Spine

Posterior Interbody Fusion Using

Laminectomy Bone and
Transpedicular Screw Fixation in
the Treatment of
Lumbar Spondylolisthesis
György I. Csécsei, Ph.D.,* Álmos P. Klekner, M.D.,* József Dobai, M.D.,‡
Attila Lajgut, M.D.,‡ and Judit Sikula, M.D.,†
Departments of *Neurosurgery, †Radiology, ‡University Medical School, Debrecen and
‡Borsod County Hospital, Miskolc, Hungary

Csécsei GI, Klekner AP, Dobai J, Lajgut A, Sikula J. Posterior
interbody fusion using laminectomy bone and transpedicular
screw fixation in the treatment of lumbar spondylolisthesis. Surg
Neurol 2000;53:2–7.
BACKGROUND
Laminectomy bone is used widely in posterolateral lum-
bar fusion, but not interbody fusion. No prospective eval-
uation of interbody fusion using bone grafts from the
posterior neural arch in spondylolisthesis has been found
in the literature. We prospectively studied series of pa-
tients operated on for lumbar spondylolisthesis to eval-
uate clinical improvement and bony fusion.
METHODS
Forty-six patients were operated on for lumbar spon-
dylolisthesis using a simplified one-stage posterior pro-
cedure. The whole mobile dorsal segment of the vertebral
arch was taken out in one piece and the bone was used
for interbody fusion. Fixation was performed with trans-
pedicular screws and rods using transverse connectors.
RESULTS
After an average follow-up time of 27.3 months, 87% of the
patients could be considered to have an excellent or good
clinical outcome. The rate of successful fusion was 95.7%.
No noteworthy complications occurred.
CONCLUSION
Laminectomy bone seems to be optimal for posterior
interbody fusion and together with transpedicular rigid
fixation the long-term clinical and radiological results are
convincingly good. The method is advisable even for
severe spondylolisthesis. © 2000 by Elsevier Science
Inc.
KEY WORDS
PLIF, interbody fusion, posterolateral fusion, laminectomy
bone.
Address reprint requests to: Dr. György I. Csécsei, Department of Neu-
rosurgery, University School of Medicine, Nagyerdei krt. 98 H-4012 Deb-
recen, Hungary.
Received January 27, 1998; accepted September 28, 1998.
0090-3019/00/$–see front matter
PII S0090-3019(99)00198-6
umbar spondylolisthesis has several different
L etiologies [5]. The treatment is conservative
or operative. The main indications for operation
are: 1) intractable pain; 2) radicular involvement; or
3) progression of the slip.
There are many different operative procedures
reported in the literature; in all of them the follow-
ing steps are important to achieve good outcome:
decompression, repositioning, fusion, and fixation.
In addition to clinical improvement, union of the
fused segment is the measure of success for any
operative procedure.
Fusion can be performed via anterior or posterior
approaches, and auto- and allografts can be used
for fusion. The use of autograft provides convinc-
ingly better results. The most popular donor sites
are iliac crest and fibula. Branch suggested the use
of laminectomy bone for interbody fusion, together
with iliac chips or banked bone. Steffee completed
posterior interbody fusion with transpedicular
plate fixation [2,12].
In the present study, we prospectively evaluated
the long-term operative results of our patients op-
erated on for unstable lumbar spondylolisthesis us-
ing laminectomy bone and transpedicular screw fix-
ation, with special regard to the fusion.
Patients and Methods
Forty-six patients were included in this study (18
male, 28 female; ages 15–58 years; mean age, 42.6
years). All patients were operated on for unstable
congenital or degenerative lumbar spondylolisthe-
© 2000 by Elsevier Science Inc.
655 Avenue of the Americas, New York, NY 10010
Interbody Fusion Using Laminectomy Bone Surg Neurol 3
2000;53:2–7

