Accepted Manuscript

Effectiveness of Transpedicular Dynamic Stabilization in Treating Discogenic Low

Back Pain

Lei Luo, Chengmin Zhang, Qiang Zhou, Chen Zhao, Liyuan Wang, Lichuan Liang,
Bing Tu, Bin Ouyang, Yibo Gan

PII: S1878-8750(17)32138-1
DOI: 10.1016/j.wneu.2017.12.022
Reference: WNEU 7035

To appear in: World Neurosurgery

Received Date: 3 November 2017

Accepted Date: 6 December 2017

Please cite this article as: Luo L, Zhang C, Zhou Q, Zhao C, Wang L, Liang L, Tu B, Ouyang B, Gan
Y, Effectiveness of Transpedicular Dynamic Stabilization in Treating Discogenic Low Back Pain, World
Neurosurgery (2018), doi: 10.1016/j.wneu.2017.12.022.

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 ACCEPTED MANUSCRIPT

Title Page

Article title:
Effectiveness of Transpedicular Dynamic Stabilization in Treating Discogenic Low Back Pain

Author names and affiliations:

Lei Luo

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tiancan86@163.com
Department of Orthopedic Surgery, Southwest Hospital, Third Military Medical University,
Chongqing, China 400038.

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Chengmin Zhang
64592317@qq.com

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Department of Orthopedic Surgery, Southwest Hospital, Third Military Medical University,
Chongqing, China 400038.

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Qiang Zhou
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zq_tlh@163.com
Department of Orthopedic Surgery, Southwest Hospital, Third Military Medical University,
Chongqing, China 400038.
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Chen Zhao
43767292@qq.com
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Department of Orthopedic Surgery, Southwest Hospital, Third Military Medical University,

Chongqing, China 400038.
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Liyuan Wang
449219340@qq.com
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Department of Orthopedic Surgery, Southwest Hospital, Third Military Medical University,

Chongqing, China 400038.
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Lichuan Liang
55760608@qq.com
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Department of Orthopedic Surgery, Southwest Hospital, Third Military Medical University,

Chongqing, China 400038.

Bing Tu
tu_bing@yahoo.com
Department of Orthopedic Surgery, Southwest Hospital, Third Military Medical University,
Chongqing, China 400038.

Bin Ouyang
hfouyangbin@qq.com
 ACCEPTED MANUSCRIPT
Department of Orthopedic Surgery, Southwest Hospital, Third Military Medical University,
Chongqing, China 400038.

Yibo Gan
ganyibo@tmmu.edu.cn
Department of Orthopedic Surgery, Southwest Hospital, Third Military Medical University,
Chongqing, China 400038.

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Corresponding Author:
Qiang Zhou

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Spinal unit of Orthopedics
Southwest Hospital, Third Military Medical University
GaoTanYan 29, Chongqing, 400038, China

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Tel: +86-023-68765283
Fax: + 86-023-65340297
E-mail: zq_tlh@163.com

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Key Words:
Dynamic Stabilization, Discogenic Low Back Pain, Wiltse Approach, Disc Rehydration
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Effectiveness of Transpedicular Dynamic Stabilization in

Treating Discogenic Low Back Pain

Abstract
Purpose. To assess clinical outcomes after dynamic stabilization in discogenic low back pain

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(DLBP).
Methods. From April 2012 to January 2015, 23 patients affected by DLBP have been treated
with dynamic stabilization (Dynesys system) via Wiltse approach. Main clinical assessments

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included: visual analogue scale (VAS), Oswestry Disability Index (ODI) and complications.
Radiographs were evaluated for lumbar Range of Motion (ROM) and intervertebral height. The
Woodend classification were measured from MRI.

