Fusion criteria for posterior lumbar interbody fusion with intervertebral cages : the significance of traction spur

Abstract

Objective: The purpose of this study was to establish new fusion criteria to complement existing Brantigan-Steffee fusion criteria. The primary purpose of intervertebral cage placement is to create a proper biomechanical environment through successful fusion. The existence of a traction spur is an essential predictable radiologic factor which shows that there is instability of a fusion segment. We studied the relationship between the existence of a traction spur and fusion after a posterior lumbar interbody fusion (PLIF) procedure.

Methods: This study was conducted using retrospective radiological findings from patients who underwent a PLIF procedure with the use of a cage without posterior fixation between 1993 and 1997 at a single institution. We enrolled 183 patients who were followed for a minimum of five years after the procedure, and used the Brantigan-Steffee classification to confirm the fusion. These criteria include a denser and more mature bone fusion area than originally achieved during surgery, no interspace between the cage and the vertebral body, and mature bony trabeculae bridging the fusion area. We also confirmed the existence of traction spurs on fusion segments and non-fusion segments.

Results: The PLIF procedure was done on a total of 251 segments in 183 patients (71 men and 112 women). The average follow-up period was 80.4 +/- 12.7 months. The mean age at the time of surgery was 48.3 +/- 11.3 years (range, 25 to 84 years). Among the 251 segments, 213 segments (84.9%) were fused after five years. The remaining 38 segments (15.1%) were not fused. An analysis of the 38 segments that were not fused found traction spur formation in 20 of those segments (52.6%). No segments had traction spur formation with fusion.

Conclusion: A new parameter should be added to the fusion criteria. These criteria should be referred to as 'no traction spur formation' and should be used to confirm fusion after a PLIF procedure.

Keywords: Instability; Posterior lumbar interbody fusion; Traction spur.

Fig. 1

Lateral radiograph and Computerized tomography image showing a radiolucent halo around cages after posterior lumbar interbody fusion. A and B : lateral radiograph (A) and computerized tomography image (B) showing a radiolucent halo around cages at 64 months after posterior lumbar interbody fusion (PLIF) using brantigan interbody fusion cages. C : lateral radiograph showing a radiolucent halo around cages at 60 months after PLIF using ray-threaded fusion Cages

Fig. 2

Lumbar plain lateral radiograph films showing complete bony trabeculae bridging beyond the cages after posterior lumbar interbody fusion. A : Lumbar plain lateral radiograph films showing complete bony trabeculae bridging beyond the cages at 68 months after posterior lumbar interbody fusion (PLIF) using Ray-threaded fusion cages. B : Lumbar plain lateral radiograph films showing complete bony trabeculae bridging beyond the cages at 64 months after PLIF using Brantigan Interbody fusion cages.

Fig. 3

Lumbar plain lateral radiograph films showing traction spur formation on non-fused segments at POD of 62 months after posterior lumbar interbody fusion (PLIF) using Ray-threaded fusion cages. A : lumbar plain lateral radiograph films at 1 day after PLIF on the L4/5/S1 segment using Ray-threaded fusion cages. B : Lumbar plain lateral radiograph films showing a growing traction spur on the L4/5 segment (arrow) at 62 months after PLIF using Ray-threaded fusion cages.