JOURNAL OF NEUROTRAUMA 29:1567–1573 (May 20, 2012)

ª Mary Ann Liebert, Inc.

DOI: 10.1089/neu.2011.2167

Posterolateral versus Posterior Interbody Fusion

in Isthmic Spondylolisthesis

Majid Reza Farrokhi, Abdolkarim Rahmanian, and Mohammad Sadegh Masoudi

Abstract
Spondylolisthesis is a heterogeneous disorder characterized by subluxation of a vertebral body over another in
the sagittal plane. Its most common form is isthmic spondylolisthesis (IS). This study aims to compare clinical
outcomes of posterolateral fusion (PLF) with posterior lumbar interbody fusion (PLIF) with posterior in-
strumentation in the treatment of IS. We performed a randomized prospective study in which 80 patients out
of a total of 85 patients with IS were randomly allocated to one of two groups: PLF with posterior instru-
mentation (group I) or PLIF with posterior instrumentation (group II). Posterior decompression was per-
formed in the patients. The Oswestry low back pain disability (OLBP) scale and Visual Analogue Scale (VAS)
were used to evaluate the quality of life (QoL) and pain, respectively. Fisher’s exact test was used to evaluate
fusion rate and the Mann-Whitney U test was used to compare categorical data. Fusion in group II was
significantly better than in group I ( p = 0.012). Improvement in low back pain was statistically more significant
in group I ( p = 0.001). The incidence of neurogenic claudication was significantly lower in group I than in
group II ( p = 0.004). In group I, there was no significant correlation between slip Meyerding grade and disc
space height, radicular pain, and low back pain. There was no significant difference in post-operative com-
plications at 1-year follow-up. Our data showed that PLF with posterior instrumentation provides better
clinical outcomes and more improvement in low back pain compared to PLIF with posterior instrumentation
despite the low fusion rate.

Key words: clinical outcome; fusion rate; isthmic spondylolisthesis; posterior lumbar interbody fusion; postero-
lateral fusion

Introduction Symptoms are usually related to axial back pain and

the sequelae of neural compression (McCulloch, 1998). The

S pondylolisthesis is a heterogeneous disorder charac-

terized by the subluxation of a vertebral body over
another in the sagittal plane (Le Roux and Winn, 2003). It
represents a particular and relatively frequent mechanism of
intervertebral instability, and occurs most frequently at the
L4–L5 and L5–S1 interspaces (Fischgrund et al., 1997; Ganju,
2002). The first case of lumbosacral spondylolisthesis was
described by Herbinaux (1782) in 1772. Spondylolisthesis has
been classified into five types, among which isthmic spon-
dylolisthesis (IS) is the most common form (Ganju, 2002). This
failure is caused by a defect in the pars interarticularis; it oc-
curs in 4–8% of the general population in individuals of all
ages (Fredrickson et al., 1984; Ganju, 2002; Jones and Rao,
2009; La Rosa et al., 2003).
A majority of patients with spondylolisthesis are asymp-
tomatic. Neurological symptoms are common with spon-
dylolisthesis (Fischgrund et al., 1997; McCulloch, 1998).
nerve root deficits and leg pains involve foraminal stenosis
caused by a combination of a fibrocartilaginous mass at
the isthmic defect, disc, and osteophyte of the slipped
body (Ming-li et al., 2009). Complete decompression of nerve
roots is essential to obtain a better prognosis and a good
surgical outcome, as is the need for stabilization (Wenger
et al., 2005).
The initial treatment for patients with low-grade spondy-
lolisthesis is nonsurgical, and consists of a combination of
pain medications, bracing, and physical therapy. The surgical
treatment of spondylolisthesis is indicated for failure of con-
servative management (Zdeblick, 1993). It typically consists of
a fusion procedure with or without neural decompression
(McCulloch, 1998). Orthopedic spinal surgeons and neuro-
surgeons use instrument-assisted posterolateral fusion (PLF),
and posterior lumbar interbody fusion (PLIF) as two common
techniques to treat IS. PLF using a pedicle screw system is the

Neurosurgery Department, Shiraz Neurosciences Research Center, Shiraz University of Medical Sciences, Shiraz, Iran.

