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. 2025 Apr 11;104(15):e42151. doi: 10.1097/MD.0000000000042151

Spinal morphological change after posterior lumbar interbody fusion in lumbar spondylolisthesis patients

Seung-Uk Oh a, Jungmin Yi b, Sunyoung Moon b, Suk Hee Park b, Hojin Shin c, Jaeho Cho d, Young Uk Kim b,*
PMCID: PMC11999409  PMID: 40228255

Abstract

Lumbar spondylolisthesis is a degenerative status in the spine. Posterior lumbar interbody fusion (PLIF) with instrumentation has considered as the standard surgical treatment for lumbar instability. Spinal canal and dural sac cross-sectional area (CSA) has been major parameters for evaluating neurologic symptoms. This study is aimed at finding the radiological change using the dural sac CSA and spinal canal CSA as an objective morphological parameter after PLIF. Of the 74 patients (24 men, 50 women; mean age 66.49 years) who had PLIF surgery were checked for preoperative magnetic resonance imaging (MRI) and MRI within 1 week after surgery. T2-weighted axial MRI scans were obtained from each patient. We measured the dural sac and spinal canal CSA on an axial MRI image at the center of L4 to L5 intervertebral disc. The average spinal canal CSA was 70.28 ± 27.77 mm2 in the preoperative MR images and 149.59 ± 35.20 mm2 in the postoperative MR images. The average dural sac CSA was 42.46 ± 18.49 mm2 in the preoperative MR images and 98.93 ± 29.32 mm2 in the postoperative MR images. After the PLIF operation, the mean spinal canal CSA was 112.84 percent increase, and the measn dural sac CSA was 132.99 percent increase. After PLIF, patients had significantly higher dural sac CSA (P < .001) and spinal canal CSA (P < .001). Spinal canal CSA have increased by 112.84 percent and Dural sac CSA have increased by 132.99 percent after PLIF. Thus, before PLIF, the treating physician should carefully explain this result to patient.

Keywords: cross-sectional area, lumbar spondylolisthesis, magnetic resonance imaging, posterior lumbar interbody fusion

1. Introduction

Lumbar spondylolisthesis (LS) is a condition in which a vertebral body in the lumbar spine slips forward out of position onto the vertebral body below it due to degenerative change of ligamentous and joint structures in the elderly.[1,2] For compensate, ligaments and facet joints are displaced and hypertrophy. This change induced compression of the spinal cord or nerve root, further worsening disability and pain. Sagittal lumbar spine in LS is out of alignment, which causes of back pain.[2,3] Sagittal spinal balance is measured in the standing position, and refers to the proper position between the pelvis and spine.[4] Most spino-pelvic parameters such as lordosis of lumbar, slope of sacrum, pelvic incidence, and pelvic tilt influence sagittal spinal alignment.[2] Patients with LS may suffer from radicular pain in lower limb and neurogenic claudication, low back pain which greatly impacts their activities.[5–8] The clinical symptoms of LS worsen when walking or standing, and relieved when flexion or supine position. Posterior lumbar interbody fusion (PLIF) has been widely done for treatment of LS patients over the past few decades. PLIF can provide early stabilization, correct of the lumbar spine alignment, and improve postoperative functional scores with effect.[9,10] Past studies have shown that PLIF can reduce the chronic low back pain incidence after surgery with recovering spino-pelvic sagittal balance parameters.[9,10] Another research have reported that PLIF improved pelvic tilt, the sagittal alignment, the recovery of the height and slip degree of the intervertebral disk.[11]

Dural sac and spinal canal cross-sectional area (CSA) also have been major morphological parameters for evaluating neurologic symptoms. Narrowing CSA has a negative effect on patient’s clinics. Past studies have shown that smaller dural sac CSA and Spinal canal CSA, higher probability of axial and radicular pain, shorter neurogenic intermittent claudication, and lower the quality of life on patient.[12,13] The most important goal of PLIF is to recover the balance and CSA. PLIF can correct vertebral alignment, addressing the displacement characteristic of spondylolisthesis. However, changes in lordosis (curvature) may occur post-surgery, impacting overall spinal alignment. The morphological changes following PLIF in LS is vital for optimizing surgical outcomes and managing long-term patient care. However, no studies have evaluated these morphological change after PLIF. This study is aimed at finding the radiological change using the dural sac CSA and spinal canal CSA as an objective morphological parameter after PLIF.

