Combination of percutaneous unilateral translaminar facet screw fixation and interbody fusion for treatment of lower lumbar vertebra diseases: a follow-up study

Lumbar facet joint stabilization for symptomatic spinal degenerative disease: A systematic review of the literature

Objective

Lumbar spinal degenerative disease (LSDD), unresponsive to conservative therapy, is commonly treated by surgical decompression and interbody fusion. Since facet joint incompetence has been suggested as responsible for the entire phenomenon of spinal degeneration, facet stabilization can be considered as an alternative technique to treat symptomatic spinal degenerative disease. The purpose of this study was to systematically review the literature for studies utilizing lumbar facet joint fixation techniques for LSDD to assess their safety and efficacy.

Methods

A systematic literature review was performed following the preferred reporting items for systematic reviews and meta-analyses statement, with no limits in terms of date of publication. Demographic data, inclusion criteria, clinical and radiological outcome, frequency of adverse events (AEs), and follow-up time were evaluated.

Results

A total of 19 studies were included with a total of 1577 patients. The techniques used for facet arthrodesis were Goel intra-articular spacers in 21 patients (5.3%), Facet Wedge in 198 patients (15.8%), facet screws fixation techniques in 1062 patients (52.6%), and facet joints arthroplasty in 296 patients (26.3%). Clinical outcomes were assessed through the evaluation of pain relief and improvement in functional outcome. Radiological outcomes were assessed by the evaluation of proper positioning of instrumentation, solid bony fusion rate, and preservation of disk height. AE's mainly observed were pseudoarthrosis, reoperation, instrumentation displacement/malpositioning/migration, neurological impairment, deep vein thrombosis, and infections. The mean follow-up time ranged from 6 months to 11.7 years.

Conclusion

Our data demonstrate that facet joint arthrodesis appears to be effective in managing LSDD. These findings, however, are limited by the small sample size of patients. Accordingly, larger series are needed before formal recommendations can be made.

Oblique lateral interbody fusion combined with different internal fixations for the treatment of degenerative lumbar spine disease: a finite element analysis

Background

Little is known about the biomechanical performance of different internal fixations in oblique lumbar interbody fusion (OLIF). Here, finite element (FE) analysis was used to describe the biomechanics of various internal fixations and compare and explore the stability of each fixation.

Methods

CT scans of a patient with lumbar degenerative disease were performed, and the l3-S1 model was constructed using relevant software. The other five FE models were constructed by simulating the model operation and adding different related implants, including (1) an intact model, (2) a stand-alone (SA) model with no instrument, (3) a unilateral pedicle screw model (UPS), (4) a unilateral pedicle screw contralateral translaminar facet screw model (UPS-CTFS), (5) a bilateral pedicle screw (BPS) model, and (6) a cortical bone trajectory screw model (CBT). Various motion loads were set by FE software to simulate lumbar vertebral activity. The software was also used to extract the range of motion (ROM) of the surgical segment, CAGE and fixation stress in the different models.

Results

The SA group had the greatest ROM and CAGE stress. The ROM of the BPS and UPS-CTFS was not significantly different among motion loadings. Compared with the other three models, the BPS model had lower internal fixation stress among loading conditions, and the CBT screw internal fixation had the highest stress among loads.

Conclusions

The BPS model provided the best biomechanical stability for OLIF. The SA model was relatively less stable. The UPS-CTFS group had reduced ROM in the fusion segments, but the stresses on the internal fixation and CAGE were relatively higher in the than in the BPS group; the CBT group had a lower flexion and extension ROM and higher rotation and lateral flexion ROM than the BPS group. The stability of the CBT group was poorer than that of the BPS and LPS-CTFS groups. The CAGE and internal fixation stress was greater in the CBT group.

Minimally invasive unilateral pedicle screws and a translaminar facet screw fixation and interbody fusion for treatment of single-segment lower lumbar vertebral disease: surgical technique and preliminary clinical results

BACKGROUND

Conventional open transforaminal lumbar interbody fusion (TLIF) using unilateral pedicle screws and a translaminar facet screw has been performed for many years with good results. The outcomes of minimally invasive TLIF (MIS TLIF) are similar to the good outcomes of open TLIF, with the additional benefits of reducing iatrogenic injury, shortening hospital stays, and reducing the recovery duration. Instead of using small cuts on both sides, we performed MIS TLIF through a single cut using unilateral pedicle screws and a translaminar facet screw. The operative feasibility, efficacy safety, and benefits of single-level MIS TLIF of such techniques require further clarification.

