In this prospective study, our aim was to compare the clinical outcome of posterior lumbar interbody fusion (PLIF) and posterolateral fusion (PLF) in spondylolisthesis. A total of 138 patients with spondylolisthesis were randomly assigned to two groups: those operated on with pedicle screw fixation and posterior lumbar interbody fusion by autografting (PLIF), and those operated on with pedicle screw fixation and posterolateral fusion by autografting (PLF). The patients were followed-up for four years. Clinical evaluation was carried out using the Oswestry disability index (ODI) and pain index (VAS). Radiography was performed preoperatively and postoperatively to assess the fusion. Both surgical procedures were effective, but the PLF group showed more complications related to hardware biomechanics. There was no significant statistical difference in clinical and functional outcome in the two groups. The PLIF group presented a better fusion rate than the PLF group.
Degenerative lumbar spinal stenosis (DLSS) has become increasingly common and is characterized by multilevel disc herniation and lumbar spondylolisthesis, which are difficult to treat. The current study aimed to evaluate the short-term clinical outcomes and value of the combined use of microendoscopic discectomy (MED) and minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) for the treatment of multilevel DLSS with spondylolisthesis, and to compare the combination with traditional posterior lumbar interbody fusion (PLIF). A total of 26 patients with multilevel DLSS and spondylolisthesis underwent combined MED and MI-TLIF surgery using a single cage and pedicle rod-screw system. These cases were compared with 27 patients who underwent traditional PLIF surgery during the same period. Data concerning incision length, surgery time, blood loss, time of bed rest and Oswestry Disability Index (ODI) score prior to and following surgery were analyzed statistically. Statistical significance was reached in terms of incision length, blood loss and the time of bed rest following surgery (P<0.05), but there was no significant difference between the surgery time and ODI scores of the two groups. The combined use of MED and MI-TLIF has the advantages of reduced blood loss, less damage to the paraspinal soft tissue, shorter length of incision, shorter bed rest time, improved outcomes and shorter recovery times and has similar short-term clinical outcomes to traditional PLIF.
microendoscopic discectomy; minimally invasive transforaminal lumbar interbody fusion; posterior lumbar interbody fusion; lumbar spinal stenosis; lumbar spondylolisthesis
Clinical and radiological results of posterior dynamic stabilization using interspinous U (ISU, Coflex™, Paradigm Spine Inc.®, NY, USA) were analyzed in comparison with posterior lumbar interbody fusion (PLIF) in degenerative lumbar spinal stenosis (LSS).
A retrospective study was conducted for a consecutive series of 61 patients with degenerative LSS between May 2003 and December 2005. We included only the patients completed minimum 24 months follow up evaluation. Among them, 30 patients were treated with implantation of ISU after decompressive laminectomy (Group ISU) and 31 patients were treated with wide decompressive laminectomy and posterior lumbar interbody fusion (PLIF; Group PLIF). We evaluated visual analogue scale (VAS) and Oswestry Disability Index (ODI) for clinical outcomes (VAS, ODI), disc height ratio disc height (DH), disc height/vertebral body length ×100), static vertebral slip (VS) and depth of maximal radiolucent gap between ISU and spinous process) in preoperative, immediate postoperative and last follow up.
The mean age of group ISU (66.2 ± 6.7 years) was 6.2 years older than the mean age of group PLIF (60.4 ± 8.1 years; p = 0.003 ). In both groups, clinical measures improved significantly than preoperative values (p < 0.001). Operation time and blood loss was significantly shorter and lower in group ISU than group PLIF (p < 0.001). In group ISU, the DH increased transiently in immediate postoperative period (15.7 ± 4.5% → 18.6 ± 5.9%), however decreased significantly in last follow up (13.8 ± 6.6%, p = 0.027). Vertebral slip (VS) of spondylolisthesis in group ISU increased during postoperative follow-up (2.3 ± 3.3 → 8.7 ± 6.2, p = 0.040). Meanwhile, the postoperatively improved DH and VS was maintained in group PLIF in last follow up.
According to our result, implantation of ISU after decompressive laminectomy in degenerative LSS is less invasive and provides similar clinical outcome in comparison with the instrumented fusion. However, the device has only transient effect on the postoperative restoration of disc height and reduction of slip in spondylolisthesis. Therefore, in the biomechanical standpoint, it is hard to expect that use of Interspinous U in decompressive laminectomy for degenerative LSS had long term beneficial effect.