1567
1568
most popular spinal fusion technique to treat IS (Dehoux et al.,
2004; Ekman et al., 2005; Lamberg et al., 2005).
We have found a few studies comparing the use of PLF and
PLIF, both with posterior instrumentation, for the treatment
of IS (Dehoux et al., 2004; Ekman et al., 2007; La Rosa et al.,
2003; Madan and Boeree, 2002; Müslüman et al., 2011). Be-
cause each of these techniques has different clinical outcomes,
functional improvements, and neurological complications,
the ideal surgical treatment for IS is still controversial (Dai
et al., 2001). This randomized prospective study aims to
evaluate the clinical outcomes of PLF with posterior instru-
mentation and PLIF with posterior instrumentation in pa-
tients with IS, and to compare the efficacy and complications
of these techniques.
Methods
Study design
We performed a randomized prospective study, in which
80 patients out of a total of 85 patients, 18 men and 62 women
aged 18–65 years with lumbar IS were eligible to participate,
and were enrolled from September 2008 to March 2010. A 1-
year follow-up was planned from March 2010 to March 2011.
A general practitioner not only assessed 85 patients for eligi-
bility, but also evaluated baseline characteristics of eligible
patients before randomization. Eligible participants were
randomly assigned to two groups by opening sealed enve-
lopes. The envelopes were prepared beforehand and sorted
randomly by using random allocation software (computer-
ized random number generators). Forty patients were oper-
ated on with PLF with posterior instrumentation (group I)
and 40 were operated on with PLIF with posterior instru-
mentation (group II). The surgeon was aware of the procedure
and all patients were followed by two radiologists who were
unaware of the study. A rater, who was likewise unaware of
the study, verified the results. The radiologists and the rater
were not involved in the care of the patients. Written informed
consent was obtained from all patients, and the medical re-
search ethics committee of Shiraz University of Medical Sci-
ences approved the study on March 18, 2009 with approval
number 2732.
Patients and evaluations
During the period from September 2008 to March 2010, 85
patients were selected for participation, and 80 patients with
lumbar IS were randomized. We excluded 5 patients in ac-
cordance with the exclusion criteria. Of the 80 remaining pa-
tients, 40 were assigned to undergo PLF with posterior
instrumentation and 40 to be operated on with PLIF with
posterior instrumentation. The population consisted of 10
men and 30 women in group I, and 9 men and 31 women in
group II. Mean ages for groups I and II were 49.66 – 9.01 year
and 50.35 – 11.30 year, respectively. Mean weight was
72 – 12.55 kg in group I and 73.47 – 12 kg in group II. Isthmic
form was confirmed by lateral and oblique simple and dy-
namic graphs of the lumbosacral area and computed tomog-
raphy (CT) scans of the pars interarticularis. Other specified
forms with no fracture in the pars interarticularis were re-
garded as non-isthmic. Neurogenic claudication was one of
the symptoms related to this disease in our patients. The pa-
tients had mild to severe hamstring spasms.
FARROKHI ET AL.
Inclusion criteria
The inclusion criteria were: (1) IS; (2) no previous spine
operation; (3) age between 18 and 65 years; (4) failed conser-
vative therapy including rest and pain medication, lumbosa-
cral orthosis, and physical therapy, at least for 6 months; and
(5) hamstring spasm.
Exclusion criteria
The exclusion criteria were: (1) non-isthmic spondylolisth-
esis; (2) the need for performing discectomy in group I pa-
tients; (3) infection; (4) generalized bone disease; and (5)
osteoporosis.
Radiological evaluation
The patients’ complete neurological examinations, per-
sonal data, and radiological findings were added to the pre-
operative part of the questionnaire. Pre-operative radiological
evaluation included static and functional lumbar spine plain
x-rays, four views: anteroposterior (AP), and lateral, right,
and left obliques, in which features relevant to spondylo-
listhesis, including percentage of subluxation, severity of slip,
slippage angle, and height of intervertebral disc space were
evaluated. CT scans and magnetic resonance imaging (MRI)
scans of the lumbosacral area without gadolinium injection
were used to assess narrowing intervertebral foramens, and
the presence or absence of lumbar spinal stenosis. If the disc
space height reduction was the same as that detected in the
upper level, this was considered to be normal disc space
narrowing; 25% reduction was considered to be mild disc
space narrowing, 25–49% reduction was considered to be
moderate disc space narrowing, and a reduction of height
more than 50% was considered to be severe disc space nar-
rowing.
Operative technique
The patients were carefully placed prone, a one skin inci-
sion about 11 cm in length was made in the midline. Spinous
processes, laminae, and the bilateral facets were exposed.
Posterior decompression, consisting of the removal of the
spinous process, bilateral laminectomy, partial bilateral face-
tectomy, and foraminotomy, was performed. Complete dis-
cectomy and total disc resection was performed with
preservation of both vertebral endplates only in group II.
Fluoroscopically-guided transpedicular fixation was per-
formed at the involved level and its caudal vertebra as a
standard technique. The nerve root release procedure was the
same in both groups. In group I, after performing neural de-
compression, the osseous surfaces of the transverse processes
and facets were decorticated using a high-speed drill to ex-
pose cancellous bone and facet joints. Intertransverse fusion
was performed by using bone chips from the resected lamina,
mixed with synthetic bone substitute granules (Medical Bio-
mate Inc., Warsaw, IN).
In both groups, medfield spine system II (MSS II) was used
for posterior pedicular fixation. We used autologous bone
graft from the excised loose lamina and spinous process
mixed with synthetic bone substitute granules to achieve fu-
sion. Fusion rate was qualitatively measured after 1 year.
Constant solid ossification, segmental ossification, and lack of
ossification were considered good, fair, and bad, respectively.
SPINAL FUSION IN SPONDYLOLISTHESIS 1569

