TLIF: transforaminal lumbar interbody fusion

Radiologic and Clinical Evaluation of Posterolateral Versus Transforaminal Interbody Fusion in Degenerative Lumbar Spondylolisthesis

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

The primary objective is to compare foraminal height (FH) and disk height (DH) differences in posterolateral (PLF) and transforaminal interbody fusions (TLIFs) and secondarily correlate these measurements with patient-reported outcomes.

BACKGROUND

The impact FH has on patient outcomes in degenerative lumbar spinal fusion surgery is unknown. Postoperative FH change and how it relates to patient-reported outcomes in posteriorly based procedures has not been well evaluated.

METHODS

A retrospective review of a subset of patients from a prospective cohort from the Canadian Spine Outcomes and Research Network was undertaken. Radiographic assessment preoperatively, at 3 months and 1 year, with standing lumbar spine radiographs were completed. FH and DH were recorded at each time interval, differences between groups were compared, and correlations with patient-reported outcomes were assessed.

RESULTS

One hundred nine patients were included (23 PLF and 86 TLIF). At 3-month follow-up, the change in FH was greater in the TLIF group (mean difference =2.3; 95% CI: 0.8-3.5, P =0.002). The change in FH remained significantly different at 12 months (mean difference=1.6, 95% CI: 0.2, 3.0 mm, P =0.028). The change in DH was greater in the TLIF group, with a mean difference between groups of 4.1 mm (95% CI: 2.5, 5.7, P <0.001) and 3.6 mm (95% CI: 2.0, 5.3, P <0.001). A positive change in FH correlated with less back pain, less disability, and improved physical function in the TLIF group ( P <0.05).

CONCLUSIONS

Patients treated with PLF lost FH over time. An increased difference in FH at 1 year was associated with improved function and less back pain in the TLIF group.

Static cage morphology in short-segment transforaminal lumbar interbody fusions is associated with alterations in foraminal height but not clinical outcomes

INTRODUCTION

Steerable "banana" cages have been posited to increase segmental lordosis in short-segment transforaminal lumbar interbody fusions (TLIF). The same is not necessarily true for straight "bullet" cages. While increased lordosis is generally thought to be advantageous, a potential complication is decreased foraminal height. Here we evaluate for any association between cage type and change in foraminal height and clinical outcomes following short-segment TLIFs.

METHODS

We retrospectively reviewed consecutive one- and two-level TLIFs with bilateral facetectomies with minimum one-year clinical and radiographic follow-up. Two cohorts were based on cage morphology: steerable "banana" cage or straight "bullet" cage. Patient reported outcome measures (PROMs), radiographic measurements, and revision rates were compared.

RESULTS

46 patients with 53 straight and 95 patients with 131 steerable cage levels were included. Steerable cages showed increased segmental lordosis (9.1 vs 13.5°, p<0.001) and decreased foraminal height (20.3 vs 18.5 mm, p<0.001) after surgery. Straight cages demonstrated similar segmental lordosis (8.7 vs 8.1°, p=0.30) and foraminal height (19.4 vs 20.0 mm, p=0.065). Both cohorts showed improved PROMs at last follow-up (p≤0.005). Sub-analysis comparing patients that had increased or decreased foraminal height revealed similarly improved PROMs between cohorts. Revision rates at one-year were similar between cohorts (4.3% for straight and 3.2% for steerable group, p=0.72).

CONCLUSION

Although the increased segmental lordosis afforded by placement of steerable cages may decrease foraminal height after short segment TLIF, clinical outcomes are not negatively affected by this association.