DECOMPRESSION
1 Preoperative Radiological Features of 46 Patients
The whole posterior neural arch was removed in
LEVEL OF NUMBER OF one piece together with the articular processes dis-
INSTABILITY PATIENTS articulating the joints. Bilateral facetectomy was
L. III–IV. 2 performed until the upper and lower roots were
L. IV–V. 17 dorsally decompressed.
L. V–S.I. 27
Grade of the slip DISCECTOMY
Meyerding I. 30 The posterior longitudinal ligament and anulus fi-
Meyerding II. 15
Meyerding III. 1
brosus were removed medially and bilaterally so
that the upper roots were ventrally decompressed
as well. The whole disc space was emptied and the
fibrosus cartilage was scratched off the bony end-
sis. Patients operated on by other surgical tech- plate until it bled.
niques were excluded from this evaluation.
The main preoperative radiographic characteris- REPOSITIONING AND FUSION
tics are summarized in Table 1. All patients fulfilled The unstable segment was opened up with an inter-
the following criteria: body distractor. Corticospongious dowels were cut
out of the removed posterior arch with the parallel
1. back pain and/or sciatic pain; cutting saw (Figure 1). The dowels were put into the
2. previous conservative treatment; emptied disc space, then impacted (Figure 2).
3. radiologically proved instability.
FIXATION
Informed consent was obtained before operation.
Titanium transpedicular screws were used for fixa-
tion with rods and transverse connectors (Spine
Operative Procedure system, JBS, France) under compression from the
two neighboring vertebrae (Figure 3). The wound
Operations were performed under general anesthe- was drained in each case for 24 – 48 hours. The
sia. Patients received 300 mg of netilmycine (Netro- patients were allowed to stand up and walk on the
mycin, Shering Plough, USA) in the form of a short 3rd postoperative day.
saline infusion 30 minutes before and 24 hours after
surgery. A posterior approach to the lumbar spine POSTOPERATIVE EVALUATION
was performed with the patient in the prone posi- Clinical outcome was graded as 1: excellent, 2:
tion using Cloward’s saddle. Important steps of the good, 3: poor, and 4: bad, according to the Wetzel’s
operation were as follows: criteria [15]. AP and lateral X-rays were taken im-

Formation of bone grafts

1 from the posterior neural
arch removed in one piece.
4 Surg Neurol
2000;53:2–7
Filling the intervertebral space with bone dowels.
2 measurement (Table 3). The average rate of repo-
mediately after the operation, then 6 weeks, 3
months, 6 months, and 1 year postoperatively and
annually thereafter. Bony fusion was estimated ac-
Postoperative AP (left) and
3 lateral (right) X-rays of a
patient operated on for L4
spondylolisthesis.
Csécsei et al
cording to Lin’s and Brantigan’s criteria [3,8]. In
ambiguous cases, a computed tomography (CT) ex-
amination was also performed. X-rays were com-
pared with the preoperative pictures (Figure 4).
Reduction of the slip, changes in the mean disc
height (MDH), segmental lordosis (SL), and lumbar
lordosis (LL) were measured and expressed in per-
centages, as described by Wiltse [16].
Results
CLINICAL OUTCOME
No operative complications occurred. The blood
loss was not enough to require transfusion in any
patient. The late clinical outcome is summarized in
Table 2. The mean follow-up period was 27.3
months (range, 1– 4 years).
RADIOLOGICAL OUTCOME
No bony fusion occurred in two patients; both un-
derwent repeated fusion. All the others showed ra-
diologically proved union of the fused segment (fu-
sion rate 95.7%) (Figure 4).
Anterior displacement 1 week and 1 year after the
operation was compared with the preoperative
sitioning was nearly 50%. The mean disc height
showed significant increase 1 week postoperatively,
but could not be exactly measured 1 year after the
operation because of the fusion. Changes in seg-
mental and lumbar lordosis are seen in Table 3.
Interbody Fusion Using Laminectomy Bone Surg Neurol 5
2000;53:2–7

3 Radiological Outcome
AD(%) MDH(CM) SL(0) LL(0)
Preop. 19.2 0.68 13.32 30.12
Postop. 1 week: 9.19*** 0.87** 20.03*** 32.52
Postop. 1 year: 9.94*** 18.03* 34.68
Radiological outcome in 46 patients. AD, anterior displacement; MDH,
mean disc height; SL, segmental lordosis; LL, lumbar lordosis.
* ⫽ p ⬍ 0.1, ** ⫽ p ⬍ 0.05, *** ⫽ p ⬍ 0.01.

