciatica significantly contribute to the

development of failed back syndrome after lumbar disk surgery. Segmental

instability is diagnosed in 20% of patients with lumbar disk herniation.

Discectomy when performed on segmental degeneration cases may cause

segmental instability and accounts for 38% of unsatisfactory results16

.

Spangfort et al , in reviewing 2504 lumbar disc excisions, found that about 30%

of the patients complained of back pain after disc surgery. Failure to relieve

sciatica was proportional to the degree of herniation. The best results of 99.5%

complete or partial pain relief were obtained when the disc was free in the canal

or sequestered. Incomplete herniation or extrusion of disc material into the canal

resulted in complete relief for 82% of patients. Excision of the bulging or

protruding disc that had not ruptured through the anulus resulted in complete

relief in 63%, and removal of the normal or minimally bulging disc resulted in

complete relief in 38%, which is near the stated level for the placebo response.

Muculloch et al found that long term results following lumbar disc surgery were

only slightly better than conservative measures and natural history of disc

33

herniation though the short term results were excellent when there is agreement

between clinical presentation and imaging studies. The outcome is more

dependent on patient selection than on surgical technique18

.

Leufven et al reported 93% fusion and 70% satisfactory outcome when PLIF was

combined with posterolateral fusion and instrumentation.. PLIF is commonly

advocated as a method of treating mechanical low back pain including LSI

(Lumbar Segmental instability) with 70-80 % fusion rate and reported 75 – 90%

return to work19

.

Tandon etal 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%20

.

Kleinstuck et al. examined whether the level of preoperative low back pain was a

predictor of outcome in patients with lumbar spinal stenosis undergoing surgical

decompression . They found that the greater the amount of preoperative low back

pain relative to leg pain, the worse the outcome of decompression surgery34

.

Jansson et al. examined predictors of health-related quality-of-life in patients who

had undergone surgery for herniated disc and found that, in addition to smoking

and a short preoperative walking distance, a long history of back pain was a

significant predictor of a lower quality of life at follow-up35

.

Pearson et al. compared the results of operative versus conservative treatment of

lumbar disc herniation in the presence of low back pain and found that while both

treatment groups showed improvement of low back pain, surgical treatment

34

seemed more favourable. In both groups, the relief of back pain was less than the

relief of leg pain,

The existing literature is sufficiently supportive of the operative management of

nerve root stenosis and disc protrusion. However, the success of these surgical

procedures and patient satisfaction with the outcome, are variable. McGregor &

Hughes found much lower levels of patient satisfaction of 58-69% which was

attributed to unrealistic expectations of surgery. Yee et al who suggested that 81%

of patient expectations were met by surgery - however, Yee provided patients

with detailed pre-operative information. It has been suggested that while leg pain

improves following decompressive surgery, functional improvements are less

marked and this in turn may impact on quality of life24

.

Discectomy for disc prolapse has higher success rates, ranging from 65-90%, but

residual back and leg pain and recurrent herniation remain the major post-

operative problem in lumbar disc surgery . Soldberg et al reported that 4% of

patients got worse after surgery.

Yorimitsu et al indicated that up to 10% had significantly more leg pain and a

further 10% had significantly more back pain. In terms of function, Yorimitsu et

al noted that only 40% of patients returned to pre-sciatica levels of recreational

activity26

.

La Rosa e al made the inference that the findings support the view that an

interbody fusion confers superior mechanical strength to the spinal construct;

when posterolateral fusion is the sole intervention, progressive loss of the extreme

correction can be expected. Such mechanical insufficiency, however, did not

influence clinical outcome27

.

35

Odai et al inferred that spinal instability with preserved anterior load sharing,

pedicle screw fixation alone is biomechanically adequate28

.

Fujiwara A et al inferred that the degenerative processes in the disc and facet

joints affect the stability of the motion segment. Abnormal tilting movement on

flexion and anteroposterior translatory instability both had negative associations

with facet joint osteoarthritis. However, anterior translatory instability was

positively associated with disc degeneration and facet joint osteoarthritis29

.

Low back pain, segmental instability, with sciatica significantly contribute to the

development of failed back syndrome after lumbar disk surgery. Segmental

instability is diagnosed in 20% of patients with lumbar disk herniation.

Discectomy when performed on segmental degeneration cases may cause

segmental instability and accounts for 38% of unsatisfactory results.

Shono et al concluded that many adverse effects have been reported in fusion

augmented with rigid instrumentation. Application of segmental instrumentation

changes the motion pattern of the residual intact motion segments, and the

changes in the motion pattern become more distinct as the fixation range becomes

more extensive and as the rigidity of the construct increases30

.

Enker et al made the final conclusion that Persistent pseudarthrosis rates and

instrumentation failures have prompted circumferential fusion techniques.

