Transforaminal Lumbar Interbody Fusion Approach Research Articles

Effectiveness and safety of transforaminal lumbar interbody fusion in patients with previous laminectomy.

To determine the efficacy and safety of transforaminal lumbar interbody fusion (TLIF) for revision lumbar spine surgery in patients with previous laminectomy. The secondary objective was to evaluate the clinical and radiological outcome after such a procedure. Retrospective case series study. Eighty-two patients were included. There were 48 women (58.5 %) and 34 men (41.5 %) with a mean age of 51 years (range 26-84) at the time of index procedure. The outpatient and inpatient charts were reviewed to identify patients' demographic data, preoperative, perioperative, and postoperative data. The outcome measures were assessed by Oswestry Disability Index (ODI) and visual analog scale (VAS) for back and leg pain. An independent spine surgeon and musculoskeletal radiologist reviewed the imaging studies. The average operative time was 160 min (range 131-250). The average estimated blood loss was 652 cc (100-1,400 cc). Nineteen patients (23.1 %) required blood transfusion. Five patients (6 %) had dural tear. One patient (1.2 %) had a surgical site infection. Two patients (2.4 %) had thromboembolic events. The average hospital stay was 3.8 days (2-5 days). At a mean follow-up of 28 months, there were statically significant improvement in the ODI and VAS for back and leg pain. None of the patients' radiographs showed hardware failure or pedicle screw loosening and no patient returned to the operating room for pseudarthrosis. The current study confirmed that TLIF approach in patients with previous laminectomy is effective and safe with good outcomes.

The “TFP” Fusion Technique for Posterior 360° Lumbar Fusion: a Combination of Open Decompression, Transforaminal Lumbar Interbody Fusion, and Facet Fusion with Percutaneous Pedicle Screw Fixation

Because degenerative spondylolithesis is prevalent in the elderly with associated osteoporosis, the rate of failure of pedicle screws is high; this leads to pseudoarthrosis and potentially requires reoperation. The burden of recurrent symptoms and reoperation is sufficiently significant to warrant prevention. We here describe a hybrid technique that involves a combination of a unilateral approach to bilateral decompression via a midline incision, transforaminal lumbar interbody fusion (TLIF), contralateral facet fusion, and percutaneously placed pedicle screws without compromising operative time and visualization. This approach is familiar to spine surgeons, adheres to the basic principles of minimally invasive spine surgery technique, minimizes dural and neural injury because of the unilateral TLIF approach, and provides a superior fusion construct because of facet fusion. In this procedure, patients with degenerative spondylolisthesis or scoliosis with moderate-severe canal/foraminal stenosis undergo a midline unilateral TLIF and contralateral facet fusion with closure of the midline incision. Percutaneous pedicle screws are inserted under stereotactic guidance with reduction of the deformity using a pedicle screws construct. Rods are inserted percutaneously to link the pedicle screws. Image intensification is used to confirmed satisfactory screw placement and reduction of the spondylolisthesis.

Comparison of perioperative outcomes following open versus minimally invasive transforaminal lumbar interbody fusion in obese patients

