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Diagnostic imaging of spinal fusion

and complications

Mohammad Reza Hayeri, MD, and Jamshid Tehranzadeh, MD

ack pain is the most common situations, this syndrome occurs after a spinal fusion, types of instrumentation
cause of limited activity in peo- minimum of 20% of spine fusion surg- and potential complications to properly
ple younger than 45 years in the eries. The syndrome can result from: appraise postoperative images.
United States. It is the second most fre- mistaken diagnoses, technique error, Stability is described as resistance of
quent reason for visits to a physician poor application, inappropriate indica- the spine to deformation under physio-
and ranks fifth as the reason for hospital tion, pseudarthrosis or continued natural logic stress. Mulholland8 in a recent
admission.1 It is estimated that 18% of progression of disease. This syndrome review of instability and low-back pain
the U.S. population experience low- can be prevented to a large extent by hypothesized that the cause of low-back
back pain each year. Fortunately, in meticulous pre- and intraoperative radi- pain could be due to abnormal disc load-
most cases, the underlying pathology is ologic examination.3,4 Since the initial ing. Currently, the most widely accepted
benign and the pain is self-limited. description of spinal instrumentation by cause of low-back pain and the underly-
Noninvasive methods of treatment such Harda in 1889 and subsequent spinal ing concept promoting the use of spinal
as physical therapy and pharmacother- fusion surgery by Fred Albee and Russel fusion is nonphysiologic movement of
apy typically resolve such pain. Hibbs in treatment of spinal tuberculosis the degenerated segment. Most appli-
Treatment of back pain is the third in 19115–7 there have been a great many ances are placed to provide stability dur-
most common indication for surgical advances in surgical methods and instru- ing bone fusion, and their function is
procedures in the nation. Decompres- mentation, as well as many more indica- complete when this has occurred. Be-
sion and occasional arthrodesis with fre- tions for fusion. Among current in- cause of the morbidity associated with
quent instrumentation are the main dications are scoliosis, spondylolisthe- repeated surgery, intact implants are gen-
surgical procedures performed in the sis, congenital deformities, spinal insta- erally left in place for life. Fractured and
U.S.2 It is a common belief that immobi- bility in trauma or by iatrogenic causes dislodged implants are often removed
lization and/or removal of the painful (e.g. extensive laminectomy), infection because of the need for revision and the
segment decreases pain. Failed back and neoplasm. The current indication for potential for migration of the compo-
surgery syndrome (FBSS) is defined as spinal arthrodesis is broad and it in- nents, leading to substantial soft-tissue or
failure to relieve lower back pain symp- cludes the category of degenerative disc neural injury.
toms following surgery. In the best of all diseases.3
Postoperative imaging is used to Spinal instrumentation
assess disease progression, positioning Surgical implants in spinal surgeries
Dr. Hayeri is a former Research Fellow,
Division of MSK Imaging at University of instrumentation, possible complica- are used to stabilize the spine, replace the
of California, Irvine Medical Center, tions and the extent of bone-graft fusion. defective parts and maintain anatomic
Orange, CA, and Dr. Tehranzadeh is Knowledge of the advantages and limi- reduction. Internal spinal instrumentation
Chief of Radiology at Long Beach VA tations of different imaging modalities is has undergone considerable advances
and Professor Emeritus and Vice Chair
necessary for optimal evaluation of during the last century. Radiologists
of Radiology, Department of Radiologi-
cal Sciences, University of California, patients with spinal instrumentation. should be able to identify the devices most
Irvine Medical Center, Orange, CA. Radiologists should also be familiar commonly used and understand their
with different surgical methods used in biomedical principles and specifications.

14 ■ APPLIED RADIOLOGY © July–August 2009

Table 1: Specifications of spinal fusion instruments and systems

Posterior instrumentation Specification
Luque system Single or double, straight or L-shaped rod(s)
attached to spine with sublaminar wires.
Hartshill rectangle Stainless steel rectangle with bends at upper
and lower ends, attached to spine with sub-
laminar wires.
Harrington system Smooth compression or distraction rod with
collar at one end and ratchets at the other,
attached to spine by hooks.
Wisconsin system Like Harrington system but the rod is attached
to the spine by interspinous wires.
Knodt rods Two threaded distraction rods with a fixed
central nut attached to lumbosacral spine
by hooks.
Cortel Dubousset rod Two serrated rods connected together by
(CD rod) cross links. Set screws attach the pedicle FIGURE 1. Fracture of pedicular screw. This
is a 67-year-old man with extensive thora-
screws or laminar hooks to the rods.
columbar spinal fusion with CD rods and
Texas Scottish Rite system Rough surface rod with hooks and pedicle pedicular screws. Lateral in-flexion radi-
(TSRH) screws attached to the rod with eyebolts ograph shows fracture of the pedicular
and nuts. screw at L5 level.
Isola system Similar to Texas Scottish Rite system with
rods, hooks, plates and cross links.

Anterior instrumentation Specification

Dwyer Staples are embedded into the vertebral body
and a cable is attached to the vertebral body
by threaded screws.
Zielke A modified Dwyer system. The cable is
replaced with solid stainless steel.
Kaneda Consists of 2 rods attached to vertebral body
via staples and screws.

Common devices spine fusion.9–11 Some of the commonly

Rods, plates and rectangles used instruments and systems, and
Rods can extend to single or multi- their specifications, are summarized in
ple spine segments. They can be single Table 1.
or double, straight, L-shaped or can be
cut and fashioned as required. They are Translaminar or facet screws
attached to the spine by hooks, pedicle These devices can be used when
screws or sublaminar or interspinous posterior spinal elements are intact.
wires or cables. Rods are usually pre- They attach the lamina of 2 adjacent
FIGURE 2. Spinal fusion with fracture of
ferred over plates for multisegment vertebrae.
anterior titanium plate. This is a 43-year-old
fusion because of their ability to span a woman with anterior and posterior spinal
long segment. The Hartshill rectangle Interbody spacers fusion. AP radiograph shows anterior fusion
is seldom used today. It is a stainless- Interbody spacers could be solid at C6 to C7 and posterior fusion at C5
steel rectangle that attaches to the spine (ramp) or hollow (cages). Cages are through C7. There is a fracture of the anterior
titanium plate. (Reprinted from Seminars in
by sublaminar wires and occasionally filled with bone-graft material and in-
Ultrasound, CT and MR, Vol 26, Tehran-
interspinous wires. Various shapes of serted into the intervertebral space or zadeh J. et al., Advances in spinal fusion,
plates in different sizes have been replace a vertebra after its removal (i.e. Pages 103-113, Copyright 2005, with per-
developed for anterior or posterior corpectomy). Cages are usually made of mission from Elsevier.)

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FIGURE 3. Broken pedicular screw of the lumbosacral fusion. This is a 60-year-old woman
with posterior spinal fusion. A (AP) and B (lateral) radiographs of lumbosacral spine show the
posterior fusion of L4 through S1 levels with fracture of pedicular screws on the left and right
sides at the S1 level (arrowhead), which is noted best on the lateral view. (Reprinted from
Seminars in Ultrasound, CT and MR, Vol 26, Tehranzadeh J. et al., Advances in spinal fusion, B
Pages 103-113, Copyright 2005, with permission from Elsevier.)


FIGURE 5. Nonunion of Bagby and Kuslich

(BAK) cages due to loosening following lum-
bar interbody fusion. This is a 47-year-old
man who underwent interbody fusion with
titanium cages filled with iliac bone graft and
developed nonunion. A (reformatted coro-
nal) and B (sagittal) CT radiographs show
bone resorption around the titanium cage,
indicating loosening and nonunion. The
cause of nonunion is due to the lack of
FIGURE 4. Failed spinal fusion due to broken Harrington rod. This is a 42-year-old woman immobilization at the posterior elements of
with scoliosis who underwent spinal fusion with Harrington rod fixation extending from the T5 the spine. (Reprinted from Seminars in
through L3 levels. A (AP) and B (lateral) radiographs of the thoracolumbar spine show fracture Ultrasound, CT and MR, Vol 26, Tehran-
of the Harrington rod at the T7 to T8 level. (Reprinted from Seminars in Ultrasound, CT and zadeh J. et al., Advances in spinal fusion,
MR, Vol 26, Tehranzadeh J. et al., Advances in spinal fusion, Pages 103-113, Copyright 2005, Pages 103-113, Copyright 2005, with per-
with permission from Elsevier.) mission from Elsevier.)