Posterior lumbar interbody fusion (PLIF) and segmental pedicle fixation allows

for wide decompression and increased exposure for disk space preparation,

minimizing neural injury. Pedicle fixation restores segmental stability and

minimizes graft retropulsion. Restoration of anterior column support prolongs

instrumentation life, and increases fusion rates irrespective of the number of

36

levels fused. Disk space distraction, with the use of instrumentation as a working

tool, permits safer decompression of the intraforaminal zone, a common area of

stenosis, and single or multilevel deformity correction to restore coronal, axial,

and sagittal alignment and spinal balance. Even though the surgical technique is

demanding, fusion rates up to 96% and clinical success up to 86% are achieved31

.

Ohman et al concluded that Posterior lumbar interbody fusion (PLIF)

incorporated with transpedicular screws can be applied to spondylolisthesis,

degenerative disc disease, recurrent disc herniation, spinal stenosis including the

central and lateral foraminal varieties. Complications include infection, fracture of

the pedicle, nerve root impingement associated with the bone graft, and screw

breakage. In cases where infection does occur, the hardware must be removed32

.

Lumbar interbody fusion 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 collapses33

.

Transpedicular fixation has advantage over other fixation devices as only 2-3

vertebra are spanned, true three dimensional fixation is achieved, eliminating

direct encroachment into the spinal canal, no special alignment between screws

needed, allowing screw placement to fully conform to anatomic structures. A final

observation concerning pedicle screw placement is that even if the pedicle cortex

is disrupted neurologic damage does not necessarily follow. Study by Salliant et

37

al noted that 10% of 375 screws in 56 patients were outside cortex but there

were only two csf leaks with spontaneous resolution and no neurologic deficits15

.

Tuncay et al studied posterior transpedicular fixation in patients with recurrent

disc herniation post microdiscectomy using Oswestry and VAS scores and

radiological follow up and concluded that posterior stabilization is an effective

alternative to fusion in the treatment of chronic instability and degenerative

disease of the lumbar spine 17

.

Complications seen with transpedicular fixation are implant failure, nerve root

injury, screw loosening, infection, non union, screw misplacement13

.

Arthur et al state in their paper that there is a poor correlation between rate of

fusion and pain relief. This suggests that more than just adequate fusion

decompression is also necessary. Decompression although usually mandatory

often cannot be performed extensively enough to free the nerve roots completely

without fear of creating instability. Adequate decompression of nerve roots is

crucial for good leg pain relief and optimal results. Using the posterior

stabilisation devices any degree of destabilisation can be performed because rigid

restabilization is immediately assured.

Rigid internal fixation and fusion have been currently the mainstay for surgical

treatment of degenerative diseases of the spine over the last 4 decades. Although

successful radiological results up to 95% associated with fusion reported, this

results were not compatible with successful clinical outcome regarding pain

alleviation.

38

METHODOLOGY

40 Randomly selected patients presenting to St Johns Medical college hospital

(Orthopaedics OPD, Casualty or other departments) with LBA, radiculopathy and

radiological correlation of intervertebral disk prolapse and undergoing

Decompression, fusion and Posterior transpedicular fixation from August 2011 –

January 2013.

Inclusion criteria

1. All patients with IVDP undergoing decompression and posterior

transpedicular fixation.

2. Age ranging from 18-70.

3. MRI proved disc prolapse with deficit.

4. Acute progressive neurological deficits associated with disc prolapse.

5. Minimum follow up of six months.

Exclusion criteria

1. History of previous spine surgery.

2. Patients with traumatic disc prolapse.

3. Patient who are medically unfit for surgery.

39

Type of study- Prospective study

All selected patients who qualify the criteria for the study are clinically assessed

and relevant history taken with the help of the prepared questionnaire . They

were subjected to thorough clinical and neurological examination. The low back

pain classified based on the Japanese Orthopaedic Association (JOA) system14

.

Radiological assessment done with study of AP/ lateral X ray L S spine.

MRI LS spine with whole spine screening to confirm diagnosis and level of the

lesion.The results of imaging were correlated with physical findings and

symptomatology of the patients.

Patient was assessed preoperatively and postoperatively on day 30 and 6 months.

Minimum follow up of 6 months was observed in all the subjects.

40

RESULTS

41

RESULTS

A total number of 40 Randomly selected patients between August 2011 and

January 2013 presenting to St Johns Medical college hospital with LBA,

radiculopathy and radiological correlation of intervertebral disk prolapse and

undergoing Decompression, fusion and Posterior transpedicular fixation.

Patients were assessed preoperatively, post operatively after one month and 6

months. Follow up duration was for a period of 6 months.

There were total of 21 females (52.5%) and 19 males (47.5%). Patients were

taken within the age limits of 17-80 with age averaging around 45.4 years.