Understanding the Future Prospects of Synergizing Minimally Invasive Transforaminal Lumbar Interbody Fusion Surgery with Ceramics and Regenerative Cellular Therapies

Transforaminal lumber interbody fusion (TLIF) is the last resort to address the lumber degenerative disorders such as spondylolisthesis, causing lower back pain. The current surgical intervention for these abnormalities includes open TLIF. However, in recent years, minimally invasive TLIF (MIS-TLIF) has gained a high momentum, as it could minimize the risk of infection, blood loss, and post-operative complications pertaining to fusion surgery. Further advancement in visualizing and guiding techniques along with grafting cage and materials are continuously improving the safety and efficacy of MIS-TLIF. These assistive techniques are also playing a crucial role to increase and improve the learning curve of surgeons. However, achieving an appropriate output through TLIF still remains a challenge, which might be synergized through 3D-printing and tissue engineering-based regenerative therapy. Owing to their differentiation potential, biomaterials such as stem/progenitor cells may contribute to restructuring lost or damaged tissues during MIS-TLIF, and this therapeutic efficacy could be further supplemented by platelet-derived biomaterials, leading to improved clinical outcomes. Thus, based on the above-mentioned strategies, we have comprehensively summarized recent developments in MIS-TLIF and its possible combinatorial regenerative therapies for rapid and long-term relief.

IMPROVEMENT OF ODI AND SF-36 QUESTIONNAIRES SCORE AFTER ONE YEAR OF PLIF OR TLIF

ABSTRACT Objective: Determine if patients undergoing PLIF or TLIF surgery achieved improvement in the score of ODI and SF-36 questionnaires one year after surgery. Methods: Retrospective, single-center and non-randomized study. Patients submitted to spinal surgery using the PLIF or TLIF technique were included who completed the ODI and SF-36 questionnaires at least at the preoperative visit, and one year after surgery. Patients were divided into two groups, Group 1 (1 surgery level) and Group 2 (> 1 surgery level) and the ODI and SF-36 scores were compared for improvement. Results: The mean age was 47 years, with 52% of males (13/25) and mean of 5 days of hospital stay. Patients presented a significant improvement of ODI questionnaire (p<0.001) and in all SF-36 domains except in General Health State (p=0.58). In each group, it was observed that patients submitted to more than one level of surgery had greater blood loss and shorter hospital stay; however, the improvement obtained in ODI and SF-36 compared to the one-level surgery group was similar. Conclusions: PLIF and TLIF techniques are effective and lead to improved scores in ODI and SF-36 questionnaires one year after surgery. Patients undergoing two or more levels of instrumentation showed significant and similar improvement in ODI and SF-36. Level of evidence II, Single-Center Retrospective Study.

Transforaminal lumbar interbody fusion (TLIF) versus posterior lumbar interbody fusion (PLIF) in lumbar spondylolisthesis: a systematic review and meta-analysis

BACKGROUND CONTEXT

Transforaminal lumbar interbody fusion (TLIF) and posterior lumbar interbody fusion (PLIF) are both frequently used as a surgical treatment for lumbar spondylolisthesis. Because of the unilateral transforaminal route to the intervertebral space used in TLIF, as opposed to the bilateral route used in PLIF, TLIF could be associated with fewer complications, shorter duration of surgery, and less blood loss, whereas the effectiveness of both techniques on back or leg pain is equal.

PURPOSE

The objective of this study was to compare the effectiveness of both TLIF and PLIF in reducing disability, and to compare the intra- and postoperative complications of both techniques in patients with lumbar spondylolisthesis.

STUDY DESIGN/SETTING

A systematic literature review and meta-analysis were carried out.

METHODS

We conducted a Medline (using PubMed), Embase (using Ovid), Cochrane Library, Current Controlled Trials, ClinicalTrials.gov and NHS Centre for Review and Dissemination search for studies reporting TLIF, PLIF, lumbar spondylolisthesis and disability, pain, complications, duration of surgery, and estimated blood loss. A meta-analysis was performed to compute pooled estimates of the differences between TLIF and PLIF. Forest plots were constructed for each analysis group.

RESULTS

A total of 192 studies were identified; nine studies were included (one randomized controlled trial and eight case series), including 990 patients (450 TLIF and 540 PLIF). The pooled mean difference in postoperative Oswestry Disability Index (ODI) scores between TLIF and PLIF was -3.46 (95% confidence interval [CI] -4.72 to -2.20, p≤.001). The pooled mean difference in the postoperative VAS scores was -0.05 (95% CI -0.18 to 0.09, p=.480). The overall complication rate was 8.7% (range 0%-25%) for TLIF and 17.0% (range 4.7-28.8%) for PLIF; the pooled odds ratio was 0.47 (95% CI 0.28-0.81, p=.006). The average duration of surgery was 169 minutes for TLIF and 190 minutes for PLIF (mean difference -20.1, 95% CI -33.5 to -6.6, p=.003). The estimated blood loss was 350 mL for TLIF and 418 mL for PLIF (mean difference -43.9 mL, 95% CI -71.2 to -16.6, p=.002).