16 ■ APPLIED RADIOLOGY © July–August 2009

titanium carbon fibers, polyetherether

A B ketan (PEEK) or of cortical bone graft.
Most cages contain 2 radiopaque mark-
ers to identify their position in radi-
ographs and to enable their assessment.
They are made in different shapes based
on the method of approach to the inter-
vertebral disc.
In anterior interbody fusion (AIF),
cages are more round in shape, while in
posterior interbody fusion (PIF) they
are more rectangular. Transforaminal
interbody fusion (TIF) cages are more
crescent-shaped. Expandable cylindri-
cal or mesh cages are used in vertebral-
body replacement procedures.
Cages are usually supported by addi-
tional posterior, anterior or lateral instru-
mentation (i.e. screw with plates or rods)
to increase stability. For a standalone
interbody fusion cage, the interbody
spacer is fixed to the adjacent vertebral
body with screws to eliminate the need
for additional instrumentation support.
Retropulsion of the cage is a possible
complication, but is more common in
PIF.12 A distance of ≤2 mm between the
cage’s posterior marker and the posterior
margin of the vertebra should exist to
provide reassurance that the cage is not
invading the spinal canal.11 Cage subsi-
dence (defined as migration of >3 mm
into the adjacent vertebra) and lateral dis-
placement is a disadvantage of using
mesh and standalone cages.13–15 The inci-
dence of subsidence is reported from
18% to ≤62.5% in patients who undergo
spinal procedures with standalone cervi-
cal cages. Expandable cages have
broader surface area and duller edges at
both ends, which minimize their subsi-
FIGURE 6. Nonunion of anterior interbody fusion at C6 to C7. This is a 47-year-old man with dence and also allow immediate load
anterior fusion of C5 through C7 with interbody cadaveric bone graft. Although C5 to C6 fused bearing and stability after corpectomy.16
very well, C6 to C7 had nonunion. A (flexion) and B (extension) lateral views of the cervical
spine show lucency at the intervertebral disc bone graft site at C6 to C7. Note the posterior Miscellaneous
compartment showing motion and interspinous-process space changes during flexion and
Dynamic stabilization devices are a
extension. The cause of nonunion is due to the lack of immobilization at the posterior elements
of the spine. C (Sagittal reformatted CT myelogram) shows resorption of the cadaveric graft at new category of instruments that are in
C6 to C7 disc space. D is a flexion lateral view radiograph of the cervical spine following poste- various stages of development. They can
rior wiring and fusion of C6 to C7. The patient proceeded to have good fusion later on, even at be used alone or in conjunction with other
the C6 to C7 level, without further intervention. However, he developed facet arthritis above instrumentation. They act by controlling
the fusion at the C4 to C5 level as shown by vaccum phenomenon and sclerosis at the facet
the abnormal motion and uneven load in
joint at this level. Later on, the C4 level had to be incorporated in the fusion to relieve the pain
caused by facet arthritis.(Reprinted from Seminars in Ultrasound, CT and MR, Vol 26, Tehran- segments adjacent to the level of fusion in
zadeh J. et al., Advances in spinal fusion, Pages 103-113, Copyright 2005, with permission order to minimize progressive degenera-
from Elsevier.) tion. Artificial ligaments (e.g. Dynamic

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either an anterior or posterior approach.

A B In interbody fusion, the intervertebral
disc or a complete vertebra is removed
and replaced with bone graft. Interbody
fusion of the spine can be approached
anteriorly or posteriorly.
Anterior interbody fusion (AIF) has
the advantage of a broader access to the
disc space. However, it is limited by
potential injury to major vessels and
sympathetic nerve chain.17 Oskouian
and Johnson reported a 5.8% incidence
(12 of 207 patients) of vascular compli-
cations in patients who underwent ante-
rior thoracolumbar spine reconstruction
Extreme lateral interbody fusion
(XLIF) is a newer surgical approach to
FIGURE 7. Loosening of screw. (A) Lateral radiograph of lumbar spine in a 49-year-old man
who underwent posterior spinal fusion of L4-S1 levels with pedicular screws and posterior bars fuse L1 to L5 and to minimize disad-
and bone graft. The 2 radiopaque markers of intradiscal PEEK spacer are noted at the L5 to vantages of AIF. Extreme lateral inter-
S1 level (thin arrows). (B) Lateral flexion view of lumbar spine shows loosening of the L4 screw body fusion approaches the anterior
(thick arrow) with spondylolysis (arrowhead) and subluxation of L5 over S1 level which indi- spine from the flank.
cates instability.
In posterior interbody fusion (PIF)
bilateral laminectomies are performed
A B and bone-graft material is inserted into
the disc space after the disc is removed.
Posterior interbody fusion has the dis-
advantage of potential injury to nerve
roots. Retrograde migration of the graft
or cage is also more common with the
posterior approach.19
Transforminal interbody fusion (TIF)
is a modified PIF that uses a more lateral
approach and thus leaves the midline
bone structures intact. Min et al. showed
both AIF and PIF can produce good out-
comes in treating lumbar spondylolis-
thesis, but AIF is more advantageous in
preventing the development of adjacent
segment degeneration.20
Overall, Lemcke et al. reported that,
with regard to the indications and con-
FIGURE 8. Infection and pseudarthrosis following spinal fusion: (A) Coronal CT reformatted traindications, AIF and PIF are unques-
image of a 74-year-old woman with spinal fusion and bone graft shows erosions around the tionably accepted as up-to-date methods.21
titanium cage indicating loosening due to infection. (B) Sagittal CT reformatted image of the
The decision to use AIF or PIF is mainly
same patient shows loosening around the titanium cage due to infection and pseudarthrosis.
based on the patient’s presenting pathol-
Stabilization System [Dynesys], Zimmer System, Archus Orthopedics, Redmond, ogy, spine anatomy, the surgeon’s experi-
Inc., Warsaw, IN), interspinous decom- WA) are examples of such devices.11 ence, history of previous surgery and
pression systems (e.g. X-STOP Spacer, other conditions that may favor one
Medtronic Spine, Memphis, TN; and the Surgical methods approach over another (e.g. AIF is diffi-
Wallis Dynamic Posterior Stabilization Surgical techniques can be divided cult in the presence of marked vascular
System, Zimmer Inc., Bordeaux, France), on the basis of perceived patient mor- calcification).11,22 Laparoscopic interbody
and posterior element replacement bidity into minimally invasive or tradi- fusion can also be performed; however,
systems (e.g. Total Facet Arthroplasty tional-open procedures performed via compared with open surgery, the overall