In addition, the subluxation in dynamic post-operative Table 1. Preoperative Quality of Life

radiographies was considered to be bad fusion. Successful and Severity of Radicular Pain in Groups I and II
fusion was defined as the integrated ossification at the fusion
Radicular QoL
bed without motion in a dynamic graph.
Groups pain (VAS) (OLBP)
Outcome measures I (n = 40)
Mean 5.6 47.7
The degree of spondylolisthesis and severity of slip was
SD 2.23 1.85
determined according to the Meyerding classification (Meyerd- Median 6.00 44
ing, 1932). All 80 patients completed a questionnaire regarding II (n = 40)
pain and lower back pain (LBP)-related disability. Evaluation Mean 5.8 43.3
measures were performed before randomization and 1 year after SD 2.01 1.17
the operation. Quality of life (QoL) or functional daily activity Median 6.00 43
and severity of LBP were evaluated using a questionnaire based Total
on the Oswestry LBP disability scale (Fairbank et al., 1980), Mean 5.7 43.8
and the severity of radicular pain was evaluated by using the SD 2.12 1.03
Huskisson Visual Analogue Scale (VAS), with scores ranging Median 6.00 43
from 1 (no pain) to 10 (excruciating pain) at the first week and QoL, quality of life; VAS, Visual Analogue Scale; OLBP, Oswestry
1 year after the surgery. low back pain disability; SD, standard deviation.

Statistical analysis II (Table 2). Over a 3-day hospitalization period, group II

Statistical analysis was conducted using the paired Stu- patients received more narcotic doses than group I patients,
dent’s t-test to compare continuous intragroup data (per- and this was statistically significant ( p = 0.016).
centage of subluxation, foraminal area, disc height, and Other clinical parameters were measured 1 year after sur-
slippage angle), and the unpaired t-test was used to compare gery. The percentage of patients who had complaints of
intergroup data. Fisher’s exact test was used to evaluate fu- neurogenic claudication 1 year after the operation was sig-
sion rate, and the Mann-Whitney U test was used to compare nificantly higher in group II than in group I (33.3% versus
categorical data (VAS and OLBP). Statistical significance was 7.3%; p = 0.004).
set at p < 0.05. The difference of OLBP score of low back pain was ob-
tained by subtracting the pre-operative OLBP score from the
OLBP score 1 year after the operation. Improvement in QoL in
Results
group I was statistically significantly more than in group II
In our study, 18 men (22.5%) and 62 women (77.5%) were (25 – 9.36 versus 17.10 – 12.98; p = 0.001; Table 3).
assigned to either group I or group II. Distribution of age, One of the other clinical symptoms was the presence of
weight, height, and body mass index was measured, but there tenderness in the surgical field at 1 year after the operation. It
was no statistically significant difference between the two was significantly more prevalent in group II patients (42.5%)
groups. In all, 70% of patients had mild hamstring spasms, than group I patients (20%; p = 0.025).
25% had moderate hamstring spasms, and 5% had severe There was no correlation between blood group, job, and
hamstring spasms. Major complaints were neurogenic clau- underlying diseases in the patients and improvement in ra-
dication, radicular pain, and low back pain. dicular pain and LBP.
In both men and women, the number of patients who had
IS at the L5–S1 level was more than for the other levels. The Radiological results
most involved levels in decreasing order were L5–S1 (36 cases,
In our patients, 17.6% had normal disc space narrowing,
45%), L4–L5 (28 cases, 35%), and L3–L4 (10 cases, 12.5%). In
34.1% had mild disc space narrowing, 32.9% had moderate
cases of involvement at more than one level, the involvement
disc space narrowing, and 15.3% had severe disc space nar-
of L3–L4 and L4–L5 levels (5 cases, 6.25%) was more than the
rowing. In group I, there was no significant correlation be-
involvement of L4–L5 and L5–S1 levels (1 case, 1.25%), es-
tween slip Meyerding grade and disc space height, radicular
pecially in women. Preoperative patient family history re-
pain, and LBP. It seemed that an increase of the slip and more
vealed a 21.1% incidence of IS in first-degree relatives.
reduction of disc height decreased the improvement of
We observed preoperative neurogenic claudication in 38
(95%) in the PLF group, and in 36 (90%) in the PLIF group.
There was no statistically significant difference in the preva- Table 2. Radicular Pain and Low Back Pain
lence of preoperative neural symptoms such as neurogenic in Groups I and II 3 Days Post-Surgery
claudication in the two groups ( p = 0.183). Table 1 shows
preoperative QoL and severity of radicular pain in groups I Mean rank Mean – p
and II. The patients’ preoperative MRI scans showed no sta- Parameters Groups (median) SD Value
tistically significant difference for the presence of interverte-
bral foraminal stenosis, improvement in radicular pain Low back pain I 35.41 2.25 – 1.34 0.0001
II 54.09 3.52 – 1.76
( p = 0.242), and LBP ( p = 0.416) in the two groups.
Radicular pain I 42.43 1 – 0.98 0.504
There was no statistically significant difference in im- II 45.85 1.2 – 1.58
provement of radicular pain in both groups 3 days after sur-
gery, but LBP in group I was statistically lower than in group SD, standard deviation.
1570
Table 3. Improvement in Low Back Pain
in Groups I and II According to the Oswestry Low
Back Pain Scale 6 Months after Surgery
Parameters Groups Mean rank Mean – SD p Value
Low back I 51.00 25.34 – 9.36 0.001
pain II 33.11 17.10 – 12.98
SD, standard deviation.
radicular pain and LBP in group II, but the difference was not
statistically significant.
There was no significant correlation between number of
fusion levels (2 vertebrae at one-level listhesis and 3 vertebrae
at two-level listhesis) and functional outcome of the patients
in groups I and II. Table 4 shows the frequency of the patients
with good, fair, and bad fusion in both groups after 1 year.
Intraoperative blood loss in group II was significantly more
than in group I (Table 5). Surgical duration in the PLIF group
was more than in the PLF group, but there was no statistically
significant difference between the two groups ( p = 0.707).
There was no significant difference between post-operative
complications in the short-term 1-year follow-up period in the
two groups (Table 6).
Discussion
Instrument-assisted PLF and instrument-assisted PLIF are
the two most common techniques for the surgical treatment of
IS. Various other minimally-invasive techniques such as ex-
treme lateral interbody fusion/direct lateral interbody fusion
(XLIF/DLIF), and transforaminal lumbar interbody fusion
(TLIF) are also commonly used for fusion in IS, but there are
few concise studies available on these techniques and their