CONCLUSIONS

TLIF has advantages over PLIF in the complication rate, blood loss, and operation duration. The clinical outcome is similar, with a slightly lower postoperative ODI score for TLIF.

A Clinical Investigation of Contralateral Neurological Symptom after Transforaminal Lumbar Interbody Fusion (TLIF)

BACKGROUND

The aim of this study was to analyze treatment outcomes and morbidity of contralateral neurological symptom in patients after TLIF surgery and to explore its possible causes.

MATERIAL AND METHODS

A retrospective study was conducted involving a total of 476 patients who underwent TILF from 2009 to 2012 in our hospital. These cases were divided into a symptomatic group (Group S) and a non-symptomatic group. The differences in contralateral foramen area and disc-height index(DHI) before and after surgery were compared between Group S and a random sample of 40 cases of non-symptomatic group patients (group N). In addition, according to whether the patient underwent second surgery, Group S patients were further divided into a transient neurologic symptoms group (Group T) and an operations exploration group (Group O). The time of symptom appearance, duration, and symptomatic severity (JOA VAS score) were compared between Group T and O.

RESULTS

Among the 476 patients, 18 had postoperative contralateral neurological symptoms; thus, the morbidity was 3.7815%. The indicators in Group S were lower than in Group N in the differences in contralateral foramen area and disc-height index(DHI) before and after surgery (p<0.05). Five patients (Group O) in Group S had second surgery because of invalid conservative treatment. The surgical exploration rate was 1.0504%. Compared with Group T, the symptoms of Group O patients appeared earlier, persisted longer, and were more serious (p<0.05).

CONCLUSIONS

Contralateral neurological symptom is a potential complication after TLIF, and its causes are diverse. Surgical explorations should be conducted early for those patients with the complication who present with obvious nerve damage.

Biomechanical evaluation of a posterolateral lumbar disc arthroplasty device: an in vitro human cadaveric model

STUDY DESIGN

This in vitro analysis defines biomechanical properties of the Triumph Lumbar Disc (TLD) for posterolateral lumbar disc arthroplasty.

OBJECTIVES

To quantify segmental kinematics afforded by the TLD, determine whether intervertebral positional changes of the device affect spinal kinematics, and compare kinematics following TLD reconstruction with historical CHARITE data.

SUMMARY OF BACKGROUND DATA

As an alternative to arthrodesis, total disc arthroplasty serves to restore the biomechanical properties of the spine. However, there are kinematic and clinical concerns regarding posterior lumbar column destabilization and reconstruction using motion-preserving technology.

METHODS

Seven human lumbosacral spines were biomechanically evaluated under the following conditions: (1) Intact; (2) Unilateral facetectomy; (3) Facetectomy and discectomy; (4) TLD-posterior; (5) TLD-central; (6) TLD-anterior. Centers of intervertebral rotation (COR) and intradiscal pressures were compared at the operative/adjacent levels.

RESULTS

In axial rotation, L4-L5 range of motion (ROM) increased to 110%+/-15.3% following unilateral facetectomy and 134.3%+/-26.9% following facet/discectomy. Implanting the TLD in 3 positions-posterior, central, and anterior-demonstrated no significant differences in ROM (P>0.05). Trends were similar in flexion/extension and lateral bending. The neutral zone increased under the facet/discectomy condition and TLD reconstructions compared to the intact condition (P<0.05). CORs were dispersed at the operative level following destabilization. TLD in posterior and central positions restored loci to near the intact condition, whereas the anterior position produced more diffuse CORs. Adjacent level intradiscal pressures decreased in flexion-extension following destabilization and reconstruction.

CONCLUSION

Axial rotation ROM following TLD reconstruction (central position) was 131.5% of intact, compared to historical controls for the CHARITE device (162.0%). This indicates that lumbar disc arthroplasty performed using a posterolateral approach may offer biomechanical advantages over the anterior approach. Moreover, this approach may minimize surgical complications and allow simultaneous decompression of the neural elements. Intervertebral positional changes of the TLD were not shown to affect spinal kinematics.

