n Review Article

Paraspinal Muscle Atrophy After Lumbar

Spine Surgery
Sina Pourtaheri, MD; Kimona Issa, MD; Elizabeth Lord, MD; Remi Ajiboye, MD; Austin Drysch;
Ki Hwang, MD; Michael Faloon, MD; Kumar Sinha, MD; Arash Emami, MD

abstract by the posterior rami of the spinal nerves

and do not have intersegmental innerva-
tion, injury to these nerves potentially
Paraspinal muscles are commonly affected during spine surgery. The pur- damages all the muscle bundles they in-
pose of this study was to assess the potential factors that contribute to para- nervate.6 Several studies have introduced
spinal muscle atrophy (PMA) after lumbar spine surgery. A comprehensive surgical modifications to attempt to pre-
review of the available English literature, including relevant abstracts and serve the posterior rami and minimize
references of articles selected for review, was conducted to identify studies potential postoperative PMA.4,5,7-12 These
that reported PMA after spinal surgery. The amount of postoperative PMA include modifying incision length, ex-
was evaluated in (1) lumbar fusion vs nonfusion procedures; (2) posterior posure techniques, retraction, and screw
lumbar fusion vs anterior lumbar fusion; and (3) minimally invasive (MIS) trajectory and using lower electrocautery
posterior lumbar decompression and/or fusion vs non-MIS equivalent pro- settings.7-12 However, to the current au-
cedures. In total, 12 studies that included 529 patients (262 men and 267
women) were reviewed. Of these, 365 patients had lumbar fusions and 164
had lumbar decompressions. There was a significantly higher mean post- The authors are from UCLA/Orthopaedic In-
stitute for Children (SP, EL, RA, AD), Department
operative volumetric PMA with fusion vs nonfusion procedures (P=.0001), of Orthopaedic Surgery, David Geffen School of
with posterior fusion vs anterior fusion (P=.0001), and with conventional Medicine at UCLA, Santa Monica, California;
fusions vs MIS fusions (P=.001). There was no significant difference in mean and the School of Health and Medical Sciences
volumetric lumbar PMA with MIS decompression vs non-MIS decompres- (KI, KH, MF, KS, AE), Seton Hall University,
South Orange Village, and the Department of Or-
sion (P=.56). There was significantly higher postoperative PMA with lumbar thopaedic Surgery, Saint Joseph Regional Medi-
spine fusions, posterior procedures, and non-MIS fusions. [Orthopedics. cal Center, Paterson, New Jersey.
2016; 39(2):e209-e214.] Dr Pourtaheri, Dr Issa, Dr Lord, Dr Ajiboye,
Mr Drysch, Dr Faloon, and Dr Sinha have no
relevant financial relationships to disclose. Dr

P
araspinal muscles are commonly
affected during spine surgery.1 This
is partly due to retraction or dissec-
tion techniques, which can potentially re-
sult in iatrogenic denervation, ischemic or
thermal damage, and progression to even-
tual atrophy of the paraspinal muscles.1-4
This may lead to pain and instability and
contribute to poor clinical outcomes, in-
creased morbidity, and surgical failures
requiring revision surgery, which is an
additional challenge for the treating sur-
geon. Furthermore, disuse of the paraspi-
nal muscles as a consequence of a lumbar
fusion may also contribute to postopera-
tive paraspinal muscle atrophy (PMA).1-3,5
Some authors have suggested that be-
cause paraspinal muscles are supplied
Hwang is on the speaker’s bureau of DePuy. Dr
Emami is a paid consultant for and is on the
speaker’s bureau of DePuy.
Correspondence should be addressed to: Sina
Pourtaheri, MD, UCLA/Orthopaedic Institute for
Children, Department of Orthopaedic Surgery,
David Geffen School of Medicine at UCLA, 1250
16th St, Ste 3145B, Santa Monica, CA 90404
(spourtah@gmail.com).
Received: August 1, 2014; Accepted: Febru-
ary 4, 2015.
doi: 10.3928/01477447-20160129-07

