INSTRUMENTATION OF THE LUMBAR SPINE

FOR DEGENERATIVE DISORDERS

HARRY N. HERKOWITZ, MD and HANI EL-KOMMOS, MD

The goals of internal fixation of the spine are to (1) correct deformity, (2) improve the fusion rate, (3) protect
neural elements, and (4) reduce the rehabilitation time. The instance of pseudarthrosis increases as the number
of levels of fusion are performed; in addition, when a fusion is performed in association with a multiple-level
laminectomy, there is also an increased rate of nonunion. Classic posterior spinal instrumentation systems have
been inadequate in dealing with fixation of the lumbar spine. Pedicle-screw fixation provides an improved
alternative when instrumentation of the lumbar spine is required. In degenerative disorders of the lumbar
spine, pedicle screw instrumentation systems may be considered in the following situations: (1) post-operative
symptomatic spondylolisthesis, (2) multiple-level decompression with significant facet joint removal, (3)
degenerative scoliosis, (4) degenerative scoliosis associated with spinal stenosis, (5) postoperative lumbar
instability, (6) single-level decompression, and (7) lumbar spondylolisthesis associated with spinal stenosis when
a fusion is contemplated.
KEY WORDS: lumbar instability, spinal stenosis, degenerative lumbar stenosis, lumbar instrumentation,
pedicle fixation

The goals of internal fixation of the spine are to (1)
correct deformity, (2) improve the fusion rate, (3) protect
the neural elements, and (4) reduce rehabilitation time.
The incidence of pseudarthrosis occurring with in situ
posterolateral lumbar spine fusion is inversely propor-
tional to the number of levels fused. For a one-level fu-
sion, the incidence is 3.5% to 10%. The incidences of
pseudarthrosis with two- and three-level fusions are 15%
to 20% and 25% to 33%, respectively. In addition, the
pseudarthrosis rate following multiple-level decompres-
sive lumbar laminectomy with intertransverse process fu-
sion is greater than that of intertransverse process fusion
alone. 1 The "'classic" posterior spinal instrumentation
system has been the Harrington rod. 1"3 However, there
are several problems in using this system in the lumbar
spine. First, maintenance of lordosis in the lumbar spine
is difficult with the Harrington distraction rod. Second,
in an elderly population osteopenia is a factor in selecting
any instrumentation system. The osteopenic lamina usu-
ally will not support the hooks necessary to secure the
distraction rods. Third, if a decompression has been per-
formed, it becomes necessary to place the hooks above
and below the fusion. This often adds unnecessary levels
of fusion and further reduces the lordosis. Fourth, if fix-
ation into the sacrum is necessary, the available distrac-
tion hooks are inadequate for providing secure fixation.
Finally, posterior instrumentation systems provide poor
torsional stability and lack the ability to provide segmen-
tal fixation if the posterior elements are lacking.
From the Section of Spine Surgery, Department of Orthopaedic
Surgery, William Beaumont Hospital, Royal Oak, MI.
Address reprint requests to Harry N. Herkowitz, MD, 16800 W
Twelve Mile Rd, Suite 100, SouthfieZd, M1 48076-2176.
Copyright 9 1991 by W. B. Saunders Company
1048-6666/91/0101/0010505.00/0
Internal fixation devices in the lumbar spine must ad-
dress the inadequacies of standard instrumentation sys-
tems. The pedicle provides an ideal anatomic structure
for fixation in the lumbar spine. 4'5 It is the strongest part
of an osteopenic vertebra~ Following decompressive
lumbar laminectomy it is often the only anatomic struc-
ture remaining intact. Utilization of the lumbar pedicles
for internal fixation is, therefore, ideally suited for aug-
mentation of a spine fusion in the lumbar spine for the
following reasons: First, the pedicle supplies a secure an-
chor for fixation, especially in older individuals with os-
teoporosis and/or a prior decompression. Second, it pro-
vides torsional stabi~ty by having both posterior, middle,
and anterior column attachments. Third, it provides seg-
mental fixation depending o n the construct selected.
Numerous pedicle-screw systems are presently avail-
able. 4'6-8 It is beyond the scope of this article to discuss
the advantages and disadvantages of each system.
A thorough knowledge of the anatomy of the lumbar
pedicles and their relation to the surrounding neurovas-
cular structures is essential before undertaking this pro-
cedure. The pedicles are the strongest part of the verte-
brae connecting the posterior elements to the anterior
column. They form the superior and inferior boundaries
of the intervertebral foramen with the exiting nerve root
in close proximity to the inferior medial borders of the
pedicle (ex. L5 nerve root exits below L5 pedicle9; Fig 1).
In the foramen the nerve root lies 0.4 to 0.5 cm superior
to the upper border of the caudal pedicle. Avoiding
placement of the pedicle screws too inferiorly will protect
against injury to the nerve root.
There )iave been a number of articles describing the
anatom~ of the pedicles and their dimensions using data
collected from direct cadaver measurements, computed
tomography, and plain radiographs. 4"7"1~
The pedicles are oval in cross section, with the trans-
verse width smaller than the sagittal width except at L5.

