Transforaminal lumbar interbody fusion for failed Graf ligamentoplasty: a report of two cases.

Abstract

We report 2 cases of transforaminal lumbar interbody fusion for failed Graf ligamentoplasty. Both patients had residual or recurrent low back pain and leg pain after Graf ligamentoplasty, caused by lumbar segmental instability or narrowing of their intervertebral foramens. The pain improved markedly after the revision surgery. We recommend transforaminal lumbar interbody fusion for failed Graf ligamentoplasty, as it provides rigid interbody bony fusion and obviates complete exposure of the dural sac or dural tube.

Full text

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ABSTRACT
We report 2 cases of transforaminal lumbar
interbody fusion for failed Graf ligamentoplasty.
Both patients had residual or recurrent low back
pain and leg pain after Graf ligamentoplasty, caused
by lumbar segmental instability or narrowing of
their intervertebral foramens. The pain improved
markedly after the revision surgery. We recommend
transforaminal lumbar interbody fusion for failed
Graf ligamentoplasty, as it provides rigid interbody
bony fusion and obviates complete exposure of the
dural sac or dural tube.
Key words: lumbar vertebrae; lumbosacral region;
reoperation; spinal fusion
INTRODUCTION
The Graf system is a device used to restrict
intersegmental motion of the lumbar spine in flexion,
Transforaminal lumbar interbody fusion for
failed Graf ligamentoplasty: a report of two
cases
Akihito Nagano,1 Kei Miyamoto,1 Hirofumi Nishimoto,2 Hideo Hosoe,1 Naoki Suzuki,3 Katsuji Shimizu1
1? Department?of?Orthopaedic?Surgery,?Graduate?School?of?Medicine,?Gifu?University,?Gifu,?Japan
2? Department?of?Orthopaedic?Surgery,?Gifu?Central?Hospital,?Gifu,?Japan
3? Department?of?Orthopaedic?Surgery,?Hashima?Municipal?Hospital,?Hashima,?Japan
Address?correspondence?and?reprint?requests?to:?Dr?Katsuji?Shimizu,?Department?of?Orthopaedic?Surgery,?Gifu?University?
School?of?Medicine,?1-1?Yanagido,?Gifu,?501-1194,?Japan.?E-mail:?shim@gifu-u.ac.jp
Journal of Orthopaedic Surgery 2009;17(2):220-2
thus re-establishing lumbar lordosis and preventing
disc degeneration.1–3 It has good early results,4 but
mid- or long-term complications including radicular
pain, screw breakage, and sensory deficits have
been reported.1,2,3,5 Revision surgery for failed Graf
ligamentoplasty includes posterolateral fusion,
anterior spinal fusion, and posterior lumbar interbody
fusion (PLIF).1,2,5 We report 2 patients who underwent
transforaminal lumbar interbody fusions (TLIF) after
failed Graf ligamentoplasties.
CASE REPORTS
Case 1
In September 2004, a 46-year-old woman presented
with low back pain and left leg pain when walking,
and sensory disturbances in both feet. She had no
other neurological deficits or muscle weaknesses.
When she was in a decubitus position or using a frame
corset, the leg pain disappeared but the numbness
remained in both feet.

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Vol. 17 No. 2, August 2009?Tranforaminal?lumbar?interbody?fusion?for?failed?Graf?ligamentoplasty? 221