MARCH/APRIL 2016 | Volume 39 • Number 2 e209

n Review Article
thors’ knowledge, no previous study has
attempted to quantify the amount of re-
ported postoperative PMA or its potential
contributors. Therefore, a systemic review
may be valuable to inform spine surgeons
and patients about the postoperative PMA
phenomenon and the risk factors for post-
operative PMA.
The purpose of this study was to assess
the potential factors that contribute to PMA
by examining the available literature on the
topic. The amount of postoperative PMA
was evaluated in (1) lumbar fusion com-
pared with nonfusion procedures; (2) poste-
rior lumbar fusion compared with anterior
lumbar fusions; and (3) minimally invasive
(MIS) posterior lumbar fusions compared
with non-MIS equivalent procedures.
Materials and Methods
A systematic review of the literature
was performed to identify studies that re-
ported PMA after lumbar spine surgery. In
accordance with the PRISMA (preferred
reporting items for systematic reviews and
meta-analyses) guidelines,13 the electronic
medical databases of PubMed, SCOPUS,
EMBASE, CINAHL, and Web of Science
were independently searched by 2 authors
(S.P., K.I.) to identify all relevant reports
of patients undergoing lumbar spine sur-
gery with evidence Level I to IV. The key-
words searched were paraspinal muscle,
paraspinal muscle atrophy, and PMA.
Only English-language full-text manu-
scripts or abstracts that had quantified
outcomes were reviewed. Following re-
view of all relevant reports, the references
of articles selected for review were further
assessed to identify studies that were not
captured in the initial database search.
Eligibility Criteria for Study Inclusion
Inclusion criteria included (1) reports
on PMA related to a lumbar spine proce-
dure irrespective of the level of evidence;
(2) studies with reported follow-up; and
(3) reports that quantified the postopera-
tive PMA. Exclusion criteria included (1)
case reports; (2) studies that did not report
e210
quantified outcomes; (3) studies with less
than 6 months of follow-up, and (4) and
non-English-language studies.
Assessment of Level of Evidence and
Methodological Quality of the Studies
Two authors (S.P., K.I.) performed the
initial literature search independently,
and, after a consensus decision, all stud-
ies included in the final analysis were se-
lected. A third author’s (A.E.) opinion was
obtained when a consensus decision could
not be reached in the assessments. Level
of evidence ratings were assigned to each
study using criteria set by the Journal of
Bone and Joint Surgery for therapeutic
studies. In addition, 2 authors (S.P., K.I.)
conducted a quality assessment for each
of the studies selected for final analysis.
Quality assessment of all the selected
reports was made by using the 12-point
Methodological Index for Non-random-
ized Studies (MINORS) criteria. These
criteria have been previously reported to
have high test-retest, external and internal
validity, and interobserver reliability.14-16
A modified 24-point quality assessment
scale for observational studies was also
used to analyze the methodological qual-
ity of the studies in this study.17,18
Analysis
Mean weighted percent of PMA, im-
mediate postoperative creatine phospho-
kinase (CPK) levels, and radiographic
outcomes were extracted, and weighted
mean values according to the number of
patients in each study were calculated.
The volumetric postoperative PMA was
defined as the percent volume of the mul-
tifidus muscle that atrophied postopera-
tively with respect to the multifidus’s ini-
tial preoperative size. Initially, all lumbar
spine fusions were evaluated as a single
cohort, and outcomes were compared with
all other procedures that did not involve a
fusion. Afterward, outcomes in the fusion
cohort were further substratified accord-
ing to the surgical approach: anterior or
posterior (posterolateral, transforaminal
lumbar interbody fusion [TLIF], and pos-
terior lumbar interbody fusion [PLIF]).
Furthermore, all outcomes were also
substratified according to whether they
were performed through MIS (paraspinal/
Wiltse) or non-MIS approaches.
All statistical analyses were performed
using SPSS version 16 statistical software
(IBM Corporation, Armonk, New York).
The degree of postoperative volumetric
PMA and elevations in postoperative CPK
levels were stratified according to the ap-
proach and surgical technique and ana-
lyzed with the unpaired 2-tailed Student’s
t test. Results with a P value less than or
equal to .05 were considered to be statisti-
cally significant.
Results
Study Identification
In total, 12 studies (Figure 1) evalu-
ating 529 patients (262 men and 267
women) were analyzed in the final review
(Table). Of these, 365 patients had lumbar
spine fusions and 164 had lumbar decom-
pressions without fusion. Radiographic
analysis was with magnetic resonance
imaging (MRI) in 9 studies and computed
tomography in 3 studies.
Quality Assessment
The levels of evidence were as follows:
1 Level I, 2 Level II, 8 Level III, and 1
Level IV. Mean score for the 12 studies
as per the modified quality assessment
scale was 12 points (range, 8-17 points;
maximum score, 22 points),17,18 whereas
mean score for the MINORS scale was
13 points (range, 11-18 points; maximum
score, 24 points).
Outcomes
Mean postoperative volumetric PMA
was significantly higher in the fusion vs
the nonfusion cohort (19.8%±11.3% vs
9.1%±6.9%, respectively; P=.0001) (Ta-
ble and Figure 2).
When outcomes were substratified
according to the type of approach in the
fusion cohort, mean postoperative volu-
Copyright © SLACK Incorporated