Degenerative spinal stenosis; Lumbar; Dynamic stabilization; Interspinous U; Coflex™; Posterior lumbar interbody fusion
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.
Spondyolisthesis; Interverterbral fusion; Internal fixation
This is a retrospective case series to evaluate clinical variables, complications and outcome of 50 patients who underwent anterior lumbar interbody fusion (ALIF) supplemented with posterior percutaneous pedicle screw fixation for degenerative conditions of the lumbar spine. Twenty-four patients underwent single-level fusion and 26 patients had a two-level fusion for a total of 76 levels fused. The mean lengths of the anterior and posterior (including repositioning) portions of the procedure were 131 and 102 min, respectively. The mean estimated blood loss for the entire procedure was 288 ml. The overall adverse event rate was 12%. The mean VAS score for leg pain, VAS score for back pain and mean ODI all improved postoperatively. This study found that ALIF using allograft bone and rhBMP-2 combined with percutaneous pedicle screw fixation had a high fusion rate and a low incidence of perioperative complications. Patient outcomes showed significant improvements in back and leg pain and physical functioning.
Lumbar arthrodesis; Anterior lumbar interbody fusion (ALIF); Percutaneous pedicle screw fixation
The authors hypothesized that the placement of the interspinous implant would show a similar clinical outcome to the posterior lumbar interbody fusion (PLIF) in patients having spinal stenosis with mild segmental instability and that this method would be superior to PLIF without significantly affecting degeneration at the adjacent segments. Forty two adult patients having degenerative spinal stenosis with mild segmental instabilit who underwent implantation of Coflex™ (Spine motion, Germany) or PLIF at L4-5 between January 2000 and December 2003 were consecutively selected and studied for one-year clinical outcome. At 12 months after surgery, both groups showed a significant improvement in the visual analogue scale score and Oswestry disability index score for both lower extremity pain and low back pain. However, the range of motion at the upper adjacent segments (L3-4) increased significantly after surgery in the PLIF group, which was not manifested in the Coflex™ group during the follow-up. The authors assumed that interspinous implantation can be an alternative treatment for the spinal stenosis with segmental instability in selected conditions posing less stress on the superior adjacent level than PLIF.
Spinal Stenosis; Outcome
Segmental pedicle screw fixation is rapidly becoming a popular method of spinal instrumentation. Few studies have investigated the rates of adjacent superior segment facet joint violation. The purpose of our study were to investigate the incidence of superior segment facet joint violation after pedicle screw instrumentation in the lumbar spine and to evaluate technical factors related to the incidence. A prospective study including 96 patients who underwent lumbar and lumbosacral fusion was conducted between March 2006 and December 2007. All patients had bilateral or unilateral posterior pedicle screw-rod instrumentation with either CD-Horizon (top-loading screw) or TSRH (side-connecting screw) implants. Pedicle screws were instrumented according to the methods advocated by Roy-Camille (Group 1, 20 cases) or Weinstein (Group 2, 76 cases). All patients had computed tomography scan at 1 week post operation. CT scans were reviewed blind by an experienced spine research fellow and a consultant radiologist to determine violation of the adjacent superior segment facet joint. Superior segment facet joint violation occurred in all of the 20 patients (100%) and all of the top-level screws (100%) in Group 1. The spinal research fellow noted the incidence of facet joint violation to be present in 23.8% of the screws and 32.9% of the patients in Group 2, whereas the consultant radiologist noted this to be the case in 25.2 and 35.5%, respectively. The incidence of facet joint violation in patients with CD-Horizon screws was far lower than patients with TSRH screws (P < 0.001). In conclusion, it seems that meticulous surgical dissection without injuring the top-level facet joints, proper instrumentation of pedicle screws with the appropriate entry site (Weinstein’s method), trajectory, and use of top-loading screw heads are some ways that surgeons could minimize the risk of top-level facet joint violation.
Pedicle screws; Facet joint violation; Lumbar spine
Percutaneous techniques may be helpful to reduce approach-related morbidity of conventional open surgery. The aim of the study was to evaluate the feasibility and safety of mini-open posterior lumbar interbody fusion for instabilities and degenerative disc diseases. From May 2005 until October 2008, 20 patients affected by monosegmental instability and disc herniation underwent mini-open lumbar interbody fusion combined with percutaneous pedicle screw fixation of the lumbar spine. Clinical outcome was assessed using the Visual Analog Scale, Oswestry Disability Index, and Short Form Health Survey-36. The mean follow-up was 24 months. The mean estimated blood loss was 126 ml; the mean length of stay was 5.3 days; the mean operative time was 171 min. At 24-month follow-up, the mean VAS score was 2.1, mean ODI was 27.1%, and mean SF-36 was 85.2%. 80 screws were implanted in 20 patients. 74 screws showed very good position, 5 screws acceptable, and 1 screw unacceptable. A solid fusion was achieved in 17 patients (85%). In our opinion, mini-open TLIF is a valid and safe treatment of lumbar instability and degenerative disc diseases in order to obtain faster return to daily activities.
Percutaneous pedicle screw; Minimally invasive fusion; Disc herniation
Both the paraspinal muscle sparing approach and percutaneous screw fixation are less traumatic procedures in comparison with the conventional midline approach. These techniques have been used with the goal of reducing muscle injury. The purpose of this study was to evaluate and to compare the safety and efficacy of the paraspinal muscle sparing technique and percutaneous screw fixation for the treatment of L5-S1 spondylolisthesis.
Twenty patients who had undergone posterior lumbar interbody fusion (PLIF) at the L5-S1 segment for spondylolisthesis were prospectively studied. They were divided into two groups by screw fixation technique (Group I : paraspinal muscle sparing approach and Group II: percutaneous screw fixation). Clinical outcomes were assessed by Low Back Outcome Score (LBOS) and Visual Analogue Scale (VAS) for back and leg pain at different times after surgery. In addition, modified MacNab's grading criteria were used to assess subjective patients' outcomes 6 months after surgery. Postoperative midline surgical scarring, intraoperative blood loss, mean operation time, and procedure-related complications were analyzed.
Excellent or good results were observed in all patients in both groups 6 months after surgery. Patients in both groups showed marked improvement in terms of LBOSs all over time intervals. Postoperative midline surgical scarring and intraoperative blood loss were lower in Group II compared to Group I although these differences were not statistically significant. Low back pain (LBP) and leg pain in both groups also showed significant improvement when compared to preoperative scores. However, at 7 days and 1 month after surgery, patients in Group II had significantly better LBP scores compared to Group I.
In terms of LBP during the early postoperative period, patients who underwent percutaneous screw fixation showed better results compared to ones who underwent screw fixation via the paraspinal muscle sparing approach. Our results indicate that the percutaneous screw fixation procedure is the preferable minimally invasive technique for reducing LBP associated with L5-S1 spondylolisthesis.
Spondylolisthesis; Paraspinal muscle sparing approach; Percutaneous screw fixation; Back pain
Interspinous spacers were developed to treat local deformities such as degenerative spondylolisthesis. To treat patients with chronic instability, posterior pedicle fixation and rod-based dynamic stabilization systems were developed as alternatives to fusion surgeries. Dynamic stabilization is the future of spinal surgery, and in the near future, we will be able to see the development of new devices and surgical techniques to stabilize the spine. It is important to follow the development of these technologies and to gain experience using them. In this paper, we review the literature and discuss the dynamic systems, both past and present, used in the market to treat lumbar degeneration.
Fusion of lumbar spine segments is a well-established therapy for many pathologies. The procedure changes the biomechanics of the spine. Initial clinical benefits may be outweighed by ensuing damage to the adjacent segments. Various surgical devices and techniques have been developed to prevent this deterioration. "Topping off" systems combine rigid fusion with a flexible pedicle screw system to prevent adjacent segment disease (ASD). To date, there is no convincing evidence that these devices provide any patient benefits.
The study is designed as a randomized, therapy-controlled trial in a clinical care setting at a university hospital. Patients presenting to the outpatient clinic with degenerative disc disease or spondylolisthesis will be assessed against study inclusion and exclusion criteria. After randomization, the control group will undergo conventional fusion. The intervention group will undergo fusion with a supplemental flexible pedicle screw system to protect the adjacent segment ("topping off").
Follow-up examination will take place immediately after treatment during hospital stay, after 6 weeks, and then after 6, 12, 24 and 36 months. Subsequently, ongoing assessments will be performed annually.
Outcome measurements will include quality of life and pain assessments using questionnaires (SF-36™, ODI, COMI). In addition, clinical and radiologic ASD, work-related disability, and duration of work disability will be assessed. Inpatient and 6-month mortality, surgery-related data (e.g., intraoperative complications, blood loss, length of incision, surgical duration), postoperative complications, adverse events, and serious adverse events will be documented and monitored throughout the study. Cost-effectiveness analysis will also be provided.
New hybrid systems might improve the outcome of lumbar spine fusion. To date, there is no convincing published data on effectiveness or safety of these topping off systems. High quality data is required to evaluate the benefits and drawbacks of topping off devices. If only because these devices are quite expensive compared to conventional fusion implants, nonessential use should be avoided. In fact, these high costs necessitate efforts by health care providers to evaluate the effects of these implants. Randomized clinical trials are highly recommended to evaluate the benefits or harm to the patient.
Today, posterior stabilization of the cervical spine is most frequently performed by lateral mass screws or spinous process wiring. These techniques do not always provide sufficient stability, and anterior fusion procedures are added secondarily. Recently, transpedicular screw fixation of the cervical spine has been introduced to provide a one-stage stable posterior fixation. The aim of the present prospective study is to examine if cervical pedicle screw fixation can be done by low risk and to identify potential risk factors associated with this technique. All patients stabilized by cervical transpedicular screw fixation between 1999 and 2002 were included. Cervical disorders included multisegmental degenerative instability with cervical myelopathy in 16 patients, segmental instability caused by rheumatoid arthritis in three, trauma in five and instability caused by infection in two patients. In most cases additional decompression of the spinal cord and bone graft placement were performed. Pre-operative and post-operative CT-scans (2-mm cuts) and plain X-rays served to determine changes in alignment and the position of the screws. Clinical outcome was assessed in all cases. Ninety-four cervical pedicle screws were implanted in 26 patients, most frequently at the C3 (26 screws) and C4 levels (19 screws). Radiologically 66 screws (70%) were placed correctly (maximal breach 1 mm) whereas 20 screws (21%) were misplaced with reduction of mechanical strength, slight narrowing of the vertebral artery canal (<25%) or the lateral recess without compression of neural structures. However, these misplacements were asymptomatic in all cases. Another eight screws (9%) had a critical breach. Four of them showed a narrowing of the vertebral artery canal of more then 25%, in all cases without vascular problems. Three screws passed through the intervertebral foramen, causing temporary paresis in one case and a new sensory loss in another. In the latter patient revision surgery was performed. The screw was loosened and had to be corrected. The only statistically significant risk factor was the level of surgery: all critical breaches were seen from C3 to C5. Percutaneous application of the screws reduced the risk for misplacement, although this finding was not statistically significant. There was also a remarkable learning curve. Instrumentation with cervical transpedicular screws results in very stable fixation. However, with the use of new techniques like percutaneous screw application or computerized image guidance there remains a risk for damaging nerve roots or the vertebral artery. This technique should be reserved for highly selected patients with clear indications and to highly experienced spine surgeons.
Cervical spine; Pedicle screw fixation; Complication; Posterior fusion
Transpedicular screws are commonly and successfully used for posterior fixation in spinal instability, but their insertion remains challenging. Even using navigation techniques, there is a misplacement rate of up to 11%. The aim of this study was to assess the accuracy of a novel pedicle screw system.
Thoracic and lumbar fusions were performed on 67 consecutive patients for tumor, trauma, degenerative disease or infection. A total of 326 pedicular screws were placed using a novel wire-guided, cannulated, polyaxial screw system (XIA Precision®, Stryker). The accuracy of placement was assessed postoperatively by CT scan, and the patients were followed-up clinically for a mean of 16 months.
The total medio-caudal pedicle wall perforation rate was 9.2% (30/326). In 19 of these 30 cases a cortical breakthrough of less than 2 mm occurred. The misplacement rate (defined as a perforation of 2 mm or more) was 3.37% (11/326). Three of these 11 screws needed surgical revision due to neurological symptoms or CSF leakage. There have been no screw breakages or dislocations over the follow up-period.
We conclude that the use of this cannulated screw system for the placement of pedicle screws in the thoracic and lumbar spine is accurate and safe. The advantages of this technique include easy handling without a time-consuming set up. Considering the incidence of long-term screw breakage, further investigation with a longer follow-up period is necessary.
