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Unstable Lumbar Spine:

Diagnosis and Assessment
Myung-Sang Moon, MD, PhD, FACS

Figure 1. Spondylolisthesis at L3 due to congenital

absence of a pedicle.
A

Initial radiograms of the (A) anteroposterior; (B) neutral lateral; (C) forward flexion; (D)
extension view; and (E) oblique view. (F) MRI. (G, H) Postoperation (pedicle screw
fixation).

nstability is now considered one of the

most important causative factors in low
back disorders. In recent years,
emphasis has been increasingly placed
on the maintenance of segmental stability of
the spine.1
Joint instability can result from various
causes, and is classified by its tilt angle
and/or translational displacement. 1-5 This
article provides a brief overview of the
definition, pathogenesis, clinical features
and diagnosis of unstable lumbar spine.

386

Definition
Segmental lumbar spine instability is a clinical concept. It differs from the mechanical
definition of stability and is difficult to
assess.6-10 It refers to clinically excessive or
inappropriate movements (wobbling) of a
motion segment under load, either within or
beyond a normal range of movement, despite
normal ligamentous constraints. Instability
may also be defined as joint deformation
with stress.8,9
Newman defined instability as a loss of
integrity of soft tissue intersegmental control,
causing potential weakness and liability to
yield under stress.8 The neutral zone of the
motion segment is enlarged, within which
the intervertebral discs and ligaments have
little resistance to movement.1-5
The terms spinal flexibility, unstable
back and weak back are sometimes used to
express spinal mobility; the latter is a layman
term and may not be synonymous with
unstable back. Weak back may manifest as
easily fatigued back muscles, stiffness and
weakness, accompanied by aching during or
after slight loading on the back.

Pathogenesis
Excessive axial rotation and translation of
the lumbar spine may follow injury to the
neural arch, including the facet joints (with
or without facet joint asymmetry). Once
degenerative changes occur in the intervertebral discs, movement between adjacent
vertebrae becomes uneven, excessive and
irregular.

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Table 1. Excessive range of movement and structural defects/damages

Excessive range of movement

Causative structural defects/damages

Hyperflexion

Posterior osseous-ligamentous injury/defect

Hyperextension

Damage to the anterior ligaments

Neural arch damage/defect (including the apophyseal
joint, articular surface and capsular ligament)

Excessive lateral bending

Gross neural arch fracture/severe tear in the

anterolateral annulus

Excessive axial rotation

Neural arch damage/defect (including the apophyseal

joint, articular surface and capsular ligament)
Gross neural arch fracture/severe tear in the
anterolateral annulus

Excessive range of movement is

associated with congenital (Figure 1)
and/or acquired structural defects
and damage. (Table 1) Intervertebral
disc injury increases the size of the
neutral zone. Loss of water in the
nucleus, either as a result of
sustained loading or degenerative
changes, also decompresses the disc,
slackens the annulus and reduces rotational stiffness, even when skeletal
stability is normal. This may explain
why repetitive shear and compression loading causes a vertebra to
creep forward and rotate slightly. On
the other hand, in the presence of
skeletal defect, the motion segments
would also become unstable
gradually despite normal ligamentous and muscular structures.
In severely unstable spine, the
disc and facet joints of the affected
segment are degenerated. As a
result, the spinal canal and neural
foramen become narrowed due to
hypertrophic bony spurs, and
stenotic symptoms are resulted from
the thickened ligamentum flavum.
The paraspinal muscles are positioned to provide stability within the
neutral zone, but only as far as
angular rotations are concerned.

Medical Progress August 2006

Figure 2. Polyarthritic
degenerative scoliosis in a
53-year-old woman.