comparison to PLF or PLIF (Gong et al., 2010; Goyal et al.,
2009; Harms and Jeszenszky, 1998; Kwon et al., 2003; Oliveira
et al., 2010). In this study, our findings suggest that PLF with
posterior instrumentation provides better clinical outcomes,
and improvement in low back pain and QoL, despite the low
fusion rate compared to PLIF with posterior instrumentation.
There was no significant difference in the improvement in
radicular pain immediately after the operation in the two
groups, but the improvement in LBP 3 days after the opera-
tion in the patients who were operated on using PLF with
posterior instrumentation was significantly more than in the
patients who were operated on with PLIF with posterior in-
strumentation. It seems that foraminotomy without dis-
cectomy is sufficient to reduce radicular pain. More LBP was
seen in the patients of group II immediately after the opera-
tion and 1 year post-operatively, and this may be due to end-
plate injury during discectomy and manipulation of the dura,
Table 4. Frequency of the Patients with Good, Fair,
and Bad Fusion in Groups I and II after 6 Months
Fusion
Groups Fair + bad Good p Value
I 33.3% 66.7% 0.012
II 10.9% 89.1%
Total 21.2% 78.8%
FARROKHI ET AL.
Table 5. Comparison of Intraoperative
Blood Loss in Groups I and II
Mean Mean – SD p
Parameters Groups rank (mL) Value
Intraoperative I 38.51 747.87 – 439 0.04
blood loss II 49.51 873.07 – 370.24
SD, standard deviation.
which can also be the cause of the mild tenderness seen in the
patients who underwent PLF compared to those with PLIF.
The need for careful and gentle release and retraction of the
nerve roots and dura in discectomy and appropriate inter-
body fusion in PLIF patients were the reasons why the pro-
cedure was longer in the PLIF group than in the PLF group.
Re-assessment of the improvement in radicular pain 1 year
after the operation showed that there was no significant dif-
ference between the two groups. In contrast with the findings
reported by Dantas and associates (2007), who reported that
the improvement in radicular pain was 82% in the PLF group
and 85.5% in the PLIF group, no statistically significant dif-
ference was found between the two groups. Inamdar and
colleagues (2006) reported that PLF with posterior instru-
mentation provides more improvement in radicular pain than
PLIF with posterior instrumentation. Our study showed that
the improvement of LBP in group I was more significant than
in group II. Inamdar’s group strongly supported our findings
and reported that the improvement of low back pain was
100% in the patients who were operated on with PLF with
posterior instrumentation and 80% in the patients who were
operated on with PLIF with posterior instrumentation. Ma-
dan and Boeree (2002) showed that clinical outcome was good
in 81% of patients who underwent PLF with posterior in-
strumentation, and 69.5% of patients who underwent PLIF
with posterior instrumentation. Our finding that PLF with
posterior instrumentation provides better clinical outcomes
than PLIF with posterior instrumentation replicates the find-
ings of these studies (Inamdar et al., 2006; Madan and Boeree,
2002).
Neurogenic claudication is a clinical syndrome due to
lumbar spinal stenosis, or inflammation of the nerves ema-
nating from the spinal cord. Neurogenic means that the
problem originates from a nerve, and claudication, from the
Latin for limp, describes the painful cramping or weakness in
the legs (Comer et al., 2009). Dantas and associates (2007)
observed neurogenic claudication in 19 patients (63.3%) in the
PLF group, and in 11 patients (36.6%) in the PLIF group, and
reported that it was improved in all cases. However, in our
study, despite posterior decompression of spinal canal and
nerve roots that was performed completely in both groups,
Table 6. Prevalence of Postoperative
Complications in Groups I and II
Group I Group II p
Complications (%) (%) Value
Cerebrospinal fluid leak 4.3 5 0.999
Infection 2.1 2.5 0.699
Permanent motor impairment 4.3 5 0.999
SPINAL FUSION IN SPONDYLOLISTHESIS
the number of the patients who had complaints of neurogenic
claudication 1 year after the operation was significantly more
in the PLIF group with posterior instrumentation than in the
PLF group with posterior instrumentation. As there was no
significant difference between the two groups before the op-
eration, the complaints might be because of the performed
discectomy, and an increased risk of more extensive epidural
fibrosis formation.
Some studies state that the use of narcotics in most cases
with IS may be appropriate for managing pain (Agabegi and
Fischgrund, 2010; O’Brien, 2003). Over the hospitalization
period, the higher rate of narcotic use in group II patients for
the reduction of post-operative pain showed that PLIF with
posterior instrumentation is a more painful procedure than
PLF with posterior instrumentation.
Similarly to the findings of most recent studies (Dehoux
et al., 2004; Kim et al., 2010; Tsirikos and Garrido, 2010), ex-
cept Inamdar and associates (2006), who reported the same
fusion rate in both groups, we found significantly higher fu-
sion rates in patients who underwent PLIF rather than PLF
with posterior instrumentation. It could be due to more fusion
bed and performing fusion under compression (Wolff’s law),
which was closer to the normal physiology of load-bearing of
the anterior spinal column. We believe a 1-year follow-up
