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1.  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.
Purpose
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.
Methods
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.
Results
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.
Conclusions
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.
doi:10.4184/asj.2014.8.2.177
PMCID: PMC3996342  PMID: 24761200
Pyogenic; Infection; Discitis; Antibiotics
2.  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.
doi:10.1007/s00586-008-0739-1
PMCID: PMC2556474  PMID: 18685873
Spondyolisthesis; Interverterbral fusion; Internal fixation
3.  Outcome of single level instrumented posterior lumbar interbody fusion using corticocancellous laminectomy bone chips 
Indian Journal of Orthopaedics  2011;45(6):500-503.
Background:
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.
Results:
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.
Conclusion:
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.
doi:10.4103/0019-5413.87117
PMCID: PMC3227352  PMID: 22144741
Corticocancellous laminectomy bone chips; Interbody cage; posterior lumbar interbody fusion
4.  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.
doi:10.1007/s00586-011-1761-2
PMCID: PMC3087043  PMID: 21461695
TLIF; Minimal invasive fusion; Degenerative disc disease; Interbody fusion
5.  Outcomes of allogenic cages in anterior and posterior lumbar interbody fusion 
European Spine Journal  2001;10(Suppl 2):S158-S168.
Abstract.
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.
doi:10.1007/s005860100292
PMCID: PMC3611548  PMID: 11716014
Biological cages Femoral ring allograft spacer Posterior lumbar interbody fusion spacer Interbody lumbar fusion Arthrodesis
6.  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.
doi:10.1007/PL00008315
PMCID: PMC3611444  PMID: 10766065
Key words Biological cages; FRA spacer; PLIF spacer; Interbody ¶lumbar fusion; Arthrodesis
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.
Purpose
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.
Materials
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.
Results
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 %).
Conclusion
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.
doi:10.1007/s00586-012-2541-3
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.
doi:10.1007/s00586-005-1021-4
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.
Purpose
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.
Methods
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.
Results
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.
Conclusions
En bloc partial laminectomy and PLIF is an effective method for treating severe spinal stenosis with foraminal narrowing.
doi:10.4184/asj.2009.3.2.66
PMCID: PMC2852073  PMID: 20404950
Lumbar vertebra; Spinal stenosis; Laminectomy; Posterior lumbar interbody fusion
10.  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.
Purpose
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.
Methods
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.
Results
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%).
Conclusions
We think that if surgeons become familiar with the surgical techniques, this is a useful method for minimally invasive spinal surgery.
doi:10.4184/asj.2011.5.2.111
PMCID: PMC3095800  PMID: 21629486
Minimally invasive; Transformainal; Lumbar interbody; Single level fusion
11.  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.
doi:10.1007/s12178-009-9053-8
PMCID: PMC2697340  PMID: 19468868
Posterior lumbar interbody fusion; Transforaminal lumbar interbody fusion; Degenerative disc disease; Low back pain; History; Fusion; Complications
12.  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.
doi:10.1007/s12178-009-9053-8
PMCID: PMC2697340  PMID: 19468868
Posterior lumbar interbody fusion; Transforaminal lumbar interbody fusion; Degenerative disc disease; Low back pain; History; Fusion; Complications
13.  Posterior lumbar interbody fusion using one diagonal fusion cage with transpedicular screw/rod fixation 
European Spine Journal  2003;12(2):173-177.
Abstract.
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.
doi:10.1007/s00586-001-0376-4
PMCID: PMC3784842  PMID: 12709855
Lumbar Fusion cage Implant Transpedicular screw Interbody
14.  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.
Object:
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.
METHOD:
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.
RESULTS:
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.
CONCLUSION:
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
15.  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.
doi:10.1007/s00586-002-0516-5
PMCID: PMC3467994  PMID: 14673717
Disc degeneration; Interbody fusion; Cages
16.  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.
Purpose
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.
Methods
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.
Results
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.
Conclusions
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.
doi:10.4184/asj.2008.2.2.94
PMCID: PMC2852085  PMID: 20404963
Tuberculous spondylitis; Psoas abscess; Neurological deficit; Anterior and posterior surgery
17.  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.
Background
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.
Methods
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.
Results
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.
Conclusions
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.
doi:10.4055/cios.2009.1.4.214
PMCID: PMC2784962  PMID: 19956479
Spinal fusion; Posterior lumbar interbody fusion; Unilateral single cage; Local morselized graft
18.  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.
Purpose
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.
Methods
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.
Results
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 %.
Conclusions
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.
doi:10.1007/s00586-012-2593-4
PMCID: PMC3657055  PMID: 23361529
Posterior lumbar interbody fusion; Autologous iliac bone graft; Local bone graft; Fusion rate
19.  Extension CT scan: its suitability for assessing fusion after posterior lumbar interbody fusion 
European Spine Journal  2011;20(9):1496-1502.
Posterior lumbar interbody fusion (PLIF) is a popular procedure for treating lumbar canal stenosis with spinal instability, and several reports concerning fusion assessment methods exist. However, there are currently no definitive criteria for diagnosing a successful interbody fusion in the lumbar spine. We suggested evaluating fusion status using computed tomography (CT) in extension position to detect pseudoarthrosis more precisely. The purpose of this study was to evaluate its usefulness for determining bone union quality after PLIF. Eighty-one patients who underwent PLIF at 97 levels were retrospectively enrolled. The study population included 48 men and 33 women (mean age 58.9 years, range 21–85 years). Patients were followed up for more than 12 months after surgery. The mean follow-up period was 27.6 months (range 14–49 months). Fusion status was evaluated using three ways: flexion–extension radiographs, CT images in flexion and extension position. In the flexion–extension radiographs, mobility of more than 3°, a remaining clear zone, or an uncertain bone connection constituted an incomplete union. For CT images, a remaining clear zone, a gas pattern, or an uncertain bone connection constituted an incomplete union. Flexion–extension radiographs demonstrated a solid fusion in 90.7% of the 97 levels at 10.7 months postoperatively. When fusion was demonstrated on flexion–extension radiographs, the rate of fusion affirmed by flexion CT and extension CT was 87.6 and 69.1% of the levels assessed, respectively. The rate of pseudoarthrosis detected on extension CT images was significantly higher than that on flexion–extension radiographs (P < 0.001) and flexion CT (P < 0.01). The rate of fusion achieved on extension CT was 85.6% at 15.1 months postoperatively. Extension CT could detect pseudoarthrosis more clearly than flexion–extension radiography and flexion CT. The CT images are influenced by body position and dilating anterior disc space in extension CT contributes to detect pseudoarthrodesis. Thus, extension CT was a useful method for assessing fusion status after PLIF.
doi:10.1007/s00586-011-1739-0
PMCID: PMC3175889  PMID: 21380745
Extension CT; Flexion–extension radiograph; Interbody fusion; Fusion rate; Radiographic assessment
20.  Comparison of the early results of transforaminal lumbar interbody fusion and posterior lumbar interbody fusion in symptomatic lumbar instability 
Indian Journal of Orthopaedics  2013;47(3):255-263.
Background:
Transforaminal lumbar interbody fusion (TLIF) has been preferred to posterior lumbar interbody fusion (PLIF) for different spinal disorders but there had been no study comparing their outcome in lumbar instability. A comparative retrospective analysis of the early results of TLIF and PLIF in symptomatic lumbar instability was conducted between 2005 and 2011.
Materials and Methods:
Review of the records of 102 operated cases of lumbar instability with minimum 1 year followup was done. A total of 52 cases (11 men and 41 women, mean age 46 years SD 05.88, range 40-59 years) underwent PLIF and 50 cases (14 men and 36 women, mean age 49 years SD 06.88, range 40-59 years) underwent TLIF. The surgical time, duration of hospital stay, intraoperative blood loss were compared. Self-evaluated low back pain and leg pain status (using Visual Analog Score), disability outcome (using Oswestry disability questionnaire) was analyzed. Radiological structural restoration (e.g., disc height, foraminal height, lordotic angle, and slip reduction), stability (using Posner criteria), fusion (using Hackenberg criteria), and overall functional outcome (using MacNab's criteria) were compared.
Results:
Pain, disability, neurology, and overall functional status were significantly improved in both groups but PLIF required more operative time and caused more blood loss. Postoperative hospital stay, structural restoration, stability, and fusion had no significant difference but neural complications were relatively more with PLIF.
Conclusions:
Both methods were effective in relieving symptoms, achieving structural restoration, stability, and fusion, but TLIF had been associated with shorter operative time, less blood loss, and lesser complication rates for which it can be preferred for symptomatic lumbar instability.
doi:10.4103/0019-5413.111484
PMCID: PMC3687902  PMID: 23798756
Lumbar instability; posterior lumbar interbody fusion; transforaminal lumbar interbody fusion
21.  Postoperative spondylitis after posterior lumbar interbody fusion using cages 
European Spine Journal  2004;13(5):419-424.
The recommended surgical options for postoperative wound infections after instrumented spine surgery include a wide debridement and irrigation with antibiotics. In most cases, implant removal is not recommended for a solid fusion. However, there are few reports on the treatment choices for persistent postoperative wound infections following a posterior lumbar interbody fusion (PLIF) using cages. This paper reviewed ten patients referred to our department, who underwent revision surgery for a postoperative, deep infection after a PLIF with cages. The surgery included an anterior radical debridement and interbody fusion with removal of all implants. The clinical and laboratory results, including a bacteriologic study for the causative organism and the radiological changes, were analyzed. All patients complained of persistent severe back pain after the primary surgery. MRSA was the main organism found in these patients (five cases). Complete bony fusion was obtained in nine patients (90%). In one patient, back pain and radiating pain prevented him from returning to his original work. Despite the anterior interbody fusion with an autogenous iliac bone graft, all cases had a complete collapse of the intervertebral disc space, without a dislodgement or collapse of the graft bone. The mean loss of the height and lordosis in the involved segment was 12.7 mm (range 4–46 mm) and 5.6° (range 0–15°), respectively. Anterior radical debridement with the removal of all implants would be an effective way to manage patients with postoperative spondylitis after a PLIF using cages.
doi:10.1007/s00586-003-0584-1
PMCID: PMC3476588  PMID: 15069614
Spondylitis; Posterior lumbar interbody fusion; Cage
22.  Defatted, gas-sterilised cortical bone allograft for posterior lumbar interbody vertebral fusion 
International Orthopaedics  1998;22(2):69-76.
Summary.
In posterior lumbar interbody vertebral fusion operations, variously sized, rectangular shaped, defatted, freeze-dried, gas-sterilised cortical bone allografts were used in combination with cancellous bone autografts from excised posterior elements. Single-level fusion, with or without internal fixation, was undertaken in 38 patients aged 50 years or less with disc herniation or a failed discectomy (the younger group) and in 33 women aged 60 years or more with degenerative spondylolisthesis (the older group). Of the various observable indicators of union, changes in the allograft-host interface alone proved to be of practical use. The incidence of nonunion in patients managed with pedicle screws, with a hook and rod system or without internal fixation was 0 of 8 patients; 1 of 14 patients; and 3 of 16 patients, respectively, in the younger group, and 0 of 11 patients; 0 of 8 patients; and 2 of 14 patients, respectively, in the older group. Of the six patients with nonunion, three had persistent low back pain and only two had mobility of the fused segment which was evident on lateral radiographs during flexion and extension. No patient had graft collapse. The decrease in the height of the intervertebral space, chiefly due to settlement of the allograft into the vertebral bodies, in the younger and older groups averaged 1.1 and 1.6 mm, respectively. We concluded that this simplified technique is mechanically sound and effective in maintaining the height of the intervertebral space. Even when the graft failed to unite, fibrous union could be obtained without graft collapse. Combination with a simple internal fixator, such as a compression rod, facilitates bone union.
doi:10.1007/s002640050212
PMCID: PMC3619706  PMID: 9651769
23.  Posterior Lumbar Interbody Fusion via a Unilateral Approach 
Yonsei Medical Journal  2006;47(3):319-325.
This study sought to determine the outcomes of posterior lumbar interbody fusion (PLIF), via a unilateral approach, in selected patients who presented with unilateral leg pain and segmental instability of the lumbar spine. Patients with a single level of a herniated disc disease in the lumbar spine, unilateral leg pain, chronic disabling lower back pain (LBP), and a failed conservative treatment, were considered for the procedure. A total of 41 patients underwent a single-level PLIF using two PEEK™ (Poly-Ether-Ether-Ketone) cages filled with iliac bone, via a unilateral approach. The patients comprised 21 women and 20 men with a mean age of 41 years (range: 22 to 63 years). Two cages were inserted using a unilateral medial facetectomy and a partial hemilaminectomy. At follow-up, the outcomes were assessed using the Prolo Scale. The success of the fusion was determined by dynamic lumbar radiography and/or computerized tomography scanning. All the patients safely underwent surgery without severe complications. During a mean follow-up period of 26 months, 1 patient underwent percutaneous pedicle screw fixation due to persistent LBP. A posterior displacement of the cage was found in one patient. At the last follow up, 90% of the patients demonstrated satisfactory results. An osseous fusion was present in 85% of the patients. A PLIF, via a unilateral approach, enables a solid union with satisfactory clinical results. This preserves part of the posterior elements of the lumbar spine in selected patients with single level instability and unilateral leg pain.
doi:10.3349/ymj.2006.47.3.319
PMCID: PMC2688150  PMID: 16807980
Posterior lumbar interbody fusion (PLIF); unilateral approach; instability
24.  Anterior Debridement and Strut Graft with Pedicle Screw Fixation for Pyogenic Spondylitis 
Asian Spine Journal  2007;1(2):91-97.
Study Design
A retrospective study.
Purpose
We evaluated the results of the use of anterior debridement and interbody fusion followed by posterior spinal instrumentation.
Overview of Literature
An early diagnosis of pyogenic spondylitis is difficult to obtain. The disease can be treated with various surgical methods (such as anterior debridement and bone graft, anterior instrumentation, and posterior instrumentation).
Methods
This study included 20 patients who received anterior debridement and interbody fusion with strut bone graft followed by posterior spinal fusion for pyogenic spondylitis between 1996 and 2005. We analyzed the culture studies, the correction of the kyphotic angle, blood chemistry, the bony union period, and the amount of symptom relief.
Results
In terms of clinical symptoms relief, eight patients were grouped as "excellent", eleven patients as "good", and one patient as "fair". The vertebral body cultures were positive in 14 patients showing coagulase (-) streptococcus and S. aureus. The average times for normalization of the erythrocyte sedimentation rate and C-reactive protein level were 3.3 and 1.9 months, respectively. Four months was required for bony union. For complications, meralgia paresthetica was found in two cases.
Conclusions
Due to early ambulation and the correction of the kyphotic angle, anterior interbody fusion with strut bone graft and posterior instrumentation could be another favorable method for the treatment of pyogenic spondyulitis.
doi:10.4184/asj.2007.1.2.91
PMCID: PMC2857475  PMID: 20411131
Pyogenic spondylitis; Anterior interbody fusion; Posterior instrumentation
25.  Evaluation of unilateral cage-instrumented fixation for lumbar spine 
Background
To investigate how unilateral cage-instrumented posterior lumbar interbody fusion (PLIF) affects the three-dimensional flexibility in degenerative disc disease by comparing the biomechanical characteristics of unilateral and bilateral cage-instrumented PLIF.
Methods
Twelve motion segments in sheep lumbar spine specimens were tested for flexion, extension, axial rotation, and lateral bending by nondestructive flexibility test method using a nonconstrained testing apparatus. The specimens were divided into two equal groups. Group 1 received unilateral procedures while group 2 received bilateral procedures. Laminectomy, facectomy, discectomy, cage insertion and transpedicle screw insertion were performed sequentially after testing the intact status. Changes in range of motion (ROM) and neutral zone (NZ) were compared between unilateral and bilateral cage-instrumented PLIF.
Results
Both ROM and NZ, unilateral cage-instrumented PLIF and bilateral cage-instrumented PLIF, transpedicle screw insertion procedure did not revealed a significant difference between flexion-extension, lateral bending and axial rotation direction except the ROM in the axial rotation. The bilateral group's ROM (-1.7 ± 0. 8) of axial rotation was decreased significantly after transpedicle screw insertion procedure in comparison with the unilateral group (-0.2 ± 0.1). In the unilateral cage-instrumented PLIF group, the transpedicle screw insertion procedure did not demonstrate a significant difference between right and left side in the lateral bending and axial rotation direction.
Conclusions
Based on the results of this study, unilateral cage-instrumented PLIF and bilateral cage-instrumented PLIF have similar stability after transpedicle screw fixation in the sheep spine model. The unilateral approach can substantially reduce exposure requirements. It also offers the biomechanics advantage of construction using anterior column support combined with pedicle screws just as the bilateral cage-instrumented group. The unpleasant effect of couple motion resulting from inherent asymmetry was absent in the unilateral group.
doi:10.1186/1749-799X-5-86
PMCID: PMC2993665  PMID: 21070626

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