METHODS

A total of 60 patients with various single-segment lower lumbar vertebral diseases were treated in our department from January 2010 to March 2013. All the patients were initially performed single-level MIS TLIF using a hybrid construction of unilateral pedicle screws and a translaminar facet screw. Patient demographics and operative data were collected. The clinical outcomes were assessed before surgery and 3, 6, 12, and 24 months after surgery using the visual analog scale (VAS) for back and leg pain and the Oswestry Disability Index (ODI). Radiologic assessment of the lumbar spine with static and dynamic plain radiographs was performed 3, 6, 12, and 24 months after surgery. The fusion rates were assessed by an independent radiologist 2 years after surgery according to the Bridwell interbody fusion grading system.

RESULTS

No patients experienced significant postoperative complications. Excepting two cases, 58 cases were followed up for 24-38 months, averaged 29.9 ± 4.1 months. The patients' average age was 46.6 ± 11.5 years, operative time 109.7 ± 17.8 min, intraoperative blood loss 67.3 ± 29.7 ml, length of incision 29.0 ± 3.2 mm, fluoroscopy time 31.1 ± 7.2 s, time to ambulation 20.3 ± 7.0 h, length of hospital stay 5.1 ± 1.1 days, and length of the translaminar facet screw 51.7 ± 3.4 mm. Screw position results: type I, 54 cases with 54 segments; type II, four cases with four segments. There were two (3.4%) translaminar facet screw failures, which were intraoperatively converted to a bilateral pedicle screw fixation procedure and excluded from the research. The postoperative images showed good positioning of the hybrid internal fixation, and all of the translaminar facet screws penetrated the facet joint. Two (3.6%) translaminar facet screws penetrated the lateral lamina and two (3.6%) translaminar facet screws penetrated the medial lamina without any serious neural complications. During the follow-up, there was no screw loosening or pedicle fracture observed. The VAS and ODI scores were significantly improved compared with the preoperative scores (P < 0.05), and the symptoms disappeared gradually. Fifty-one patients (87.9%) achieved grade I fusion radiographically at the final follow-up.

CONCLUSIONS

MIS TLIF using a hybrid construction of unilateral pedicle screws and a translaminar facet screw is safe and effective in the treatment of single-segment lower lumbar vertebral disease, and it can be used as an optimal choice for fixation and fusion of some single-segment lower lumbar vertebral diseases.

Surgical techniques for lumbo-sacral fusion

Lumbo-sacral (L5-S1) fusion is a widely performed procedure that has become the reference standard treatment for refractory low back pain. L5-S1 is a complex transition zone between the mobile lordotic distal lumbar spine and the fixed sacral region. The goal is to immobilise the lumbo-sacral junction in order to relieve pain originating from this site. Apart from achieving inter-vertebral fusion, the main challenge lies in the preoperative determination of the fixed L5-S1 position that will be optimal for the patient. Many lumbo-sacral fusion techniques are available. Stabilisation can be achieved using various methods. An anterior, posterior, or combined approach may be used. Recently developed minimally invasive techniques are gaining in popularity based on their good clinical outcomes and high fusion rates. The objective of this conference is to resolve the main issues faced by spinal surgeons in their everyday practice.

A biomechanical comparison of 3 different posterior fixation techniques for 2-level lumbar spinal disorders

OBJECT

This study sought to make a biomechanical comparison of 3 different posterior fixation techniques for 2-level lumbar spinal disorders.

METHODS

Eight fresh-frozen human cadaver lumbar spines (4 from L-1 to L-5, 4 from L-1 to S-1) were tested by applying pure moments of ± 8 Nm. Each specimen was first tested intact, and then the left facetectomies of L3-4 and L4-5 were performed to establish an unstable condition without removal of discs. Three instrumentation systems were then tested randomly: unilateral pedicle screw (UPS), UPS with contralateral translaminar facet screw (UPSFS), and bilateral pedicle screw (BPS). The range of motion (ROM) and the neutral zone (NZ) of L3-5 were measured.

RESULTS

All fixation types could reduce the ROM of L3-5 significantly in flexion, extension, and lateral bending, compared with the intact state. In axial torsion, only BPS reduced the ROM significantly, compared with the intact state. The UPSFS technique provided intermediate stability, which was superior to the UPS in flexion-extension and lateral bending, and inferior to the BPS in lateral bending. Compared with the intact state, the NZs decreased significantly for UPS, UPSFS, and BPS in flexion-extension, while not significantly in lateral bending and axial torsion.

CONCLUSIONS

In this study, among the 3 fixation techniques, BPS offered the highest stability, UPSFS provided intermediate stability, and UPS was the least stable for 2-level lumbar spinal disorders. UPSFS appeared to be able to offer a less invasive choice than BPS in well-selected patients with 2-level lumbar spinal disorders.