spinal instrumentation; pedicle screws; misplacement; pedicle wall perforation
Adjacent segment degeneration (ASD) is discussed to impair long-term outcome after lumbar interbody fusion. Nevertheless the amount and origin of degeneration and its clinical relevance remain unclear. Only little data is published studying quantitative disc height reduction (DHR) as indicator for ASD in long-term follow-up. Forty patients (23 men, 17 women) (group 1: degenerative disc disease, n = 27; group 2: lytic spondylolisthesis, n = 13) underwent lumbar 360° instrumentation and fusion between 1991 and 1997. Preoperative and follow-up lateral lumbar radiographs were studied. Disc heights of first and second cephalad adjacent segments were measured by Farfan’s technique and Hurxthal’s technique modified by Pope. Clinical outcome was studied using Oswestry disability index (ODI) and visual analogue scale (VAS). Age, gender, prior surgery, fusion rate and number of fusion levels were investigated as potential factors affecting the outcome. Mean follow-up was 114 (72–161) months. Clinical outcome showed an improvement of 44.6% in ODI and 43.8% in VAS with a tendency towards better results in group 2. Fusion rate was 95%. Disc height of the first cephalad adjacent segment in all patients was reduced by on average 21% (Farfan, P < 0.001) and 19% (Pope, P < 0.001), respectively, and that of the second adjacent level by on average 16% (Farfan, P < 0.001) and 14% (Pope, P < 0.001), respectively. A tendency towards more disc height reduction (DHR) in the degenerative group was observed. Advanced age correlated with advanced DHR (P ≤ 0.003, r = 0.5). Multiple level fusion led to a more pronounced DHR than 1-level fusion (P = 0.028). There was a tendency towards more DHR in the first adjacent disc compared to the second. Gender, prior surgery of the fused segment and fusion level did not affect the amount of DHR. There was no correlation between the clinical outcome and DHR. Lumbar fusion is associated with DHR of adjacent discs. This may be induced by additional biomechanical stress, ongoing degeneration affecting the lumbar spine and advancing age. However, clinical outcome is not correlated with adjacent DHR.
Adjacent segment; Lumbar fusion; Disc height; Clinical outcome; Disc degeneration
This is a retrospective study.
To evaluate the advantages and effects of posterior lumbar interbody fusion (PLIF) using allograft and posterior instrumentation in the lumbar pyogenic discitis, which are resistant to antibiotics.
Overview of Literature
To present preliminary results of PLIF using a compressive bone graft with allograft and pedicle screw fixation in the lumbar pyogenic discitis.
Fifteen patients who had lumbar pyogenic discitis were treated by posterior approach from May 2004 to July 2008. The mean follow-up duration was 27.2 ± 18.68 months. The standing radiographs of the lumbar spine and clinical results were compared and analyzed in order to assess the bony union, the changes in the distance between the two vertebral bodies and the changes in the lordotic angle formed between the fused bodies immediately after surgery and at the final follow-up.
Fifteen solid unions at an average of 15.2 ± 3.5 weeks after operation. The mean preoperative lordotic angle of the affected segments was 14.3 ± 15.1°, compared to 20.3 ± 12.3° after surgery and 19.8 ± 15.2° at last follow-up. For the functional result according to the Kirkaldy-Willis criteria, the outcome was excellent in 9, good in 5, fair in 1, and there were no poor cases. The average visual analogue scale score was decreased from 7.4 before surgery to 3.4 at 2 weeks postoperative.
The main advantage in the procedure of PLIF using compressive bone graft with allograft and post instrumentation is early ambulation. We believe that this is another good procedure for patients with poor general condition because a further autograft bone harvest is not required.
Lumbar spine; Discitis; Posterior lumbar interbody fusion; Homologous transplantation
The bone–screw interface has been indicated as the weak link in pedicle screw spine fixation. Bisphosphonate treatment may have the effect of improving bone–screw interface fixation in spine fusion by inhibiting bone resorption. An experimental study was conducted using a porcine model to evaluate the influence of alendronate treatment on bone–pedicle screw interface fixation. Eleven pigs in the treatment group received alendronate 10 mg/day orally for three months postoperatively. The other 11 pigs served as a control group. Posterior lateral fusion with the CD Horizon pedicle screw system was performed with autograft on the lumbar spine on all animals. Biomechanical torsion test and histomorphometric parameters of screw fixation were evaluated three months after the operation. The maximum torque and initial angular stiffness of the treatment group was higher than that of the control group, but there was no statistical significance. The bone–screw contact surface was 23.3 ± 10% for the treatment group and 9.8 ± 5.9% for the control group (P < 0.01). This study indicated that alendronate treatment increased bone purchase of stainless steel screw surfaces.