2. Materials and methods

2.1. Patients

This study was registered at the University of Catholic Kwandong, Republic of Korea, Incheon (IS18RISI0048). The Institutional Review Board reviewed and approved the research protocol. 74 patients with LS were retrospectively evaluated from July 2017 to July 2018. 74 patients underwent PLIF.

Patients who had any of the following conditions were included: clinical symptoms of LS, such as neurogenic intermittent claudication and numbness at lower extremity or pain with associated neurologic signs; MRI image(s) taken and radiographically confirmed LS; age > 50 years of age; LS is observed in the at the L4/L5 lumbar spine level.

Patients who had any of the following conditions were excluded: LS caused by pathologic conditions such as tumor, infection, congenital and iatrogenic reasons; severe osteoporosis; polyneuropathy and arterial insufficiency; history of spine inflammatory disease; history of spine interventions, such as vertebroplasty or kyphoplasty; multiple bone metastasis of cancer in the spine.

Of the 74 patients (24 men, 50 women; mean age 66.49 years) who had PLIF surgery were checked for MRI preoperatively and postoperatively (within 1 week after surgery). The preoperative and the early postoperative CSAs were measured at the same patients.

Patients who diagnosed with LS confirmed by an board-certified experienced neuro-radiologist and who met the inclusion criteria were enrolled.

2.2. Imaging parameters

3T Avanto (Siemens Healthcare, Erlangen, Germany) with 3 T scanners (Achieva; Philips Healthcare, The Netherlands) was used for lumbar spine MRI. Axial T2-weighted images was obtained using with a slice thickness < 4.0 mm, 0.9 mm intersection gap, 120-ms/3087-ms repetition time/echo time/repetition time, 464 × 320 field of view, and 820 × 254 matrix. MRI data was sent to an INFINITT system (INFINITT Healthcare Co., Seoul, Korea) from the MRI unit.

2.3. Image analysis

Axial T2-weighted lumbar MR images were obtained at which the facet joint is best observed of each patient. CSA was measured at the L4/L5 intervertebral disc in the scan using picture archiving and communications system.

The dural sac CSA – the dural sac is measured at the border of signal change due to fat pad at epidural space.

The spinal canal CSA – spinal canal CSA was measured by posterior margin of disc on the anterior side and anterior margin of ligament flavum on the posterior side at the L4 to L5 level (Fig. 1).

Figure 1.

Figure 1.

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Axial T2-weighted lumbar spine MR images were obtained at the facet joint level (operation level). The white stars indicate regions with visible artifacts after PLIF. (A) Dural sac CSA before PLIF, (B) CSA after PLIF, (C) Spinal canal CSA before PLIF, (D) CSA after PLIF. CSA = cross-sectional area, MR = magnetic resonance, PLIF = posterior lumbar interbody fusion.

3. Statistical analyses

Data are expressed as mean ± standard deviation. We used unpaired t tests to compare the dural sac and spinal canal CSA between the preoperative MR images and postoperative MR images; we set that a P-value < .05 was considered statistically significant. SPSS for Windows version 22 (IBM SPSS Inc., Chicago) was used for the statistical analyses.

4. Results

Of the 74 individuals were 24 (32.4%) men and 50 (67.6%) women and average age is 66.49 ± 8.19 years (range, 50 to 87 years) (Table 1). All patients underwent PLIF by 1 neurosurgeon. The average dural sac CSA was 42.46 ± 18.49 mm2 in the preoperative MR images and 98.93 ± 29.32 mm2 in the postoperative MR images. The average spinal canal CSA was 70.28 ± 27.77 mm2 in the preoperative MR images and 149.59 ± 35.20 mm2 in the postoperative MR images. After the PLIF operation, the mean dural sac CSA was 132.99 percent increase (Fig. 2), and the mean spinal canal CSA was 112.84 percent increase (Table 2 and Fig. 3). After the PLIF, patients had significantly higher dural sac CSA (P < .001) and spinal canal CSA (P < .001).