Maximum age in the study was 65 years and minimum of 17 years.

TABLE-2

42

TABLE 3

19

21

MALE

FEMALE

13

27

HEAVY

LIGHT

43

TABLE-4

A:<19 kg/m2

, B:19-25 kg/m2, C:25-30 kg/m

2,D:>40 kg/m

2

65% of the patients were in the 19-25kg/m2 category. No association between

BMI and clinical outcome was found in the study.

TABLE-5

0

10

20

30

BMI

26

13

1

B

C

D

44

No significant association was found between smoking and clinical outcome in

the study.

ONSET

42% of patients came with acute onset of presenting complaint while 57% had a

chronic presentation.

0

10

20

30

40

SMOKING

13

27 NO

YES

0

10

20

30

40

ONSET

17

23 CHRONIC

ACUTE

45

92% of patients had lower back ache with 98% having associated radiculopathy.

Radiculopathy to right was equal to left at 35%, with bilateral radiculopathy of

25%.

TABLE-6

TABLE-7

TABLE-8

TABLE-9

42% of patients had a SLRT between 20-70 degrees. 90% of the subjects had

associated muscle spasm. 57% patients had sensory deficits with L4-L5 being the

most common level at 25%, while 77% of operated patients had motor deficits.

46

Only 1 patient had bowel bladder involvement

TABLE-12

TABLE-13

0

10

20

SLRT

7

17 16 A

B

C

47

TABLE-14

TABLE-15

TABLE-16

TABLE-17

Preoperative MRI was done for all the patients. Most common finding was disc

bulges(42%) and disc prolapse(37%). Associated finding of facetal OA and

48

ligamentum hypertrophy were seen in 25% and 22% of cases respectively.

TABLE-18

Patients were given a trial of physiotherapy prior to surgery in 65% of cases while

17% cases received epidural steroid injection.

TABLE-20

49

TABLE-21

Most common surgical procedure executed was PLIF in 60% of cases.TLIF was

done in 37.5% of cases. Two level fusions were done in 24 (60%)cases while

single level fusion was attempted in 10(25%) cases.

80% of operated cases had no complications. Intraoperative bleeding was the

most common complication experienced in total of 3 (7.5%)cases, followed by

superficial infection in one case which was controlled by IV antibiotics. Only two

screws were found to be placed out of pedicle. No instance of implant failure was

seen in this study.

0

5

10

15

20

25

FUSION PERFORMED

15

24

1

TLIF

PLIF

TLIF+PLF

50

TABLE-22

TABLE-23

17(42.5%) cases have shown fusion on x-ray review at 6 month review.

TABLE-24

Mean JOA scores for the 40 study subjects was found to be 6.43 which improved

to a mean average of 11.68 at 1 month post op and 12.18 after 6 months. On

comparing the JOA scores, pre op JOA scores - 1month JOA scores, 1 month

JOA scores- 6 month JOA scores as well as pre op JOA-6 months JOA scores the

improvement of JOA scores has been found to be statistically significant (chi

51

square test) with a p value of <0.001.

Mean JOA score improvement over 6 months

TABLE-25

Minimum –

maximum

Mean ± SD P value

Pre OP JOA

Score

2 -13 6.4 ± 2.4

52

Post OP JOA

Score – 1 month

6 – 15 11.7 ± 2.1 <0.001a

Post OP JOA

Score – 6 month

7 -15 12.2 ± 2.1 <0.001a,b

Reported as mean ± SD; P values using paired t test;

a – Comparison of pre with post 1 and post2

b – Comparison of post1 with post2

The final outcome shows clinical good results in 45% of cases with excellent

outcome seen in 32.5% study subjects at the end of 1 month post operatively. At

the end of 6 months this outcome further improved to 52.5% of subjects showing

excellent clinical results and 27% showing good results a total of 80% of study

subjects.

Results at the end of 1 month and 6 months using JOA scores.

5

17.5

45

32.5

5

15

27.5

52.5

0

10

20

30

40

50

60

Unchanged Fair Good Excellent

pe

rce

nat

ge

Recovery Rate

Recovery Rate at 1 month

Recovery Rate at 6 month

53

DISCUSSION

Although lumbar discectomy is a common operation, valid indications for

operative treatement of patients who have herniation of lumbar disc are still

elusive and the results of such treatement have been inconsistent36

.

IVDP is common in otherwise healthy people in 3rd

and 4th

decade of life. In

our study average age of presentation was 45.4years.

Neurological deficit not being a predictive if outcome has been shown by

previous studies37

.

Irrespective of duration of symptoms the results were found to be uniform. Thus

showing that the outcome of the surgery was not dependent on the durations of

the symptoms.

In our study light workers were found to have better outcome when compared to

the heavy workers.