Operative Techniques in Orthopaedics, Vol 1, No 1 (January), 1991: pp 91-96 91

 i, , 9 " r 20-

18-
.

16-

t4-

L 2 t2-
o

10-
~

8-

,', t~ ,', 6 ~', ,12,:, ,I0 ;, 4 4, & ;~ ~', & ;2 ;,

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L-4 Fig 3. Sagittal pedicle width of lumbar vertebrae. (Reprinted

P& with permission. TM)

L-5 lumbar pedicles in females is contemplated, because

Fig 1. Anatomy of the lumbar pedicie and its relation to the
surrounding neurovascular structures. (Reprinted with
permission? Copyright 9 1989, the Williams & Wilkins Co.,
Baltimore.)
The transverse width determines the maximum allowable
screw diameter. There is a decreasing transverse pedicle
width from L5 to L1 with the mean of 18 mm at L5 and 10
mm at the L1 pedicle (Fig 2). The sagittal pedicle width is
larger than the transverse diameter at all lumbar levels
except L5. The mean sagittal width at L1 is 15 ram, di-
minishing to a mean of 14 mm at L5 (Fig 3). It is apparent
from these measurements that the lower lumbar verte-
brae can accommodate a 6.5-mm-diameter pedicle screw,
the most common diameter used. However, preopera-
tive determination of pedicle diameter using computed
tomography is indicated when instrumentation of the up-
per lumbar vertebrae with screws or instrumentation of
women tend to have smaller pedicles than m e n ?
Pedicles are directed from a posterolateral to an an-
teromedial direction. The transverse angle between the
long axis of the pedicle and the midsagittal line increases
from L1 to L5 with a mean of 12~ at L1 and 30 ~ at L5 (Fig
4). The sagittal pedicle angle is less variable than the
transverse angle, with less than 10~difference between L1
and L5 (Fig 5). The distance from the anterior cortex of
the vertebral body to the posterior entrance point to the
pedicle is approximately 50 mm at each lumbar level (Fig
6). Oslewski et al report a 5% to 20% difference in the
transverse and sagittal pedicle diameter and length of the
vertebral body cortex to posterior entrance point of the
pedicle between males and females, males having the
higher values. 1~
SURGICAL TECHNIQUE OF
PEDICLE-SCREW PLACEMENT"
The patient is placed prone on an image intensifier-
compatible operating table with the chest resting on a
well-padded radiolucent frame or blanket rolls to allow
the abdomen to hang free. The hips are extended to
accentuate lumbar lordosis (Fig 7). There must be suffi-
cient clearance beneath the table to allow the image in-

25- 40-

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20-
3o-
25-

20-
x 15-
]r |S-

tO-

i s-
o
5-

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".4s
o & ~ & 6 ~', ,I~,I, ,10 4 4 4, ;~ ;~ ;, ;, ;, ;, ,~ t~ 6 6 ~', ,:2,1, ,;o /, /~ ~, /6 ~'~ /, ,'3 ~'2 ~',
SP1~r LEVEL

Fig 2. Transverse pedicle width of lumbar vertebrae. (Re- Fig 4. Transverse pedicle angle of lumbar vertebrae. (Re-
printed with permission? 2) printed with permission. TM)

92 HARRY N. HERKOWlTZ
 30-

2s-

,s-
,0-

0
s-"

L5 LI~ L~3 1.2 LIt T]2 TIlt 'i'~O 1"19 TI8 T~ 1"16 TIS TI4 TI3 Ti2 Tit

SPINAL~L
Fig 5. Sagittal pedicle angle of lumbar vertebrae. (Reprinted
with permission, l= )

Fig 8. Positioning of patient for lumbar instrumentation with

60--
image intensifier in place.

50

40

30

20

10

o ! i I I I I r
L5 L4 L3 L2 LI T12 TI1 TIO T9 T8 17 T6 T5 T4 T3 T2 TI

~LEVEL
Fig 6. Distance from the anterior cortex of vertebral body to L .
the posterior entrance point of the pedicle. (Reprinted with Fig 9. Entrance point to the lumbar pedicle as described by
permission. 12)
Roy-Camille. (Reprinted with permission. >)

Fig 7. Positioning of patient for lumbar instrumentation sur~
gery.
tensifier arm to swing freely in the anteroposterior, lat-
eral, and oblique projections (Fig 8). The surgical ap-
proach is midline posterior with subperios!eal stripping
of the paraspinal muscles to the tips of the. transverse
processes of the involved vertebrae. This is necessary for
identification of the landmarks for insertion of the pedicle
screws. A decompressive laminectomy, if necessary, is
performed at this time. Different pedicle entry points
;i ii
Fig 10. Entrance point to the lumbar pedicle as described by
Weinstein et al. (Reprinted with permission. 13)
have been described in the literature. The entrance point
identified by Roy-Camille is situated at the juncture of a
horizontal line through the middle of the transverse pro-
cess and ~ vertical line at the medial tip of the superior
articulaf~facet7 (Fig 9). Weinstein recommends a more
lateral approach for the lower lumbar spine to prevent
entrance into an uninvolved facet joint, with the entrance
point at the lateral and inferior corners of the superior
articular facet z3 (Fig I0). The entrance point for sacral

