Letter to the Editor. Lumbar fusion

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TO THE EDITOR: I read with interest the article by Reid et al.8 (Reid PC, Morr S, Kaiser MG: State of the union: a review of lumbar fusion indications and techniques for degenerative spine disease. JNSPG 75th Anniversary Invited Review Article. J Neurosurg Spine 31:1–14, July 2019).

The authors correctly state that the justification for spinal stabilization has changed as our understanding of the intricacies of lumbar instability and spinal alignment has grown.8 Despite the fact that our understanding of spinal instability may not be consistent with existing world opinion, the authors should have referred to our work on the subject.1–7

The study of the subject of spinal degeneration has been “disc-centric” for more than a century. Our analysis suggests that spinal instability related to weakness, disuse, or injury to the muscles that support lifelong standing human posture is probably the point of initiation of the entire cascade of spinal alterations that are grouped under the definition of “spinal degeneration.”2 A lateral location away from neural structures and an oblique profile make identification of instability at the facets difficult or impossible using plain radiographs or even with modern computer-based imaging. Facetal telescoping or listhesis of facets of the rostral vertebrae over those of caudal vertebrae in one or more spinal segments is the primary effect of muscle weakness. The secondary effects of facetal listhesis include buckling of intervertebral ligaments that include the ligamentum flavum and posterior longitudinal ligament, osteophyte formation, and reduction of disc space height. The overall outcome is reduction of spinal and neural foraminal width. The secondary and so-called “pathological” effects that lead to neural deformation can be clearly visualized on imaging. In 2010, we proposed facetal distraction using a “Goel facet spacer” as a treatment for single- or multiple-level radiculopathy or myelopathy for both cervical and lumbar spinal degeneration.2 We identified that a single act of facetal distraction resulted in reversal of all the known, recognized, and radiologically visible features of spinal degeneration.2,7 The aim of our operation was secondary decompression and spinal arthrodesis. Our remarkably satisfying clinical and radiological results validated our concepts.

As our experience in the field grew, we realized that it was not neural deformation or compression but subtle instability-related micro-injuries that are the cause of neurological symptoms and deficits. Accordingly, for single- or multiple-level spinal degeneration we resorted to “only fixation” as the treatment.1,3,4,6 Our articles on the subject are the first in the literature in which we did not recommend decompression of the neural structures by bone, ligaments, osteophytes, or disc resection.1–7 Transarticular facetal fixation using 1, 2 (double insurance), or 3 (triple insurance) screws provided remarkable stability to the spinal segments.5 Identification of the unstable spinal segments on the basis of clinical and radiological evaluation, and direct assessment of the status of the facets by manual palpation of the bones, was a critical issue that determined the levels of spinal segments that were stabilized.

Decompression of the compressed neural structures has been the basic tenet of spine surgery. However, our studies suggest the futility of both direct and indirect spinal decompression. We have been so convinced of the validity of only fixation as a form of surgical treatment that our recent editorial on the subject discusses a possibility that bone decompressive surgery, including laminectomy and foraminotomy, can eventually become historical.1

Disclosures

The author reports no conflict of interest.

References

  • 1

    Goel A: Can decompressive laminectomy for degenerative spondylotic lumbar and cervical canal stenosis become historical? J Craniovertebr Junction Spine 6:1441462015

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  • 2

    Goel A: Facet distraction-arthrodesis technique: can it revolutionize spinal stabilization methods? J Craniovertebr Junction Spine 2:122011

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  • 3

    Goel A: Letter: Lumbar fusion for degenerative disease: a systematic review and meta-analysis. Neurosurgery 81:E64E652017

  • 4

    Goel A: Only fixation for lumbar canal stenosis: report of an experience with seven cases. J Craniovertebr Junction Spine 5:15192014

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    • Export Citation
  • 5

    Goel AGoel AASatoskar SRMehta PH: Double insurance transfacetal screws for lumbar spinal stabilization. J Craniovertebr Junction Spine 5:85872014