metric PMA was significantly different
between anterior and posterior procedures
(6%±10% vs 24.7%±10.1%, respectively;
P=.0001) (Figure 3).
When fusion outcomes were sub-
stratified according to MIS fusion vs non-
MIS fusion, mean postoperative PMA
was significantly lower in MIS fusions
(10.2%±8.9% vs 24.7%±11.7%, respec-
tively; P=.001).
When posterior nonfusion outcomes
(ie, lumbar laminectomies/diskectomies)
were substratified according to MIS de-
compression and non-MIS decompres-
sion, there were no significant differ-
ences in the mean PMA (8.6%±4.3% vs
9.4%±10.2%, respectively).
Discussion
Paraspinal muscles are commonly af-
fected during lumbar spine surgery due to
retraction and dissection.1-3 Thus, postop-
erative PMA may be an approach-related
issue. With anterior procedures, the para-
spinal muscles are not violated; there-
fore, postoperative PMA may not occur.
Similarly, with MIS approaches (para-
spinal/Wiltse procedures) vs non-MIS
approaches, there may be less paraspinal
denervation and subsequent postopera-
tive PMA. However, an additional culprit
was noted in the current study because
there was significant postoperative PMA
with the standalone anterior lumbar in-
terbody fusions. Also, when the cohorts
were matched with respect to surgical
approach, more postoperative PMA was
seen in the fusion procedures than in the
decompression-alone procedures. There-
fore, the purpose of this study was to
systematically assess the literature and
quantify postoperative PMA as a result of
disuse muscle atrophy from lumbar fusion
and separately assess how much postop-
erative PMA is an approach-related issue.
There are several limitations to this
study, which are potentially inherent in
most systematic reviews. The authors
were limited by the methodological
quality of the original studies, length of
MARCH/APRIL 2016 | Volume 39 • Number 2
Figure 1: Consort flow diagram representing the results of the literature search.
follow-up, and number of patients ana-
lyzed in each study. Most studies were
based on Level III or IV evidence, and
quantification methods were not identical
in all cases. Some of the studies did not
report the different preoperative lumbar
pathologies that necessitated the surgery,
which may potentially affect the postop-
erative outcomes. The physical therapy
protocols were often not reported, and
it is unlikely there was uniformity in the
methods or duration of various modali-
ties. Radiographic analyses were per-
formed during different time frames, and
inter- and intraobserver error margins for
the radiographic outcomes were not rou-
tinely reported. Medical comorbidities
that could potentially affect the healing
process, including diabetes mellitus and
smoking, were not evaluated in any study.
Despite these limitations, the authors be-
lieve the results are valuable because, to
their knowledge, no previous study has
attempted to systematically quantify the
amount of postoperative PMA according
to surgical procedure.
The current study showed that an ad-
dition of fusion (posterolateral or in-
terbody) to lumbar surgery increased
n Review Article
the amount of postoperative PMA. This
conclusion was supported by all studies.
Disuse muscle atrophy after a lumbar fu-
sion is significant. Suwa et al5 evaluated
the amount of postoperative PMA in 42
patients who had received single-level
laminectomy, 13 patients who had re-
ceived multi-level laminectomy, and 34
patients who had received posterolateral
fusion (PLF). Magnetic resonance imag-
ing at 10-month follow-up showed PMA
amounts of approximately 3% and 6.5%
in the single-level and multi-level cohorts,
respectively; however, the PLF cohort had
approximately 11.5% PMA.
An equally important determinant of
postoperative PMA may be the surgical
approach, specifically anterior vs poste-
rior lumbar surgery. There is a paucity of
literature on the anterior approach; how-
ever, all studies that evaluated this con-
cept showed that posterior lumbar fusion
cohorts had more postoperative PMA.
Therefore, by going anteriorly, where
none of the paraspinal muscles are disrupt-
ed, there may be less postoperative PMA.
Motosuneya et al4 compared PMA in 11
patients who had received anterior lumbar
interbody fusion (ALIF) with 19 patients
e211
e212
Table
Summary of Patient Demographics and Surgical Characteristics
Total Mean Mean Change in
n Review Article

