J Neurosurg Spine 2:298302, 2005

Unilateral progressive alterations in the lumbar spine: a biomechanical study

GABRIEL C. TENDER, M.D., SCOTT KUTZ, M.D., RICHARD BARATTA, PH.D., AND RAND M. VOORHIES, M.D.
Department of Neurosurgery, Louisiana State University Health Sciences Center; and Ochsner Clinic Foundation, New Orleans, Louisiana
Object. Lumbar radiculopathy secondary to foraminal stenosis can be treated by unilateral removal of the overlying pars interarticularis. The main concern after this procedure is spinal stability. In this study the authors evaluate the biomechanical behavior of the lumbar spine under torsional loading after unilateral progressive alterations, including resection of the pars. Methods. Six human cadaveric L5sacrum functional spinal units were tested while intact and then after the following sequential unilateral alterations: excision of the pars, capsulectomy, facetectomy, and discectomy. Specimens were tested in rotation by using a biomechanical testing machine, with an axial load of 280 N and torques of 7.5 Nm. The specimens remained in the machine throughout testing, and the angular displacements were recorded after each set of trials. No statistically significant difference in any of the measured parameters was found between intact spines and those undergoing resection of the pars. For positive displacement (toward the side of the lesion), a significant difference from the intact condition was found after facetectomy and discectomy. For overall displacement (range of motion), spines treated with capsulectomy, facetectomy, and discectomy were significantly different from those in the intact condition. Conclusions. Unilateral removal of the pars interarticularis does not increase spinal mobility in a statistically significant fashion. The clinical implication is that the spine may not become acutely unstable after unilateral resection of the pars.

KEY WORDS biomechanical testing lumbar spine pars interarticularis spinal stability

radiculopathy is one of the most frequently encountered problems in clinical practice. Sometimes the lumbar nerve root is compressed as it passes through the intervertebral foramen. Foraminal stenosis can be caused by one or more of the following factors: intraforaminal disc herniation, bone hypertrophy (especially in older patients with degenerative changes), and/ or spondylolisthesis. The pars interarticularis is the isthmic portion of the posterior arch connecting the pedicle and superior articulating process with the inferior articulating vertebral process (Fig. 1 left). It forms the roof of the intervertebral foramen, overlying the corresponding nerve root throughout its intraforaminal course (Fig. 1 right). Unilateral removal of the pars interarticularis unroofs the foraminal compartment and decompresses the whole length of the root. It also allows for removal of any herniated intraforaminal disc fragment that may be present. The inferior articulating process remains connected to the inferior ipsilateral joint and, through the lamina, to the contralateral joint and pars interarticularis. In this study we evaluate the biomechanical behavior of the lumbar spine after unilateral progressive resections.

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Materials and Methods

Six human cadaveric L5sacrum FSUs were used. The age of the cadavers ranged from 50 to 80 years (median 58 years), and the sexes were equally represented (three specimens from males and three from females). Each specimen was separated from the upper spine at the L34 disc level; four screws were placed longitudinally through the bodies of L-4 and L-5 to form a fused unit, which was then potted and attached to the actuator of the servohydraulic mechanical testing system (858 Bionix; MTS, Eden Prairie, MN). The paraspinous muscles were removed, but all the ligaments were carefully preserved. Specimens were potted in rigid urethane foam (Kingsley Manufacturing Co., Costa Mesa, CA), and were reinforced with four screws placed transversally through the L45 unit and the sacrum, respectively (Fig. 2). Care was taken not to include the spinous process of L-5 in the rigid foam. The testing protocol was as follow. Each trial consisted of a compressive load of 280 N, at a rate of 20 N/second, followed by five torsional sine waves from 0 to 7.5 Nm, and then a 4-minute hold at 7.5 Nm (to allow for creep). This was done first in the positive direction (with torsion creating relative compression across the ipsilateral facet joint) and then in the negative direction (with torsion creating relative distraction of the ipsilateral facet joint). The degree of angular displacement at the end of the 4-minute creep period was recorded in both positive and negative trials, yielding three outcome angles: positive, negative, and positivenegative differential (representative of ROM). Two warm-up trials were performed to ensure that the test system was functioning reproducibly, and to establish the repeatability of recordings (within 0.2) The third trial was labeled as intact and constituted the baseline measurement against which all others were

Abbreviations used in this paper: FSU = functional spinal unit; ROM = range of motion.

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Resection of the pars interarticularis: a biomechanical study

FIG. 1. Photographs of spine models showing the left L-5 pars interarticularis (black stripe). Left: Posterior view. Right: Oblique view, showing the underlying L-5 nerve root in the intervertebral foramen.

compared. After this set of trials, a resection of the pars was performed and the trial was repeated. The cranial limit of the resection was the corresponding pedicle. A bone window of 3 to 4 mm, oriented craniocaudally, was created using the high-speed drill. Complete resection of the pars was checked with a small curette (Fig. 3 upper left). After resection of the pars interarticularis, the following procedures were performed in consecutive order, each followed by a trial to measure its effect: capsulectomy, facetectomy, and partial discectomy. Capsulectomy was performed by incising the exposed parts of the capsule (that is, superior, posterolateral, and inferior; Fig. 3 upper right), being careful not to disrupt the articulating surfaces. An ipsilateral complete hemilaminectomy isolated the inferior articulating facet, which was easily removed with a pituitary forceps (Fig. 3 lower left). Discectomy was accomplished through an incision in the anulus fibrosus made just anterior to the plane of the pedicles, and approximately 25% of the disc material was removed (Fig. 3 lower right). All procedures were performed without removing the specimen from the testing machine. Samples of the data recorded for each specimen are shown in Fig. 4. In summary, each specimen was tested as follows: 1) intact; 2) after unilateral excision of the pars; 3) after unilateral removal of the pars and capsulectomy; 4) after unilateral resection of the pars, capsulectomy, and inferior facetectomy; and 5) after unilateral removal of the pars, capsulectomy, inferior facetectomy, and partial discectomy.

FIG. 2. Photograph showing a human cadaveric L5sacrum FSU potted in the crossbolts of the testing machine.

Results An analysis of variance with repeated measures was used to determine the effect of the procedures performed; post hoc group contrasts were performed by comparing the displacement reached after each procedure against the intact condition. Significance was set at the level of 0.05. Post hoc contrasts were performed in which the displacement reached after each procedure was compared with that obtained in the intact condition. Table 1 shows the mean angular displacements for the positive, negative, and total displacements (or ROM) for all conditions. There are gradual increases as the procedures are executed; some changes are not beyond our expected measurement error (0.2). The greatest changes occur after facetectomy and discectomy. The statistical analysis showed a significant overall effect of the procedures on the positive displacement (p = 0.0003), negative displacement (p = 0.014), and overall displacement (ROM; p 0.0001). The probability values for post hoc group comparisons are shown in Table 2. For the positive displacements, defined as axial rotation
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toward the surgically altered side, significant differences from the intact condition were found for facetectomy and discectomy; a marginal effect was found for capsulectomy. For negative displacement, marginal differences were found for capsulectomy, facetectomy, and discectomy. For overall displacement, the results in spines treated with capsulectomy, facetectomy, and discectomy were found to be significantly different from results in intact spines. No differences in any of the measured parameters were found between intact spines and those that underwent resection of the pars interarticularis. Discussion Fenestration of the pars interarticularis for the treatment of intraforaminal disc herniations was first described by Di Lorenzo, et al.6 Although intraforaminal disc herniations are relatively rare, foraminal stenosis due to degenerative changes is more frequent and can also be treated by removing the pars interarticularis unilaterally at the affected level. Spondylolisthesis can also lead to foraminal stenosis, but a simple excision of the pars (without fusion) is probably inappropriate for the treatment of an already unstable spine. Complete removal of the pars interarticularis allows for decompression of the whole length of the intraforaminal nerve root. Nevertheless, the main concern following this procedure is spinal stability. In this study we have evaluated stability in the acute setting, immediately after performing the sequential alterations. Biomechanically, forc299