22 ■ APPLIED RADIOLOGY © July–August 2009



FIGURE 9. Infection and abscess formation. (A) Lateral radiograph of lumbar spine in a 57-
year-old man shows erosion around base of proximal screw (arrows). (B) Sagittal spin echo
T1-weighted image of lumbar spine shows low signal areas in posterior spine following spinal
fusion (stars). (C) Sagittal T2-weighted fat saturated image shows focal areas of increased
signal in posterior spine due to infection and abscess formation (arrowheads). (D) Axial T1-
weighted fat saturated image shows contrast enhancement in the margin of abscesses in the
posterior spine (arrows) with soft tissue inflammation.

complication rate is higher (19% vs. 14%, rates to nearly 100%. Using cages in
respectively). interbody fusions provides more imme-
Posterolateral fusion is an alternative diate stability during bone graft incor-
for interbody fusion. In posterolateral poration.23–25
fusion, adjacent vertebrae are fused
together by placing the bone-graft mate- Imaging of postoperative FIGURE 10. Collapsd vertebral endplate fol-
rial between the transverse processes. In spine fusion lowing spinal fusion. (A) Lateral radiograph
comparison, interbody fusion provides Postoperative imaging plays an of lumbar spine in a 61-year-old man with
a greater surface area of bone contact important role in the assessment of posterior spinal fusion of L2 to L5 levels with
pediclular screws, posterior bars and bone
and produces a more favorable fusion fusion and bone formation. It is also
graft. (B) Lateral radiograph of lumbar spine
compared to the posterolateral helpful to detect instrument failure and 3 months later shows spinal fusion with col-
method.23 Addition of instrumentation other suspected complications. It is nec- lapse of superior endplate of L2 and inferior
to interbody fusion increases success essary to compare current images with endplate of L1 vertebrae.

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FIGURE 11. Poor screw placement in thoracic spinal fusion. This is a 61-year-old woman who underwent thoracic spinal fusion. A. (AP) radi-
ographs show thoracic spine fusion with rod and pedicular screws with side plate and screw fixation and corpectomy with titanium cage
placement. B (axial) and C (coronal reformatted) CT scans show the screw is protruding through the soft tissue of the posterior mediastinum
and lung.