operation [9]. Results of combined anterior and

posterior operations are good in general, but the
burden on the patient and the frequency of possible
complications are increased [6].
Lee reported good results of posterior reposition-
ing and fusion without laminectomy [7]. In contrast,
Plötz and Benini drew attention to the danger of any
kind of repositioning without decompression [10].
Extended laminectomy and complete discectomy
are the only methods of complete decompression.
Distraction of the emptied intervertebral space and
filling it with bone dowels will result in partial re-
positioning. The remaining slip is then easy to cor-
rect with screws and rods.
Fusion is the most decisive factor in the treat-
ment of lumbar spondylolisthesis. Two kinds of fu-
sion are most frequently reported in the literature:
Lateral X-ray of a patient 1 year after operation. posterolateral (intertransversal) and intercorporal
4 Note the continuous dorsal cortical bone between (interbody). The latter can be done via ventral or
the fourth and fifth vertebrae. dorsal approaches. Autologous or heterologous
bones can be used for interbody fusion. The most
popular donor site for autograft is the iliac crest.
Discussion We found that laminectomy bone is excellent for
interbody fusion, both in quantity and in quality. In
A number of operative solutions to treat lumbar
the case of iliac crest bone graft harvest, the donor
spondylolisthesis caused by different etiologies
site morbidity is an additional factor that can in-
have been reported in the literature [2,3,5–11]. Stef-
crease the rate of possible complications. This rate
fee was the first to report good results with poste-
of morbidity was found to be extremely variable by
rior interbody fusion together with dorsal transpe-
different authors. According to Banwart et al, in a
dicular plate fixation [12].
large number of patients the rate of major compli-
One of the main goals of surgery is elimination of
cations was 10%, that of minor complications 39%
the neural compression. Satisfactory decompres-
[1]. The technique we describe eliminates this kind
sion cannot be achieved with anterior fusion so this
of morbidity.
approach must usually be completed with a dorsal
When grafting with foreign implants, (screws or
cages made of titanium, ceramic, or other materi-
als) the bony endplate must usually be partially
2 Late Clinical Outcome in 46 Patients
removed, which carries the risk of driving the im-
plant into the vertebral body under axial load. With
RATING SCORE PERCENT the method we propose, the bony endplate remains
1. Excellent 25 54 intact, providing good mechanical resistance to
2. Good 15 33 keep the graft in place. At the same time, all neces-
3. Fair 6 13 sary conditions for rapid ossification are met.
4. Poor — 0 Takeda compared the fusion rates of unicortical
Average improvement rate, 1.8. and bicortical bone grafts harvested from the iliac
6 Surg Neurol
2000;53:2–7
crest. He found that the failure rate was significantly
lower in the case of bicortical grafts [14]. The grafts
we used for PLIF contained spongious bone sur-
rounded by cortical bone. We believe it is the main
factor in our good fusion results.
Reviewing the literature, Fraser found that clini-
cal outcome was better after anterior interbody
fusion than after posterolateral, although the fusion
rate was much higher in the latter group [6]. Both
techniques carry the risk of complications, primar-
ily vascular and neural damage. No complications
were found in our patients; this could be the result
of the relatively simply technique. However, the
rate of successful fusion was higher than that of
favorable clinical outcome. Thus, successful fusion
is a necessary, but not exclusive, condition of the
patient’s improvement.
REFERENCES
1. Banwart IC, Asher MA, Hassamein RS. Iliac crest bone
graft harvest donor site morbidity. A statistical eval-
uation. Spine 1995;20:1055– 60.
2. Branch CL, Branch CL Jr. Posterior lumbar interbody
fusion with the keystone graft: Technique and results.
Surg Neurol 1987;27:449 –54.
3. Brantigan IW. Radiographic interpretation of fusion
after posterior lumbar interbody fusion using the
Brantigan I/F cage. Draft manuscript, presented at
“Anterior column support” Paradise Island, Nov. 7–9,
1996.
4. Buttermann GR, Glaser PA, Bradford DS. The use of