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Results. Twenty-three cases were evaluated, with a mean follow-up of 39 months. At last
follow-up, the VAS scores and ODI improved significantly compared with preoperation (P 0.05).
At the stabilized segments, the height of intervertebral discs were increased significantly after

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surgery (P 0.05). However, the height reduced to the level of preoperative at last follow-up. 47.4%
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of the flexion-extension ROM was retained at the operated segment. Six discs showed
rehydration with one grade improvement on the Woodend classification.
Conclusion. Dynamic stabilization resulted in a safe and effective treatment for carefully
selected groups of patients with DLBP and could promote disc regeneration to some extent.
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Key words: dynamic stabilization, discogenic low back pain, Wiltse approach, disc rehydration
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Discogenic low back pain is a common cause of disability in middle-aged people. Various
therapies, including fusion, disc replacement, injection therapies, and thermal annular
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procedures have been used when patients fail conservative management[1]. However, there is
considerable controversy over the efficacy of these procedures. At present, the intervertebral
fusion is considered the gold standard for treatment of DLBP, but clinical follow-up results
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suggest there are still some complications, such as nonunion, chronic pain, adjacent segment
degeneration, and so on[2]. Total disc replacement have been performed by many surgeons as an
effective treatment for DLBP. However, this procedure may carry a risk of prosthesis failure and
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heterotopic ossification[3]. Percutaneous procedures (intradiscal electrothermal therapy,

intradiscal methylene blue, and so on) are minimally invasive, but the parameters of the
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operation are hard to be precisely controlled with poor long-term clinical outcomes. Brett
reported the reasonable early results of intradiscal electrothermal therapy diminished with time
and up to 20% of patients report worsening of baseline symptoms at final follow-up[4]. In
addition, the original structure of the intervertebral disc is damaged in these methods because of
directly operation to disc. It may accelerate the degeneration of the disc.

Though the exact mechanism remains unknown, a widely accepted view is that the pathogenesis
of discogenic back pain may arise from the abnormal mechanical stress which leads to radial
annulus fibrosus tear[5]. After initial injury, inflammatory factors cause chemical irritation of the
nociceptive nerve fibres that mainly distribute in dorsolateral vertebral disc and posterior
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longitudinal ligament[6]. Based on this pathophysiology, we proposed the transpedicular dynamic
stabilization technique to extend the height of the intervertebral disc and reduce the mechanical
load of the spinal segment without directly operation to the disc. Besides, This technique
targeted to achieve instant stability and retain activities of the fixed segments. Therefore, the
purpose of this study is to assess the clinical outcomes of dynamic stabilization with the Dynesys
System (Zimmer Spine, Minneapolis, MN) for DLBP. The mid-term clinical results are reported
here. To our knowledge, this is the first report in the English-language literature using the
Dynesys system for the management of DLBP.

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Materials and methods

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Patients.
Between April 2012 and January 2015, 23 patients with discogenic low back pain were enrolled in
this study. There were 6 males and 17 females with average age of 40.6 years (age range:21–55

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years). In this group, 5 patients had two-level procedures and the remaining 18 patients had
single-level painful discs. All subjects had failed at least 6 months of nonoperative treatment. Inclusion
and exclusion criteria are contained in Table 1.

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Surgical Technique
The dynamic neutralization system consists of Ti-Al-Nb alloy (Protasul 100) pedicle screws,
polyethylene terephthalate (Sulene PET) cords and polycarbonate urethane (Sulene PCU) spacers.
The screws are connected with a cord that goes through the center of a hollow cylinder spacer.
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By appropriately tightening the cord and selecting the length of the spacer, dynamic stabilization
would be achieved in the fixed segment[7].
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All patients were placed in the prone position under general anesthesia. A midline dorsal incision
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on the skin, subcutaneous tissue and lumbodorsal fascia was made over the spinous process. The
aponeurosis of sacrospinalis muscle was cutted bilaterally through the space between the
longissimus and multifidus muscles. Blunt dissection was performed slightly between longissimus
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and multifdi with fingers, directing to the basilar part of transverse process and the lateral margin
of the superior articular process. Dynesys pedicle screws were positioned under imaging control.
The polycarbonate urethane spacer was cut according the measured distance between the
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screws driving force 1.5N , with the length being chosen to extend the intervertebral disc
appropriately. The central cord and the spacer were then locked within the screw heads (Figure
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3). A soft brace was administered after surgery until wound healing had occurred.