The back muscles are poorly

oriented to prevent small translations. They can nevertheless affect
translational stability indirectly by
changing the compressive force
acting on the spine: an abnormally
low compressive preload arising
from impaired muscle action would
reduce impaction of the adjacent
neural arches, thereby reducing the
spines resistance to bending and
axial rotation. Inadequate local
muscle tone may similarly allow
greater translational movement, especially if the disc is degenerated.
It is important to consider the
cause of segmental instability in individual cases, which can be neural
(eg, acquired Charcot joint) or nonneural (eg, skeletal anomaly, isthmic
defect [Figures 2-4], pedicle defect
[Figure 1]) in origin.

Classification
Table 2 and Figure 5 illustrate the
various patterns of spinal instability.
In general, spinal instability is
classified by the directions and the
degree of displacement.11,12 There are
seven types of angulatory and translational instabilities, consisting of

Lateral rotatory slip of L2 and anterior slip of L3

are seen.

basic (anterior, posterior, lateral,

vertical and rotational) and
combined forms. Among these, angulatory,
translational
and
combined angulatory-translational
instability in the sagittal and coronal
planes are the most common. 8,13
True lateral translation has never
been reported in clinical settings,
although lateral rotatory olisthesis is
frequently encountered in elderly
patients with degenerative lumbar
scoliosis. Also, unlike vertical instability, pure rotatory instability is not
clinically observed.6,7,14,15
This simplified classification,
however, may not suffice in
providing the necessary information
for correctly diagnosing unstable
lumbar and lumbosacral spines, and
to guide selection of surgical procedures. For this reason, I use a
classification that takes into account
also the severity of instability and
the clinical symptoms and signs:
The severity of angulation, translation and rotation; and
The presence of central stenosis,
which can be further classified as
(1) dynamic or static and (2)
reducible or nonreducible.9,13
In some cases of dynamic central

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Figure 3. Postlaminectomy
spondylolisthesis of L4.
A

Extension angular instability with anterior slip is

seen. (A) Initial (spinal stenosis). (B) Immediate
postoperative radiograms. (C) Postoperative 6 years
and 8 months.

Figure 4. Three types of lumbar

scoliosis with lateral rotatory
slips.
A

stenosis, symptoms can be relieved

by flexion; whereas in others,
symptoms can be relieved by
extension with or without reduction
of the slipped vertebral body. The
nonreducible type is considered a
non-hypermobile instability, manifesting the progression of the
hypermobile segment to a near endstage, when the degenerative and
reparative processes have reached a
static equilibrium.
Other systems of classification
have been proposed by Pope,
Frymoyer and Krag, who have
divided segmental instability into
primary and secondary types;4 and
by Lee and Kopacz, who have classified discogenic lumbar instability
into three major groups on the basis
of the instability plane involved:
sagittal plane instability, coronal
plane instability and axial instability. 12 An example of coronal plane
instability would be degenerative
lumbar scoliosis. The condition
should be differentiated from adult
idiopathic scoliosis; in the former,
there is advanced degenerative
change, lower lumbar curve, and

minimal
structural
vertebral
deformity. Radiologically it can be
further divided into two main types:
oligoarticular and polyarticular.

Clinical Symptoms and Signs

Patients with an unstable lumbar
spine complain mainly of low back
pain, sciatica and/or claudication.
Some may experience frequent
episodes of catching pain or acute
asymmetrical low back pain against a
background of chronic pain with or
without leg involvement. This pain is
automatically accompanied by asymmetrical muscle contractions.
Pain is the most common early
symptom of unstable lumbar spine,
although it may also arise from a
number of structures within or
adjacent to the spinal column. These
structures include the intervertebral
disc, zygapophyseal joints, vertebral
bodies and surrounding ligaments
and muscles. In addition to musculoskeletal causes, pain can also result
from compression or damage to the
nerve roots exiting from the spinal
canal, or to the spinal cord itself.

Table 2. Patterns of hypermobile instability

(A) Idiopathic scoliosis with hyperlordosis and

L3 lateral rotatory slip. (B) Degenerative scoliosis
with L3 lateral rotatory slip and loss of lordosis.
Vacuum sign is seen at L3-L4 disc in A-P view.
(C) Post-laminectomy scoliosis with advanced
disc de-generation at L3-4 and L4-5, and anterior
slip of L4.

388

Abnormal motion (displacement)

Plane of motion

Degree of displacement

Translation
Anterior
Posterior
Lateral (rotatory)

Horizontal

>2-3mm*

Angulation (angle of disc space or tilt)

Forward (flexion)
Backward (extension)
Lateral right
Left

Sagittal
Coronal

>9**
L2-L3 14.3
L3-L4 15.5
L4-L5 18

Rotation
Right
Left

Axial

Facet joint gapping

*Wiltse and Winter14; **Graf7; Dvorak.6

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Figure 5. Patterns of spinal

instability.
Angulation

Table 3. Classification of low

back pain

Angulation and
translation

Group I

Radiculopathy and spinal

stenosis

Extension

Group II

Anterior column origin or

discogenic pain associated with
degenerative disc disease or
spondylolisthesis

Group III

Posterior column pain including

the facet joints

Normal
(neutral lateral)

Group IV Back pain of soft tissue origin*

Flexion

*Generally a non-surgical condition.

Translation

Apart from back pain, patients

with degenerative lumbar scoliosis
also present with spinal deformity
with body tilt and rotatory slip
and/or stenotic symptoms.

Diagnosis
While there are many modern diagnostic modalities available, plain
roentgenograms remain the key for
diagnosis. Simple and stress x-rays
should be used as the first step in
diagnosing patients whose symptoms suggest unstable back.
The diagnosis of clinical instability of a spinal motion segment can
be established when pain is
accompanied by demonstrable
hypermobility. Low back pain is
usually divided into four groups
according to their probable origins.
(Table 3) For a definite diagnosis
of unstable back, the following
findings must be present on plain
radiograms: (1) angulatory and/or

Medical Progress August 2006

translational displacement of a
vertebral body against an apposing
vertebral body; (2) Hadleys lazy S
sign;16 (3) traction spur; and (4) the
Knuttsons vacuum sign in the disc.17
(Figure 4) The latter sign, however,
may have a higher detection rate
with CT scan (Lin, personal communication, 2006).
The exact cause of the unstable
back and pain should be identified
before commencing treatment.
However, this may not be straightforward. Angulatory instability can
be difficult to assess. Currently,
there is no reliable diagnostic test to
identify rotational instability at its
early phases, although manifestation
of pain on axial rotation is highly
suggestive. Dynamic CT scan with
the patient twisting the trunk is also
useful in the diagnosis (showing
signs of facet joint gapping). It is
mandatory to take x-rays of the unstressed and stressed lumbar spine in
bending and twisting positions.7
The diagnosis is also difficult to
establish when the pain is caused by
non-hypermobile abnormal motion
and/or abnormal biomechanical
response to a physiological loading
condition.

The diagnosis of stenosis in an

unstable spine depends mainly on
clinical symptoms, with further proof
from myelogram, CT myelogram and
MRI. A CT scan using the twist-test
technique can demonstrate gapping
in a posterior joint with recurrent
spinal nerve entrapment.7 MRI of the
lumbar spine can show discal involution as well as subchondral marrow
changes adjacent to a degenerative
disc. However, MRI changes are not
definitive.

References
1. Panjabi MM, Goel RK, Takata K. Physiologic
strains in the lumbar spinal ligaments: An in vitro
biomechanical study. Spine 1982;7:192.
2. Pearcy M, Sheperd J. Is there instability in
spondylolisthesis spine? 1985;10:175.
3. Pope M, Panjab M. Biomechanical definitions
of spinal instability spine. 1985;10:255-256.
4. Pope M, Frymoyer JW, Krag MH. Diagnosing
instability. Clin Orthop 1992;279:60-67.
5. Strauss PJ, Novotmy JE, Wilder DG, Grosler LJ,
Pope MH. Multidirectional stability of the Graf
system. Spine 1994;19:965-972.
6. Dvorak J, Panjabi M, Chang D. Functional radiographic diagnosis of the lumbar spine Flexion,
extension and lateral bending. Spine 1991;165:
562-571.
7. Graf H. Instabilite vertebrale. Treatment a
1aide dun system soule. Rachis, 1992.
8. Moon MS. Treatment of unstable lumbar spine
with Graf band system. Presented at 19th World
Congress, SICOT, Aug. 30, 1993.
9. Moon MS, Moon YW, Moon JL, Kim SS, Shim
YS. Treatment of flexion instability of lumbar spine
with Graf band. J Musculoskelet Res 1999;3:49-63.
10. Kirkaldy-Willis WH, Farfan HF. Instability of the
lumbar spine. Clin Orthop 1982;165:110-123.
A complete list of references can be obtained
upon request to the editor.

About the Author

Dr Moon is Professor Emeritus at the Catholic
University of Korea, Director of the MoonKims Institute of Orthopedic Research, Seoul,
and Spine Center, Sun General Hospital,
Daejeon, Korea. Dr Moon is currently President
of the Asia Pacific Orthopaedic Association.
E-mail: msmoonos@hotmail.com

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Unstable Lumbar Spine:

Management
Myung-Sang Moon, MD, PhD, FACS

Figure 1. Treatment chart for clinical instability.

Diagnosis of
clinical instability

Is there associated
pain at diagnosis?

No

Yes

Pain persisted?
Course
of
disease

Yes

Stabilization
surgery

his article discusses some of the

management issues regarding
unstable lumbar spine, with a brief
review on its surgical treatment
options. It needs to be stressed that, however,
the treatment for painful unstable back
remains poorly defined, and disagreement
exists as to when surgery is indicated in low
back pain that appears to be originating
from spinal structures.

Management Principles
A suggested treatment algorithm for clinical
instability is outlined in Figure 1. Some

390

No

Static equilibrium

Bracing and observe

Treatment not
required
(Watchful
waiting)

general management principles are as follow:

Even when unstable low back is diagnosed, stabilization should not be started
until the origin can be confirmed.1
In patients with persistent disabling low
back pain, deteriorating stability and/or
no signs of spontaneous stabilization,
bracing and movement restriction should
be done to stabilize the segment.
When conservative treatment fails, surgery is indicated.
Sufficient time must be given for the trial
of conservative treatment to adequately
determine the patients clinical response
and the next treatment.2,3

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Table 1. Posture and exercise suggestions for patients without stenotic

symptoms

Table 2. Motion-preserving
stabilization surgeries

Avoid activities such as shovelling, lifting and gardening.

Avoid sports such as handball, squash, tennis and cycling.

1. Direct osteosynthesis of lytic isthmus

with screwing and bone graft

Avoid standing on one leg, as it produces asymmetrical stress on the pelvis and spine.

2. Scott wiring for direct repair

Isometric, abdominal and low back exercises that work primarily on the deep muscles of the
back/the multifidus stabilize the back and improve balance. These exercises are best done on
exercise mats.

3. Combined stabilization surgery

Physiotherapy with a back muscle training programme and lifting technique training are
beneficial.

Unstable Back Without Stenotic

Symptoms
In unstable lumbar spine without
stenotic symptoms, conservative
treatment aims at reducing the stress
on the unstable segment to halt deterioration and minimize pain. Rotation appears to be the most harmful
motion, since it creates both compression and shear, and should be
avoided. Patients should be advised
to avoid certain activities, and training programmes can be provided to
improve posture and strengthen back
muscle. (Table 1) In obese patients,
especially men, the increased weight
around the abdomen worsens lordosis, and weight reduction should be
advised.
With proper conservative care,
time alone will reduce hypermobility
and improve long-term stability.
Unstable Back With Symptomatic
Stenosis
In these patients, the stenotic symptoms should be relieved by all means,
conservatively or surgically. This
should be done prior to the treatment
of instability, regardless of the cause.
Tables 2 to 5 list the available
motion-preservation, -restriction
and -elimination (fusion) surgical
options and nerve decompression
Medical Progress August 2006

procedures for the management of

unstable back with symptomatic
stenosis. The following should be
considered when planning for
treatment:
Instrumented stabilization generally relieves pain completely
except in a few cases.
While spinal stabilization surgery
can relieve musculoskeletal pain
in trauma-related cases, it may
not be useful for pre-existing neuropathic pain.
For dynamic stenosis, flexion-distraction or extension-distraction
fusion without decompressive
laminectomy can theoretically
relieve stenotic symptoms. However, flexion-distraction fusion is
not preferred because it misaligns
the sagittal lumbar curvature (ie,
making the back flat).
In static stenosis, decompressive
laminectomy with or without
facetectomy should be done,
followed by stabilization surgery.
Extensive decompressive laminectomy should always be followed
by stabilization surgery, because
the former further destabilizes the
unstable decompressed segment.
This holds true even in patients
with non-hypermobile instability.
In the case of posterior column

Table 3. Motion-restriction
surgeries
Type of instability Procedure
Flexion instability

Ligamentoplasty
1. Grafs procedure
2. Mochidas
procedure

Extention instability

Interspinous soft
cushion spacer
1. Silicone device
2. Metal device

defect, posterior stabilization surgery is indicated, whereas anterior

stabilization surgery is indicated
for anterior column defect.
Facet rhizotomy is contraindicated because it denervates the
multifidus and increases hypermobility and instability.

Stabilization Surgery
Stabilization surgery for symptomatic unstable spine aims at spinal
restoration by reinforcing the deficient ligamentous and bony structures, in order to normalize the
spine-spinal nerve relationship. This
is done by stabilizing the spinal unit,
restoring normal alignment and correcting deformity, and/or decompressing the nerves. Figure 2 shows
the various treatments for different
types of instability.

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Figure 2. Stabilization surgery for different types of instability.

Table 4. Motion-elimination
surgeries
1. Posterior stabilization surgery
Posterior fusion ( posterior
instrumentation)
Posterolateral fusion ( posterior
instrumentation)
Posterior interbody fusion
Transforaminal interbody fusion

Angulation
Anterior
stabilization
Posterior
stabilization

Laminotomy
Foraminotomy
Combined extensive laminectomy and
foraminotomy
Facetectomy

Flexion
instability
Anterior
stabilization

Normal
(neutral lateral)
Flexion instability
Translation
Anterior
stabilization
or
Posterior
stabilization

Table 5. Nerve decompression

procedures

Translational
instability
(discogenic)

principle therefore suggests that in

stabilization surgery, a posterior instrumentation should act as a
compressive device.
In the following discussion, we
will consider the common procedures for sagittal and coronal spinal
instability (degenerative scoliosis).

In situ or post-reduction fusion

Stabilization surgery of the spine

follows the basic mechanics of the
spine. The spine has two mobile
columns, the anterior and posterior
columns. In the anterior column,
motion is transferred through the
disc in relation to its elasticity, while
in the posterior column motion is
transferred through the facet joints.
Load sharing between these two
columns maintains spinal integrity.
The architecture of the spine is so
designed as to resist anteriorly
against compression and torque
forces, and posteriorly against
tension forces. The muscles and
ligaments exert posteriorly compression forces. The tension band

392

Angulation and
translation
Extension instability

2. Anterior stabilization surgery

Anterior interbody fusion anterior
instrumentation
3. Combined anterior and posterior
fusion anterior and/or posterior
instrumentation