The unilateral transforaminal approach for lumbar interbody fusion as an alternative to the anterior (ALIF) and traditional posterior lumbar interbody fusion (PLIF) combined with pedicle screw instrumentation is gaining in popularity. At present, a prospective study using a standardized tool for outcome measurement after the transforaminal lumber interbody fusion (TLIF) with a follow-up of at least 3 years is not available in the current literature, although there have been reports on specific complications and cost efficiency. Therefore, a study of TLIF was undertaken. Fifty-two consecutive patients with a minimum follow-up of 3 years were included, with the mean follow-up being 46 months (36–64). The indications were 22 isthmic spondylolistheses and 30 degenerative disorders of the lumbar spine. Thirty-nine cases were one-level, 11 cases were two-level, and two cases were three-level fusions. The pain and disability status was prospectively evaluated by the Oswestry disability index (ODI) and a visual analog scale (VAS). The status of bony fusion was evaluated by an independent radiologist using anterior–posterior and lateral radiographs. The operation time averaged 173 min for one-level and 238 min for multiple-level fusions. Average blood loss was 485 ml for one-level and 560 ml for multiple-level fusions. There were four serious complications registered: a deep infection, a persistent radiculopathy, a symptomatic contralateral disc herniation and a pseudarthrosis with loosening of the implants. Overall, the pain relief in the VAS and the reduction of the ODI was significant (P<0.05) at follow-up. The fusion rate was 89%. At the latest follow-up, significant differences of the ODI were neither found between isthmic spondylolistheses and degenerative diseases, nor between one- and multiple-level fusions. In conclusion, the TLIF technique has comparable results to other interbody fusions, such as the PLIF and ALIF techniques. The potential advantages of the TLIF technique include avoidance of the anterior approach and reduction of the approach related posterior trauma to the spinal canal.
Transforaminal lumbar interbody fusion (TLIF); Low back pain; Spinal fusion; Lumbar fusion; Interbody fusion
There are technical limitations of multi-level posterior pedicle screw fixation performed by the percutaneous technique. The purpose of this study was to describe the surgical technique and outcome of minimally invasive multi-level posterior lumbar interbody fusion (PLIF) and to determine its efficacy.
Forty-two patients who underwent mini-open PLIF using the percutaneous screw fixation system were studied. The mean age of the patients was 59.1 (range, 23 to 78 years). Two levels were involved in 32 cases and three levels in 10 cases. The clinical outcome was assessed using the visual analog scale (VAS) and Low Back Outcome Score (LBOS). Achievement of radiological fusion, intra-operative blood loss, the midline surgical scar and procedure related complications were also analyzed.
The mean follow-up period was 25.3 months. The mean LBOS prior to surgery was 34.5, which was improved to 49.1 at the final follow up. The mean pain score (VAS) prior to surgery was 7.5 and it was decreased to 2.9 at the last follow up. The mean estimated blood loss was 238 mL (140-350) for the two level procedures and 387 mL (278-458) for three levels. The midline surgical scar was 6.27 cm for two levels and 8.25 cm for three level procedures. Complications included two cases of asymptomatic medial penetration of the pedicle border. However, there were no signs of neurological deterioration or fusion failure.
Multi-level, minimally invasive PLIF can be performed effectively using the percutaneous transpedicular screw fixation system. It can be an alternative to the traditional open procedures.
Posterior lumbar interbody fusion; Percutaneous; Minimally invasive surgery
Degenerative disease of the lumbar spine is common in ageing populations. It causes disturbing back pain, radicular symptoms and lowers the quality of life. We will focus our discussion on the surgical options of posterior lumbar interbody fusion (PLIF) and transforaminal lumbar interbody fusion (TLIF) and minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) for lumbar degenerative spinal deformities, which include symptomatic spondylolisthesis and degenerative scoliosis. Through a description of each procedure, we hope to illustrate the potential benefits of TLIF over PLIF. In a retrospective study of 53 ALIF/PLIF patients and 111 TLIF patients we found reduced risk of vessel and nerve injury in TLIF patients due to less exposure of these structures, shortened operative time and reduced intra-operative bleeding. These advantages could be translated to shortened hospital stay, faster recovery period and earlier return to work. The disadvantages of TLIF such as incomplete intervertebral disc and vertebral end-plate removal and potential occult injury to exiting nerve root when under experienced hands are rare. Hence TLIF remains the mainstay of treatment in degenerative deformities of the lumbar spine. However, TLIF being a unilateral transforaminal approach, is unable to decompress the opposite nerve root. This may require contralateral laminotomy, which is a fairly simple procedure. The use of minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) to treat degenerative lumbar spinal deformity is still in its early stages. Although the initial results appear promising, it remains a difficult operative procedure to master with a steep learning curve. In a recent study comparing 29 MI-TLIF patients and 29 open TLIF, MI-TLIF was associated with longer operative time, less blood loss, shorter hospital stay, with no difference in SF-36 scores at six months and two years. Whether it can replace traditional TLIF as the surgery of choice for degenerative lumbar deformity remains unknown and more studies are required to validate the safety and efficiency.