Minimally invasive (MI) transforaminal lumbar interbody fusion (TLIF) has proven to be effective in the treatment of spondylolisthesis and degenerative disc disease (DDD). Compared with the traditional open TLIF, the MI procedure has been associated with less blood loss, less postoperative pain, and a shorter hospital stay. However, it is uncertain whether the advantages of an MI TLIF also apply specifically to obese patients. This study was dedicated to evaluating whether obese patients reap the perioperative benefits similar to those seen in patients with normal body mass index (BMI) when undergoing MI TLIF. Obese patients-that is, those with a BMI of at least 30 kg/m(2)-who had undergone single-level TLIF were retrospectively identified and categorized according to BMI: Class I obesity, BMI 30.0-34.9 kg/m(2); Class II obesity, BMI 35.0-39.9 kg/m(2); or Class III obesity, BMI ≥ 40.0 kg/m(2). In each obesity class, patients were stratified by TLIF approach, that is, open versus MI. Perioperative outcomes, including intraoperative estimated blood loss (EBL), complications (overall, intraoperative, and 30-day postoperative), and hospital length of stay (LOS), were compared. The chi-square test, Fisher exact test, or 2-tailed Student t-test were used when appropriate. One hundred twenty-seven patients were included in the final analysis; 49 underwent open TLIF and 78 underwent MI TLIF. Sixty-one patients had Class I obesity (23 open and 38 MI TLIF); 45 patients, Class II (19 open and 26 MI); and 21 patients, Class III (7 open and 14 MI). Overall, mean EBL was 397.2 ml and mean hospital LOS was 3.7 days. Minimally invasive TLIF was associated with significantly less EBL and a shorter hospital stay than open TLIF when all patients were evaluated as a single cohort and within individual obesity classes. Overall, the complication rate was 18.1%. Minimally invasive TLIF was associated with a significantly lower total complication rate (11.5% MI vs 28.6% open) and intraoperative complication rate (3.8% MI vs 16.3% open) as compared with open TLIF. When stratified by obesity class, MI TLIF was still associated with lower rates of total and intraoperative complications. This effect was most profound and statistically significant in patients with Class III obesity (42.9% open vs 7.1% MI). Minimally invasive TLIF offers obese patients perioperative benefits similar to those seen in patients with normal BMI who undergo the same procedure. These benefits include less EBL, a shorter hospital stay, and potentially fewer complications compared with open TLIF. Additional large retrospective studies and randomized prospective studies are needed to verify these findings.

Surgical strategy for management of L1-L2 disc, based on unique differences with other lumbar levels

Background and Objective: Because of the scarceness and absence of hectic painful radiculopathic feature of L1-L2 disc, surgeons don’t usually pay enough clinical attention to them. Their main manifestation is severe axial pain or myeloradiculopathy failure attributed to conus or high cauda equine syndrome.Material and method: During 2006 to 2011, a total of 11 patients with L1 L2 dysfunctions underwent a surgery. Their mean age was 56 years old and sex ratio of 6 male to 7 female. 4 of them had florid neurological deficit as paraparesis and sphincter dysfunction. In other patients, radiculopathies and axial pain were dominant clinical manifestations.Considering the conus position and the extent of canal compromise and disc consistency (presence of calcification) either anterior or posterior surgical approach followed by segmental fusions was used.Result: 3 patients underwent thoracoabdominal and fusion surgery, while ten underwent a posterior transfacet pedicle sparing surgery combined with transforaminal lumbar interbody fusion (TLIF) surgery. In all patients, satisfactory outcomes were achieved; all radiculopathy and signs of conus dysfunction were improved except one case that showed sphincter dysfunction persistent post operation. Axial pain was resolved and in follow-up assessments no kyphosis or axial pain were observed. Discussion: Due to the biomechanical traits of L1-L2 disc and its adjacency to thoracolumbar region as well as high degree of osteodiscal degeneration on its manifestation we propose TLIF and Posterior spinal fusion (PSF) surgical approaches after canal decompression to alleviate axial pain and also prevent later kyphosis. Furthermore, because of nearby conus and the risk of thecal sac retraction, the same strategy as thoracic disc was performed in this region considering reverence for conus if good results are to be achieved.

Preparing the Lumbar Intervertebral Disk Space for Interbody Procedures

Cadaveric laboratory study. To quantify and compare automated disk-space preparation with traditional methods. Removal of nucleus pulposus to prepare a disk space for interbody fusion is performed with various techniques. Our aim was to determine the safety and effectiveness of an automated technique in comparison to traditional methods and gauge its expected clinical application. This study was conducted in 2 phases. In the phase 1 safety trial, ''maximal'' force was applied to an automated shaver against cadaveric annulus and endplates until flexion of the shaft caused the blades to bind. This simulated the risk of creating an incidental cortical or annular defect. In phase 2, 27 cadaveric lumbar disk spaces were randomized to traditional or automated preparation techniques through a standard transforaminal lumbar interbody fusion approach. Traditional method comprised the use of paddle shavers, pituitary rongeurs, and curettes. Automated technique involved insertion of an 8-mm paddle shaver, followed by straight and angled hand pieces to remove nucleus pulposus and endplate cartilage. Unintended cortical and annular breaches, preparation time, instrument insertions, percentage area of exposed endplate underlying the nucleus pulposus, and percentage volume of nuclear space cleared were measured and compared. In phase 1, ''maximal'' force applied for 10 seconds produced no full-thickness annular or cortical defects. In phase 2, automated technique produced fewer endplate cortical defects (3 vs. 7) and full-thickness annular breaches (0 vs. 1), required fewer instrument insertions (29 vs. 6; P<0.001), exposed more endplate (65% vs. 52%; P=0.037), and removed more nucleus pulposus volume (83% vs. 59%; P=0.01). Automated shaving decreased instrument insertions and prepared the disk space more effectively, with fewer cortical or annular defects. This technique holds promise for improved outcomes in spinal fusion surgery.

Complications in patients undergoing combined transforaminal lumbar interbody fusion and posterior instrumentation with deformity correction for degenerative scoliosis and spinal stenosis

Background:Utilization of the transforaminal lumbar interbody fusion (TLIF) approach for scoliosis offers the patients deformity correction and interbody fusion without the additional morbidity associated with more invasive reconstructive techniques. Published reports on complications associated with these surgical procedures are limited. The purpose of this study was to quantify the intra- and postoperative complications associated with the TLIF surgical approach in patients undergoing surgery for spinal stenosis and degenerative scoliosis correction.Methods:This study included patients undergoing TLIF for degenerative scoliosis with neurogenic claudication and painful lumbar degenerative disc disease. The TLIF technique was performed along with posterior pedicle screw instrumentation. The average follow-up time was 30 months (range, 15–47).Results:A total of 29 patients with an average age of 65.9 years (range, 49–83) were evaluated. TLIFs were performed at 2.2 levels on average (range, 1–4) in addition to 6.0 (range, 4–9) levels of posterolateral instrumented fusion. The preoperative mean lumbar lordosis was 37.6° (range, 16°–55°) compared to 40.5° (range, 26°–59.2°) postoperatively. The preoperative mean coronal Cobb angle was 32.3° (range, 15°–55°) compared to 15.4° (range, 1°–49°) postoperatively. The mean operative time was 528 min (range, 276–906), estimated blood loss was 1091.7 mL (range, 150–2500), and hospitalization time was 8.0 days (range, 3–28). A baseline mean Visual Analog Scale (VAS) score of 7.6 (range, 4–10) decreased to 3.6 (range, 0–8) postoperatively. There were a total of 14 (49%) hardware and/or surgical technique related complications, and 8 (28%) patients required additional surgeries. Five (17%) patients developed pseudoarthrosis. The systemic complications (31%) included death (1), cardiopulmonary arrest with resuscitation (1), myocardial infarction (1), pneumonia (5), and pulmonary embolism (1).Conclusion:This study suggests that although the TLIF approach is a feasible and effective method to treat degenerative adult scoliosis, it is associated with a high rate of intra- and postoperative complications and a long recovery process.

The clinical results of minimally invasive transforaminal lumbar interbody fusion through the Wiltse approach for the treatment of lumbar spondylolisthesis

Objective To assess the clinical value of minimally invasive transforaminal lumbar interbody fusion (TLIF) through the Wiltse approach for the treatment of lumbar spondylolisthesis. Methods Sixty-nine patients with lumbar spondylolisthesis were randomly divided into two groups. Group A underwent minimally invasive TLIF via the Wiltse approach, Group B via the traditional approach. There were 31 cases in group A, the affected level was L4.5 in 19 cases and L5S1 in 12. The degree of vertebrae slippage was Ⅰ degree in 17 cases,and Ⅱ degree in 14. There were 38 cases in group B, the affected level was L4,5 in 22 cases and L5S1 in 16. The degree of vertebrae slippage was Ⅰ in 21 cases, and Ⅱ in 17. The Japanese Orthopaedics Association (JOA) score, visual analogue scale (VAS) of low back pain and leg pain were evaluated at 3, 6, and 12 months follow-up. The post-operative dynamic X-rays, CT and/or MRI were used for image evaluation. Results There was no statistically difference in operating time between the two groups. The incision length, blood loss and exposing time of group A were shorter than those of group B. The JOA scores, recovery rate, VAS of low back pain and leg pain, interbody fusion rate and atrophy rate of multifidus in group A were 24.7±3.5, 77.0％±3.1％, 1.0±0.7, 1.1±0.3, 71.0％±5.8％, 2.1±0.2, respectively, and in group B were 24.3±2.8, 73.6％±6.4％, 3.1±0.6, 1.8±0.5, 76.3％±6.1％, 0.5±0.1, respectively. The VAS of low back pain was lower in group A than in group B. The atrophy rate was better in group A than in group B. Conclusion Both TLIF approaches can acquire satisfactory clinical results. Minimally invasive TLIF through the Wiltse approach can significantly reduced damage of multifidus and incidence of chronic low back pain postoperative. Key words: Spondylolisthesis; Spinal fusion; Muscular atrophy

TLIF for symptomatic disc degeneration: a retrospective study of 100 patients

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.

Minimally invasive versus open transforaminal lumbar interbody fusion

BackgroundAvailable clinical data are insufficient for comparing minimally invasive (MI) and open approaches for transforaminal lumbar interbody fusion (TLIF). To date, a paucity of literature exists directly comparing minimally invasive (MI) and open approaches for transforaminal lumbar interbody fusion (TLIF). The purpose of this study was to directly compare safety and effectiveness for these two surgical approaches. Materials and MethodsOpen or minimally invasive TLIF was performed in 63 and 76 patients, respectively. All consecutive minimally invasive TLIF cases were matched with a comparable cohort of open TLIF cases using three variables: diagnosis, number of spinal levels, and history of previous lumbar surgery. Patients were treated for painful degenerative disc disease with or without disc herniation, spondylolisthesis, and/or stenosis at one or two spinal levels. Clinical outcome (self-report measures, e.g., visual analog scale (VAS), patient satisfaction, and MacNab's criteria), operative data (operative time, estimated blood loss), length of hospitalization, and complications were assessed. Average follow-up for patients was 37.5 months. Results:The mean change in VAS scores postoperatively was greater (5.2 vs. 4.1) in theopen TLIF patient group (P = 0.3). MacNab's criteria score was excellent/good in 67% and 70% (P = 0.8) of patients in open and minimally invasive TLIF groups, respectively. The overall patient satisfaction was 72.1% and 64.5% (P = 0.4) in open and minimally invasive TLIF groups, respectively. The total mean operative time was 214.9 min for open and 222.5 min for minimally invasive TLIF procedures (P = 0.5). The mean estimated blood loss for minimally invasive TLIF (163.0 ml) was significantly lower (P < 0.0001) than the open approach (366.8 ml). The mean duration of hospitalization in the minimally invasive TLIF (3 days) was significantly shorter (P = 0.02) than the open group (4.2 days). The total rate of neurological deficit was 10.5% in the minimally invasive TLIF group compared to 1.6% in the open group (P = 0.02). Conclusions: Minimally invasive TLIF technique may provide equivalent long-term clinical outcomes compared to open TLIF approach in select population of patients. The potential benefit of minimized tissue disruption, reduced blood loss, and length of hospitalization must be weighted against the increased rate of neural injury-related complications associated with a learning curve.

Comparison of SpineJet™ XL and Conventional Instrumentation for Disk Space Preparation in Unilateral Transforaminal Lumbar Interbody Fusion

Although unilateral transforaminal lumbar interbody fusion (TLIF) is widely used because of its benefits, it does have some technical limitations. Removal of disk material and endplate cartilage is difficult, but essential, for proper fusion in unilateral surgery, leading to debate regarding the surgery's limitations in removing the disk material on the contralateral side. Therefore, authors have conducted a randomized, comparative cadaver study in order to evaluate the efficiency of the surgery when using conventional instruments in the preparation of the disk space and when using the recently developed high-pressure water jet system, SpineJet XL. Two spine surgeons performed diskectomies and disk preparations for TLIF in 20 lumbar disks. All cadaver/surgeon/level allocations for preparation using the SpineJet XL (HydroCision Inc., Boston, MA, USA) or conventional tools were randomized. All assessments were performed by an independent spine surgeon who was unaware of the randomizations. The authors measured the areas (cm(2)) and calculated the proportion (%) of the disk surfaces. The duration of the disk preparation and number of instrument insertions and withdrawals required to complete the disk preparation were recorded for all procedures. The proportion of the area of removed disk tissue versus that of potentially removable disk tissue, the proportion of the area of removed endplate cartilage, and the area of removed disk tissue in the contralateral posterior portion showed 74.5 +/- 17.2%, 18.5 +/- 12.03%, and 67.55 +/- 16.10%, respectively, when the SpineJet XL was used, and 52.6 +/- 16.9%, 22.8 +/- 17.84%, and 51.64 +/- 19.63%, respectively, when conventional instrumentations were used. The results also showed that when the SpineJet XL was used, the proportion of the area of removed disk tissue versus that of potentially removable disk tissue and the area of removed disk tissue in the contralateral posterior portion were statistically significantly high (p < 0.001, p < 0.05, respectively). Also, compared to conventional instrumentations, the duration required to complete disk space preparation was shorter, and the frequency of instrument use and the numbers of insertions/withdrawals were lower when the SpineJet XL was used. The present study demonstrates that hydrosurgery using the SpineJet XL unit allows for the preparation of a greater portion of disk space and that it is less traumatic and allows for more precise endplate preparation without damage to the bony endplate. Furthermore, the SpineJet XL appears to provide tangible benefits in terms of disk space preparation for graft placement, particularly when using the unilateral TLIF approach.

Debate: To Fuse or Not to Fuse to the Sacrum, the Fate of the L5–S1 Disc

Debate: To Fuse or Not to Fuse to the Sacrum, the Fate of the L5–S1 Disc

Paramedian approach for transforaminal lumbar interbody fusion with unilateral pedicle screw fixation

Lumbar fusion is a commonly performed procedure for a variety of pathological conditions, and it is frequently used in the treatment of degenerative lumbar instability that is refractory to medical management. Pedicle screws and interbody devices have been used for internal fixation to promote arthrodesis, prevent nonunion, and facilitate early mobilization. Recently, attempts have been made to reduce the morbidity associated with lumbar fusion by using a variety of minimally invasive techniques. Many minimally invasive lumbar fusion procedures require specialized retractors, implants, image guidance systems, or insertion instruments. Other minimally invasive techniques are primarily applied to an ideal patient population (thin, healthy, and with no previous surgery). The authors describe their experience with a paramedian approach for minimally invasive transforaminal lumbar interbody fusion (TLIF) with unilateral pedicle screw (PS) fixation. This procedure requires only standard implants, instruments, and retractors, with direct visualization for all aspects of the procedure. The authors describe encouraging early results in a challenging patient population in which there was a high incidence of obesity, medical comorbidities, and previous surgery at the same level. The paramedian approach for TLIF performed using unilateral lumbar PSs has yielded successful outcomes in this series of 47 patients, and further study of this technique may help define its role as a minimally invasive procedure for spinal fusion.

Treatment of Lumbar Instability: Transforaminal Lumbar Interbody Fusion

Transforaminal lumbar interbody fusion (TLIF) was originally described by Blume, Harms and Rollinger in the early 1980s as a surgical method of treating symptomatic lumbar disk degeneration. The TLIF approach offers a number of potential benefits over conventional posterolateral intertransverse arthrodesis including increased fusion surface area, improved fusion blood supply via subchondral cancellous vertebral body bone, complete access for medial canal and lateral recess decompression, and restoration of intervertebral body height. The following manuscript is a technical description of the TLIF procedure.