bone allografts in the spine. Clin Orthop 1996;324:75–
85.
5. Cloward RB. Spondylolisthesis: Treatment by lami-
nectomy and posterior interbody fusion. Clin Orthop
1981;154:74 – 82.
6. Fraser RD. Interbody posterior and combined lumbar
fusion. Spine 1995;20:167–77S.
7. Lee TC. Reduction and stabilisation without laminec-
tomy for unstable degenerative spondylolisthesis: a
preliminary report. Neurosurgery 1994;35:1072– 6.
8. Lin PM, Cantilli RA, Joyce MF. Posterior lumbar inter-
body fusion. Clin Orthop 1983;180:154 – 68.
9. Louis R. Spondylolisthesis. In: Bauer R. et al, eds.
Atlas of spinal operations. Thieme, 1993;293–307.
10. Plötz GMJ, Benini A. Surgical treatment of degenera-
tive spondylolisthesis in the lumbar spine: no repo-
sition without prior decompression. Acta Neurochir
1995;137:188 –91.
11. Schnee CL, Freese A, Ansell LV. Outcome analysis for
adults with spondylolisthesis treated with posterolat-
eral fusion and transpedicular screw fixation. J Neu-
rosurg 1997;86:56 – 63.
12. Steffee AD, Sitkowski DJ. Posterior lumbar interbody
fusion and plates. Clin Orthop 1988;227:99 –102.
13. Stonecipher T, Wright S. Posterior lumbar interbody
fusion with facet-screw fixation. Spine 1989;14:468 –
71.
14. Takeda M. Experience in posterior lumbar interbody
fusion: unicortical versus bicortical autologous
grafts. Clin Orthop 1985;193:120 –26.
Csécsei et al
15. Wetzel FT, LaRocca SH, Adinolfi M. The treatment of
chronic extremity pain in failed lumbar surgery. Spine
1992;17:1462– 68.
16. Wiltse LL, Winter RB. Terminology and measurement
of spondylolisthesis. J Bone Joint Surg 1981;65:768 –
72.
COMMENTARY
Dr. Csecsei and his colleagues report their experi-
ence with 46 patients with lumbar spondylolisthesis
who were treated by one-stage posterior lumbar
interbody fusion using the laminectomy bone and
transpedicular screw fixation. It is noteworthy that
they used bone graft from the posterior neural arch,
and that long-term results in their patients were
exceptionally good. Iliac bone grafts, rather than
grafts of small bone pieces, have been widely used
for interbody fusion because of their vastly supe-
rior bony fusion rate. Bone grafts with small pieces
of bone are frequently used combined with cage
fixation. Therefore, this paper introduces a new
surgical technique for the treatment of lumbar
spondylolisthesis.
We would like to point out that the bone pieces
obtained from laminectomy usually have less vol-
ume than the iliac bone graft; therefore, it is
rather difficult to interpret the exceptionally good
results reported in this paper. It would have been
an excellent report if the authors had included
and compared their experience with iliac bone
grafts.
The other issue is that surgical approaches for
lumbar spondylolisthesis should be chosen accord-
ing to etiologic factors. It may be necessary to re-
move the entire posterior neural arch in patients
with spondylolytic spondylolisthesis, allowing the
surgeon to obtain one whole piece of laminectomy
bone. However, it is inappropriate to do the same
procedure for patients with degenerative spon-
dylolisthesis who could be treated successfully by
decompressive laminectomy and fusion. Therefore,
we would have liked the authors to discuss their
indications for removal of the whole posterior neu-
ral arch.
Do Heum Yoon, M.D.
Kyu Chang Lee, M.D.
Department of Neurosurgery
Yonsei University
Seoul, Korea
The authors have presented a small, well followed
series of 46 patients operated for lumbar spon-
dylolisthesis using a single-stage procedure with
posterior segmental fixation with a transpedicular
rigid fixation system and interbody fusion, using
Interbody Fusion Using Laminectomy Bone Surg Neurol 7
2000;53:2–7

the bone obtained from the free-floating neural
arch that occurs in a spondylolysis spondolylis-
thesis. The patients have done very well, and the
evidence that satisfactory fusion occurred in 95%
of patients is noteworthy. This technique cer-
tainly merits consideration as one of many to
correct the problem with lytic spondylolisthesis.
Other alternatives include cage stabilization and
fusion as well as interbody threaded bone dowels
without additional instrumentation. The authors
should be congratulated on an excellent series
with very satisfactory outcome.
George W. Sypert, M.D.
Neurosurgeon
Fort Myers, Florida

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