Degenerative spine; lumbar spine fusion; minimally invasive transforaminal fusion
Interspinous fusion devices (IFDs) are increasingly offered to patients over the age of 50 with lumbar spinal stenosis and intermittent neurogenic claudication. Here, we review the literature on complication rates, reoperation rates, and outcomes for implanting IFD, and offer an assessment of IFD charges at a single institution in 2010.
The literature concerning IFD implants was reviewed with particular attention focused on complications, reoperation rates, and outcomes. Additionally, the costs of implanting 31 IFD devices in 16 patients at one to three levels at a single institution in 2010 are presented.
Reviewing the spinal literature concerning the postoperative status of IFD followed over an average of 23–42.9 postoperative months revealed that IFD resulted in 11.6–38% complication rate, 4.6–85% reoperation rate, and 66.7–77% frequency of poor outcomes. Additionally, the 31 devices implanted in 16 patients at a single university hospital in 2010 cost a total of $576,407.
With high maximal complication rates (38%), reoperation rates (85%), poor outcomes (77%), and high costs ($576,407 for 31 devices in 16 patients), the utilization and implantation of IFD remains extremely controversial and should be investigated further.
Complications; high costs; interspinous fusion devices; lumbar stenosis; poor outcomes; reoperations
No consensus has been reached regarding surgical management of degenerative spondylolisthesis. The optimal type of surgical procedure and surgical indications have not been precisely defined. In order to screen for predictors of outcome, we retrospectively studied patient outcomes after posterior decompression and fusion for isolated lumbar degenerative spondylolisthesis. Twenty-four consecutive patients (age range 50–78 years) underwent primary surgery for isolated lumbar degenerative spondylolisthesis. The surgical procedure consisted of posterior decompression and pedicle screw instrumented fusion using autogeneous bone graft, with or without interbody fusion. Clinical and radiologic status were assessed using the Beaujon functional score and plain AP and lateral radiographs. A multivariate analysis was used to correlate the functional score increase with surgical procedure modifications and preoperative clinical and radiologic features in order to determine which of them led to better results. Eighteen patients completed the evaluation. Six others were lost to follow-up after a minimum of 0.87 years. Combining all the results, the mean follow-up was 2.87 years. The Beaujon score was improved in the 24 patients (P<0.001), and fusion was successful in all cases. Additional interbody fusion and preoperative leg pain were significantly correlated with larger score increase (P=0.016 and P=0.003). Posterior decompression and fusion is successful in treating lumbar degenerative spondylolisthesis. From this study, circumferential fusion improves the outcomes and leg pain is a fair indication for surgery.
Degenerative spondylolisthesis; Postero-lateral fusion; Interbody fusion; Decompression; Surgical indication; Multivariate analysis
The use of biological technologies for the treatment of degenerative spinal diseases has undergone rapid clinical and scientific development. BMP strategies have gained wide support for an inherent potential to improve the ossification process. It has been extensively studied in combination with various techniques for spinal stabilisation from both anterior and posterior approach. We studied the fusion process after implantation of rhBMP-2 in 17 patients with degenerative lumbar spine diseases in combination with dorsal fixation with pedicle screws and poly-ether-ether-ketone (PEEK) interbody cages. We used 12 mg rhBMP-2 carried by collagen sponge, 6 mg in every cage. Patient follow up consisted of pre-operative radiographic and clinical evaluation. Similar post-operative evaluations were performed at 3 and 6 months. Clinical assessment demonstrated clear improvement in all patients despite evidence of vertebral endplate osteoclastic activity in the 3-month radiographs. The 6-month radiograph, however, confirmed evidence of fusion, and no untoward results or outcomes were noted. While previous studies have shown exclusively positive results in both fusion rates and process, our study demonstrated an intermediate morphology at 3 months during the ossification process using Induct Os in combination with peek-cages using a PLIF-technique. The transient resorption of bone surrounding the peek cage did not result in subsidence, pain or complication, and fusion was reached in all cases within a 6-month-controlled evaluation. Although there was no negative influence on clinical outcome, the potential for osteoclastic or metabolic resorption bears watching during the post-surgical follow up.