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    • Export Citation
  • 6

    Goel ARanjan SShah APatil AVutha R: Lumbar canal stenosis: analyzing the role of stabilization and the futility of decompression as treatment. Neurosurg Focus 46(5):E72019

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  • 7

    Goel AShah AJadhav MNama S: Distraction of facets with intraarticular spacers as treatment for lumbar canal stenosis: report on a preliminary experience with 21 cases. J Neurosurg Spine 19:6726772013

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    • Export Citation
  • 8

    Reid PCMorr SKaiser MG: State of the union: a review of lumbar fusion indications and techniques for degenerative spine disease. JNSPG 75th Anniversary Invited Review Article. J Neurosurg Spine 31:1142019

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Response

The authors appreciate Dr. Goel’s insights on our review of lumbar fusion techniques and indications. A topic as broad and controversial as lumbar fusion for degenerative disease provides for myriad opinions, and a review article presents challenges with regard to not only space constraints but also clarity of presentation. Admittedly, and regrettably, we were unable to cover everything.

But as much as the volume and diversity of literature on the topic is a burden for reviewers, it is (obviously) a strength and a boon to our field. The studies cited in our review are the most rigorous available, with long follow-up, high enrollment, and randomized controls in many studies. They represent, in our opinion, the best available evidence.

Recently, Goel et al. (2019) have published data on 70 patients who have undergone transarticular fusion without decompression for lumbar stenosis. In their data they report, ultimately, 100% success, a difficult outcome to achieve with any intervention. It is also, as Goel et al. note, not consistent with existing world opinion, nor is their characterization of decompression for spinal stenosis as “futile.”

The heterogeneity of both our patients and their pathology allows for different treatment approaches, and there are undoubtedly improvements to be made in both operative technique and patient selection. There may well be a role for fusion (transarticular or otherwise) without decompression in well-selected patients, but stronger evidence will be needed to change current practices.

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Article Information

Contributor Notes

Correspondence Atul Goel: atulgoel62@hotmail.com.INCLUDE WHEN CITING Published online November 29, 2019; DOI: 10.3171/2019.7.SPINE19792.Disclosures The author reports no conflict of interest.
Headings
References
  • 1

    Goel A: Can decompressive laminectomy for degenerative spondylotic lumbar and cervical canal stenosis become historical? J Craniovertebr Junction Spine 6:1441462015

    • Search Google Scholar
    • Export Citation
  • 2

    Goel A: Facet distraction-arthrodesis technique: can it revolutionize spinal stabilization methods? J Craniovertebr Junction Spine 2:122011

    • Search Google Scholar
    • Export Citation
  • 3

    Goel A: Letter: Lumbar fusion for degenerative disease: a systematic review and meta-analysis. Neurosurgery 81:E64E652017

  • 4

    Goel A: Only fixation for lumbar canal stenosis: report of an experience with seven cases. J Craniovertebr Junction Spine 5:15192014

    • Search Google Scholar
    • Export Citation
  • 5

    Goel AGoel AASatoskar SRMehta PH: Double insurance transfacetal screws for lumbar spinal stabilization. J Craniovertebr Junction Spine 5:85872014

    • Search Google Scholar
    • Export Citation
  • 6

    Goel ARanjan SShah APatil AVutha R: Lumbar canal stenosis: analyzing the role of stabilization and the futility of decompression as treatment. Neurosurg Focus 46(5):E72019

    • Search Google Scholar
    • Export Citation
  • 7

    Goel AShah AJadhav MNama S: Distraction of facets with intraarticular spacers as treatment for lumbar canal stenosis: report on a preliminary experience with 21 cases. J Neurosurg Spine 19:6726772013

    • Search Google Scholar
    • Export Citation
  • 8

    Reid PCMorr SKaiser MG: State of the union: a review of lumbar fusion indications and techniques for degenerative spine disease. JNSPG 75th Anniversary Invited Review Article. J Neurosurg Spine 31:1142019

    • Search Google Scholar
    • Export Citation
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