Extension
instability

Stabilization Surgery for Sagittal

Instability
Motion-restriction (Non-fusion)
Surgery
For forward flexion sagittal instability, two ligamentoplasty procedures
are available: Graf ligament stabilization procedure and the posterior
ligamentoplasty
described
by
Mochida et al.
Graf ligament stabilization is a
re-enforcement, band fixation
procedure for inefficient posterior stabilizer. The Graf artificial
ligament serves as a tension band
to suppress firstly excess flexion,
and secondly rotation, by apposing or locking the facet joints in
lordosis. The procedure is indicated only in pure forward flex-

Posterior
stabilization

ion instability, and should not be

used in the presence of extension
instability secondary to anterior
stabilizer inefficiency or failure.
With the posterior stabilization
provided by the pre-stressed, flexible Graf ligaments, facet joint
gapping can be eliminated, which
is the major source of pain. It also
restores normal lumbar lordosis,
which repositions the stabilized
joint so that exposure to rotative
mechanical aggression is minimized. Graf ligament fixation
should not be used in cases with
anterior, posterior and rotatory
corporal translation with posterior angulation.2,3 In cases of lateral canal stenosis, complete
unroofing of the lateral canal is
mandatory, because banding
causes extension and compression to the applied segment,
which in turn causes narrowing
of the neural foramen.
In the posterior ligamentoplasty
described by Mochida et al, artificial ligaments are used to stabilize
the posterior element through the

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Figure 3. Isthmic spondylolisthesis at L4 without

neurological involvement in a
54-year-old man.
A

Figure 4. Isthmic spondylolisthesis at L5 in a 13-year-old girl with severe

back muscle spasm and markedly limited straight leg raising.
A

(A) Preoperation. (B) After anterior interbody fusion.

pedicles. The problem with this

procedure is that the ligament
fixation area is too close to the
spinal flexion axis, and provision
of proper ligament tension is difficult. Some authors therefore
suggested that the procedure is
not beneficial in re-enforcing the
inefficient posterior stabilizer.
Also, compared with the Graf
band, material creep may be a
problem with this procedure,
undermining its usefulness in providing long-term posterior stability without failure.2-4
For extension sagittal instability,
interspinous soft cushions are now
available for stabilization surgery.5,6
These devices prevent further
extension of the instrumented
segment from its neutral position.
This helps to maintain a wider
foraminal space and prevent the development of symptoms secondary

Medical Progress August 2006

(A) Preoperation. (B) Immediate after posterior instrumentation. (C) After anterior interbody fusion at L5-S1.
(D) Postoperation 1 year. (E) Postoperation 6 years. Solid anterior fusion at L5-S1 is seen.

to dynamic extension and stenosis

of the segment.
Motion Elimination (Fusion)
Surgery
Based on the tension band principle
mentioned above, some authors have
recently argued that a secure fusion
requires combined anterior and posterior instrumental stabilization.
However, this is still debated.
Posterior procedures include
posterior fusion, posterolateral
fusion and posterior lumbar
interbody fusion. The latter two are
the more popular procedures, and
can be done with or without
posterior instrumentation. For
spinal instability with preserved
anterior load sharing, pedicle screw
fixation alone provides sufficient
stability, and interbody cages should
not be used, because they further
increase segmental motion in the

adjacent segment. 7 When the

anterior column is deficient,
however, the use of interbody cages
significantly increase construct
stiffness and decrease hardware
strain. For axial rotatory instability,
derotation facet fusion is indicated.8
The procedure alone should decompress the nerve roots. However, the
current trend is to supplement it
with transverse process fusion and
instrumented stabilization, after stabilizing the unstable segment with
derotation facet fusion.
Anterior procedure involves
anterior lumbar interbody fusion
with or without instrumentation.
(Figures 3 and 4) Both in situ and
post-reduction fusions are well
accepted for oligoarticular spinal
disorders with instability. Anterior
lumbar interbody fusion can be used
in cases of sagittal translational
instability without neurological

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symptoms. In such cases, intertransverse fusion is also indicated, which

can be supplemented by posterior
instrumentation.

