Objectives Multiple different approaches are used to treat lumbar degenerative disc disease and spinal instability Both anterior-posterior (AP) reconstructive surgery and transforaminal lumbar interbody fusion (TLIF) provide a circumferential fusion and are considered reasonable surgical options The purpose of this study was to quantitatively assess clinical parameters such as surgical blood loss, duration of the procedure, length of hospitalization, and complications for TLIF and AP reconstructive surgery for lumbar fusion Methods A retrospective analysis was completed on 167 consecutive cases performed between January 2002 and March 2004 TLIF surgical procedure was performed on 124 patients, including 73 minimally invasive and 51 open cases AP surgery was performed on 43 patients Patients were treated for painful degenerative disc disease, facet arthropathy, degenerative instability, and spinal stenosis Results The mean operative time for AP reconstruction was 455 minutes, for minimally invasive TLIF 255 minutes, and open TLIF 222 minutes The mean blood loss for AP fusion surgery was 550 mL, for minimally invasive TLIF 231 mL, and open TLIF 424 mL The mean hospitalization time for AP reconstruction was 72 days, for minimally invasive TLIF 31 days, and open TLIF 41 days The total rate of complications was 767% for AP reconstruction, including 628% major and 139% minor complications The minimally invasive TLIF patients group had the total 301% rate of complications, 219% of which were minor and 82% major complications There were no major complications in the open TLIF patients group, with 353% minor complications Conclusions AP lumbar interbody fusion surgery is associated with a more than two times higher complication rate, significantly increased blood loss, and longer operative and hospitalization times than both percutaneous and open TLIF for lumbar disc degeneration and instability

https://www.bnasurg.com/downloads/AP_vs_TLIF_paper.pdf

Perioperative complications in transforaminal lumbar interbody fusion versus anterior-posterior reconstruction for lumbar disc degeneration and instability.

ObjectivesThe surgical approach that should be used for degenerative spondylolisthesis (DS) is a controversial issue. Decompression and posterolateral fusion (PLF) with or without lumbar interbody fusion is widely used. Many studies have compared the outcomes of these 2 approaches, but the appropria

Comparison of posterolateral fusion with and without additional posterior lumbar interbody fusion for degenerative lumbar spondylolisthesis.

Object The objectives of this study were to compare the biomechanical effects of five lumbar reconstruction models on the adjacent segment and to analyze the effects of three factors: construct stiffness, sagittal alignment, and the number of fused segments. Methods Nondestructive flexion–extension tests were performed by applying pure moments to 10 calf spinal (L3–S1) specimens. One-segment (L5–6) or two-segment (L5–S1) posterior fusion methods were simulated: 1) one-segment posterolateral fusion (PLF); 2) one-segment PLF with interbody fusion cages (one-segment PLIF/PLF); 3) two-segment PLF; 4) two-segment PLIF/PLF; and 5) two-segment PLF in kyphosis (two-segment kyphotic PLF). The range of motion (ROM) of the reconstructed segments, intradiscal pressure (IDP), and lamina strain in the upper (L4–5) adjacent segment were analyzed. The ROM was significantly decreased in the PLIF/PLF models compared with that in the PLF alone models after both the one- and two-segment fusions. If the number of fused segmen...

https://eprints.lib.hokudai.ac.jp/dspace/bitstream/2115/14612/1/JN2006-5-2.pdf

Biomechanical study on the effect of five different lumbar reconstruction techniques on adjacent-level intradiscal pressure and lamina strain.

Object Both posterior lumbar interbody fusion (PLIF) and transforaminal lumbar interbody fusion (TLIF) have been frequently undertaken for lumbar arthrodesis. These procedures use different approaches and cage designs, each of which could affect spine stability, even after the addition of posterior pedicle screw fixation. The objectives of this biomechanical study were to compare PLIF and TLIF, each accompanied by bilateral pedicle screw fixation, with regard to the stability of the fused and adjacent segments. Methods Fourteen human L2–S2 cadaveric spine specimens were tested for 6 different modes of motion: flexion, extension, right and left lateral bending, and right and left axial rotation using a load control protocol (LCP). The LCP for each mode of motion utilized moments up to 8.0 Nm at a rate of 0.5 Nm/second with the application of a constant compression follower preload of 400 N. All 14 specimens were tested in the intact state. The specimens were then divided equally into PLIF and TLIF conditio...

Biomechanical comparison of single-level posterior versus transforaminal lumbar interbody fusions with bilateral pedicle screw fixation: segmental stability and the effects on adjacent motion segments

Lumbar degenerative spondylolisthesis (DS) is a common cause of low back pain, radiculopathy, and/or neurogenic claudication. Treatment begins with a trial of nonsurgical methods, including physical therapy, NSAIDs, and epidural corticosteroid injections. Surgical treatment with decompression and fusion is recommended for patients who do not respond to this initial regimen. Although much has been published in the past two decades on the surgical management of DS, the optimal method remains controversial. Interbody fusion may improve arthrodesis rates and can be performed via numerous surgical approaches. Minimally invasive techniques continue to be developed. Particular attention to surgical management of DS in the elderly is warranted given the increasing numbers of elderly persons. Healthcare utilization in the future must take into account evidence-based medicine that establishes clinically effective practices while simultaneously being cost effective.

/pdf/surgical-management-of-lumbar-degenerative-spondylolisthesis-153z54rtqf.pdf

Surgical management of lumbar degenerative spondylolisthesis

STUDY DESIGN Pedicle screw fixation alone for sequential spinal instabilities was biomechanically compared with pedicle screw fixation using interbody cages. OBJECTIVE To evaluate biomechanical effects of interbody cages on construct stiffness, pedicle-screw strain, and the adjacent level in posterior lumbar reconstruction using pedicle screw fixation. SUMMARY OF BACKGROUND DATA It remains undetermined what types of spinal instability require interbody support in posterior lumbar reconstruction. METHODS For this study, 10 calf spines (L3-L6) were used. Sequential destabilization was performed at L4-L5 followed by posterior reconstruction using pedicle screw fixation (PS) and interbody cages as follows: intact + PS (I-PS), medial facetectomy + PS (MF-PS), total facetectomy + PS (TF-PS), partial discectomy + PS (D-PS), and D-PS + interbody cages (PLIF). Biomechanical testing was performed under flexion and extension loading modes. Construct stiffness (L4-L5), rod-screw bending strain, and range of motion (ROM) at the upper adjacent level (L3-L4) were analyzed. RESULTS In terms of construct stiffness (L4-L5), all the reconstructions except D-PS demonstrated higher construct stiffness than the intact spine (P < 0.05). The PLIF showed the highest stiffness among all the reconstructions (P < 0.05). In terms of ROM (L3-L4), all the reconstructions increased the ROM, as compared with the intact state (P < 0.05). Importantly, PLIF showed significantly greater ROM than all the other reconstructions except I-PS (P < 0.05). In terms of rod-screw strain, the D-PS resulted in higher strain than the other groups (P < 0.05). The PLIF presented less strain than the other reconstructions (P < 0.05). CONCLUSIONS For spinal instability with preserved anterior load sharing, pedicle screw fixation alone is biomechanically adequate, and interbody cages should not be used because they further increase segmental motion at the adjacent segment. However, PS alone provides insufficient stability and high implant strain in case of damaged anterior column. In such cases, additional interbody cages significantly increase construct stiffness and decrease hardware strain. However, they increase ROM at the adjacent segment as well.

Bin-Sheng Yu

Papers

Types of spinal instability that require interbody support in posterior lumbar reconstruction: an in vitro biomechanical investigation.