Is it a requirement or a preference to use cross-links in lumbar instrumentation?

Should cross-links be used?



Internal fixators, Pedicle screws, Pseudoarthrosis, Lumbar vertebrae


Background/Aim: The use of cross-links (CL) is controversial due to reasons such as cost increases and instrument redundancy. While there are many biomechanical studies, the clinical data is limited. The aim of this study is to present the clinical effects of CL by putting forward postoperative clinical outcomes and long-term results of patients with (CL+) and without (CL-) CL augmentation.

Methods: In this retrospective cohort study, patients who underwent lumbar posterior instrumentation with CL+ (n = 164) and without CL- (n = 111) augmentation were evaluated. Demographic data, surgical results, preoperative and postoperative visual analogue scale (VAS), the Oswestry Disability Index (ODI) differences, and pseudoarthrosis and adjacent segment disease (ASD)-related recurrence for more than three years of follow-up were determined. Data of CL+ and CL- groups were compared.

Results: CL+ and CL- groups were similar in terms of age and gender (P = 0.319 and P = 0.777, respectively) There was no difference between the two groups in terms of bleeding amount, duration of surgery, and duration of hospitalization (P = 0.931, P = 0.669 and P = 0.518, respectively). Groups were similar in terms of VAS and ODI differences (P = 0.915 and P = 0.983, respectively), yet there was one case of infection in the CL+ group and two cases of infection detected in the CL- group. There were 13 ASDs in the CL+ group, and eight ASDs in the CL- group. Pseudoarthrosis was seen seven times in the CL+ group, while it was four in the CL- group.

Conclusion: It was observed that adding CL in patients who underwent lumbar instrumentation did not change the early period surgical results. The prevalence of complications was compatible with the scientific literature. In our study, there was no preventive advantage in terms of clinical or postoperative complications found in the use of CL.


Download data is not yet available.


Kalichman L, Cole R, Kim DH, Li L, Suri P, Guermazi A, et al. Spinal stenosis prevalence and association with symptoms: Framingham study. Spine J. 2009;9(7):545–50. DOI:

Yabuki S, Fukumori N, Takegami M, Onishi Y, Otani K, Sekiguchi M, et al. Prevalence of lumbar spinal stenosis, using the diagnostic support tool, and correlated factors in Japan: a population-based study. J Orthop Sci. 2013 Nov;18(6):893–900. DOI:

Schneider M, Ammendolia C, Murphy D, Glick R, Piva S, Hile E, et al. Comparison of non-surgical treatment methods for patients with lumbar spinal stenosis: protocol for a randomized controlled trial. Chiropr Man Ther. 2014 May 10;22:19. DOI:

Sengupta DK, Herkowitz HN. Lumbar spinal stenosis. Treatment strategies and indications for surgery. Orthop Clin North Am. 2003 Apr;34(2):281-95. DOI:

Weinstein JN, Lurie JD, Olson PR, Bronner KK, Fisher ES. United States’ trends and regional variations in lumbar spine surgery: 1992-2003. Spine. 2006 Nov 1;31(23):2707-14. DOI:

Zdeblick T A. A prospective, randomized study of lumbar fusion: preliminary results. Spine Phila Pa 1976 . 1993 Jun 15;18(8):983–91. DOI:

Cornaz F, Widmer J, Snedeker JG, Spirig JM, Farshad M. Cross-links in posterior pedicle screw-rod instrumentation of the spine: a systematic review on mechanical, biomechanical, numerical and clinical studies . Eur Spine J. 2021 Jan; 30(1):34-49. DOI:

Brodke DS, Bachus KN, Mohr RA, Nguyen BK. Segmental pedicle screw fixation or cross-links in multilevel lumbar constructs. A biomechanical analysis. Spine J. 2001 Sep-Oct; 1(5):373–9. DOI:

Arand M, Wilke HJ, Schultheiss M, Hartwig E, Kinzl L, Claes L. Comparative stability of the “internal fixator” and the “universal spine system” and the effect of crosslinking transfixating systems. A biomechanical in vitro study. Biomed Tech. 2000 Nov; 45(5):311–6. DOI:

Wahba GM, Bhatia N, Bui CNH, Lee KH, Lee TQ. Biomechanical evaluation of short-segment posterior instrumentation with and without crosslinks in a human cadaveric unstable thoracolumbar burst fracture model. Spine Phila Pa 1976. 2010 Feb 1;35(3):278–5. DOI:

Lehman RA, Dimitriev AE, Wilson KW. Biomechanical analysis of the C2 intralaminar fixation technique using a cross- link and offset connector for an unstable atlantoaxial joint. Spine J. 2012 Feb;12(2):151–6. DOI:

Shaw MN, Morel EP, Utter PA , Gussous YM, Ginoux L, Berglund LJ, et al. Transverse connectors providing increased stability to the cervical spine rod-screw construct: an in vitro human cadaveric study. Lab invest J Neurosurg Spine. 2011 Jun;14(4):719–25. DOI:

O’Brien JR, Dmitriev AE, Yu W , Gelb D, Ludwig S. Posterior-only stabilization of 2-column and 3-column injuries at the cervicothoracic junction: a biomechanical study. J Spinal Disord Tech. 2009 Jul; 22(5):340–6. DOI:

Kuklo TR, Dmitriev AE, Cardoso MJ, Lehman Jr RA, Erickson M, Gill NW. Biomechanical contribution of transverse connectors to segmental stability following long segment instrumentation with thoracic pedi cle screws. Spine Phila Pa 1976. 2008 Jul 1; 33(15):E482–7. DOI:

Doulgeris JJ, Aghayev K, Gonzalez-Blohm SA, Valle M D, Waddell J, William LE, et al. Comparative analysis of posterior fusion constructs as treatments for middle and posterior column injuries: an in vitro biomechanical investigation. Clin Biomech. 2013 Jun;28(5):483–9. DOI:

Kulkarni AG, Dhruv AN, Bassi AJ. Should we cross the cross-links? Spine (Phila Pa 1976). 2013 Aug 15;38(18):E1128-34. DOI:

Garg S, Niswander C, Pan Z, Erickson M. Cross-links do not improve clinical or radiographic outcomes of posterior spinal fusion with pedicle screws in adolescent idiopathic scoliosis: A multicenter cohort study. Spine Deform. 2015 Jul; 3(4):338–44. DOI:

Sato S, Yagi M, Machida M, Yasuda A, Konomi T, Miyake A ,et al. Reoperation rate and risk factors of elective spinal surgery for degenerative spondylolisthesis: minimum 5-year follow-up. Spine J. 2015 Jul 1;15(7):1536–44. DOI:

Lad SP, Babu R, Ugiliweneza B, Patil CG, Boakye M. Surgery for spinal stenosis: long-term reoperation rates, health care cost, and impact of instrumentation. Spine. 2014 May 20;39(12):978–87. DOI:

Radcliff K, Curry P, Hilibrand A, Kepler C, Lurie J, Zhao W, et al. Risk for adjacent segment and same segment reoperation after surgery for lumbar stenosis: a subgroup analysis of the Spine Patient Outcomes Research Trial (SPORT). Spine. 2013 Apr 1;38(7):531–9. DOI:

El-Gindi S, Aref S, Salama M. Infection of intervertebral discs after operation. J Bone Joint Surg Br. 1976 Feb;58(1):114–6. DOI:

Deyo RA, Cherkin DC, Loeser JD, Bigos SJ, Ciol MA. Morbidity and mortality in association with operations on the lumbar spine. J Bone Joint Surg Am. 1992 Apr;74(4):536–43. DOI:

How NE, Street JT, Dvorak MF, Fisher CG , Kwon BK, Paquette S, et al. Pseudarthrosis in adult and pediatric spinal deformity surgery: a systematic review of the literature and meta-analysis of incidence, characteristics, and risk factors. Neurosurg Rev. 2019 Jun; 42(2):319–36 DOI:

Bradford DS, Tay BKB, Hu SS. Adult scoliosis: surgical indications, operative management, complications, and outcomes. Spine (Phila Pa 1976). 1999 Dec 15;24(24):2617–29. DOI:

Yadla S, Maltenfort MG, Ratliff JK, Harrop JS. Adult scoliosis surgery outcomes: a systematic review. Neurosurg Focus. 2010 Mar;28(3):E3. DOI:

Lynn G, Mukherjee DP, Kruse RN, Sadasivan KK, Albright JA. Mechanical stability of thoracolumbar pedicle screw fixation: the effects of crosslinks. Spine. 1997 Jul 15;22(14):1568-72. DOI:






Research Article

How to Cite

Tunçkale T, Engin T. Is it a requirement or a preference to use cross-links in lumbar instrumentation? : Should cross-links be used?. J Surg Med [Internet]. 2022 Dec. 1 [cited 2023 Feb. 6];6(12):943-6. Available from: