Problems of posterior lumbar interbody fusion (PLIF) for the rheumatoid spondylitis of the lumbar spine.

We performed posterior lumbar interbody fusion (PLIF) on 7 patients with rheumatoid spondylitis (RA) of the lumbar spine with severe low-back pain and/or cauda equina symptoms, and evaluated the effectiveness of PLIF for the lumbar spinal instability in RA secondary to destruction of the anterior elements, including vertebral endplates and the apophyseal joint. The subjects were 7 patients with classic RA, 2 men and 5 women, mean age 65 years old, and the mean duration of RA was 21 years. All had severe low-back pain and difficulty with walking. According to the ARA classification, the patients were at stage 3 or worse and in class 3. Diagnostic imaging including magnetic resonance imaging (MRI), tomography, myelography, and computed tomographic myelography (CTM) of the lumbar spine clearly delineated pathology, destruction of the vertebral endplate, subluxation, and cauda compression which can be well treated with PLIF. We performed L4/5PLIF (5 cases), L3/4 and L4/5 PLIF (2 cases), and posterior fixation with instruments for anterior column repair and stabilization and posterior decompression. Autografts (all cases) and Brantigan IF cage (2 cases) were used. Stable fixation of the lumbar spine was achieved after surgery, and improvement in gait and activities of daily living were achieved through the relief of low-back pain and radicular pain; the mean duration of follow-up was 22 months. Postoperative, plain radiography, CT, and MRI revealed the enlargement of the lumbar canal and fusion and incorporation of grafted bone, but in some cases, collapse of graft, migration of pedicle screw, instability of adjacent level, and collapse of adjacent vertebra were noted. PLIF with spinal instruments is a preferred treatment for rheumatoid spondylitis of the lumbar spine, but in the mutilating type of RA with severe osteoporosis, PLIF in combination with a long fixation system and/or augmentation of the vertebral bodies might be needed.