42% of patients had a SLRT between 20-70 degrees. 90% of the subjects had

associated muscle spasm. 57% patients had sensory deficits with L4-L5 being the

most common involved level at 25%, while 77% of operated patients had motor

deficits. Only 1 patient had bowel bladder involvement which resolved after

surgery.

The present study analyses the results of this surgical technique on the basis of the

clinical outcome. Mean JOA scores for the 40 study subjects was found to be 6.43

which improved to a mean average of 11.68 at 1 month post op and 12.18 after 6

months. On comparing the JOA scores, pre op JOA scores - 1month JOA scores,

54

1 month JOA scores- 6 month JOA scores as well as pre op JOA-6 months JOA

scores the improvement of JOA scores has been found to be statistically

significant (chi square test) with a p value of <0.001

Good result is seen in only 80% as compared to 77.3% in Pappas study and 89%

in Richard davies study38,39

. Pappas study show poor outcome in 6.40% cases

while Davies study show poor outcome in 3.3% cases as compared to 5% cases

with unchanged outcome in our study. Leufven et al reported 93% fusion and

70% satisfactory outcome when PLIF was combined with posterolateral fusion

and instrumentation.

55

CONCLUSION

Good to excellent clinical outcome with statistical significance has been noted

in 80% of study subjects following the surgical procedure of fusion with

posterior transpedicular fixation with posterior decompression in IVDP.

Average age of study subjects is 45.4years with most commonly involved level

L4-L5 in 25% of cases.

Good neurological recovery has been noted following this surgery.

Preoperative neurological deficits had no influence on the outcome of the surgery.

Sex of patient, SLRT, BMI and duration of symptoms had no influence on the

outcome of the surgery.

Type of work has a significant association with the clinical outcome.

Radiological signs of Fusion has been noted in 47% of cases at 6 months

postoperatively.

JOA evaluation system appears to be a useful tool for evaluation of lumbar disc

surgery.Widespread use of this score will allow different studies and procedures

to be compared more objectively to improve the outcome of disc surgery.

Posterior decompression with posterior transpedicle screw application with

fusion is a safe and reliable method for treating patients with lumbar disc

prolapse who have been carefully scrutinized for surgery.

56

SUMMARY

Low backache is a common ailment in the general population and 80% of the

adults experience it in some point of their life. Lumbar disc herniation is a

common cause for the same. Of the numerous methods posterior decompression

and fusion with transpedicular screw fixation is one of the surgical interventions.

The present study analyses the results of the clinical outcome of 40 study patient

who were treated with this surgical technique . Mean JOA scores for the 40 study

subjects was found to be 6.43 which improved to a mean average of 11.68 at 1

month post op and 12.18 after 6 months post op. On comparing the JOA scores,

pre op JOA scores - 1month JOA scores, 1 month JOA scores- 6 month JOA

scores as well as pre op JOA-6 months JOA scores the improvement of JOA

scores has been found to be statistically significant (chi square test) with a p value

of <0.001.

Radiological signs of Fusion has been noted in 47% of cases at 6 months

postoperative radiograph.

The final outcome shows clinical good results in 45% of cases with excellent

outcome seen in 32.5% study subjects at the end of 1 month post operatively. At

the end of 6 months this outcome further improved to 52.5% of subjects showing

excellent clinical results and 27% showing good results a total of 80% of study

subjects.

57

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62

ANNEXURES

63

PERFORMA

1. NAME-

2. AGE-

3. SEX-

4. CONTACT ADDRESS-

5. PHONE NO-

6. PROFESSION-

7. SMOKING-

8. WT- HT-

PRE OPERTATIVE INFORMATION

THE PRESENTING COMPLAINTS:

BACK PAIN (JOA) DURATION:

RADICULOPATHY: LEFT: RIGHT: B/L: DURATION:

CLAUDICATION: DURATION:

WALKING DISTANCE: (JOA)

BOWEL/BLADDER INVOLVEMENT: DURATION:

CLINICAL SIGNS:

SCOLIOSIS TENDERNESS: SPASM:

SLRT: <30 30-50 >50

CROSS SLRT:

MOTOR DEFICITS

SENSORY DEICITS:

DEEP TENDON REFLEXES: ANKLE: KNEE: PLANTAR:

ANKLE TONE:

64

PERIANAL SENSATIONS:

INVESTIGATIONS:

MRI FINDINGS: L1/L2 L2/L3 L3/L4 L4/L5 L5/S1

CENTRAL CANAL STENOSIS:

ROOT CANAL STENOSIS: RIGHT: LEFT: B/L:

SEVERITY OF PROLAPSE:

BULGE:

PROTRUSION:

EXTRUSION:

SEQUESTRATION:

FACET JOINTS:

LIGAMENTS HYPERTROPHY:

CALCIFIED POSTERIOR LONGITUDINAL LIGAMENT:

ADDITIONAL FINDINGS:

PRE OPERATIVE TREATMENT TAKEN:

CONSERVATIVE:

PHYSIOTHERAPY:

SWD IFT USM DURATION:

TRACTION: DURATION:

EPIDURAL STEROID INJECTION: NUMBER:

DRUGS TAKEN: DURATION:

SURGICAL PROCEDURE:

DISCECTOMY+FIXATION+PLIF

DISCECTOMY+FIXATION+TLIF

INTRA OPERATIVE FINDINGS:

BLOOD LOSS:

65

NERVE ROOT EDEMA: LIGAMENTUM

HYPERTROPHY:

DURAL TEAR:

OTHERS:

ON POST OP DAY 10

SYMPTOMS:

BACK PAIN(JOA):

RADICULOPATHY: RIGHT : LEFT: B/L:

CLAUDICATION:

BOWEL/BLADDER INVOLVEMENT:

CLINICAL SIGNS:

SCOLIOSIS:

TENDERNESS:

SPASM:

SLRT <30 30-50 >50

CROSS SLRT:

MOTOR DEFICITS:

SENSORY DEFICITS:

DEEP TENDON REFLEX: ANKLE: KNEE: PLANTAR:

ANAL TONE: PERIANAL SENSATIONS:

X-RAY FINDINGS:

DISC HEIGHT:

SCOLIOSIS:

IMPLANT POSITION:

LISTHESIS: GRADE:

FOLLOW UP ON POST OP 1 MONTH:

SYMPTOMS

66

BACK PAIN(JOA):

RADICULOPATHY: RIGHT : LEFT: B/L:

CLAUDICATION:

BOWEL/BLADDER INVOLVEMENT:

CLINICAL SIGNS:

SCOLIOSIS:

TENDERNESS:

SPASM:

SLRT <30 30-50 >50

CROSS SLRT:

MOTOR DEFICITS:

SENSORY DEFICITS:

DEEP TENDON REFLEX: ANKLE: KNEE: PLANTAR:

ANAL TONE: PERIANAL SENSATIONS:

X-RAY FINDINGS:

DISC HEIGHT:

SCOLIOSIS:

IMPLANT POSITION:

LISTHESIS: GRADE:

FOLLOW UP AFTER 6 MONTH:

SYMPTOMS

BACK PAIN(JOA):

RADICULOPATHY: RIGHT : LEFT: B/L:

BOWEL/BLADDER INVOLVEMENT:

CLINICAL SIGNS:

SCOLIOSIS:

TENDERNESS:

67

SPASM:

SLRT <30 30-50 >50

CROSS SLRT:

MOTOR DEFICITS:

SENSORY DEFICITS:

DEEP TENDON REFLEX: ANKLE: KNEE: PLANTAR:

ANAL TONE: PERIANAL SENSATIONS:

X-RAY FINDINGS:

DISC HEIGHT:

SCOLIOSIS:

IMPLANT POSITION:

LISTHESIS: GRADE:

SUMMARY OF THE JOA SYSTEM FOR CLASSIFYING LOW-BACK PAIN

CATEGORY SCORE Day 1 Day 30 6 months

SUBJECTIVE SYMPTOMS OF:

1. LOW BACK PAIN:

CONTINUOUS SEVERE PAIN 0

OCCASIONAL SEVERE PAIN 1

OCCASIONAL MILD PAIN 2

NONE 3

2. LEG PAIN, TINGLING OR

BOTH

CONTINUOUS SEVERE SYMPTOMS

0

OCCASONAL SEVERE SYMTOMS 1

OCCASIONAL SLIGHT SYMPTOMS

2

NONE 3

3. WALKING ABILITY

ABLE TO WALK<10m 0

68

ABLE TO WALK >100m BUT<500m

1

ABLE TO WALK>500m BUT WITH LEG PAIN

2

NORMAL 3

4. CLINICAL SIGNS

STRAIGHT LEG-RAISING(INCLUDING TIGHT HAMSTRINGS)

<30 0

>30 BUT <70 1

NORMAL 2

SENSORY

MARKED DISTURBANCE 0

SLIGHT DISTURBANCE(NT SUBJECTIVE)

1

NORMAL 2

MOTOR

MARKED DISTURBANCE(MANUAL MUSCLE TESTING GRADE 3-0)

0

SLIGHT DISTURBANCE(MANUAL MUSCLE TESTING GRADE 4/5)

1

NORMAL 2

1

WORK SHEET

S no NAME AGE SEX O P No

WORK

TYPE BMI

SMOK

ING

ONSE

T

BACK

PAIN

DURATIO

N

RADIC

ULOPA

THY

DURAT

ION SIDE SLRT

MUSCLE

SPASM/

TENDERN

ESS

SENSORY

DEFICIT LEVEL

MOTOR

DEFICIT LEVEL POWER DTR

BOWEL

BLADDER

INVOLVE

MENT

1 SRIKANTAIAH 64 M 2896189 L B YES ACUTEYES A YES A LEFT C YES NO NA NO NA 5 NORMAL NO

2 SAHED ALI 53 M 2856254 H C YES CHRONICYES C YES C B/L C YES YES L4,L5,S1 YES L4,L5 2 ANKLE/KNEEYES

3 NAVARATHNA 30 F 2690158 L C NO CHRONICYES C NO NA NA C YES NO NA YES L5 4 NORMAL NO

4 KEMPAMMA 57 F 2865283 L C NO CHRONICYES C YES C RIGHT B YES YES L4,L5 YES L5 3 ANKLE/KNEENO

5 RAVI B. R. 28 M 2927705 H B YES CHRONICYES C YES B RIGHT B YES NO NA YES L4,L5 4 ANKLE/KNEENO

6 ROOPA 26 F 3040399 L B NO ACUTEYES A YES A B/L A YES YES L4,L5 YES L4,L5,S1 2 ANKLE/KNEENO

7 DOUGLAS A. 55 M 1199949 L C YES CHRONICYES C YES A LEFT C YES YES L4,L5 NO NA 5 ANKLE/KNEENO

8 SHASHIKALA 46 F 2826079 L B NO CHRONICYES C YES C LEFT B YES NO NA YES L5,S1 4 ANKLE NO

9 KANAKAMMA 48 F 3019306 H B NO CHRONICYES C NO NA NA C YES NO NA NO NA 5 NORMAL NO

10 ARIF BASHA 40 M 3040399 H B YES CHRONICNO NA YES C RIGHT B YES NO NA YES L5 4 ANKLE/KNEENO

11 YASHODAMMA 50 F 1101013 L C NO CHRONICYES C YES C B/L C YES YES L4,L5 YES L4,L5 4 KNEE NO

12 KALIYAMMA 65 F 2895221 L B NO CHRONICYES C YES C B/L C YES YES L3,L4,L5,S1NO NA 5 ANKLE/KNEENO

13 KUMAR 23 M 2996986 H B YES ACUTEYES A YES A B/L B YES NO NA YES L5 4 ANKLE/KNEENO

14 PANCHOLAU 45 F 3010731 L B NO ACUTEYES A YES A RIGHT B YES NO NA YES L5 4 ANKLE/KNEENO

15 SULOCHANA 45 F 3005266 L B NO ACUTEYES A YES A RIGHT C YES YES L5 YES L5 4 ANKLE/KNEENO

16 CHANDRA MOHAN35 M 3062729 L C NO ACUTEYES A YES A LEFT B YES YES L5 YES L5 4 ANKLE/KNEENO

17 CHINNAKKA B. 56 F 2695482 L B NO ACUTEYES B YES B B/L C YES YES L5,S1 YES L5 4 ANKLE NO

18 VENKATESH 52 M 2468442 H C YES CHRONICYES C YES A RIGHT B YES YES L4,L5 YES L5 4 ANKLE NO

19 MUNIYAMMAL 45 F 3055393 H B NO CHRONICYES C YES A LEFT B YES YES L4,L5 YES L5 4 ANKLE/KNEENO

20 MUNISWAMY 64 M 2880560 H B YES ACUTEYES A YES A LEFT C YES NO NA NO NA 5 NORMAL NO

21 RATHNAMMAL 55 F 2946598 L C NO CHRONICYES C YES C LEFT B YES YES L4,L5 YES L5 3 ANKLE/KNEENO

22 SAVITHRAMMA 52 F 2881079 L C NO CHRONICYES C YES B LEFT C YES YES L4,L5 YES L4,L5 4 ANKLE/KNEENO

23 RAGHAVA 65 M 2910765 H C YES ACUTEYES A YES A RIGHT B YES YES L4,L5,S1 YES L4,L5 3 ANKLE/KNEENO

24 EUDORA DOOLAND30 F 2872706 L D NO ACUTEYES A YES A LEFT A YES NO NA YES L4,L5 4 NORMAL NO

25 RAMANA 45 M 2910786 H B YES CHRONICYES C YES A RIGHT B YES NO NA NO NA 5 NORMAL NO

26 SRINIVAS 38 M 2916435 L B NO ACUTEYES A YES A LEFT B YES NO NA YES L4,L5 4 NORMAL NO

27 SARASWATHI 43 F 1301885 L C NO ACUTEYES A YES A RIGHT A YES YES L5,S1 YES L5,S1 3 ANKLE NO

28 ROOPA S. 26 F 2924031 L B NO ACUTENO NA YES A LEFT A NO YES L3,L4,L5 YES L3,L4,L5 1 ANKLE/KNEENO

29 CHINNAPAYAN 48 M 2942826 H B YES CHRONICYES B YES B RIGHT B YES YES L4,L5,S1 YES L4,L5,S1 4 ANKLE/KNEENO

30 RATHANAMMA 33 F 2807202 L B NO CHRONICYES C YES C LEFT C YES YES L5 YES L4,L5 4 ANKLE NO

31 MANICKYAM 63 M 2927615 H C YES CHRONICYES A YES C B/L B YES YES L4,L5 YES L4,L5 4 ANKLE/KNEENO

32 MUNIYAMMAL 55 F 2938089 L B NO CHRONICYES C YES A LEFT C YES NO NA NO NA 5 NORMAL NO

33 THIPPENDRA 16 M 2936539 L B NO ACUTEYES A YES A B/L A YES YES L4,L5,S1 YES L4,L5,S1 2 ANKLE/KNEENO

34 MALLASHI 45 M 2877483 L B NO CHRONICYES B YES B RIGHT C YES YES L5,S1 YES L5,S1 3 ANKLE/KNEENO

35 RANI 26 F 2393876 L B NO ACUTEYES B YES A RIGHT A YES NO NA YES L5 4 ANKLE/KNEENO

36 CHIKKA RAM 58 M 3009354 H B YES CHRONICYES C YES C B/L C NO YES L4,L5 YES L5 4 ANKLE/KNEENO

37 CHANGAL REDDY45 M 3058614 L B NO CHRONICYES C YES C LEFT B NO NO NA NO NA 5 NORMAL NO

38 VASANTHA 60 F 1878935 L C NO ACUTENO NA YES A B/L A NO YES L3,L4,L5,S1YES L3,L4,L5,S1 2 ANKLE/KNEENO

39 BAYA REDDY 49 M 3034885 L B NO CHRONICYES C YES B RIGHT C YES NO NA NO NA 5 NORMAL NO

40 MARGARET 58 F 2554021 L C NO ACUTEYES A YES A RIGHT B YES NO NA YES L4 4 NORMAL NO

1

MRI -

TYPE OF

PROLAPS

E

ADDED

FINDING

S

PHYSIOT

HERAPHY

DURATIO

N(DAYS) ESI

FUSION

PERFOR

MED

LEVELS

INSTRUM

ENTED &

FUSED

IMPLANT

STATUS

AT 6

MONTH

REVIEW

POST OP

SENSORY-

1MONTH

POST OP

MOTOR-

1MONTH

POST OP

SENSORY-

6 MONTH

POST OP

MOTOR-6

MONTH

POST OP

DTR

POST OP

SLRT

POST OP

BOWEL /

BLADDER

COMPLIC

ATION

PRE OP

JOA

SCORE

POST OP

SCORE-

1MONTH

POST OP

SCORE 6

MONTH

FUSION

ON X RAY

AT 6

MONTH

E LH YES 30 NO PLIF 3 IN SITU NORMAL 5 NORMAL 5 NORMAL C NORMAL NO 9 14 14 NO

E NIL YES 60 YES PLIF 2 IN SITU L4,L5,S1 2 L4,L5,S1 3 ANKLE/KNEEC NORMAL NO 2 6 7 NO

E NIL YES 30 NO PLIF 1 IN SITU NORMAL 5 NORMAL 5 NORMAL C NORMAL NO 10 12 12 YES

E OA/LH YES 90 YES TLIF 1 IN SITU L5 3 L5 3 ANKLE/KNEEC NORMAL NO 8 10 10 NO

P NIL YES 60 YES TLIF+PLIF 4 IN SITU L4,L5 4 NORMAL 4 ANKLE/KNEEC NORMAL NO 8 12 12 NO

E+S NIL NO 0 NO TLIF 3 IN SITU L4,L5 3 L4,L5 4 ANKLE/KNEEC NORMAL NO 2 9 9 NO

P+S NIL YES 30 YES PLIF 2 IN SITU L4,L5 5 L4,L5 5 ANKLE/KNEEC NORMAL NO 9 13 14 NO

B LH YES 30 NO TLIF 2 IN SITU NORMAL 4 NORMAL 4 ANKLE C NORMAL NO 7 13 14 NO