Table 1.

Comparison of the characteristics of preoperative and postoperative morphological parameters.

Variable Preoperative group (n = 74) Postoperative group (n = 74) Statistical significance
Gender (male/female) 24/50 24/50 NS
Age (yr) 66.49 ± 8.19 66.49 ± 8.19 NS
Dural sac CSA (mm2) 42.46 ± 18.49 98.93 ± 29.32 P < .001
Spinal canal CSA (mm2) 70.28 ± 27.77 149.59 ± 35.20 P < .001
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Data represent the mean ± SD or the numbers of patients.

CSA = cross-sectional area, NS = not statistically significant (P > .05).

Figure 2.

Figure 2.

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Bar graph showing changes in the cross-sectional area of the dural sac at the L4 to L5 level on pre- and postoperative MRI. MRI = magnetic resonance imaging.

Table 2.

Calculating percent increase of morphological parameters.

Variable Preoperative mean parameters Postoperative mean parameters Percent increase
Dural sac CSA (mm2) 42.46 ± 18.49 98.93 ± 29.32 132.99
Spinal canal CSA (mm2) 70.28 ± 27.77 149.59 ± 35.20 112.84
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Note: Data represent the mean ± SD or the numbers of patients.

Percent increase = Postoperative mean parameters − preoperative mean parameters × 100.

Preoperative mean parameters.

CSA = cross-sectional area, NS = not statistically significant (P > .05), SD = standard deviation.

Figure 3.

Figure 3.

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Bar graph showing changes in the cross-sectional area of the spinal canal at the L4 to L5 level on pre- and postoperative MRI. MRI = magnetic resonance imaging.

5. Discussion

Lumbar spondylolisthesis is a condition in which a vertebral body in the lumbar spine slips forward out of position onto the vertebral body below it that can be clinically symptomatic. The prevalence of LS is usually considered to be 5% to 7% of the general population and is prevalent in L4/L5 level, especially in older women.[14,15] Most LS patients have no or mild symptoms that do not interfere with their daily lives. Most patients with symptoms show sufficient effect with conservative treatment, but some patients with refractory pain require surgical treatment.[6] The purpose of surgery is to stabilize the spine and remove pressure on the neural elements.[14] The PLIF is considered a gold standard of surgical treatment for LS patients with spine segmental instability. For fusion, firm osseous bridge must be formed between the target levels.[16] And fusion involves bone graft incorporation and remodeling at the fusion site, leading to structural changes. Over time, the vertebrae may adapt to the new load distribution, influencing surrounding vertebrae. The results from surgical management of LS usually have been reported as preferable and satisfactory. Bourassa-Moreau have reported that the health-related quality of life significantly improves after surgery in LS patients.[17]

Previous studies demonstrated that the PLIF provided improvements in leg visual analogu scale (VAS), back VAS, slip angle, and Oswetry disablily index scores.[18] Yijian et al have demonstrated that significant recovery of spino-pelvic sagittal balance, pelvic tilt, and lumbar lordosis was observed after PLIF surgery.[10] According to Ito et al study, the volumes of interbody bone grafts was shown an increase particularly between the 2nd and 5th years after the PLIF surgery. Even in elderly or having poor bone density patients showed increases of volume during that time. For accommodating bone grafts, there should be sufficient interbody space through intraoperative reduction.[19]

The most important goal of PLIF is to recover the balance and CSA. PLIF can correct vertebral alignment, addressing the displacement characteristic of spondylolisthesis. Changes in lordosis (curvature) may occur post-surgery, impacting overall spinal alignment. However, no studies have evaluated the morphological change of CSA after PLIF. Spinal canal CSA and dural sac CSA has been major morphological parameters for evaluating neurologic symptoms. Through sliding of the superior vertebrae, spinal canal narrowing, reducing the volume and deformation occurs from a biomechanical point of view.[1,5,15,20] The most commonly used method for objectively quantifying is measurement diameter of the diameter of the CSA of the spinal canal and dural sac.[21] Narrowing of the dural sac and spinal canal CSA due to decrease in spinal canal volume has been considered the biggest cause for clinical symptom onset of LS patients. According to previous research, smaller Dural sac CSA and Spinal canal CSA, the higher probability of axial and radicular pain, shorter neurogenic intermittent claudication, and lower quality of life of patients.[13] Thus, spinal canal and dural sac CSA are the most sensitive and specific radiologic parameter for predicting the lumbar spinal stenosis.[21] Narrowing CSA has negative effect on patient’s clinic. The etiologies of change of dural sac and spinal canal CSA are multi-factorial in LS patients. Thus, the analysis of the dural sac and spinal canal CSA is also very important to make a surgical decision.

