Research Article: Skipping Posterior Dynamic Transpedicular Stabilization for Distant Segment Degenerative Disease

Date Published: October 3, 2012

Publisher: Hindawi Publishing Corporation

Author(s): Bilgehan Solmaz, Ahmet Levent Aydin, Cengiz Gomleksiz, Yaprak Ataker, Mehdi Sasani, Tunc Oktenoglu, Ali Fahir Ozer.


Objective. To date, there is still no consensus on the treatment of spinal degenerative disease. Current surgical techniques to manage painful spinal disorders are imperfect. In this paper, we aimed to evaluate the prospective results of posterior transpedicular dynamic stabilization, a novel surgical approach that skips the segments that do not produce pain. This technique has been proven biomechanically and radiologically in spinal degenerative diseases. Methods. A prospective study of 18 patients averaging 54.94 years of age with distant spinal segment degenerative disease. Indications consisted of degenerative disc disease (57%), herniated nucleus pulposus (50%), spinal stenosis (14.28%), degenerative spondylolisthesis (14.28%), and foraminal stenosis (7.1%). The Oswestry Low-Back Pain Disability Questionnaire and visual analog scale (VAS) for pain were recorded preoperatively and at the third and twelfth postoperative months. Results. Both the Oswestry and VAS scores showed significant improvement postoperatively (P < 0.05). We observed complications in one patient who had spinal epidural hematoma. Conclusion. We recommend skipping posterior transpedicular dynamic stabilization for surgical treatment of distant segment spinal degenerative disease.

Partial Text

The most frequent clinical problem of the adult spine is back pain. It is known that 60–80% of the population will have back pain at some point in their lives that may affect their general health, daily activities, and their working capacity. It is assumed that back pain only has a defined pathology in 15% of patients [1], and dysfunctional segmental motion and discogenic pain are problems that may need to be treated surgically. According to Bertagnoli, disc-related spinal problems could be treated because of the state of degenerative segmental alterations [2]. Those at an earlier stage of disc degeneration may respond to the conservative treatment. More advanced disc degeneration may require open-disc surgery, especially concomitant nerve root compression. Fusion surgery is usually indicated in more advanced segmental degeneration. Discectomy and fusion are performed with the aim of reducing pain and eliminating neural compression rather than restoring disc or segmental function. Researchers have demonstrated the benefits of fusion over nonsurgical treatment in the alleviation of chronic low-back pain [3, 4]. Although studies have shown improvements in the instrumentation techniques that have increased the radiological fusion rate to >94%, they have failed to provide evidence of actual improvements in clinical outcome [5].

This study included 18 patients averaging 54.94 years of age; there were 10 females and 8 males. Our selection criteria for this procedure included any neurogenic, radicular pain and/or chronic low-back pain that was resistant to any conservative treatment and neurological deficit. The level of provocative pain was determined by discography in cases where the source of pain was not confirmed by clinical and radiological findings (Figure 1). Radiological evaluations prior to magnetic resonance (MR) (Figure 2) and after surgery consisted of anteroposterior (AP) and lateral X-ray studies (Figure 3). Primary indications, demographic data, and details of the operations performed are shown in Table 1.

Oswestry scale and VAS scale values were compared between the following groups: preoperative and 3-month postoperative, preoperative and 12-month postoperative, 3-month postoperative and 12-month postoperative. We observed significant changes between the groups. The preoperative mean Oswestry scale score was 68.00, the 3-month postoperative mean Oswestry scale score was 23.89, and the 12-month postoperative mean Oswestry scale score was 14.00. This decrease in the mean Oswestry scale score as the postoperative time increased was significant (P < 0.05, Wilcoxon test). The preoperative mean VAS score was 7.28, the 3-month postoperative mean VAS score was 2.50, and the 12-month postoperative mean VAS score was 1.33 (Table 2). This decrease in the mean VAS as the postoperative time increased was also significant (P < 0.05, Wilcoxon test). Back pain at a symptomatic motion segment may originate from vertebral endplates, disc annulus, vertebral periosteum, facet joints, and/or surrounding soft tissue structures [7]. These structures also contribute to the biomechanical stability of the spinal column. The pathology of discogenic pain and degenerative instability has been described by Kirkaldy-Willis and Farfan [8]. Pain is reported to be the simplest description as well as the major symptom of instability. If a patient's limited instability is the result of glacial instability and dysfunctional segmental motion, he or she will experience pain but will be able to lead a life without neurologic deficit [9]. Recent studies have suggested that the chronic instability related to the disc or vertebral body degenerative changes associated with abnormal motion results in the potential for pain.   Source: