Abstract
Abstract Objective: To illustrate a hybrid technique that involves a combination of open decompression and Posterior Lumbar Interbody Fusion (PLIF) and percutaneously placed pedicle screws. This technique allows for PLIF via a midline incision and approach, and decompression without compromise in operative time and visualisation. Furthermore, this approach is proposed to reduce post-operative wound pain by: smaller midline incision, significantly reduced muscle trauma by not dissecting the paraspinal muscles off the facet joint complex, avoidance of a posterolateral fusion to facilitate limited lateral muscle dissection off the transverse processes. Summary of background data: PLIF fusion rates are comparable to posterolateral fusion rates, as well as providing greater sagittal and coronal balance. There is positive evidence that degenerative spondylolisthesis with canal and/or foraminal stenosis requires stabilisation when decompressed via laminectomy. Methods: Patients with Grade I-II spondylolisthesis at L4/5 with moderate - severe canal/foraminal stenosis undergo a midline PLIF at L4/5, with closure of the midline incision. Percutaneous pedicle screws are inserted, therefore minimising local muscle trauma, with reduction of the spondylolisthesis performed using the pedicle screw construct. Rods are inserted percutaneously to link the L4 and L5 pedicle screws. Image intensification is used to confirmed satisfactory screw placement and reduction of the spondylolisthesis. Conclusion: Percutaneous lumbar pedicle screws can be combined with a standard midline PLIF to reduce postoperative wound pain while allowing for satisfactory screw placement.
Highlights
Degenerative lumbar spondylolisthesis provides a challenging clinical entity
Percutaneous lumbar pedicle screws can be combined with a standard midline Posterior Lumbar Interbody Fusion (PLIF) to reduce postoperative wound pain while allowing for satisfactory screw placement
Kim et al [4], found that in directly comparing PLIF, posterolateral fusion and PLIF with posterolateral fusion, that there was no difference in regards to clinical results and union rates between the three; they noted that PLIF alone allowed for less donor site pain, shorter operating time and less blood loss [4]
Summary
Degenerative lumbar spondylolisthesis provides a challenging clinical entity. When associated with lumbar canal and/or foraminal stenosis the patient can present with claudicant and/or radicular symptoms respectively. One of the treatment methods proposed for degenerative spondylolisthesis with claudicant and/or radicular symptoms is lumbar laminectomy with instrumented fusion. This can take the form of a posterior approach (pedicle screw fixation ± posterolateral graft ± posterior or transforaminal lumbar interbody fusion: PLIF/TLIF), as well as an anterior approach (anterior lumbar interbody fusion: ALIF), or a combination of the above. Kim et al [4], found that in directly comparing PLIF, posterolateral fusion and PLIF with posterolateral fusion, that there was no difference in regards to clinical results and union rates between the three; they noted that PLIF alone allowed for less donor site pain, shorter operating time and less blood loss (it has been noted that these benefits are, at least in part, attributable to not taking any iliac crest bone graft for the PLIF group) [4]. An earlier review noted improved statistical parameters for PLIF over posterolateral fusion in isthmic spondylolisthesis, but without any clinical outcome variation [6]
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