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FIG. 3. Photographs showing the L5sacrum FSU after progressive unilateral alterations have been made on the left side. Upper Left: Excision of the pars. A curette is placed through the created pars defect. Upper Right: Capsulectomy. The scalpel blade lies in the L5S1 joint space. Lower Left: Facetectomy. A left L-5 hemilaminectomy has been performed. Lower Right: Discectomy. A pituitary rongeur is inserted into the disc space.

es acting on one inferior articulating process are transmitted through the pars interarticularis to the corresponding pedicle, through the apophysial joint to the ipsilateral pedicle of the inferior vertebral body,18 and through the lamina to the contralateral pars interarticularis and pedicles. The geometry of the facets is such that they primarily limit excessive rotation, as well as shear translation.4,13 Rotation toward one side is limited mainly by the ipsilateral facets and contralateral capsular ligaments.2,20,22 The intervertebral disc is not an important factor in limiting rotation, under physiological conditions.3,7 Axial load, mimicking the weight of the upper body, increases spine stiffness and facet contact.9,23 Also, the load supported by the facets in rotation is influenced by body position.19,21 Previous biomechanical studies involving the pars interarticularis have been directed mostly to bilateral defects (spondylolysis) and different stabilizing techniques.5,10,12,14 Other studies involving facetectomy have shown that partial unilateral or bilateral facetectomy ( 75%) does not make the spine unstable, whereas total facetectomy, even when unilateral, does.1,16 No study has been conducted to analyze spinal stability after unilateral resection of the pars interarticularis. We chose the L5sacrum FSU for testing because this is the level most frequently involved in clinical practice. An axial load of 280 N and a torque of 7.5 Nm were considered close to the physiological conditions.9 For consistency, we always made the sequential alterations on the left side. We positioned the L5sacrum FSU so that the axis of rotation of the testing machine would correspond to the
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axis of rotation of the FSU; also, the disc space was positioned parallel to the horizontal, to mimic the neutral position and to minimize coupling.15,17 The biomechanical role of the pars interarticularis is mainly to support the inferior articulating process. Hence, because unilateral procedures affecting the facet joints are performed, testing in rotation seemed most likely to reveal changes in spinal stability. This also allowed for testing of the spine after sequential alterations without removing it from the machine. Because our interest was to evaluate whether each procedure would render the spine unstable, and to minimize the number of post hoc tests, we chose always to perform post hoc tests in comparison with the baseline. Unilateral removal of the pars interarticularis did not alter segmental biomechanics in a statistically significant fashion. In the clinical setting, this implies that patients undergoing unilateral excision of the pars may not need a fusion of the involved spinal segment. Capsulectomy and discectomy were not strictly necessary for the purpose of our study. They were performed because they did not alter the results for the main three measurements (intact, resection of the pars, and facetectomy), may help in understanding the biomechanical properties of spine elements, and allow us to compare their destabilizing effects to those of the removal of the pars and facetectomy. Capsulectomy has no in vivo surgical equivalent. In our experiment, the significantly increased ROM after excision of the pars plus capsulectomy confirmed the role of the articular capsule in limiting rotation toward the opposite side.2,20,22
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Resection of the pars interarticularis: a biomechanical study

FIG. 4. Graphs showing the angular deformation in degrees (deg) measured against time (sec) in a representative FSU under positive (left) and negative (right) torsion.

Facetectomy significantly increased spinal mobility in the positive direction as well as the overall displacement (or ROM). Our findings concur with previous studies, indicating that unilateral facetectomy is a destabilizing procedure.1,16 Discectomy following facetectomy led to a further significant increase in segmental spinal mobility. In clinical practice, these results indicate that a segmental fusion is probably indicated after unilateral facetectomy and discectomy (for example, for removal of a foraminal disc herniation). Cadaveric spines have an inherent variability in their mechanical properties,11 as is the case with most physiological measurements. We attempted to provide a graphic representation of the mean data for the six specimens. Nevertheless, because variability among the spines was often greater than among procedures, the graph had little informative value. Instead, we selected a representative sample (Fig. 4) of the graphs obtained from each specimen. It shows that in all curves, for positive torsion, each of the sines reaches a slightly greater displacement than the previous one. Similarly, on the constant torque part of each curve, the displacement gradually increases. The difference in maximum angles between consecutive trials is attributed to the procedure; however, given the series of warm-up trials, we know that our repeatability error is in the order of 0.2. In this particular sample, excision of the pars had no measurable effect on the angular displacement, nor did capsulectomy. This is expected, because the
TABLE 1 Angular displacements in human cadaveric spines*
Condition Positive () Negative () ROM ()

ipsilateral intact capsule is not strained under positive torsion. Facetectomy, however, resulted in a large increase in angular displacement, as did discectomy. In general, the results of the negative trials were essentially similar, except that consistent albeit small changes in the displacement were found after capsulectomy. Considerable variation in the axial rotation across different spines was noted;11 this was most likely due to preexisting degenerative changes. These findings have two important implications. Unilateral removal of the pars interarticularis does not increase spinal mobility in a statistically significant fashion. Our study is sensitive enough to show that unilateral total facetectomy does increase spinal mobility, as demonstrated by other authors.1,16 In the clinical setting, we have prospectively studied 36 consecutive patients with lumbar radiculopathy who underwent unilateral removal of the pars (unpublished data). In this series, 18 patients had acute foraminal disc herniations compressing the nerve root against the superior pedicle. The other 18 patients had foraminal stenosis secondary to degenerative changes (hypertrophied superior facet), with or without a chronic disc protrusion. At 1-year follow-up review, leg pain improved in 35 patients (97%). Low-back pain appeared or worsened in eight patients (22%): in one patient in the acute herniation group and in seven in the chronic degeneration group. Only one patient required a lumbar fusion for pain caused by advanced widespread degenerative changes; the fusion extended

TABLE 2 Probability values for group comparisons against the baseline (intact) condition
Condition Positive Negative Overall

1: intact 2: resection of the pars 3: 2 capsulectomy 4: 3 facetectomy 5: 4 discectomy

5.57 1.94 5.75 2.15 5.94 2.21 7.08 2.44 7.81 2.66

5.63 2.97 5.63 2.88 5.90 2.77 6.22 2.68 6.88 2.76

11.20 4.48 11.38 4.60 11.84 4.66 14.34 5.25 15.89 5.56

* Values are presented as the means standard deviations.

1: resection of the pars 2: 1 capsulectomy 3: 2 facetectomy 4: 3 discectomy

0.15 0.07 0.006 0.003

0.99 0.09 0.08 0.09

0.21 0.035 0.019 0.012

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from L-2 to S-1. These preliminary results indicate that unilateral removal of the pars interarticularis is effective in relieving lumbar radicular symptoms in patients with intraforaminal entrapment. Patients with acute foraminal disc herniations did not experience an increased incidence of low-back pain as a result of this procedure. In patients with degenerative foraminal stenosis, unilateral excision of the pars may be a better alternative to facetectomy and segmental fusion. Our study has certain limitations. First, we only tested the FSU in rotation. Although this is the most important motion biomechanically in the facet joints and pars interarticularis, other motions, like shear translation and flexion, may play an important role. Second, we only tested the L5sacrum segment; other segments may behave differently. Third, the paraspinous muscles were removed; however, these muscles have a stabilizing effect in vivo and therefore our results probably overestimate the destabilizing effect of the sequential bone and other soft tissue alterations.8 In this study we evaluated spinal stability only in the acute setting; a fatigue study may be necessary to show whether, after unilateral resection of the pars, the mechanical integrity of the spine may be compromised during the healing period. Conclusions Unilateral removal of the pars interarticularis does not increase spinal mobility in a statistically significant fashion, whereas unilateral facetectomy does. The clinical implication of our findings is that the spine may not become acutely unstable after unilateral resection of the pars interarticularis.
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Manuscript received July 23, 2003. Accepted in final form May 11, 2004. Financial support for this work was received from Synthes Spine, Incorporated, by Dr. Voorhies. Address reprint requests to: Gabriel C. Tender, M.D., Department of Neurosurgery, Louisiana State Health Sciences Center, 1542 Tulane Avenue, Box T7-3, New Orleans, Louisiana 70112.

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