INSTRUMENTATION OF THE LUMBAR SPINE 93

 ~- ~rtical
Fig 11. Modified pelvic inlet view to assess the penetration
of sacral screws. (Reprinted with permission. 14)
screw insertion(s) begins by exposing the dimple below
the L5-$1 facet joint in line with the dorsal $1 foramen. A
drill bit is then inserted 35 ~ laterally and 25 ~ caudally to
Fig 12. Saw bone model showing surgical construct used in patients with symptomatic postoperative spondylolisthesis.
94
parallel the end plate of $1 and inserted until it abuts
against the anterior cortex. The 2-mm drill bit is replaced
with a 3.5-ram bit. The screw should engage the anterior
cortex and not penetrate it more than 2 mm. The correct
screw depth will range from 35 to 50 ram. 6
The techniques for entrance to the pedicles are also
varied, ranging from drilling of the pedicle under imag-
ing intensification to decortication of the pedicle cortex
followed by the use of a curet or blunt probe to localize
the pedicle.
The technique we use involves the image intensifier to
facilitate pedicle localization. The C-arm is adjusted in
the anteroposterior plane until the truest outline of the
pedicle is obtained. A 2-mm drill bit is then inserted to
penetrate the middle of the pedicle except at the proximal
screw where it is inserted inferiorly to protect the facet
joint. Once insertion of the drill is verified on the antero-
posterior image, the lateral plane is then evaluated.
When confirmation is made on the lateral image, a 3.5-
mm drill bit relaces the 2-mm bit followed by the pedicle
screw measuring 6.5 mm. Penetration of the screw to
HARRY N. HERKOWlTZ
 r
Fig 13. Spinal stenosis (case 1).
50% to 80% of the distance to the anterior cortical border
of the vertebral body is optimal. 9'~3 It is recommended
that radiation glasses and gloves along with a thyroid
shield and radiation gown be worn by those involved in
the surgical procedure.
To accurately assess pedicle screw placement in the
sacrum, a specialized view of the pelvis is required 14 (Fig
11). This modified pelvic-inlet view described by Stein-
mann et al is preferable to the anteroposterior view for
evaluating sacral screw penetration and angulation in the
transverse plane, whereas screw angulation in the sagit-
tal plane can only be evaluated using the lateral radio-
graph.
In degenerative disorders of the lumbar spine, pedicle
screw instrumentation systems may be considered in the
following situations: (1) postoperative symptomatic
spondylolisthesis; (2) multiple-level decompression with
significant facet joint removal; (3) degenerative scoliosis;
(4) degenerative scoliosis associated with spinal stenosis;
(5) postoperative lumbar instability; and (6) single-level
decompression for lumbar spondylolisthesis associated
with spinal stenosis when a fusion is contemplated.
The theoretical advantages of spondylolisthesis reduc-
tion are that it (1) provides immediate stability; (2) recon-
stitutes neuroforaminal height and vertebral alignment;
(3) prevents further vertebral slippage; (4) improves fu-
sion rate; and (5) maintains lumbar lordosis.
INSTRUMENTATION OF THE LUMBAR SPINE
,hL
At the present time exact indications for this procedure
cannot be determined until comparison studies with fu-
sion alone or fusion with conventional instrumentation
systems are performed.
This techniqfie has been used for symptomatic postop-
erative lumbar spondylolisthesis with recurrent spinal
stenosis after extensive decompression has been per-
formed (Fig 12). The preliminary results in 15 cases have
been good with minimal morbidity.
The following cases are presented to illustrate the use
of pedicle fixation in lumbar degenerative disorders.
Case 1
M.G. is a 62-year-old woman with symptomatic spinal
stenosis. Figure 13A and B show the preoperative de-
generative spondylolisthesis at L4-L5. Following decom-
pressive laminectomy, the patient did well until 1989,
when recurrent symptoms of spinal stenosis were noted.
Radiographs (Fig 13C and D) showed progressive
spondylalisthesis with spinal stenosis confirmed by my-
elography. The patient underwent pedicle screw instru-
mentation and intertransverse process fusion, with re-
duction of the spondylolisthesis (Fig 13E and F) and sig-
nificant reduction of back and leg pain.
95
 Fig 14. Spinal stenosis (case 2).
Case 2
S.F. is a 5 9 - y e a r - o l d w o m a n w i t h s y m p t o m a t i c s p i n a l ste-
nosis associated with a progressive degenerative spon-
d y l o l i s t h e s i s at L4-L5 (Fig 14A a n d B). A l u m b a r m y e l o -
g r a m s h o w e d c o m p l e t e b l o c k a g e at L4-L5 d u e to s p i n a l
s t e n o s i s (Fig 14C a n d D). T h e p a t i e n t u n d e r w e n t r e d u c -
tion with pedicle screw instrumentation and intertrans-
v e r s e p r o c e s s f u s i o n (Fig 14E a n d F) a n d h a d e x c e l l e n t
results.
REFERENCES
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HARRY N. HERKOWITZ