Preoperative Vertebral Level No. of Mean Age Follow-up Paraspinal Muscle

Study Diagnosis Involvement Treatment Patients (Range), y Evaluation (Range), mo Volume
Kim et al2 Spondylolytic spon- L4-L5: 37% Group I: OPF 19 52 MRI 21 OPF: -31.5%±25%
dylolisthesis: 79% L5-S1: 52.5% Group II: PPF (35 to 72) (18 to 31) PPF: -3.5%±25%
Degenerative spon- L4-L5-S1: 10.5%
dylolisthesis: 10.5%
Foraminal stenosis:
10.5%
Hyun et al12 Degenerative condi- - Group I: Paramedian interfascial 26 52 CT 12 Group I: 17.3%±1.8%
tions of lumbar (MIS) (26 to 69) Group II: 15.2%±1.3%
spine Group II: Midline approach Group III: 4.5%±1.1%
Motosuneya Single-level de- L3-4: 16% Group I: ALIF 49 (36 to 63) MRI (16 to 19) Group I: -6%±1%
et al4 generative lumbar L4-5: 79.5% Group II: PLIF Group II: -12%±1%
disease Group III: -16%±1.3%
L5-S1: 18% Group III: PLF
Group IV: LAM Group IV: -6%±1.3%
Group V: LOVE Group V: -4%±0.6%
Suwa et al5 - - Group I: Single-interlaminar-level 89 56 MRI 10 Group I: -3%
laminectomy (21 to 82) Group II: -6.5%
Group II: 13 multiple-interlaminar- Group III: -11.5%
level laminectomy
Group III: 34 PLF procedures
Watanabe et Spinal stenosis L3-L4 Group I: Modified spinous split- 44 70 MRI 1 MIS: 24%±15%
al23 Degenerative spon- L4-L5 ting fusion (n=18) Open: 43%±22%
dylolisthesis Group II: Conventional fusion
(n=16)
Fan et al19 Isthmic spondylolis- L3-L4: 1.7% Group I: MIS fusion 59 53 MRI 12 MIS: 12.2%
thesis (22%) L4-L5: 69.5% Group II: Conventional open CO: 36.8%
Degenerative spon- L5-S1: 28.8% fusion
dylolisthesis (46%)
Lumbar disk hernia-
tion (8%)
Spinal stenosis with
instability (24%)
Tsutsumimo- Single-level stenosis L4-L5: 100% Lumbar degenerative spondylo- 20 62 MRI 14 CO: 36.8%±12.3%
to et al24 Degenerative spon- listhesis (39 to 76) MIS: 12.2%±4.5%
dylolisthesis
Remes et Isthmic spondylolis- L4-L5: 43% Group I: PLF 67 14.5 MRI (6 to 18) Group I: -4.8%
al25 thesis L5-S1: 57% Group II: ALF (9 to 19.5) Group II: -20.7%
Group III: CF

Copyright © SLACK Incorporated

 Table (cont’d)
Summary of Patient Demographics and Surgical Characteristics
Total Mean Mean Change in
Preoperative Vertebral Level No. of Mean Age Follow-up Paraspinal Muscle
Study Diagnosis Involvement Treatment Patients (Range), y Evaluation (Range), mo Volume
28
Kim et al - - Group I: Unilateral paraspinal 71 53 CT >24 Conventional:
dissection with cutting of the (19 to 81) -24%±6% to -38%±9%
spinous process (posterior MIS: -3%±7% to
decompression) 15%±8%
Group II: Modified bilateral
decompression via hemilami-
nectomy (MIS) (posterior de-
compression)
Group III: Modified bilateral
decompression via spinous
process splitting (MIS) (posterior

MARCH/APRIL 2016 | Volume 39 • Number 2

decompression)
Hartwig et Symptomatic degen- L4-L5: 100% Circumferential lumbar fusion 20 64.5 CT 6 MIS: 0.9±0.8 (atrophy
al26 erative disk disease (45 to 85) score)
Open: 1.4±1.1 (atrophy
score)
Mori et al20 Degenerative spon- L3-L4: 5.5% Group I: Modified spinous 53 63.5 MRI 12 Modified: -2%±8%
dylolisthesis L4-L5: 94.5% splitting fusion (n=27) (44 to 79) Open: -13%±7%
Group II: Conventional fusion
(n=26)
Stevens et - L4-L5: 100% Group I: MIS PLF 12 51.5 MRI (24 to 96) T2 relaxation time:
al27 Group II: Conventional PLF MIS: 47 ms
CF: 90 ms
Abbreviations: ALF, anterior fusion; ALIF, anterior lumbar interbody fusion; CF, circumferential fusion; CO, conventional; CT, computed tomography; LAM, laminectomy or
fenestration; LOVE, Love’s nucleotomy; MIS, minimally invasive; MRI, magnetic resonance imaging; OPF, open pedicle screw fixation; PLF, posterolateral fusion; PLIF, posterior
lumbar interbody fusion; PPF, percutaneous pedicle screw fixation.
dures.

posterior fusion cohorts.

approaches during fusion procedures.
Figure 3: Comparison of anterior and nonanterior
lar atrophy between fusion and nonfusion proce-
Figure 2: Comparison of mean paraspinal muscu-

ated the amount of PMA in 11 patients

dard midline, open lumbar procedures).

e213
interbody fusion (ALIF or PLIF) as well.
spondylolisthesis. All patients underwent
surgery were degenerative and isthmic
screw fixation (PPF). The indications for
fixation (OPF) compared with 8 patients
after an MIS procedure. Kim et al2 evalu-
concept showed less postoperative PMA
with conventional techniques (eg, stan-
A current topic of discussion is
anterior fusion cohort was approximately
up, they reported that mean PMA in the

Magnetic resonance imaging evaluation

who had received percutaneous pedicle
less postoperative PMA when compared
n Review Article

who had received open pedicle screw

Most of the studies that evaluated this
whether MIS lumbar surgery results in
6%, compared with 12% to 16% in the
PLIF (n=8). At a mean 16-month follow-
who had received either PLF (n=11) or
n Review Article
showed that the mean PMA in the ORF
cohort was approximately 31.5%, com-
pared with 3.5% in the PPF cohort. Fan
et al19 compared PMA in 16 patients who
had undergone PLIF using an MIS ap-
proach with 16 patients who had under-
gone a conventional open approach. Us-
ing MRI evaluations, they reported that
the mean PMA in the MIS cohort was
approximately 12.2%, compared with
36.8% in the conventional open cohort.
Few studies have attempted to correlate
clinical outcomes with postoperative
PMA using other metrics.19-22
Conclusion
According to the findings of the cur-
rent study, lumbar spinal fusions were
associated with significantly higher post-
operative PMA vs decompressions alone.
Anterior lumbar procedures resulted in
less PMA than equivalent posterior pro-
cedures. Furthermore, there may be less
postoperative PMA in MIS fusions com-
pared with non-MIS fusions. Further pro-
spective studies are necessary to evaluate
potential correlations of PMA with clini-
cal and patient-reported outcomes.
References
1. Sihvonen T, Herno A, Paljarvi L, Airaksinen
O, Partanen J, Tapaninaho A. Local denerva-
tion atrophy of paraspinal muscles in postop-
erative failed back syndrome. Spine (Phila Pa
1976). 1993; 18(5):575-581.
2. Kim DY, Lee SH, Chung SK, Lee HY. Com-
parison of multifidus muscle atrophy and
trunk extension muscle strength: percutane-
ous versus open pedicle screw fixation. Spine
(Phila Pa 1976). 2005; 30(1):123-129.
3. Fleckenstein JL, Watumull D, Conner KE,
et al. Denervated human skeletal muscle:
MR imaging evaluation. Radiology. 1993;
187(1):213-218.
4. Motosuneya T, Asazuma T, Tsuji T, Wata-
nabe H, Nakayama Y, Nemoto K. Postop-
erative change of the cross-sectional area of
back musculature after 5 surgical procedures
as assessed by magnetic resonance imaging.
J Spinal Disord Tech. 2006; 19(5):318-322.
5. Suwa H, Hanakita J, Ohshita N, Gotoh K,
Matsuoka N, Morizane A. Postoperative
changes in paraspinal muscle thickness af-
e214
ter various lumbar back surgery procedures.
Neurol Med Chir (Tokyo). 2000; 40(3):151-
154.
6. Bogduk N, Wilson AS, Tynan W. The human
lumbar dorsal rami. J Anat. 1982; 134(pt
2):383-397.
7. Sangala JR, Nichols T, Freeman TB. Tech-
nique to minimize paraspinal muscle atrophy
after posterior cervical fusion. Clin Neurol
Neurosurg. 2011; 113(1):48-51.
8. Boelderl A, Daniaux H, Kathrein A, Maurer
H. Danger of damaging the medial branches
of the posterior rami of spinal nerves during
a dorsomedian approach to the spine. Clin
Anat. 2002; 15(2):77-81.
9. Datta G, Gnanalingham KK, Peterson D, et
al. Back pain and disability after lumbar lam-
inectomy: is there a relationship to muscle
retraction? Neurosurgery. 2004; 54(6):1413-
1420.
10. de Coul AA, Lie TA. A comparative electro-
myographic study before and after operations
for protruded lumbar disc. Electromyogra-
phy. 1970; 10(2):193-199.
11. Hodges P, Holm AK, Hansson T, Holm S.
Rapid atrophy of the lumbar multifidus fol-
lows experimental disc or nerve root injury.
Spine (Phila Pa 1976). 2006; 31(25):2926-
2933.
12. Hyun SJ, Kim YB, Kim YS, et al. Postop-
erative changes in paraspinal muscle volume:
comparison between paramedian interfascial
and midline approaches for lumbar fusion. J
Korean Med Sci. 2007; 22(4):646-651.