linical and Radiological Evaluation

Clinical evaluation included assessment of pain by a visual analog scale (VAS), and evaluation of
functional impairment by Oswestry disability index (ODI). Operative time, blood loss, and early
complications (such as screw misplacement and wound infection) were documented. Plain and
dynamic radiographs were taken for every patient preoperatively, 3 to 5 days after surgery, at 6
months and last follow-up. For dynamic radiographs, the patients were asked to bend as far
forward and backward as possible. Evaluation index included the height of intervertebral disc
(Figure 1), ROM at the index level and the lumbar spine(Figure 2). All subjects underwent MRI for
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evaluation of Modic changes and Woodend classification(Table 2)[8].

Statistical analysis
The clinical and radiologic results were analyzed using two-way ANOVA and rank-sum test. All
analyses were carried out with SPSS 16.0 for Windows (SPSS, Inc., Chicago, IL). Statistical
significance was accepted at α=0.05.

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Results
Perioperative data and complications

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28 segments had been fixed in this study. The mean operative time was 97 minutes (range 75–183),
with an average blood loss of 230 ml (range 100–400). The mean follow-up was 39 months (range,
26–59). There were no cases of infection, screw misplacement/loosening, or reoperation. Only one

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patient with diabetes developed poor wound healing 4 days after operation and she was satisfactorily
cured by debridement and suture.

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Clinical outcome
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All 23 patients included in the study have properly filled out questionnaires before surgery, at 6 months
after surgery and at last follow-up (Table 3).
Mean back pain on VAS decreased from a preoperative score of 5.2 (range, 4-7) to a mean score of 2.3
(range, 1-4) 6 months after operation and to a score of 1.7 (range, 0-4) at last follow-up, for a 66.2%
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mean improvement (range, 25%–100%), that resulted statistically significant (P 0.05). The mean
preoperative ODI score was 61.9% (range, 40%– 80%) and the mean score 6 months after operation
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was 24.7% (range, 6%–50%), while at last follow-up score was 15.6% (range, 0%–40%), for a 72.7%
mean improvement (range, 9.1%–100%). The differences were statistically significant (P 0.05).
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Radiologic Outcome
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Preoperative images (radiographs, CT scan, and MRI) as well as plain and dynamic radiographs at
postoperative, 6 months after surgery and last follow-up were analyzed for all 23 patients (Table 4).
The average ROM at each stabilized segment was 10.2° (range, 2.2°-17.7°) before surgery, 3.7° (range,
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0.8°-10.8°) 6 months after surgery, and 4.6° (range, 1.5°-11.3°) at last follow-up. Compared to
preoperation, the ROM at each stabilized segment decreased signifcantly at 6-months after surgery and
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the fnal follow-up (P<0.01). 47.4% of the ROM at fixed segments was retained at last follow-up (range,
7%–97%). The difference between 6-months after surgery and last follow-up had not statistical
significance P 0.05 . The average lumbar motility was reduced from 46.7° before surgery to 29.6° at
6-months after operation (P<0.01), and to 40.69° at last follow-up (P 0.05). The average disc height
was significantly increased from preoperative 0.40 to postoperative 0.44 (P<0.01). At last follow up
disc height had decreased to preoperative values (P 0.05) . From 6-months to last follow-up disc
height showed no significant alteration (P 0.05).
8 patients (13 discs) received the MRI scanning after at follow up. The mean Woodend score decreased
from 2.77 preoperative to 2.54 at last follow-up (P 0.05) . Of the 13 levels bridged, there was an
improvement at 6 levels (46.2%) (Figure 4), no change at 5 levels (38.5%) . Progressive degeneration
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was noted at 2 levels (15.4%) (Table 5) .

Discussion
The diagnosis of DLBP is still a very difficult clinical problem. Provocative discography has been
widely used in the diagnosis of discogenic pain. Although the efficacy of lumbar discography has been
questioned and the high false positive rate of discography has been reported[9], there are some

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systematic reviews found that discography is a useful imaging and pain evaluation tool for DLBP if
performed according to the criteria of the International Association for the Study of Pain[10][11]. So
the inclusion criteria we used in this study was mainly composed of symptoms, positive discography,

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and MRI imaging of disc degeneration.