disc herniation. In December 2003, she underwent a
L5/S1 PLIF and L4/5 Graf ligamentoplasty to avoid
adjacent disc degeneration for L5/S1 disc herniation.
The pain improved but the numbness remained.
Plain radiography showed excellent bony fusion
at L5/S1 with no loosening or malposition of the
pedicle screws (Fig. a) and slight narrowing of the
L4/5 disc space with no instability. No dural or root
compression was visible on magnetic resonance
imaging.
In May 2005, the Graf system was removed and
an L4/5 TLIF performed. Postoperative radiography
showed an increase in the intervertebral space by
2 mm and unchanged alignment of the lumbar
spine (Fig. b). At the 3-year follow-up, the pain had
disappeared, but her feet remained numb.
In 1996, she underwent diskectomy for L4/5 lumbar
Case 2
In January 2002, a 40-year-old man presented with
pain in the lower back and left thigh. The pain was
reduced when he wore a frame corset.
In 2000, he underwent an L4 and L5 laminectomy
with a Graf ligamentoplasty at L3/4 and L4/5 for
lumbar spinal canal stenosis and disc degeneration.
The pain was relieved, but recurred 2 year later,
secondary to progressive arthritis.
Plain radiography showed no evidence of screw
loosening or rupture of the artificial ligaments. The
L4/5 disc height was markedly reduced. Computed
tomography revealed that an osteophyte at the left L4
pedicle was compressing the nerve root.
In May 2002, he underwent removal of the Graf
system and osteophyte, and an L3/4, L4/5 TLIF via a
left extreme lateral approach. He was pain-free at the
5-year follow-up.
DISCUSSION
Graf ligamentoplasty involves stabilisation of the
lumbar spinal segments without fusion,1 constraining
each motion segment in maximum extension. It is
used to provide a firm but flexible posterior constraint
to restore lumbar lordosis and stabilise the facet joints
in extension,6 and avoids adjacent disc problems.7
The spinal instability seen in radiographs does
not always correlate with clinical symptoms.8
Clinical symptoms of lumbar instability are not
always associated with abnormal movements seen
on flexion-extension radiographs. There are few
methods available for functionally diagnosing lumbar
instability.8 It is important to examine patients with
instability both radiologically and clinically.
In our patients, instability was suggested clinically
despite no radiographic evidence of instability, as the
pain was reduced by fitting the patients with frame
corsets and placed them in a decubitus position. The
pain disappeared after TLIF, suggesting that alteration
of the intervertebral space led to passive foraminal
decompression, or that the circumferential fusion
stabilised the affected segments and thus improved
the symptoms.
Spinal instability is a cause of low back pain and
leg pain, and spinal fusion can stabilise the spine and
improve these symptoms.8 TLIF achieves interbody
fusion via the posterior approach9; it enables wide
lateral insertion of interbody spacers and graft
bone and obviates the need to explore the dural
tube. This procedure has an advantage over PLIF in
patients with previous posterior lumbar surgery. We
recommend TLIF over PLIF because of the excessive
root retraction and unnecessary bone and soft tissue
resection required during a PLIF.9
Figure
fusion?at?L5/S1?with?no?loosening?or?malposition?of?pedicle?
screws,?and?(b)?conversion?of?the?Graf?system?to?transforaminal?
lumbar? interbody? fusion? at? L4/5,? with? an? increase? in? the?
intervertebral?space?by?2?mm.
Case?1:?radiographs?showing?(a)?successful?bony?
(a)
(b)

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222? A?Nagano?et?al.?
Journal of Orthopaedic Surgery
REFERENCES
?1.? Markwalder?TM,?Wenger?M.?Dynamic?stabilization?of?lumbar?motion?segments?by?use?of?Graf’s?ligaments:?results?with?an?
average?follow-up?of?7.4?years?in?39?highly?selected,?consecutive?patients.?Acta?Neurochir?(Wien)?2003;145:209–14.
?2.? Hadlow?SV,?Fagan?AB,?Hillier?TM,?Fraser?RD.?The?Graf?ligamentoplasty?procedure.?Comparison?with?posterolateral?fusion?
in?the?management?of?low?back?pain.?Spine?1998;23:1172–9.
?3.? Rigby?MC,?Selmon?GP,?Foy?MA,?Fogg?AJ.?Graf?ligament?stabilisation:?mid-?to?long-term?follow-up.?Eur?Spine?J?2001;10:234–
6.?
?4.? Hashimoto?T,?Oha?F,?Shigenobu?K,?Kanayama?M,?Harada?M,?Ohkoshi?Y,?et?al.?Mid-term?clinical?results?of?Graf?stabilization?
for?lumbar?degenerative?pathologies.?A?minimum?2-year?follow-up.?Spine?J?2001;1:283–9.
?5.? Grevitt?MP,?Gardner?AD,?Spilsbury?J,?Shackleford?IM,?Baskerville?R,?Pursell?LM,?et?al.?The?Graf?stabilisation?system:?early?
results?in?50?patients.?Eur?Spine?J?1995;4:169–75.
?6.? Graf?H.?Vertebral?instability:?stabilization?without?arthrodesis.?Safir?R?Groups?SEM?(procedural?manual),?1990.
?7.? Kanayama?M,?Hashimoto?T,?Shigenobu?K,?Harada?M,?Oha?F,?Ohkoshi?Y,?et?al.?Adjacent-segment?morbidity?after?Graf?
ligamentoplasty?compared?with?posterolateral?lumbar?fusion.?J?Neurosurg?2001;95(1?Suppl):5–10.
?8.? Tokuhashi?Y,?Matsuzaki?H,?Sano?S.?Evaluation?of?clinical?lumbar?instability?using?the?treadmill.?Spine?1993;18:2321–4.
?9.? Humphreys?SC,?Hodges?SD,?Patwardhan?AG,?Eck?JC,?Murphy?RB,?Covington?LA,?et?al.?Comparison?of?posterior?and?
transforaminal?approaches?to?lumbar?interbody?fusion.?Spine?2001;26:567–71.