13. Liberati A, Altman DG, Tetzlaff J, et al. The
PRISMA statement for reporting system-
atic reviews and meta-analyses of studies that
evaluate healthcare interventions: explana-
tion and elaboration. BMJ. 2009; 339:2700.
14. Slim K, Nini E, Forestier D, Kwiatkowski F,
Panis Y, Chipponi J. Methodological index
for non-randomized studies (minors): devel-
opment and validation of a new instrument.
ANZ J Surg. 2003; 73(9):712-716.
15. Khan M, Adamich J, Simunovic N, Philippon
MJ, Bhandari M, Ayeni OR. Surgical man-
agement of internal snapping hip syndrome:
a systematic review evaluating open and ar-
throscopic approaches. Arthroscopy. 2013;
29(5):942-948.
16. Banerjee S, Issa K, Kapadia BH, Pivec R,
Khanuja HS, Mont MA. Highly-porous met-
al option for primary cementless acetabular
fixation: what is the evidence? Hip Int. 2013;
23(6):509-521.
17. Rometsch E, Bos PK, Koes BW. Survival of
short hip stems with a “modern,” trochanter-
sparing design: a systematic literature review.
Hip Int. 2012; 22(4):344-354.
18. Huisstede B, Miedema HS, van Opstal T, de
Ronde MT, Verhaar JA, Koes BW. Interven-
tions for treating the radial tunnel syndrome:
a systematic review of observational studies.
J Hand Surg Am. 2008; 33(1):72-78.
19. Fan S, Hu Z, Zhao F, Zhao X, Huang Y, Fang
X. Multifidus muscle changes and clinical ef-
fects of one-level posterior lumbar interbody
fusion: minimally invasive procedure versus
conventional open approach. Eur Spine J.
2010; 19(2):316-324.
20. Mori E, Okada S, Ueta T, et al. Spinous
process-splitting open pedicle screw fusion
provides favorable results in patients with
low back discomfort and pain compared to
conventional open pedicle screw fixation
over 1 year after surgery. Eur Spine J. 2012;
21(4):745-753.
21. Gejo R, Matsui H, Kawaguchi Y, Ishihara
H, Tsuji H. Serial changes in trunk muscle
performance after posterior lumbar surgery.
Spine (Phila Pa 1976). 1999; 24(10):1023-
1028.
22. Fujimura Y, Nishi Y. Atrophy of the nuchal
muscle and change in cervical curvature af-
ter expansive open-door laminoplasty. Arch
Orthop Trauma Surg. 1996; 115(3-4):203-
205.
23. Watanabe K, Matsumoto M, Ikegami T, et
al. Reduced postoperative wound pain after
lumbar spinous process-splitting laminecto-
my for lumbar canal stenosis: a randomized
controlled study. J Neurosurg Spine. 2011;
14:51-58.
24. Tsutsumimoto T, Shimogata M, Ohta H, Mi-
sawa H. Mini-open versus conventional open
posterior lumbar interbody fusion for the
treatment of lumbar degenerative spondylo-
listhesis: comparison of paraspinal muscle
damage and slip reduction. Spine (Phila Pa
1976). 2009; 34:1923-1928.
25. Remes V, Lamberg T, Tervahartiala P, et al.
Long-term outcome after posterolateral, an-
terior, and circumferential fusion for high-
grade isthmic spondylolisthesis in children
and adolescents: magnetic resonance imag-
ing findings after average of 17-year follow-
up. Spine (Phila Pa 1976). 2006; 31:2491-
2499.
26. Hartwig T, Streitparth F, Gross C, et al. Digi-
tal 3-dimensional analysis of the paraverte-
bral lumbar muscles after circumferential
single-level fusion. J Spinal Disord Tech.
2011; 24:451-454.
27. Stevens KJ, Spenciner DB, Griffiths KL, et
al. Comparison of minimally invasive and
conventional open posterolateral lumbar fu-
sion using magnetic resonance imaging and
retraction pressure studies. J Spinal Disord
Tech. 2006; 19:77-86.
28. Kim K, Isu T, Sugawara A, Matsumoto R,
Isobe M. Comparison of the effect of 3 dif-
ferent approaches to the lumbar spinal canal
on postoperative paraspinal muscle damage.
Surg Neurol. 2008; 69:109-113.
Copyright © SLACK Incorporated