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The exact pathogenesis of DLBP is extremely complicated and poorly understood. Mulholland et al
described that the primary mechanism of chronic low back pain is abnormal load distribution across the
disc space following disc degeneration[12]. Abnormal load may stimulate the nociceptor located in the
outer zone of the annulus fibrosus leading to low back pain. Motion is not the cause of pain. But

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abnormal motion may produce pain by causing an abnormal load. The Dynesys system is supposed to
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restore posterior disc height, reduce intradiscal pressure, and stabilize the motion segment with
partially motion preservation. So we investigated the effects of dynamic stabilization on discogenic low
back pain. In general, patients had clinically and statistically significant improvements in VAS and ODI
scores, only 2/23 (8.7%) patients did not show clinical improvements. The outcomes were slightly
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better than other treatments (interbody fusion, disc replacement, injection therapies, and thermal
annular procedures) reported in literature. The intervertebral height could be extended postoperative
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and maintained in most patients at last follow-up. Furthermore, flexion/extension radiographs showed
significantly reservation of ROM at stabilized segments. Attention to details in the surgical technique is
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necessary. Niosi et al. found that The spacer length had a significant effect on ROM with the long
spacer resulting in the largest ROM[13]. However, there may exist a maximum spacer length that once
exceeded would place the spine in a significantly altered neutral position such that the spine becomes
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kyphotic. Considering that the posterior distraction may cause loss of lordosis, it would be
inappropriate to treat patients with segmental recurvation. Although profile of the screw placement
caused only a minor influence on the ROM, annulus stress, and facet loading, the screw stress was
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noticeably increased[14]. So, it was better to choose the intersection of the basilar part of transverse
process and the lateral margin of the superior articular process. In addition, retain the integrity of the
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joint capsule when exposing the entrance point of pedicle screw.

In concern of the involved disc change, Vaga et al. collected ten patients who underwent Dynesys
and analyzed the quantification of glycosaminoglycan(GAG) concentration by MRI at follow up. The
GAG was increased in 61% of fixed segment discs and the result suggested that dynamic stabilization
was able to stop or partially reverse the degeneration[15]. Some researchers have reported the
phenomenon of intervertebral disc rehydration after lumbar dynamic stabilization[16][17]. Our study
evaluated the disc signal on T2WI series preoperative and at last follow-up. The increased signal on T2
in bridged level (6/13), which was consistent to Vaga’s report, represented the Dynesys could stop and
reverse the disc degeneration. The mechanism of hydration remains unknown. Recently, a
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molecule biological research confirmed that appropriate dynamic compression was able to maintain or
promote matrix biosynthesis without substantially disrupting disc structural integrity[18]. Disc
degeneration is closely related to some predisposing factors such as alteration of disc height, intradiscal
pressure, load distribution, and motion[19]. In a biomechanical study on cadaver, the Dynesis system
was found to limit excessive flexion of lumbar spine[20]. Another biomechanical study found that the
Dynesis system could reduce intradiscal pressure in the treated segment[21]. The restoration of the
physiological status of the affected segment with the Dynesys systems seems to offer the potential of a
mechanical approach to intervertebral disc regeneration.

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Traditional surgery selects a post-middle approach that results in muscle injury and innervation loss
due to dissection and traction, which involves a wide range of soft tissues. Worse, this process will last

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longer and cause backache and amyotrophia due to the specifc features of blood supply, metabolism,
and innervation of paravertebral muscle[22]. For the purpose of reducing the harm to paravertebral

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muscle, Wiltse proposed the approach of inter-muscular space of the lumbar spine in 1968[23]. In this
approach, operators can reach the transverse process and facet joints through the space between
multifdi and longissimus without striping the muscle enthesis. It better meet the requirements of the
Dynesys system for pedicle screw placement in the lateral facet joint. This approach also has little

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impact on the blood supply and innervation of paravertebral muscle[24]. In conclusion, the advantages
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include reducing operative bleeding, muscle injury, and incidence of postoperative backache[25]. From
this point, it is a minimally invasive surgery for DLBP.
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Conclusions
In patients with discogenic low back pain, dynamic stabilization with the Dynesys system lead to
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excellent clinical and radiologic results. This method can partially retain the motion of the fixed
segment, restore the disc height and reduce intradiscal pressure. Further long-term and
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Prospective controlled studies are necessary to confirm our 4-year data.