Stabilization Surgery for Coronal

Spinal Instability
Two types of fusion procedures,
poly-articular and oligoarticular
fusion, are available for coronal
spinal instability (degenerative lumbar scoliosis). Depending on the clinical types, surgical management may
differ:
In cases with neurological compromise, decompression surgery
should precede the combined corrective and fusion operation.
In case with symptomatic progressive degenerative scoliosis
without stenotic symptoms,
fusion supplemented by internal
fixation after complete correction
of coronal deformity and sagittal
alignment is the most appropriate.
In fusion surgery for the scoliotic
spine, deformity correction
should be included, because in
most cases undercorrection of
coronal deformity would complicate junctional instability.
For painful, unstable degenerative lumbar scoliosis without
rotation and stenotic symptoms
(localized to 1-2 joints), anterior
lumbar interbody fusion is recommended.
For stable, nonprogressive, polyarticular degenerative lumbar
scoliosis with stenotic symptoms,
decompression surgery alone
would suffice.
For unstable degenerative lumbar
scoliosis with stenotic symptoms,
instrumental stabilization of the
entire scoliotic segment after
complete decompression and
deformity correction is preferred.

Nerve Decompression Surgery for

Stenosis
Posterior Decompression
Posterior decompression involves
posterior unroofing of the central
and/or lateral canal. It is the procedure of choice for unstable degenerative lumbar spine with stenotic
symptoms, regardless of the associating deformity. However, since this
procedure further destabilizes the
spine, it should be combined with
stabilization surgery.
Anterior Decompressive
Corpectomy
This procedure is in general not indicated in the treatment of unstable
lumbar spine with stenosis. Even in
static stenosis, anterior lumbar interbody fusion alone would suffice, as it
reduces and realigns the slipped
vertebra, thereby stabilizing the
fused segment and relieving stenotic
symptoms.9
Posterior Instrumented Reduction
Posterior instrumented reduction for
lateral and vertical displacement, or
disc migration, restores the central
canal size and spinal alignment,
thereby decompresses the entrapped
nerves. However, decompression
may not always be achieved with
this procedure.

Fusion in the Flexion-distraction or

Extension-distraction Position
A proper position for fusion is
important in relieving stenosis
symptoms. Fusion in the flexiondistraction or extension-distraction
position effectively relieves dynamic
stenosis symptoms and provides
stability at the same time.
In cases of retrolisthetic instability at L5, which is frequently
associated with lateral spinal canal
stenosis affecting the S1 nerve root,

fusion in flexion (with distraction

rods, pedicle fixation devices and
facet fusion) is the treatment of
choice.
In general, during spinal fusion,
an internal fixation system should
be used as an adjunct to stabilize the
fusion segment and to maintain the
fusion position.

Prognostic Factors
The prognosis of unstable back will
depend on the patients age and sex,
the degree of disc degeneration, bony
and facet configuration and defect,
traction and claw spurs, lumbosacral
angle, and height of L4 in regards to
the intercrestal line.
Prognosis is generally good if
signs of symptom relief and radiological improvement can be
observed during the course of stabilization. Clinical symptoms should
gradually subside towards the end
stage of instability when the static
equilibrium is reached. Radiologically, gradual decrease of motion
should be demonstrated with the
stress test, with no further collapse
of disc height. Formation of anterior
or lateral bony buttress should be
seen in the upper margin of the
lower body.
A list of references can be obtained upon
request to the editor.

About the Author

Dr. Moon is Professor Emeritus at the Catholic
University of Korea, Director of the MoonKims Institute of Orthopedic Research, Seoul,
and Spine Center, Sun General Hospital,
Daejeon, Korea. Dr Moon is currently
President of the Asia Pacific Orthopaedic
Association.
E-mail: msmoonos@hotmail.com

Answers to questions on page 385: 1. T 2. F 3. F 4. T 5. T

394

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