previous studies to identify any subtle Sometimes radiographs are nondiag- commonly with titanium implants com-
changes and disease progression. nostic and, based on clinical suspicion pared with stainless steel because of the
Evaluation of the postoperative spine and the type of the applied instrument, lower beam attenuation coefficient of
usually begins with conventional radi- additional imaging with other modalities titanium implants.11
ographs in AP and lateral projections. It may be applied. Currently, computed Magnetic resonance imaging (MRI)
usually takes 6 to 9 months for a solid tomography (CT) with multiplanar has been used increasingly in recent
bone fusion to be established radi- reconstruction (MPR) is considered the years since introduction of titanium-
ographically. Conventional radiographs modality of choice for imaging bony based implants with reduced artifact
are capable of detecting instrument fail- detail and assessing osseous formation compared to formerly used stainless-
ure, infection and other causes of failed and hardware position despite artifact steel devices. These artifacts could
fusion (Figures 1 through 7). Addi- formation. CT is also useful in demon- be decreased even more by changing
tional views in lateral flexion and strating the spinal canal and its alignment imaging parameters such as reducing
extension are sometimes used to evalu- and is capable of detecting infection and echo time, increasing bandwidth and
ate the presence of motion and the pseudarthrosis12 (Figure 8). Cook et al. decreasing voxel size. Aligning the
integrity of the fusion.17 Ray defined 6 evaluated the extent of bony fusion in an implant along the axis of the magnetic
criteria to radiographically verify a animal model and reported that CT was field also reduces artifact although it is
solid fusion: capable of detecting fusion in 83% of often not completely achievable due to
(1) no motion or <3 degrees of inter- cases, but coincidence of CT image the multidirectional configuration of
segment position change on lat- results with histological findings was most hardware. Spin echo sequences
eral flexion and extension views, present in only 14% of specimens and are less vulnerable to magnetic suscep-
(2) lack of a lucent area around the CT significantly overestimated the extent tibility artifact and give better quality
implant, of fusion.27 images compared with gradient echo
(3) minimal loss of disc height, In another study, Heithoff et al. com- sequences. MRI is useful in detecting
(4) no fracture of the instrument, pared CT images with reoperation find- infection (Figure 9) and assessing
bone graft or vertebrae, and ings in symptomatic pseudarthrosis recurrent tumor. MRI is the modality of
(5) no sclerotic change in the graft or patients and reported that CT was not choice in assessing intraspinal contents.
adjacent vertebrae, reliable in identifying these patients.28 Myelography (Figure 6) is an alterna-
(6) visible osseous formation in or Artifacts are the primary disadvantage tive when MRI is contraindicated or is
around the cage.26 of CT although artifacts are seen less nondiagnostic because of artifact.

24 ■ APPLIED RADIOLOGY © July–August 2009


FIGURE 12. Poor technical fusion and screw insertion of sacroiliac joint. This is a 26-year-old woman who underwent fusion of the right sacroil-
iac joint. The posterior screw is violating the sacral neural foramen on the right. A (axial) and B (coronal) views show the screw encroaching on
the first sacral foramen on the right.
instruments can cause chronic tissue
irritation leading to pain, bursa forma-
tion and even pressure sores with tissue
necrosis. This is an occasional indica-
tion for hardware removal.30 There is
also a risk of bone resorption around
screws or under the implants that are in
direct contact with the bone (Figures 5
and 7). This will cause the bones to
weaken and predisposes them to frac-
ture and it leads to hardware failure. A
loose appliance repeatedly moves and
produces bone resorption or erosion.
Fused bones are less mobile, which
makes the bones vulnerable to fractures
FIGURE 13: Screw inside the neural foramen. Axial CT of the sacrum in a 59-year-old woman
above or below the implants if sub-
with spinal tuberculosis shows destruction of sacral vertebra. The sacral screw placed for
spinal fusion is in the neural foramen of the sacrum, impinging on the left sacral nerve root. jected to trauma (Figure 10). Unsuc-
cessful fusion may have other causes
Radionuclide scans are mainly used Besides the common complications such as development of facet arthritis
to detect infection.29 Early stages of associated with spinal fusion proce- (Figure 6C) or disc disease above or
pseudarthrosis can also be assessed by dures; there are some additional com- below the fusion level.3 Premature
increased radionuclide uptake, although plications based on site, procedure and degenerative changes at the disc levels
this may appear indistinguishable from type of instrumentation. above and below the fused segment can
remodeling. Sonography is used to Hardware fracture (Figures 1 through occur due to the reduced number of
detect fluid collections and abscesses in 4) occurs most commonly as a result of mobile segments. This complication is
the postoperative spinal fusion.17 metal fatigue from the repeated stress in reported in 10.2% of patients with pos-
spinal movements. The fractured appli- terior fusion and instrumentation.31
Spinal fusion instrumentation ance may not be displaced, making its In the cervical spine, potential com-
and complications detection difficult. A dislodged or frac- plications of the posterior approach are
Potential complications of spinal tured appliance does not necessarily mainly neurological and include dural,
surgery vary based on the site of indicate instability or clinical failure of nerve root or cord injury. The anterior
surgery, surgical approach, underlying the fusion but is most frequently associ- approach is associated with risks of
disease, applied instrumentation, sur- ated with motion, instability and injuring the main vascular structures
geon skill and other clinical factors. pseudarthrosis.30 The prominence of the (carotid and vertebral arteries, jugular

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vein), causing recurrent damage to the