Funding: This work was supported by the Third Military Medical University, Award Number:
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2012XLC01, Recipient: Qiang Zhou

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Figure 1. Methods to measure intervertebral disc height (L4/5) on the
lateral radiograph. Disc height (L4/5) = (anterior height of L4/5 intervertebral disc +
posterior height of L4/5 intervertebral disc) / anterior height of L4 vertebral body / 2.

Figure 2. ROM measurement at the index level (L4/5) and the lumbar spine (L1–S1).
The difference between the angles in flexion and extension radiographs are used for
calculation of the ROM.

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Figure 3. A representative case of Dynesys surgery. A postoperative anteroposterior

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view. B postoperative lateral view.

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Figure 4. MRI T2-weighted images of a 39-year-old female. A preoperative MRI
sagittal view. B Rehydratation was seen in L4/5 level at 24-month follow up.

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Table 1 Inclusion and exclusion criteria

Inclusion criteria
1. More than 6-month history of axial low back pain without radicular symptoms, especially in the sedentary or long standing
position.
2. Magnetic resonance imaging scans demonstrating degeneration of the intervertebral disc without nerve root compression
3. Positive provocative discography
4. Failed nonoperative treatment.

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5. With complete clinical and imaging data
Exclusion criteria
1. Spinal stenosis, spondylolisthesis, lumbar spine instability, and/or other diseases of the lumbar spine

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2. Previous lumbar surgery
3. Chronic pain not originated from lumbar

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4. Chemical dependency or mental disorder

Table 2 Woodend Classification

Grade Disc Changes Disc Height

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1 White Normal
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2 White or speckled Reduced by 10%

3 Speckled or dark Reduced by 10%–50%

4 Dark Reduced by 50% or more

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Table 3 Clinical Outcomes

Preoperative 6-months after operation Last follow-up Last follow-up Correction(%) P
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VAS back pain 5.2±1.0 2.3±0.9 1.7±0.9 66.2±19.1 0.000

ODI (%) 61.9±13.6 24.7±10.1 15.6±11.2 72.7±23.1 0.000
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VAS, Visual Analog Scale; ODI indicates Oswestry Disability Index.

Table 4 radiographic outcome

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Preoperative Postoperative Postoperative 6-months Last follow-up P

ROM at Each segment 10.2±4.4 3.7±2.2 4.6±2.2 0.000

Stabilized(n=28)
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lumbar motility(n=23) 46.7±23.5 29.6±11.3 40.7±14.8 0.000

Disc Height(n=28) 0.40±0.08 0.44±0.08 0.40±0.08 0.40±0.08 0.000
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Table 5 Mean Preoperative and Postoperative Woodend Scores at Segments Bridged by Dynesys (n=13)
Postoperative
Preoperative 1 2 3 4 Total

1 0 0 0 0 0
2 0 1 1 1 3
3 0 6 4 0 10
4 0 0 0 0 0
Total 0 7 5 1 13
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Highlights:
1. Dynamic stabilization was safe and effective to treat discogenic low back pain.
2. Dynamic stabilization could keep the original disc structure intact.
3. Dynamic stabilization could promote disc regeneration to some extent.

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Abbreviations list:
DLBP discogenic low back pain
ROM range of motion
VAS Visual Analog Scale
DXA/DEXA dual-energy X-ray absorptiometry
CT computed tomography
VBH vertebral body height
ABC Anterior vertebral body compression

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AHR Anterior vertebral body height restoration
SI Injury level sagittal index
BMI body mass index

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Conflict of Interest
Lei Luo, Chengmin Zhang, Qiang Zhou, Chen Zhao, Liyuan Wang, Lichuan Liang,
Bing Tu, Bin Ouyang and Yibo Gan declare that they have no competing interests.

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