B LH YES 30 NO TLIF 2 IN SITU NORMAL 5 NORMAL 5 NORMAL C NORMAL NO 13 14 14 NO

B LH YES 90 NO TLIF 1 IN SITU NORMAL 4 NORMAL 4 ANKLE/KNEEC NORMAL NO 9 13 14 NO

B OA/LH YES 30 NO PLIF 2 IN SITU NORMAL 5 NORMAL 5 NORMAL C NORMAL NO 6 13 13 NO

P OA/LH/L YES 45 NO TLIF 1 L4 S OUT L3,L4,L5,S1 5 L3,L4,L5,S1 5 ANKLE/KNEEC NORMAL DT 7 12 12 NO

P NIL NO 0 NO PLIF 2 L4 S OUT NORMAL 4 NORMAL 4 ANKLE/KNEEB NORMAL L4 S OUT/ DT 8 10 10 NO

B LH YES 30 NO PLIF 1 IN SITU NORMAL 4 NORMAL 5 ANKLE/KNEEC NORMAL NO 9 13 14 NO

B NIL YES 10 NO PLIF 2 IN SITU L5,SI 5 L5,S1 5 ANKLE/KNEEC NORMAL NO 7 13 14 NO

B NIL NO 0 NO TLIF 2 IN SITU NORMAL 5 NORMAL 5 NORMAL C NORMAL NO 6 13 13 YES

P OA/LH YES 10 NO PLIF 3 L4 S OUT L5,S1 4 NORMAL 4 ANKLE C NORMAL L5 S OUT 5 13 13 NO

P LH YES 30 NO PLIF 2 IN SITU L4,L5 4 L4,L5 4 ANKLE C NORMAL NO 6 12 12 NO

P LH NO 0 NO PLIF 2 IN SITU L5 4 L5 4 ANKLE C NORMAL NO 7 13 13 NO

B OA/LH NO 0 NO PLIF 2 IN SITU NORMAL 5 NORMAL 5 NORMAL C NORMAL INFECTION 9 12 12 NO

B OA/LH YES 60 NO PLIF 2 IN SITU L4,L5 3 L4,L5 3 ANKLE/KNEEB NORMAL NO 5 7 7 NO

P OA/LH YES 30 NO PLIF 2 IN SITU L4,L5 4 L4,L5 4 ANKLE/KNEEC NORMAL NO 7 10 10 NO

B OA/LH NO 0 NO TLIF 2 IN SITU L4,L5,S1 3 L4,L5,S1 4 ANKLE/KNEEC NORMAL NO 5 11 12 NO

B NIL YES 15 NO PLIF 2 IN SITU NORMAL 5 NORMAL 5 NORMAL C NORMAL NO 8 14 14 NO

B NIL YES 30 NO PLIF 2 IN SITU NORMAL 5 NORMAL 5 NORMAL C NORMAL NO 7 15 15 NO

P NIL NO 0 NO PLIF 2 IN SITU L4,L5 3 L4,L5 3 ANKLE/KNEEB NORMAL NO 5 7 7 NO

P NIL NO 0 NO PLIF 2 IN SITU L5,S1 2 L5,S1 4 ANKLE C NORMAL NO 2 9 12 NO

P NIL NO 0 NO TLIF 3 IN SITU L3,L4,L5 4 L3,L4,L5,S1 4 ANKLE/KNEEC NORMAL BLEEDING 5 12 12 YES

B OA/LH YES 15 YES PLIF 2 IN SITU L4,L5,S1 4 L4,L5 5 ANKLE/KNEEC NORMAL NO 4 9 10 NO

B NIL YES 30 YES PLIF 2 IN SITU L5 4 L5 4 ANKLE C NORMAL NO 5 15 15 NO

B OA/LH/CPLLYES 30 NO TLIF 2 IN SITU L4,L5 4 L4,L5 5 ANKLE/KNEEC NORMAL NO 5 12 12 NO

P LH YES 30 NO PLIF 2 IN SITU NORMAL 5 NORMAL 5 NORMAL C NORMAL NO 8 13 14 NO

P NIL NO 0 NO TLIF 2 IN SITU L4,L5 4 NORMAL 5 NORMAL C NORMAL NO 2 12 14 NO

P NIL NO 0 NO TLIF 1 IN SITU L5,S1 4 L5,S1 5 ANKLE C NORMAL NO 4 11 13 NO

B NIL NO 0 NO PLIF 1 IN SITU NORMAL 4 NORMAL 5 NORMAL C NORMAL DT 7 13 13 NO

S OA/LH YES 45 NO PLIF 1 IN SITU L4,L5 4 L4,L5 4 ANKLE/KNEEC NORMAL BLEEDING 7 9 9 NO

P LH YES 15 YES TLIF 2 IN SITU NORMAL 5 NORMAL 5 NORMAL C NORMAL NO 9 12 13 NO

S+P OA/LH YES 20 NO TLIF 4 IN SITU L3,L4,L5,S1 4 L3,L4,L5,S1 4 ANKLE/KNEEC NORMAL BLEEDING 3 11 12 NO

P NIL NO 0 NO PLIF 1 IN SITU NORMAL 5 NORMAL 5 NORMAL C NORMAL NO 5 13 14 NO

B NIL NO 0 NO TLIF 1 IN SITU NORMAL 5 NORMAL 5 NORMAL C NORMAL NO 7 12 13 NO