A B laryngeal nerve or soft tissue, such as the
esophagus, trachea or lungs (Figure 11).
Postoperative complications include
hematoma, pseudomeningocele, infec-
tion and instability as a result of lami-
nectomy or incorrect hardware place-
ment. Wires and cables are used as a pri-
mary or supplementary instrument in sta-
bilizing the posterior cervical spine
(Figure 6). Complications include break-
age and slippage of skeletal attachments.
Cables (e.g. Songer cable) are much
more resistant to fatigue fracture and fail-
ure. Plates are used for the anterior and
posterior cervical spine. They are also
prone to fracture and failure (Figure 2).
Screws may break or dislodge or may be
misplaced and impinge the cord or nerve
root when placed posteriorly.17 In a retro-
spective study of 1015 patients who
underwent anterior cervical discectomy
for cervical radiculopathy and/or myelop-
FIGURE 14. Pedicular screw encroaching the spinal canal. (A) This is a 51-year-old man with
athy due to degenerative disc disease and/
spinal fusion.The CT scan following spinal fusion shows the pedicular screw is encroaching on
the right side of the spinal canal. (B) Sagittal CT reformatting of the same patient as figure A or cervical spondylosis, Fountas et al. re-
shows the L2 pedicular screw is crossing the spinal canal on the right side. ported the most common postoperative
complications to be dysphagia (9.5%),


FIGURE 15. Poor fusion technique of lumbosacral spine with misplacement of pedicular screw. This is a 67-year-old woman with posterior
spinal fusion at the L5 to S1 level with pedicular screws. A (coronal reformatted) and B (axial) CT scans at L4 and L5 disc space show misplace-
ment of the pedicular screws in the right lateral disk space. (Reprinted from Seminars in Ultrasound, CT and MR, Vol 26, Tehranzadeh J. et al.,
Advances in spinal fusion, Pages 103-113, Copyright 2005, with permission from Elsevier.)

26 ■ APPLIED RADIOLOGY © July–August 2009

postoperative hematoma (5.6%) and In anterior fusion of the thoracic or failed instrument that may have caused
recurrent laryngeal nerve palsy (3.1%).32 lumbosacral spine, the devices should neurologic deterioration. Rare but life-
Screws should approach the opposite be laterally located in the anterior col- threatening complications such as
cortex but should not breach it. In ante- umn. Neurologic deterioration is the delayed aortic rupture due to instrumen-
rior-plate screw fixation, the screws may most-feared complication of surgery tation have also been reported.35
back out and impinge soft tissue (e.g. and may be caused by hardware move- Infection is reported in 1% to 2.4% of
great vessels, trachea and esophagus) or ment or malpositioned screws (Figures patients undergoing lumbar instrumen-
overpenetrate the posterior cortex and 12 through 15). Incorrect use and later tation. Infection leads to bone destruc-
impinge on the cord. These complications dislodgment or fracture of instruments tion and resorption around the implant.
can be prevented by using a cervical- may also contribute to complications On imaging, a lucent area around an
spine locking plate with screw caps (e.g. such as instability, fusion failure or implant implies a loose appliance and
Morscher). This device prevents the pain—with possible resultant neuro- potential infection (Figures 8 through 9).
screws from backing out and provides logic damage. Postoperative neurologic CT-guided aspiration can be used to iso-
increased holding power removing the complication due to lumbar instrumen- late the microorganism. Unlike superfi-
need for transcortical purchase with the tation has been reported in 3% to 11% cial infections that can even be diag-
risk of overpenetration. of patients undergoing spinal proce- nosed clinically, deeper infections such
Immobility of the fused segment dures. Postoperative neurologic injuries as discitis are sometimes more challeng-
causes additional stress on adjacent can also be due to cord edema or ing. Osteomyelitis in adjacent vertebrae,
levels of the vertebral column. Ossifi- hematoma and are often self-limited.30 disc collapse and destruction indicate
cation of anterior longitudinal ligament Bone graft material can migrate or discitis radiographically. Radionuclide-
and facet disease are common compli- hypertrophy resulting in impingement labeled white blood cell scintigraphy
cations of anterior plate and screw fix- on the spinal canal or neural fora- and MRI can be helpful to detect infec-
ation (Figure 6).9,17 men.17,33,34 Radiographs often show the tion in early stages.36

Sectionals for Teaching and Training in

Diagnostic Radiology
m aterial

O paque


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July–August 2009 APPLIED RADIOLOGY ©