period is inadequate to evaluate fusion, and fusion rates
should be determined at a later time period than 1 year, be-
cause the PLF technique probably requires more time to
achieve fusion.
Similarly to Kho and Chen (2008), we used the bone chips
obtained from laminectomy and posterior decompression
mixed with synthetic bone substitute granules to achieve fu-
sion. Farrokhi and colleagues (2010) reported that regarding
fusion with either autologous bone or tricalcium phosphate
granules, and whether or not decompressive laminectomy
had been performed, there were no significant differences.
Because the amount of the material used for fusion in groups
I and II was substantially different, it was not possible to
find a prognostic statistical difference. However, the use of
more material was associated with better fusion rates and
more improvement in LBP in both groups at 1 year after the
operation.
Excessive bleeding, often requiring multiple blood trans-
fusions, can cause not only hemodynamic changes, but also
fever and complications following the injection of allogenic
blood (Farrokhi et al., 2011; Rhine and Menard, 1991). Möller
and Hedlund (2000) showed that supplementary pedicle
screw fixation in adult IS increased the total blood loss. Clo-
ward (1985) reported that despite increased the fusion rate of
the PLIF technique, it was associated with complications re-
lated to blood loss. Yehya (2010) reported that the in-
traoperative blood loss among the patients undergoing either
transforaminal lumbar interbody fusion or PLIF was not sig-
nificantly different. In our study, intraoperative blood loss in
the patients who underwent PLIF was significantly more than
those who were operated on with PLF with posterior instru-
mentation, and there was a significant difference between
intraoperative blood loss in the two groups. Our data con-
flicted with the findings of the study conducted by Ohtori and
associates (2011), in which they reported more blood loss in
the PLF patients. However, similarly to our findings, Ming-li
and colleagues (2009) found that PLF gives rise to less blood
loss.
1571
The prevalence of multiple-level spondylolisthesis, that is
spondylolisthesis in more than one level, is rare. Only a few
articles have reported on multiple-level spondylolysis in the
lumbar spine and its treatment (Al-khawashki and Al-sebai,
2001; Al-sebai and Al-khawashki, 1999; Chang et al., 2000;
Eingorn and Pizzutillo, 1985; Mathiesen et al., 1984). Wong
(2004) reported a rare multi-level IS in a patient following an
acute onset of low back pain. Al-sebai and Al-khawashki
(1999) reported a case with a combination of multiple bilateral
spondylolyses at L2, L3, and L4, spondylolisthesis at L3–L4,
spondyloptosis at L4–L5, and sacralization of L5. In our study,
the most involved level was L5–S1, and the involvement of
L3–L4 and L4–L5 levels was more than the involvement of
L4–L5 and L5–S1 levels. Although most of our patients had
pars interarticularis defects at L5, the number of the patients
with involvement at L4 was remarkable, perhaps because of
our patients’ spinal anatomy, and the difference in the force
exerted on the spine. Wiltse and Winter (1983) reported that
the site of IS was at L5 in 90% of cases and L4 in 5%. They
showed less involvement at the L4 vertebra compared to our
study.
Although the genetic basis of IS is unknown, one possibility
can be inferred from the increased incidence of the disease in
first-degree relatives of patients with IS (Meyerding, 1932).
Wynne-Davies and Scott (1979) showed that the close rela-
tives of patients with IS had a 15% chance of having a similar
lesion. Some studies have reported that the incidence in close
relatives is about 25–30% (Al-sebai and Al-khawashki, 1999;
Ganju, 2002; Wiltse and Rothman, 1989). In our study, pre-
operative patient family history revealed a 21.1% incidence of
IS in first-degree relatives of the patients, unrelated to the
degree of improvement in LBP. Family history can help us
predict the predisposition of a patient to IS. These findings
necessitate further investigation of IS in close relatives of the
patients.
Conclusions
Compared with PLIF, the improvement in LBP and QoL
was better in patients who underwent PLF with posterior
instrumentation. In this study, PLF with posterior instru-
mentation is recommended for patients with IS, because the
procedure is simple, has fewer neurological deficits and less
blood loss, as well as better clinical outcomes, especially in
patients in whom most complaints are about LBP rather than
radicular pain. Our results extend only 1 year, and other
conclusions about the advantages of each procedure will re-
quire longer follow-up.
Acknowledgments
The authors would like to thank Ms. Hosseini of the Shiraz
Neurosciences Research Center (SNRC) for her kind assis-
tance, and the Vice-Chancellor for Research Affairs of Shiraz
University of Medical Sciences and Apadana Tajhizgostar Co.
for their financial support. We also wish to thank Ms. Gholami
of SNRC for translating the manuscript, and Dr. Sedighi for
improving the English in the manuscript.
Author Disclosure Statement
No competing financial interests exist.
1572
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Address correspondence to:
Majid Reza Farrokhi, M.D.
Shiraz Neurosciences Research Center
Chamran Hospital
Chamran Boulevard
P.O. Box 7194815644
Shiraz, Iran
E-mail: farrokhimr@yahoo.com
or
farokhim@sums.ac.ir