Degenerative disc disease; Bone morphogenetic protein 2; Lumbar spine; Posterior lumbar interbody fusion; Osteoclastic activity
Porous β-calcium pyrophosphate (β-CPP) was developed to improve the fusion success of posterolateral lumbar fusion (PLF). The possibility of accomplishing PLF using a mixture of porous β-CPP and iliac bone was studied. This paper reports the radiologic results of PLF using the β-CPP plus autograft for lumbar degenerative disease as a bone graft extender.
A prospective, case-matched, radiographic study evaluating the results of short segment lumbar fusion using a β-CPP plus autograft was performed to compare the efficacy of β-CPP plus autograft with that of an autograft alone for short segment lumbar fusion. Thirty one consecutive patients (46 levels) underwent posterolateral fusion with pedicle screw fixation and additional posterior lumbar interbody fusion. In all patients, 3 mL of β-CPP plus 3 mL of autogenous bone graft was placed randomly in one side of a posterolateral gutter, and 6 mL of autogenous iliac bone graft was placed on the other. The fusion rates, volumes of fusion masses, and bone absorption percentage were evaluated postoperatively using simple radiographs and 3 dimensional computed tomography (3D-CT) scans.
The control sides treated with an autograft showed significantly better Lenke scores than the study sides treated with β-CPP at 3 and 6 months postoperatively, but there was no difference between the two sides at 12 months. The fusion rates (confirmed by 3D-CT) were 87.0% in the β-CPP group and 89.1% in the autograft group, which were not significantly different. The fusion mass volumes and bone absorption percentage at 12 months postoperatively were 2.49 mL (58.4%) and 1.89 mL (69.5%) for the β-CPP and autograft groups, respectively, and mean fusion mass volume was significantly higher in the β-CPP group.
β-CPP combined with an autograft is as effective as autologous bone for grafting during instrumented posterolateral spinal fusion. These findings suggest that β-CPP bone chips can be used as a novel bone graft extender for short-segment posterolateral spinal fusion.
Beta-calcium pyrophosphate; Bone graft extender; Fusion rate; Lumbar posterolateral fusion; Prospective consecutive study
Medial or lateral pedicle screw penetration with the potential to affect neural structures in a well-known and frequent problem associated with posterior spinal fusion. We evaluated the placement of pedicle screws (n = 141) in 36 patients following posterior lumbar spinal fusion with Socon or Kluger instrumentation via a lateral transpedicular approach. The examination was based on CT and MR images performed after removal of the instrumentation, on average 1 year after implantation. We found seven pedicle screws with lateral cortical penetration of the pedicle and five screws with medial cortical penetration of the pedicle (8.5% pedicle penetration overall). No severe radicular complications accompanied these pedicle penetrations. The mean insertion angles of the pedicle screws at the L4 level were 22.6° and 23.1° for the left and the right side, respectively. At the L5 level the mean insertion angle was 20.5° on the left side and 21.5° on the right, and at the S1 level the mean angle was 16.2° on the left and 15.2° on the right. The results of this study indicate that the lateral transpedicular approach is a safe procedure for pedicle screw insertion.
Pedicle fixation; Posterior spine surgery; Lumbar spine; Complications
Segmental instability in degenerative disc disease is often treated with anterior lumbar interbody fusion (ALIF). Current techniques require an additional posterior approach to achieve sufficient stability. The test device is an implant which consists of a PEEK-body and an integrated anterior titanium plate hosting four diverging locking screws. The test device avoids posterior fixation by enhancing stability via the locking screws. The test device was compared to an already established stand alone interbody implant in a human cadaveric three-dimensional stiffness test. In the biomechanical test, the L4/5 motion segment of 16 human cadaveric lumbar spines were isolated and divided into two test groups. Tests were performed in flexion, extension, right and left lateral bending, right and left axial rotation. Each specimen was tested in native state first, then a discectomy was performed and either of the test implants was applied. Finite element analysis (FE) was also performed to investigate load and stress distribution within the implant in several loading conditions. The FE models simulated two load cases. These were flexion and extension with a moment of 5 Nm. The biomechanical testing revealed a greater stiffness in lateral bending for the SynFix-LR™ compared to the established implant. Both implants showed a significantly higher stiffness in all loading directions compared to the native segment. In flexion loading, the PEEK component takes on most of the load, whereas the majority of the extension load is put on the screws and the screw–plate junction. Clinical investigation of the test device seems reasonable based on the good results reported here.
Biomechanics; Lumbar spine; Finite element analysis; Interbody fusion