We recently performed morphological analysis of PLIF, and we found that Spinal canal CSA have increased by 112.84 percent and Dural sac CSA have increased by 132.99 percent. We think that this study will immediately help physicians understand the postoperative effect of PLIF. As far as our knowledge, this is the first study of the spinal morphological change after PLIF.

There were several limitations to the current research.

First, the morphology changes under axial loading may induce the L4 to L5 segmental instability including the ligamentum flavum buckling, the herniated disc that already existed, facet joint subluxation, lateral recess narrowing, and the changes in spinal canal CSA, dural sac CSA.[22–28] Therefore, a number of factor such as the segmental angulation, sagittal translation, disc height, and both spinal canal CSA, dural sac CSA can cause the vertebral structures segmental instability in patients with LS.[29–38] However we focused on spinal canal CSA, dural sac CSA only. Thus, our study has limitations because we did not measure several other morphological changes.

Second, this trial only contributes to the understanding of the short-term radiological postoperative course in patients after PLIF. Thus, future study should investigate the long-term morphological change.

Third, measuring the CSA by MRI might have some errors. Even though we tried to get this radiologic findings at the facet joints level where the CSA is best shown, the axial images that we measured and analyzed could be inhomogeneous due to differences in the angle and level of cutting in MRI resulting from technical influence and individual anatomic variation. 4.0mm slice of T2-weighted axial MR images cut thicker than appropriate intervals.

Fourth, the number of LS patients included in the study was too small. The demography of the patients such as body mass index, weight, height was very diverse. However, we strictly limited the age range to reduce bias caused by age differences. This study involved only patients in LS above 50 years old.

Fifth, clinical data on this subject are based on retrospective investigations.

Despite these limitations, this study’s results are important in that it is the first study to investigate a change in spinal canal and dural sac CSA after PLIF.

6. Conclusions

Spinal canal CSA have increased by 112.84 percent and Dural sac CSA have increased by 132.99 percent after PLIF. Thus, before PLIF, the treating physician should carefully explain this result to the patient. It will help a decision making and informed consent tool for both surgeons and patients.

Acknowledgments

The all authors thank the Catholic Kwandong International ST. Mary’s Hospital.

Author contributions

Conceptualization: Jaeho Cho, Young Uk Kim.

Data curation: Jaeho Cho, Young Uk Kim.

Formal analysis: Jaeho Cho, Young Uk Kim.

Investigation: Seung-Uk Oh, Sunyoung Moon, Suk Hee Park, Young Uk Kim.

Methodology: Hojin Shin, Young Uk Kim.

Project administration: Jungmin Yi, Young Uk Kim.

Resources: Seung-Uk Oh, Jungmin Yi, Young Uk Kim.

Software: Seung-Uk Oh, Jungmin Yi.

Visualization: Seung-Uk Oh.

Writing – review & editing: Seung-Uk Oh.

Abbreviations:

CSA
cross-sectional area
LS
lumbar spondylolisthesis
MRI
magnetic resonance imaging
PLIF
posterior lumbar interbody fusion

The authors have no conflicts of interest to disclose.

The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.

How to cite this article: Oh S-U, Yi J, Moon S, Park SH, Shin H, Cho J, Kim YU. Spinal morphological change after posterior lumbar interbody fusion in lumbar spondylolisthesis patients. Medicine 2025;104:15(e42151).

Contributor Information

Seung-Uk Oh, Email: seunguk.cardio@gmail.com.

Jungmin Yi, Email: jminyi19@gmail.com.

Sunyoung Moon, Email: tjsdudm19@naver.com.

Suk Hee Park, Email: appealex@gmail.com.

Jaeho Cho, Email: jaehotv@gmail.com.

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