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1.  Preliminary Report of Instrumentation in Tuberculous Lumbosacral Spine 
Malaysian Orthopaedic Journal  2014;8(3):15-21.
The aims of spinal tuberculosis treatment are to eradicate the disease, to prevent the development of paraplegia and kyphotic deformity, to manage the existing deformity and neurological deficit, to allow early ambulation and to return the patient back to daily life. Methods for the treatment of tuberculosis of vertebra are still controversial. Conservative treatment includes medical therapy as well as external supports and surgery is indicated for deformity of spine, severe pain, or neurological compromise conditions. Most cases in our country were late presentations with disc space already infected, and after débridement there was a large gap needing bone graft to enhance bony fusion and anterior column support. Although the spine was infected, instrumentation posed no additional hazard in terms of tuberculous discitis. Oga et al. reported that M. tuberculosis has low adhesion capability and forms only a few microcolonies surrounded by a biofilm. Moon et al. stated that interbody fusion performed with classical anterior radical surgery per se was ineffective in the correction of kyphosis and did not prevent the increase in kyphosis angle. The present study focuses on collected clinical and radiographic outcomes in ten patients who underwent Posterior Lumbar Interbody Fusion (PLIF) for tuberculous lumbosacral spine. All the cases had instability with kyphotic deformity or loss of lordosis. Clinical outcomes were measured by Visual Analogue Scale (VAS), modified MacNab Criteria, and radiographic outcomes (segmental kyphotic angle and total lumbar lordotic, TLL, angle) on follow-up to six months. The mean VAS back scores showed decrease, and kyphotic angles and lordotic angles improved. Three cases had excellent results, six good and one fair using the modified MacNab criteria.
PMCID: PMC4536394  PMID: 26401230
Spinal tuberculosis, Posterior Lumbar Interbody Fusion, Visual Analogue Scale, MacNab criteria
2.  Surgical Management of Pyogenic Discitis of Lumbar Region 
Asian Spine Journal  2014;8(2):177-182.
Study Design
Retrospective review of patients who had pyogenic discitis and were managed surgically.
To analyze the bacteriology, pathology, management and outcome of pyogenic discitis of the lumbar region treated surgically.
Overview of Literature
Surgical management of pyogenic discitis is still an infrequently used modality of treatment.
A total of 42 patients comprised of 33 males and 9 females who had pyogenic discitis with a mean age of 51.61 years (range, 16-75 years) were included in this study. All the cases were confirmed as having pyogenic discitis by pus culture report and histopathological examination. The mean follow-up period was 41.9 months.
Debridement and posterior lumbar interbody fusion with autologous iliac bone graft was done in all cases. Thirteen (30.95%) patients had other medical co-morbidities. Five cases had a previous operation of the spine, and three cases had a history of vertebral fracture. Three patients were operated for gynaecological problems, and four cases had a history of urological surgery. L4-5 level was the most frequent site of pyogenic discitis. The most common bacterium isolated was Staphylococcus aureus (S. aureus). Radiologically good fusion was seen in the majority of patients.
Pyogenic discitis should be suspected in people having pain and local tenderness in the spinal region with a rise in inflammatory parameters in blood. The most common bacterium was S. aureus, but there were still a greater number of patients infected with other types of bacteria. Therefore, antibiotics therapy should be started only after isolating the bacteria and making the culture sensitivity report.
PMCID: PMC3996342  PMID: 24761200
Pyogenic; Infection; Discitis; Antibiotics
3.  Comparative study of PILF and TLIF treatment in adult degenerative spondylolisthesis 
European Spine Journal  2008;17(10):1311-1316.
This study is to compare the therapeutic effect of posterior lumbar interbody fusion (PLIF) and transforaminal lumbar interbody fusion (TLIF) with pedicle screw fixation on treatment in adult degenerative spondylolisthesis. A retrospective analysis of 187 patients to compare the complications and associated predictive factors of the two techniques of one level lumbar fusion. Ninety-one had PLIF with two cages and pedicle fixation (group 1), and ninety-six had TLIF with one cage and pedicle fixation (group 2). The two groups had similar age and sex distribution, and level of pain. Inclusion criteria and outcome measurements were identical in both groups. The two groups were operated on with autograft and cage with pedicle fixation. Before surgery and at the 2-year follow-up, pain (VAS) and functional disability (JOA) were quantified. The results showed there were no intraoperative deaths in our study. In the end 176 cases had 2-year follow-up while 11 cases were lost to follow-up. The follow-up rate was 93.4% (85/91) in the PLIF group and 94.8% (91/96) in the TLIF group. All patients had bone fusion, and there were no cases of cage extrusion. The pain index improved from 7.08 ± 1.13 to 2.84 ± 0.89 in PLIF patients and improved from 7.18 ± 1.09 to 2.84 ± 0.91 in TLIF patients (P < 0.001). There were 42 cases of excellent, 29 cases of good, 11 cases of general, and 3 cases of poor results in PLIF group. There were 46 cases of excellent, 31 case of good, 12 case of general, and 2 cases of poor results in TLIF group. The JOA score in all patients was 84.1% of good or excellent (83.5% in PLIF and 84.6% in TLIF, P > 0.05). The average preoperative slip was 30.1 ± 7.2% in PLIF group while in the TLIF it was 31.4 ± 8.3%. Immediately post operatively it was reduced to 7.3 ± 2.1% and 7.4 ± 2.7% and at last F/U it was 8.1 ± 2.8% and 8.2 ± 2.6%, respectively. The average of reduction rate was 75.2 ± 6.4% in PLIF and 75.4 ± 6.2 in TLIF on the initial post operatively X-ray, and 72.6 ± 5.2% and 72.4 ± 5.4% on the follow-up. The percentage rate, reduction rate and lost of reduction rate between the two groups was similar (P > 0.05). The average pre operative disk and foramen height in the PLIF group improved from 6.8 ± 2.3 and 14.2 ± 1.7 preoperatively to 11.6 ± 1.5 and 18.7 ± 1.8 post operatively, respectively. At last follow up there was minimal lost of correction down to 11.24 ± 1.2 and 18.1 ± 1.8, respectively. Similarly in the TLIF group, pre operative disk and foramen height were improved from 6.7 ± 1.7 and 14.1 ± 1.8 to 11.4 ± 1.6 and 18.5 ± 1.6 immediately post operative. At last follow up minimal lost of correction was noted with average disc height of 11.3 ± 1.4 and 18.2 ± 1.7. Both techniques achieve statistical significance in restoration of disc and foraminal (P < 0.01); however, there was no statistical difference between the two techniques. In conclusion, interbody fusion with either a PLIF technique or a TLIF technique provides good outcomes in the treatment of adult degenerative spondylolisthesis. The TLIF procedure is simpler and is as safe and effective as the PLIF technique.
PMCID: PMC2556474  PMID: 18685873
Spondyolisthesis; Interverterbral fusion; Internal fixation
4.  Outcome of single level instrumented posterior lumbar interbody fusion using corticocancellous laminectomy bone chips 
Indian Journal of Orthopaedics  2011;45(6):500-503.
Interbody fusion surgery has been considered by many to be a treatment of choice for instability in lumbar degenerative disc disease. A posterior lumbar interbody fusion (PLIF) has the advantages of spinal canal decompression, anterior column reconstruction, and reduction of the sagittal slips from a single posterior approach. The PLIF using double cage was a standard practice till many studies reported comparable results and lesser complications with single cage. Iliac crest was considered as an appropriate source of bone graft until comparable spinal fusion rates using local bone graft and cage emerged. Till date, there has been no report of corticocancellous laminectomy bone chips alone being used for spinal fusion. In this paper, we present radiologic results of single level instrumented PLIF, where in only corticocancellous laminectomy bone chips were used as a fusion device.
Materials and Methods:
It is a retrospective cohort study of 35 consecutive patients, who underwent single level instrumented PLIF surgery, wherein only locally obtained bone chips was used for spinal fusion. The average follow-up was 26 months. The indications for the surgery were as follows: 19 patients had disc herniations, with back pain of instability type, normal disc height on radiology. Ten patients had grade 1 spondylolisthesis, with significant back pain and translational instability on radiography. Three patients were redo spine surgeries, and three patients had healed spondylodiscitis with significant back pain and instability. All patients were regularly followed up and decision of spinal fusion or no fusion was taken at 2 years using modified criteria of Lee.
Of total 35 patients, there were 24 males and 11 females, with a mean age of 41 years. There were 16 patients with definitive fusion, 15 patients with probable fusion, 04 patients with possible pseudoarthrosis, and no patient had definitive pseudoarthrosis. The mean time for fusion to occur was 18 months. The average loss of disc height, over 2 year follow up, was only 3 mm in 8 patients. Three patients had a localized kyphosis of more than 3° at the fusion level. The average blood loss was 356 ml and average operating time was 150 min.
Corticocancellous laminectomy bone chips alone can be used as a means of spinal fusion in patients with single level instrumented PLIF. This has got a good fusion rate.
PMCID: PMC3227352  PMID: 22144741
Corticocancellous laminectomy bone chips; Interbody cage; posterior lumbar interbody fusion
5.  TLIF for symptomatic disc degeneration: a retrospective study of 100 patients 
European Spine Journal  2011;20(Suppl 1):57-60.
The goal of a fusion of the lumbar spine is to obtain a primary solid arthrodesis thus to alleviate pain. Different circumferential fusion techniques have been described such as combined anterior–posterior fusion (APF), instrumented posterior lumbar interbody fusion (PLIF) and transforaminal lumbar interbody fusion (TLIF). The TLIF procedure has rapidly gained popularity; because of its posterolateral extracanalar discectomy and fusion, it has been reported as a safe technique, without the potential complications described when using combined APF and PLIF techniques. A retrospective clinical and radiographic study was performed. The database of our Center was interrogated in a retrospective way to extract data from patients that underwent a one or two level lumbar fusion with TLIF approach. All patients had symptomatic disc degeneration of the lumbar spine. One hundred and fourteen levels fused from 2003 to 2008. All patients were operated in the same center. All the patients were operated by the same surgical team. Patients were evaluated preoperatively and postoperatively at 1 and 3 months and 1 and 2 years follow-up. The spine was approached through a classic posterior midline incision and subperiosteal muscular detachment. The side of facetectomy was chosen according to the subject’s symptoms of leg pain if present. A posterolateral annulotomy was made and subtotal discectomy was performed and the hyaline cartilage of endplates was removed. Once the surgeon was satisfied with endplate preparation, a banana shaped allograft spacer was inserted through the annulotomy and placed anteriorly. Additional autograft locally harvested from decompression was packed behind the allograft spacer in all cases. Laminae and the remaining contralateral facet joint were decorticated, and packed with bone graft (local autologous and allograft chips in some cases). The posterior fusion was instrumented with pedicle screws and titanium rods. The TLIF procedure had led to shortened surgical times, less neurologic injury, and improved overall outcomes. The introduction of the TLIF procedure has allowed surgeons to achieve successful fusion without the risk of nerve root tethering that is seen so frequently with standard PLIF techniques.
PMCID: PMC3087043  PMID: 21461695
TLIF; Minimal invasive fusion; Degenerative disc disease; Interbody fusion
6.  Comparison of Clinical and Radiological Results of Posterolateral Fusion and Posterior Lumbar Interbody Fusion in the Treatment of L4 Degenerative Lumbar Spondylolisthesis 
Asian Spine Journal  2016;10(1):143-152.
Study Design
Multicenter analysis of two groups of patients surgically treated for degenerative L4 unstable spondylolisthesis.
To compare the clinical and radiographic outcomes of posterolateral fusion (PLF) and posterior lumbar interbody fusion (PLIF) for degenerative L4 unstable spondylolisthesis.
Overview of Literature
Surgery for lumbar degenerative spondylolisthesis is widely performed. However, few reports have compared the outcome of PLF to that of PLIF for degenerative L4 unstable spondylolisthesis.
Patients with L4 unstable spondylolisthesis with Meyerding grade II or more, slip of >10° or >4 mm upon maximum flexion and extension bending, and posterior opening of >5 degree upon flexion bending were studied. Patients were treated from January 2008 to January 2010. Patients who underwent PLF (n=12) and PLIF (n=19) were followed-up for >2 years. Radiographic findings and clinical outcomes evaluated by the Japanese Orthopaedic Association (JOA) score were compared between the two groups. Radiographic evaluation included slip angle, translation, slip angle and translation during maximum flexion and extension bending, intervertebral disc height, lumbar lordotic angle, and fusion rate.
JOA scores of the PLF group before surgery and at final follow-up were 12.3±4.8 and 24.1±3.7, respectively; those of the PLIF group were 14.7±4.8 and 24.2±7.8, respectively, with no significant difference between the two groups. Correction of slip estimated from postoperative slip angle, translation, and maintenance of intervertebral disc height in the PLIF group was significantly (p<0.05) better than those in the PLF group. However, there was no significant difference in lumbar lordotic angle, slip angle and translation angle upon maximum flexion, or extension bending. Fusion rates of the PLIF and PLF groups had no significant difference.
The L4–L5 level posterior instrumented fusion for unstable spondylolisthesis using both PLF and PLIF could ameliorate clinical symptoms when local stability is achieved.
PMCID: PMC4764527  PMID: 26949470
Degenerative spondylolisthesis; Instability; Posterolateral fusion; Posterior lumbar interbody fusion
7.  The use of beta-tricalcium phosphate and bone marrow aspirate as a bone graft substitute in posterior lumbar interbody fusion 
European Spine Journal  2012;22(5):1173-1182.
Due to the disadvantages of iliac crest bone and the poor bone quality of autograft gained from decompression surgery, alternative filling materials for posterior lumbar interbody fusion cages have been developed. β-Tricalcium phosphate is widely used in cages. However, data regarding the fusion rate of β-TCP assessed by computer tomography are currently not available.
A prospective clinical trial involving 34 patients (56.7 years) was performed: 26 patients were treated with single-level, five patients double-level and three patients triple-level PLIF filled with β-TCP and bone marrow aspirate perfusion, and additional posterior pedicle screw fixation. Fusion was assessed by CT and X-rays 1 year after surgery using a validated fusion scale published previously. Functional status was evaluated with the visual analogue scale and the Oswestry Disability Index before and 1 year after surgery.
Forty-five levels in 34 patients were evaluated by CT and X-ray with a follow-up period of at least 1 year. Clinically, the average ODI and VAS for leg and back scores improved significantly (P < 0.001). CT assessment revealed solid fusion in 12 levels (26.67 %) and indeterminate fusion in 15 levels (34.09 %). Inadequate fusion (non-union) was detected in 17 levels (38.63 %).
The technique of PLIF using β-TCP yielded a good clinical outcome 1 year after surgery, however, a high rate of pseudoarthrosis was found in this series therefore, we do not recommend β-TCP as a bone graft substitute using the PLIF technique.
PMCID: PMC3657048  PMID: 23073745
Posterior lumbar interbody fusion; Alternative graft materials; β-Tricalcium phosphate; Fusion rate; Computer tomography
8.  Fusion for low-grade adult isthmic spondylolisthesis: a systematic review of the literature 
European Spine Journal  2005;15(4):391-402.
The objective of this study was to evaluate which fusion technique provides the best clinical and radiological outcome for adult low-grade lumbar isthmic spondylolisthesis, and to assess the overall clinical and radiological outcome of each fusion technique. A systematic review was performed. Medline, Embase, Current Contents, and Cochrane databases as well as reference lists of selected articles were searched. Randomised controlled trials (RCTs) were used to evaluate the best treatment; controlled studies and non-controlled studies were used to determine the outcomes after surgery. Two independent reviewers evaluated the studies with the methodological checklists of van Tulder and Jadad for the randomised studies and of Cowley for the non-randomised studies. The search resulted in 684 references and eventually 29 studies met the inclusion criteria, of which eight were RCTs, four were prospective, and 17 were retrospective case series. Ten of the case series did not clearly identify consecutive patient selection. All the eight RCTs evaluated the effect of different techniques of posterolateral fusion (PLF). Evidence was found that the PLF was superior to non-operative treatment (exercise). Circumferential fusion was compared to PLF, but no difference could be found. PLF with or without instrumentation was evaluated in three studies, but no benefits from additional instrumentation were found. Other comparisons within PLF showed no effect of decompression, alternative instrumentation, or bone graft substitute. The 21 case series included 24 patient groups. PLF was used in 15 groups, good or excellent clinical outcome varied from 60 to 98% and fusion rate varied from 81 to 100%. Anterior interbody fusion was used in five groups, good or excellent clinical outcome varied from 85 to 94% and fusion rate varied from 47 to 90%. Posterior interbody fusion was used in two groups, good or excellent clinical outcome was 45% and fusion rate was 80 and 95%, respectively. Reduction, loss of reduction, and lordotic angles before and after the treatment was reported in only four studies. Average reduction achieved was 12.3%, average loss of reduction at follow-up was 5.9%. Preoperative lordotic angles were too heterogeneous to pool the results. Adjacent segment degeneration was not reported in any of the publications. A wide variety of complications were reported in 18 studies and included neurological complications, instrument failure, and infections. Fusion for low-grade isthmic spondylolisthesis has better outcomes than non-operative treatment. The current study could not identify the best surgical technique (PLF, PLIF, ALIF, instrumentation) to perform the fusion. However, instrumentation and/or decompression may play a beneficial role in the modern practice of reduction and fusion for low-grade isthmic spondylolisthesis, but there are no studies yet available to confirm this. The outcomes of fusion are generally good, but reports vary widely.
PMCID: PMC3489314  PMID: 16217665
Lumbar vertebrae; Spondylolisthesis; Spinal fusion; Evidence based medicine; Review literature
9.  En Bloc Partial Laminectomy and Posterior Lumbar Interbody Fusion in Foraminal Spinal Stenosis 
Asian Spine Journal  2009;3(2):66-72.
Study Design
A retrospective study.
An en bloc partial laminectomy and posterior lumbar interbody fusion (PLIF) in spinal stenosis patients with severe foraminal narrowing has a shorter operation time, less neural manipulation and allows indirect decompression by restoring the interforaminal height compared to other procedures. This study investigated the efficacy of the procedure.
Overview of Literature
PLIF is one of the most popular surgery for degenerative spine such as foraminal spinal stenosis, instability spondylolisthesis and discogenic pain. Various techniques for PLIF have their own advantages and disadvantages. But in some severe cases, we need an efficient method of PLIF for decompression and fusion.
This study examined 61 patients, who had 85 levels treated with PLIF using an en bloc partial laminectomy and facetectomy, and could be followed up for more than 2 years. The mean age of the patients and mean follow up period was 66 years and 39 months, respectively. The clinical results were evaluated using the MacNab's criteria, Visual Analogue Scale (VAS) score, and Korea Version Oswestry Disability Index (KODI). The union of the intervertebral space was evaluated using Lenke's criteria. The intervertebral angle and height of the posterior intervertebral disc were also measured.
Excellent and good results were obtained in 54 cases (89%) according to MacNab's criteria. The VAS and KODI scores were 8.1 and 34.6, preoperatively, and 3.4, and 14.1, postoperatively. Bone union was A and B grades according to Lenke's criteria in 57 cases. The mean segmental angle and mean height of the posterior disc were respectively, 7.4° and 6.5 mm preoperatively, 9.1° and 10.6 mm postoperatively, and 8.0° and 9.7 mm in the last follow-up. There were 5 cases of postoperative infection, 4 cases of junctional problems and 1 case of screw malposition.
En bloc partial laminectomy and PLIF is an effective method for treating severe spinal stenosis with foraminal narrowing.
PMCID: PMC2852073  PMID: 20404950
Lumbar vertebra; Spinal stenosis; Laminectomy; Posterior lumbar interbody fusion
10.  Outcomes of allogenic cages in anterior and posterior lumbar interbody fusion 
European Spine Journal  2001;10(Suppl 2):S158-S168.
Interbody lumbar fusions provide a proven logical solution to diseases of the intervertebral discs by eliminating motion of the segment. Historically, there are many techniques to achieve spinal fusion in the lumbar spine. These include anterior, posterior, and foramenal approaches, often in combination with various internal fixation devices. The surgeon's choice of the approach and mechanical or biological implant is dependent on the patient's specific pathology and anatomy, in addition to the experience and training of the surgeon in similar conditions. In the past decade, new mechanical spine implants/spacers have been designed to provide restoration of disc height and improve stabilization of the spine. The ability to radiographically assess the "biology" of bone incorporation in these mechanical (metal) spacers has become a significant limitation.
The femoral ring allograft (FRA) and the posterior lumbar interbody fusion (PLIF) spacers have been developed as "biological cages" that permit restoration of the anterior column with machined allograft bone biological cages. Test results demonstrate that the FRA and PLIF spacers have a compressive strength of over 25,000 N. The pyramid-shaped teeth on the surfaces and the geometry of the implant increase the resistance to expulsion at clinically relevant loads (1053 and 1236 N). The technique of anterior column reconstruction with both the FRA and the PLIF biological cages have been previously reported.
Clinical outcomes and experience with the FRA spacer (137 patients) and the PLIF spacer (13 patients) were reported on and did not reveal any evidence of bone cage resorption or infectious inflammatory process. There was clinical migration with one PLIF spacer, which was later revised with an anterior approach and a FRA spacer. The radiographic outcomes demonstrated that 94% arthrodesis was achieved with the biological spacer and additional posterior instrumentation. The clinical success of every spine fusion procedure is dependent on many factors such as the extent of the instability, the pathology, type of graft used, the patient's pathology/anatomy and lifestyle.
PMCID: PMC3611548  PMID: 11716014
Biological cages Femoral ring allograft spacer Posterior lumbar interbody fusion spacer Interbody lumbar fusion Arthrodesis
11.  Biological cages 
European Spine Journal  2000;9(Suppl 1):S102-S109.
Restoring a stable anterior column is essential to achieve normal spinal biomechanics. A variety of mechanical spacers have been developed and advocated for both anterior and posterior approaches. The ability to radiographically assess the “biology” of bone incorporation in these mechanical (metal) spacers is an inherent limitation. The femoral ring allograft (FRA) and posterior lumbar interbody fusion (PLIF) spacers have been developed as biological cages that permit restoration of the anterior column with a machined allograft bone (biological cage). Test results demonstrate that the FRA and PLIF Spacers have a compressive strength over 25,000 N. The pyramid shaped teeth on the surfaces and the geometry of the implant increase the resistance to expulsion at clinically relevant loads (1053 and 1236 N). The technique of anterior column reconstruction with both the FRA and the PLIF biological cages are discussed. Clinical experience with the PLIF biological cage (10 patients) and the FRA biological cage (90 patients) has not revealed any graft migration, infection, or subsidence. Additional posterior instrumentation may increase the stability of the motion segment, but the degree of stability necessary to achieve a biological union remains unclear. The incorporation of these biological cages can be monitored by conventional radiographic techniques. The method of insertion preserves the vertebral end-plates and can be performed by a minimally invasive or standard open procedure.
PMCID: PMC3611444  PMID: 10766065
Key words Biological cages; FRA spacer; PLIF spacer; Interbody ¶lumbar fusion; Arthrodesis
12.  Outcome of instrumented lumbar fusion for low grade spondylolisthesis; Evaluation of interbody fusion with & without cages 
Asian Journal of Neurosurgery  2010;5(1):41-47.
The aim is to evalute the outcome of posterior lumbar interbody fusion with autologous bone graft versus titanium Cages, BAK system (Bagby – Kuslich, Spine Tech, Inc. Minneapolis, MN) for low grade spondyloisthesis (Grade1,11). Interbody cages have been developed to replace tricortical Interbody grafts in posterior lumbar interbody fusion (PLIF) procedures. The cages provide immediate post operative stability and facilitate bony union with cancellous bone packed in the cage itself.
We Evaluated 50 consecutive patients in whom surgery was performed between June 2000 to June 2003 in the Main Alexandria University Hospital at EGYPT. Twenty five patients were operated using autologous bone graft and 25 patients using the BAK cages. The neuro–radiologic al work up consisted of; plain X – ray lumbosacral spine including dynamic films preoperative and postoperative follow up; C.T lumbosacral spine and MRI lumbosacral spine.
The surgery was performed at L4-5 level in 34 cases and at L5-S1 level in 16 cases. The median follow up was 15 months.
Satisfactory fusion was obtained at all levels at a minimum one year follow – up. The fusion rate was 96% (24 patients) for the cage group and 80% (20 patients) for bone graft group however clinical improvement was 64% (16 patients) for those with bone graft group.
A higher fusion rates and a better clinical outcome have been obtained by Instrumented PLIF with titanium cages that with bone graft.
Inderbody fusion cages help to stabilize spainal segment primarily by distracting them as well as by allowing bone ingrowth and fusion. The procedure is safe and effective with 96% fusion rate and 76% overall Satisfactory rate.
The use of cages help to distract the space between the vertebral bodies making the correction of the degree of spondylolisthesis easier.
Long term follow up revealed better fusion rate and better realignment and less resorption with cages than with bone grafts.
PMCID: PMC3198657  PMID: 22028742
13.  Posterior Lumbar Interbody Fusion Using an Unilateral Cage: A Prospective Study of Clinical Outcome and Stability 
Korean Journal of Spine  2014;11(2):52-56.
The purpose of this study was to evaluate the clinical and radiological results of instrumented posterior lumbar interbody fusion (PLIF) using an unilateral cage.
Seventeen patients with unilateral radiculopathy who underwent bilateral percutaneous screw fixation with a single fusion cage inserted on the symptomatic side for treatment of focal degenerative lumbar spine disease were prospectively enrolled in this study. Their clinical results, radiological parameters, and related complications were assessed 10 days, 3 months, and 12 months postoperatively.
There was no pseudarthrosis, instrumented fusion failure, significant cage subsidence, or retropulsion in any patient. The surgery restored the disc space height and maintained it as of 12 months postoperatively and did not exacerbate the lumbar lordotic and scoliotic angles. All patients had excellent or good outcomes according to the modified MacNab's criteria. The mean pain score according to the visual analogue scale was 7.5 preoperatively but had improved to 2.5 when reassessed 3 months postoperatively. The improvement was maintained as of 12 months postoperatively.
In cases of uncomplicated unilateral radiculopathy, PLIF using a single cage can be an effective and safe procedure with the advantage of preserving the posterior elements of the contralateral side. A shorter operative time and greater cost-effectiveness than for PLIF using bilateral cages can be expected.
PMCID: PMC4124929  PMID: 25110483
Spine; Fusion; Cage; Unilateral
14.  The Clinical and Radiological Outcomes of Minimally Invasive Transforaminal Lumbar Interbody Single Level Fusion 
Asian Spine Journal  2011;5(2):111-116.
Study Design
This is a retrospective study that was done according to clinical and radiological evaluation.
We analyzed the clinical and radiological outcomes of minimally invasive transforaminal lumbar interbody single level fusion.
Overview of Literature
Minimally invasive transforaminal lumbar interbody fusion is effective surgical method for treating degenerative lumbar disease.
The study was conducted on 56 patients who were available for longer than 2 years (range, 24 to 45 months) follow-up after undergoing minimally invasive transforminal lumbar interbody single level fusion. Clinical evaluation was performed by the analysis of the visual analogue scale (VAS) score and the Oswestry Disability Index (ODI) and the Kirkaldy-Willis score. For the radiological evaluation, the disc space height, the segmental lumbar lordotic angle and the whole lumbar lordotic angle were analyzed. At the final follow-up after operation, the fusion rate was analyzed according to Bridwell's anterior fusion grade.
For the evaluation of clinical outcomes, the VAS score was reduced from an average of 6.7 prior to surgery to an average of 1.8 at the final follow-up. The ODI was decreased from an average of 36.5 prior to surgery to an average of 12.8 at the final follow-up. In regard to the clinical outcomes evaluated by the Kirkaldy-Willis score, better than good results were obtained in 52 cases (92.9%). For the radiological evaluation, the disc space height (p = 0.002), and the whole lumbar lordotic angle (p = 0.001) were increased at the final follow-up. At the final follow-up, regarding the interbody fusion, radiological union was obtained in 54 cases (95.4%).
We think that if surgeons become familiar with the surgical techniques, this is a useful method for minimally invasive spinal surgery.
PMCID: PMC3095800  PMID: 21629486
Minimally invasive; Transformainal; Lumbar interbody; Single level fusion
15.  Comparison of low back fusion techniques: transforaminal lumbar interbody fusion (TLIF) or posterior lumbar interbody fusion (PLIF) approaches 
The authors review and compare posterior lumbar interbody fusion (PLIF) with transforaminal lumbar interbody fusion (TLIF). A review of the literature is performed wherein the history, indications for surgery, surgical procedures with their respective biomechanical advantages, potential complications, and grafting substances are presented. Along with the technical advancements and improvements in grafting substances, the indications and use of PLIF and TLIF have increased. The rate of arthrodesis has been shown to increase given placement of bone graft along the weight-bearing axis. The fusion rate across the disc space is further enhanced with the placement of posterior pedicle screw–rod constructs and the application of an osteoinductive material. The chief advantages of the TLIF procedure compared with the PLIF procedure included a decrease in potential neurological injury, improvement in lordotic alignment given graft placement within the anterior column, and preservation of posterior column integrity through minimizing lamina, facet, and pars dissection.
PMCID: PMC2697340  PMID: 19468868
Posterior lumbar interbody fusion; Transforaminal lumbar interbody fusion; Degenerative disc disease; Low back pain; History; Fusion; Complications
16.  Comparison of low back fusion techniques: transforaminal lumbar interbody fusion (TLIF) or posterior lumbar interbody fusion (PLIF) approaches 
The authors review and compare posterior lumbar interbody fusion (PLIF) with transforaminal lumbar interbody fusion (TLIF). A review of the literature is performed wherein the history, indications for surgery, surgical procedures with their respective biomechanical advantages, potential complications, and grafting substances are presented. Along with the technical advancements and improvements in grafting substances, the indications and use of PLIF and TLIF have increased. The rate of arthrodesis has been shown to increase given placement of bone graft along the weight-bearing axis. The fusion rate across the disc space is further enhanced with the placement of posterior pedicle screw–rod constructs and the application of an osteoinductive material. The chief advantages of the TLIF procedure compared with the PLIF procedure included a decrease in potential neurological injury, improvement in lordotic alignment given graft placement within the anterior column, and preservation of posterior column integrity through minimizing lamina, facet, and pars dissection.
PMCID: PMC2697340  PMID: 19468868
Posterior lumbar interbody fusion; Transforaminal lumbar interbody fusion; Degenerative disc disease; Low back pain; History; Fusion; Complications
17.  Posterior lumbar interbody fusion using one diagonal fusion cage with transpedicular screw/rod fixation 
European Spine Journal  2003;12(2):173-177.
Posterior lumbar interbody fusion (PLIF) using threaded cages has gained wide popularity for lumbosacral spinal disease. Our biomechanical tests showed that PLIF using a single diagonal cage with unilateral facetectomy does add a little to spinal stability and provides equal or even higher postoperative stability than PLIF using two posterior cages with bilateral facetectomy. Studies also demonstrated that cages placed using a posterior approach did not cause the same increase in spinal stiffness seen with pedicle screw instrumentation, and we concluded that cages should not be used posteriorly without other forms of fixation. On the other hand, placement of two cages using a posterior approach does have the disadvantage of risk to the bilateral nerve roots. We therefore performed a prospective study to determine whether PLIF can be accomplished by utilizing a single diagonal fusion cage with the application of supplemental transpedicular screw/rod instrumentation. Twenty-seven patients underwent a PLIF using one single fusion cage (BAK, Sulzer Spine-Tech, Minneapolis, MN, USA) inserted posterolaterally and oriented anteromedially on the symptomatic side with unilateral facetectomy and at the same level supplemental fixation with a transpedicular screw/rod system. The internal fixation systems included 12 SOCON spinal systems (Aesculap AG, Germany) and 15 TSRH spinal systems (Medtronic Sofamor Danek, USA). The inclusion criteria were grade 1 to 2 lumbar isthmic spondylolisthesis, lumbar degenerative spondylolisthesis, and recurrent lumbar disc herniations with instability. Patients had at least 1 year of low back pain and/or unilateral sciatica and a severely restricted functional ability in individuals aged 28–55 years. Patients with more than grade 2 spondylolisthesis or adjacent-level degeneration were excluded from the study. Patients were clinically assessed prior to surgery by an independent assessor; they were then reassessed at 1, 3, 6, 12, 18, and 24 months postoperatively by the same assessor and put into four categories: excellent, good, fair, and poor. Operative time, blood loss, hospital expense, and complications were also recorded. All patients achieved successful radiographic fusion at 2 years, and this was achieved at 1 year in 25 out of 27 patients. At 2 years, clinical results were excellent in 15patients, good in 10, fair in 1, and poor in 1. Regarding complications, one patient had a postoperative motor and sensory deficit of the nerve root. Reoperation was required in one patient due to migration of pedicle screws. No implant fractures or deformities occurred in any of the patients. PLIF using diagonal insertion of a single threaded cage with supplemental transpedicular screw/rod instrumentation enables sufficient decompression and solid interbody fusion to be achieved with minimal invasion of the posterior spinal elements. It is a clinically safer, easier, and more economical means of accomplishing PLIF.
PMCID: PMC3784842  PMID: 12709855
Lumbar Fusion cage Implant Transpedicular screw Interbody
18.  Comparison of instrumented anterior interbody fusion with instrumented circumferential lumbar fusion 
European Spine Journal  2003;12(6):567-575.
Posterior lumbar interbody fusion (PLIF) restores disc height, the load bearing ability of anterior ligaments and muscles, root canal dimensions, and spinal balance. It immobilizes the painful degenerate spinal segment and decompresses the nerve roots. Anterior lumbar interbody fusion (ALIF) does the same, but could have complications of graft extrusion, compression and instability contributing to pseudarthrosis in the absence of instrumentation. The purpose of this study was to assess and compare the outcome of instrumented circumferential fusion through a posterior approach [PLIF and posterolateral fusion (PLF)] with instrumented ALIF using the Hartshill horseshoe cage, for comparable degrees of internal disc disruption and clinical disability. It was designed as a prospective study, comparing the outcome of two methods of instrumented interbody fusion for internal disc disruption. Between April 1994 and June 1998, the senior author (N.R.B.) performed 39 instrumented ALIF procedures and 35 instrumented circumferential fusion with PLIF procedures. The second author, an independent assessor (S.M.), performed the entire review. Preoperative radiographic assessment included plain radiographs, magnetic resonance imaging (MRI) and provocative discography in all the patients. The outcome in the two groups was compared in terms of radiological improvement and clinical improvement, measured on the basis of improvement of back pain and work capacity. Preoperatively, patients were asked to fill out a questionnaire giving their demographic details, maximum walking distance and current employment status in order to establish the comparability of the two groups. Patient assessment was with the Oswestry Disability Index, quality of life questionnaire (subjective), pain drawing, visual analogue scale, disability benefit, compensation status, and psychological profile. The results of the study showed a satisfactory outcome (score≤30) on the subjective (quality of life questionnaire) score of 71.8% (28 patients) in the ALIF group and 74.3% (26 patients) in the PLIF group (P>0.05). On categorising Oswestry Index scores into "excellent", "better", "same", and "worse", we found no difference in outcome between the two groups: 79.5% (n=31) had satisfactory outcome with ALIF and 80% (n=28) had satisfactory outcome with PLIF. The rate of return to work was no different in the two groups. On radiological assessment, we found two nonunions in the circumferential fusion (PLIF) group (94.3% fusion rate) and indirect evidence of no nonunions in the ALIF group. There was no significant difference between the compensation rate and disability benefit rate between the two groups. There were three complications in ALIF group and four in the PLIF (circumferential) group. On the basis of these results, we conclude that it is possible to treat discogenic back pain by anterior interbody fusion with Hartshill horseshoe cage or with circumferential fusion using instrumented PLIF.
PMCID: PMC3467994  PMID: 14673717
Disc degeneration; Interbody fusion; Cages
19.  Posterior lumbar interbody fusion with instrumented posterolateral fusion in adult spondylolisthesis: description and association of clinico-surgical variables with prognosis in a series of 36 cases 
We present our experience in the treatment of patients with isthmic or degenerative spondylolisthesis, by means of a posterior lumbar interbody fusion (PLIF) and instrumented posterolateral fusion (IPLF), and we compare them with those published in the literature. We analyse whether there exists any statistical association between the clinical characteristics of the patient, radiological characteristics of the disease and our surgical technique, with the complications and the clinical-radiological prognosis of the cases.
We designed a prospective study. A total of 36 cases were operated. The patients included were 14 men and 22 women, with an average age of 57.17±27.32 years. Our technique consists of PLIF+IPLF, using local bone for the fusion. The clinical results were evaluated with the Visual Analogical Scale (VAS) and the Kirkaldy-Willis criteria. The radiological evaluation followed the Bratingan (PLIF) and Lenke (IPLF) methodology. A total of 42 variables were statistically analysed by means of SPSS18. We used the Paired Student's T-test, logistic regression and Pearson's Chi-square-test.
The spondylolisthesis was isthmic in 15 cases and degenerative in 21 cases. The postoperative evaluations had excellent or good results in 94.5% (n = 34), with a statistically significant improvement in the back pain and sciatica (p < 0.01). The rate of circumferential fusion reached was approximately 92%. We had 13.88% of transitory morbility and 0% of mortality associated with our technique. A greater age, degree of listhesis or length of illness before the intervention, weakly correlated with worse clinical results (p< -0.2). In our series, the logistical regression showed that the clinical characteristics of the patient, radiological characteristics of the lesion and our surgical technique were not associated with greater postoperative complications.
Although a higher level of training is necessary, we believe that the described technique is a very effective decision in cases of spondylolisthesis, isthmic or degenerative, refractory to conservative treatment, for the obtaining the best clinical results and rates of fusion, with similar risks to those of the other published techniques. Our statistical analysis could contribute to improve outcomes after surgery.
PMCID: PMC4505389  PMID: 26196029
Spondylolisthesis; instrumented posterolateral fusion; posterior lumbar interbody fusion; spinal fusion; cages
20.  Posterior Lumbar Interbody Fusion Using a Unilateral Single Cage and a Local Morselized Bone Graft in the Degenerative Lumbar Spine 
Clinics in Orthopedic Surgery  2009;1(4):214-221.
We retrospectively evaluated the clinical and radiological outcomes of posterior lumbar interbody fusion (PLIF) with using a unilateral single cage and a local morselized bone graft.
Fifty three patients who underwent PLIF with a unilateral single cage filled with local morselized bone graft were enrolled in this study. The average follow-up duration was 31.1 months. The clinical outcomes were evaluated with using the visual analogue scale (VAS) at the pre-operative period, at 1 year post-operation and at the last follow-up, the Oswestry Disability Index, the Prolo scale and the Kim & Kim criteria at the last follow-up; the radiological outcomes were evaluated according to the change of bone bridging, the radiolucency, the instablity and the disc height.
For the clinical evaluation, the VAS pain index, the Oswestry Disability Index, the Prolo scale and the Kim & Kim criteria showed excellent outcomes. For the the radiological evaluation, 52 cases showed complete bone union at the last follow-up. Regarding the complications, only 1 patient had cage breakage during follow-up.
PLIF using a unilateral single cage filled with a local morselized bone graft has the advantages of a shorter operation time, less blood loss and a shorter hospital stay, as compared with the PLIF using bilateral cages, for treating degenerative lumbar spine disease. This technique also provides excellent outcomes according to the clinical and radiological evaluation.
PMCID: PMC2784962  PMID: 19956479
Spinal fusion; Posterior lumbar interbody fusion; Unilateral single cage; Local morselized graft
21.  Simultaneous Anterior and Posterior Surgery in the Management of Tuberculous Spondylitis with Psoas Abscess in Patients with Neurological Deficits 
Asian Spine Journal  2008;2(2):94-101.
Study Design
This is a retrospective study.
We wanted to evaluate the treatment outcomes of performing simultaneous anterior and posterior surgery for patients with tuberculous spondylitis and psoas abscess.
Overview of Literature
Although various treatment options have been used for spinal tuberculosis, there are only a few reports on the treatment of tuberculous spondylitis with psoas abscess.
Between March 1997 and February 2006, we performed operations on 14 cases of tuberculous spondylitis with psoas abscess. All the cases underwent anterior debridement with an interbody bone graft and posterior fusion with using pedicle screws.
Under the Frankel classification, 1 case improved by two grades, 10 cases improved by 1 grade and 3 cases demonstrated no change. The Kirkaldy-Willis functional outcomes were classified as excellent in 10 cases and good in 4. One year after surgery, bony union was confirmed in all 14 cases. The mean kyphotic angle of the spinal lesion was 12.4° and the mean lordotic angle at the final follow-up was 6.4°. Postoperative complications (superficial wound infections) were encountered in 2 cases.
Our results demonstrate that anterior debridement with interbody bone grafting and posterior instrumented fusion can provide satisfactory results for treating tuberculous spondylitis with psoas abscess in patients with neurological deficits.
PMCID: PMC2852085  PMID: 20404963
Tuberculous spondylitis; Psoas abscess; Neurological deficit; Anterior and posterior surgery
22.  Mini-open PLIF for Moderate to High Grade Spondylolisthesis: Technique to Achieve Spontaneous Reduction 
Korean Journal of Spine  2015;12(4):251-255.
The purpose of this study was to evaluate the surgical technique and outcome of mini-open posterior lumbar interbody fusion (PLIF) under circumferential releasing technique.
Fourty patients who underwent mini-open PLIF using the percutaneous screw fixation system for Meyerding Grade II spondylolisthesis or more were retrospectively studied. After complete circumferential release, the slipped vertebrae would tend to obtain spontaneous reduction, and with compressive force by percutaneous screw fixation, additional reduction could be achieved. The radiological measurements including slippage reduction, disc height, restoration of lumbar lordotic angle and focal segmental angle were analyzed. The clinical outcome was assessed using the visual analog scale (VAS) and low back outcome score (LBOS), and procedure related complications were also analyzed.
Slippage percentage was improved from 38.0±12.6% to 9.3±7.8% and lumbar lordotic angle was changed from 43.0±13.8° to 48.2±10.3°. Focal segmental angle improved from 10.1±8.5° to 15.9±6.0°. The mean LBOS and mean pain score were also improved significantly. Complications included one case of medial penetration of pedicle border and two cases of transient radiculopathy. However, there were no signs of neurological aggravation or fusion failure during the follow-up period.
Mini-open PLIF using the percutaneous screw fixation following complete circumferential release can be safe and effective treatment for even moderate to severe grade spondylolisthesis.
PMCID: PMC4731559  PMID: 26834812
Spondylolisthesis; Fusion; Reduction
23.  Bone union rate with autologous iliac bone versus local bone graft in posterior lumbar interbody fusion (PLIF): a multicenter study 
European Spine Journal  2013;22(5):1158-1163.
The purpose of this study is to compare bone union rate between autologous iliac bone and local bone graft in patients treated by posterior lumbar interbody fusion (PLIF) using carbon cage for single level interbody fusion.
The subjects were 106 patients whose course could be observed for at least 2 years. The diagnosis was lumbar spinal canal stenosis in 46 patients, herniated lumbar disk in 12 patients and degenerative spondylolisthesis in 51 patients. Single interbody PLIF was done using iliac bone graft in 53 patients and local bone graft in 56 patients. Existence of pseudo-arthrosis on X-P (AP and lateral view) was investigated during the same follow up period.
No significant differences were found in operation time and blood loss. Significant differences were also not observed in fusion grade at any follow up period or in fusion progression between the two groups. Donor site pain continued for more than 3 months in five cases (9 %). The final fusion rate was 96.3 versus 98.3 %.
Almost the same results in fusion were obtained from both the local bone group and the autologous iliac bone group. Fusion progression was almost the same. Complications at donor sites were seen in 19 % of the cases. From the above results, it was concluded that local bone graft is as beneficial as autologous iliac bone graft for PLIF at a single level.
PMCID: PMC3657055  PMID: 23361529
Posterior lumbar interbody fusion; Autologous iliac bone graft; Local bone graft; Fusion rate
24.  A Comparative Study of Lateral Lumbar Interbody Fusion and Posterior Lumbar Interbody Fusion in Degenerative Lumbar Spondylolisthesis 
Asian Spine Journal  2015;9(5):668-674.
Study Design
Level 4 retrospective review.
To compare the radiographic and clinical outcomes between posterior lumbar interbody fusion (PLIF) and lateral lumbar interbody fusion (LLIF) with posterior segmental spinal instrumentation (SSI) for degenerative lumbar spondylolisthesis.
Overview of Literature
Both PLIF and LLIF have been performed for degenerative spondylolisthesis with good results, but no study has directly compared these two techniques so far.
The electronic medical and radiographic records of 78 matched patients were analyzed. In one group, 39 patients underwent PLIF with SSI at 41 levels (L3-4/L4-5), while in the other group, 39 patients underwent the LLIF procedure at 48 levels (L3-4/L4-5). Radiological outcomes such as restoration of disc height and neuroforaminal height, segmental lumbar lordosis, total lumbar lordosis, incidence of endplate fracture, and subsidence were measured. Perioperative parameters were also recorded in each group. Clinical outcome in both groups was assessed by the short form-12, Oswestry disability index and visual analogue scale scores. The average follow-up period was 16.1 months in the LLIF group and 21 months in the PLIF group.
The restoration of disc height, foraminal height, and segmental lumbar lordosis was significantly better in the LLIF group (p<0.001). The duration of the operation was similar in both groups, but the average blood loss was significantly lower in the LLIF group (p<0.001). However, clinical outcome scores were similar in both groups.
Safe, effective interbody fusion can be achieved at multiple levels with neuromonitoring by the lateral approach. LLIF is a viable treatment option in patients with new onset symptoms due to degenerative spondylolisthesis who have had previous lumbar spine surgery, and it results in improved sagittal alignment and indirect foraminal decompression.
PMCID: PMC4591435  PMID: 26435782
Interbody fusion; Degenerative spondylolisthesis; Segmental spinal instrumentation
25.  Lumbar Lateral Interbody Fusion (LLIF): Comparative Effectiveness and Safety versus PLIF/TLIF and Predictive Factors Affecting LLIF Outcome 
Study Design Systematic review.
Study Rationale The surgical treatment of adult degenerative lumbar conditions remains controversial. Conventional techniques include posterior lumbar interbody fusion (PLIF) or transforaminal lumbar interbody fusion (TLIF). A new direct approach known as lumbar lateral interbody fusion (LLIF), or extreme lateral interbody fusion (XLIF®) or direct lateral interbody fusion (DLIF), has been introduced.
Objectives The objective of this article is to determine the comparative effectiveness and safety of LLIF, at one or more levels with or without instrumentation, versus PLIF or TLIF surgery in adults with lumbar degenerative conditions, and to determine which preoperative factors affect patient outcomes following LLIF surgery.
Materials and Methods A systematic review of the literature was performed using PubMed and bibliographies of key articles. Articles were reviewed by two independent reviewers based on predetermined inclusion and exclusion criteria. Each article was evaluated using a predefined quality rating scheme.
Results The search yielded 258 citations and the following met our inclusion criteria: three retrospective cohort studies (all using historical cohorts) (class of evidence [CoE] III) examining the comparative effectiveness and safety of LLIF/XLIF®/DLIF versus PLIF or TLIF surgery, and one prospective cohort study (CoE II) and two retrospective cohort studies (CoE III) assessing factors affecting patient outcome following LLIF. Patients in the LLIF group experienced less estimated blood loss and a lower mortality risk compared with the PLIF group. The number of levels treated and the preoperative diagnosis were significant predictors of perioperative or early complications in two studies.
Conclusion There is insufficient evidence of the comparative effectiveness of LLIF versus PLIF/TLIF surgery. There is low-quality evidence suggesting that LLIF surgery results in fewer complications or reoperations than PLIF/TLIF surgery. And there is insufficient evidence that any preoperative factors exist that predict patient outcome after LLIF surgery.
PMCID: PMC3969425  PMID: 24715870
XLIF®; DLIF; LLIF; PLIF; TLIF; minimally invasive; extreme lateral interbody fusion; direct lateral interbody fusion

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