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Failed fusion with the development 2. Deyo RA, Gray DT, Kreuter W, et al. United 23. Ekman P, Moller H, Tullberg T, et al. Posterior
of pseudarthrosis is a common end States trends in lumbar fusion surgery for degener- lumbar interbody fusion versus posterolateral fusion
ative conditions. Spine. 2005;30:1441-1445; dis- in adult isthmic spondylolisthesis. Spine. 2007;32:
result of implant failure or improper cussion 1446-1447. 2178-2183.
surgical technique (Figures 5 and 6). Its 3. Tehranzadeh J, Ton JD, Rosen CD. Advances 24. Weatherley CR, Prickett CF, O'Brien JP. Disco-
in spinal fusion. Semin Ultrasound CT MR. genic pain persisting despite solid posterior fusion.
incidence in lumbar instrumentation is
2005;26:103-113. J Bone Joint Surg Br. 1986;68:142-314.
reported in 5% to 32% of patients. CT is 4. Rosales-Olivares LM, Miramontes-Martínez V, 25. Brantigan JW, Steffee AD, Lewis ML, et al.
the optimal method for evaluating a Alpízar-Aguirre A, et al. Failed back surgery syn- Lumbar interbody fusion using the Brantigan I/F
drome. Cir Cir. 2007;75:37-41. cage for posterior lumbar interbody fusion and
bone graft. A failed fusion with pseud- 5. Hadra BE. The classic: Wiring of the vertebrae the variable pedicle screw placement system:
arthrosis formation results in continued as a means of immobilization in fracture and Pott’s Two-year results from a Food and Drug Adminis-
stress on the implant, and hardware disease. Berthold E. Hadra. Med Times and Regis- tration investigational device exemption. Clinical
ter. 1891;Vol 22. Clin Orthop Relat Res. 1975; trial. Spine. 2000;25:1437-1446.
fracture is inevitable. Suda et al. 112:4-8. 26. Ray CD. Threaded fusion cages for lumbar
described radiological risk factors for 6. Albee FH. The classic: Transplantation of a por- inter-body fusions: An economic comparison with
pseudarthrosis and/or instrument break- tion of the tibia into spine for Pott’s disease. JAMA. 360 degrees fusions. Spine. 1997;22:681–685.
1911;57:885-887. 27. Cook SD, Patron LP, Christakis PM, et al.
age after PLF with pedicle screws to be 7. Hibbs RA: A report of 59 cases of scoliosis Comparison of methods for determining the pres-
related to preserved disc height and the treated by fusion operation. By Russel A. Hibbs, ence of anterior lumbar interbody fusion. Spine.
presence of segmental kyphosis.37 1924. Clin Orthop Relat Res. 1988;229:4-19. 2004;29:1118-1123
8. Mulholland RC. The myth of lumbar instability: 28. Heithoff KB, Mullin WJ, Holte D, et al. The fail-
The risk of pseudarthrosis escalates The importance of abnormal loading as a cause of ure of radiographic detection of pseudoarthrosis in
with increased patient age and smok- low-back pain. Eur Spine J. 2008;17:619-625. patients with titanium lumbar interbody fusion
ing. Pseudarthrosis is more common 9. Slone RM, MacMillan M, Montgomery WJ. cages. Paper presented at: International Society
Spinal fixation. Part 1. Principles, basic hardware, for the Study of the Lumbar Spine; June 1999;
using external braces than internal fix- and fixation techniques for the cervical spine. Kona, HI.
ation. The rate of pseudarthrosis is Radiographics. 1993;13:341-356. 29.Berquist TH, Currier BL, Broderick DF. The
decreased with meticulous surgical 10. Slone RM, MacMillan M, Montgomery WJ, spine. In: Berquist TH, editor. Imaging atlas of
Heare M. Spinal fixation. Part 2. Fixation tech- orthopedic appliances and prosthesis. New York,
technique, including careful facet exci- niques and hardware for the thoracic and lum- NY:Raven Press;1995:109-215
sion and adequate graft placement. bosacral spine. Radiographics. 1993;13:521-543. 30. Heller JG, Whitecloud TS III, Butler JC, et al.
Repair is necessary if the patient pre- 11. Rutherford EE, Tarplett LJ, Davies EM, et al. Complications of spinal surgery. In: Rothman RR,
Lumbar spine fusion and stabilizaion: Hardware, Simeone FA, eds. The spine. 3rd ed. Philadelphia,
sents with implant failure or pain. In techniques, and imaging appearances. Radi- PA:Saunders;1992:1817-1898.
asymptomatic patients, intervention ographics. 2007;27:1737-1749. 31. Cho KJ, Suk SI, Park SR, et al. Complica-
12 Berquist TH. Imaging of the postoperative tions in posterior fusion and instrumentation for
may be deferred and the patient’s con-
spine. Radiol Clin North Am. 2006;44:407-418. degenerative lumbar scoliosis. Spine. 2007;32:
dition should be followed.38,39 13. Bartels RH, Donk RD, Feuth T. Subsidence of 2232-2237.
standalone cervical carbon fiber cages. Neuro- 32. Fountas KN, Kapsalaki EZ, Nikolakakos LG,
surgery. 2006;58:502–508.
Conclusion 14. Gercek E, Arlet V, Delisle J, Marchesi D. Sub-
et al. Anterior cervical discectomy and fusion
associated complications. Spine. 2007;32:
Radiologists face new challenges as sidence of stand-alone cervical cages in anterior 2310-2317.
the number of, and indications for, interbody fusion: Warning. Eur Spine J. 2003; 33. Lowery GL, McDonough RF. The significance
12:513–516. of hardware failure in anterior cervical plate fixa-
spinal surgery grow. Adequate under- 15. Barsa P, Suchomel P. Factors affecting sagittal tion. Patients with 2- to 7-year follow-up. Spine.
standing of various surgical techniques malalignment due to cage subsidence in stand- 1998;23:181-186; discussion 186-187.
and instruments, coupled with improved alone cage assisted anterior cervical fusion. Eur 34. Spanu G, Marchionni M, Adinolfi D, Knerich
Spine J. 2007;16:1395-1400. R. Complications following anterior cervical spine
awareness of the possible complications, 16. Riaz S, Fox R, Lavoie MV, Mahood JK. Verte- surgery for disc diseases: An analysis of ten
are vital when interpreting postoperative bral body reconstruction for thoracolumbar spinal years experience. Chir Organi Mov. 2005;90:
studies. Radiologists should carefully metastasis – a review of techniques. J Ayub Med 229-240.
Coll Abbottabad. 2006;18:70-77. 35. Ohnishi T, Neo M, Matsushita M, et al. Delayed
compare these critical points with base- 17. Slone RM, MacMillan M, Montgomery WJ. aortic rupture caused by an implanted anterior
line studies to develop a targeted assess- Spinal fixation. Part 3. Complications of spinal instru- spinal device. Case report. J Neurosurg. 2001;95
ment of grafts and hardware. With more mentation. Radiographics. 1993;13:797-816. (2 Suppl):253-256.
18. Oskouian RJ Jr, Johnson JP. Vascular complica- 36. Young PM, Berquist TH, Bancroft LW, Peter-
familiarity of postoperative spinal tions in anterior thoracolumbar spinal reconstruction. son JJ. Complications of spinal instrumentation.
images obtained on various modalities J Neurosurg. 2002;96(1 Suppl):1-5. Radiographics. 2007;27:775-789.
and the knowledge of how certain situa- 19. McAfee PC. Interbody fusion cages in recon- 37. Suda K, Ito M, Abumi K, et al. Radiological
structive operation on the spine. J Bone Joint Surg risk factors of pseudoarthrosis and/or instrument
tions (e.g. surgical technique and hard- [AM].1999;81-A:859-878. breakage after PLF with the pedicle screw sys-
ware) contirbute to failed back surgery 20. Min JH, Jang JS, Lee SH. Comparison of ante- tem in isthmic spondylolisthesis. J Spinal Disord
syndrome, radiologists can quickly rior- and posterior-approach instrumented lumbar Tech. 2006;19:541-546.
interbody fusion for spondylolisthesis. J Neurosurg 38. Schlegel J, Yunan HA, Fredricksen B. Ante-
arrive at a precise diagnosis, permitting Spine. 2007;7:21-26. rior interbody fixation devices. In: Frymoyer JW,
appropriate treatment and minimizing 21. Lemcke J, Klötzer S, Klötzer R, Meier U. PLIF Ducker TB, eds. The adult spine: principles of
and ALIF for the degenerative spondylolisthesis of practice. New York, NY: Raven;1991:1947-1959.
patient suffering.
the lumbar spine. Z Orthop Ihre Grenzgeb. 2007; 39. Emami A, Deviren V, Berven S, et al. Outcome
145:48-54. and complications of long fusions to the sacrum in
REFERENCES 22. Blumenthal SL, Ohnmeiss DD; NASS. Interver- adult spine deformity: Luque-galveston, combined
1. Andersson GB. Epidemiological features of tebral cages for degenerative spinal diseases. Spine iliac and sacral screws, and sacral fixation. Spine.
chronic low-back pain. Lancet. 1999;354:581-585. J. 2003; 3:301-309. 2002;27:776-786.

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