Minimally invasive versus open transforaminal lumbar interbody fusion

Background

Available 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 Methods

Open 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.

Association between Asymptomatic Urinary Tract Infection and Postoperative Spine Infection in Elderly Women : A Retrospective Analysis Study

OBJECTIVE

The purpose of this study is to identify the relationship between asymptomatic urinary tract infection (aUTI) and postoperative spine infection.

METHODS

A retrospective review was done in 355 women more than 65 years old who had undergone laminectomy and/or discectomy, and spinal fusion, between January 2004 and December 2008. Previously postulated risk factors (i.e., instrumentation, diabetes, prior corticosteroid therapy, previous spinal surgery, and smoking) were investigated. Furthermore, we added aUTI that was not previously considered.

RESULTS

Among 355 patients, 42 met the criteria for aUTI (Bacteriuria >/= 10(5) CFU/mL and no associated symptoms). A postoperative spine infection was evident in 15 of 355 patients. Of the previously described risk factors, multi-levels (p < 0.05), instrumentation (p < 0.05) and diabetes (p < 0.05) were proven risk factors, whereas aUTI (p > 0.05) was not statistically significant. However, aUTI with Foley catheterization was statistically significant when Foley catheterization was added as a variable to the all existing risk factors.

CONCLUSION

aUTI is not rare in elderly women admitted to the hospital for lumbar spine surgery. The results of this study suggest that aUTI with Foley catheterization may be considered a risk factor for postoperative spine infection in elderly women. Therefore, we would consider treating aUTI before operating on elderly women who will need Foley catheterization.

Anterior lumbar interbody fusion in comparison with transforaminal lumbar interbody fusion: implications for the restoration of foraminal height, local disc angle, lumbar lordosis, and sagittal balance

OBJECT

A primary consideration of all spinal fusion procedures is restoration of normal anatomy, including disc height, lumbar lordosis, foraminal decompression, and sagittal balance. To the authors' knowledge, there has been no direct comparison of anterior lumbar interbody fusion (ALIF) with transforaminal lumbar interbody fusion (TLIF) concerning their capacity to alter those parameters. The authors conducted a retrospective radiographic analysis directly comparing ALIF with TLIF in their capacity to alter foraminal height, local disc angle, and lumbar lordosis.

METHODS

The medical records and radiographs of 32 patients undergoing ALIF and 25 patients undergoing TLIF from between 2000 and 2004 were retrospectively reviewed. Clinical data and radiographic measurements, including preoperative and postoperative foraminal height, local disc angle, and lumbar lordosis, were obtained. Statistical analyses included mean values, 95% confidence intervals, and intraobserver/interobserver reliability for the measurements that were performed.

RESULTS

Our results indicate that ALIF is superior to TLIF in its capacity to restore foraminal height, local disc angle, and lumbar lordosis. The ALIF procedure increased foraminal height by 18.5%, whereas TLIF decreased it by 0.4%. In addition, ALIF increased the local disc angle by 8.3 degrees and lumbar lordosis by 6.2 degrees, whereas TLIF decreased the local disc angle by 0.1 degree and lumbar lordosis by 2.1 degrees.

CONCLUSIONS

The ALIF procedure is superior to TLIF in its capacity to restore foraminal height, local disc angle, and lumbar lordosis. The improved radiographic outcomes may be an indication of improved sagittal balance correction, which may lead to better long-term outcomes as shown by other studies. Our data, however, demonstrated no difference in clinical outcome between the two groups at the 2-year follow-up.

Comparison of polyetheretherketone cages with femoral cortical bone allograft as a single-piece interbody spacer in transforaminal lumbar interbody fusion

OBJECT

Transforaminal lumbar interbody fusion (TLIF) is an accepted alternative to circumferential fusion of the lumbar spine in the treatment of degenerative disc disease, spondylolisthesis, and recurrent disc herniation. To maintain disc height while arthrodesis takes place, the technique requires the use of an interbody spacer. Although titanium cages are used in this capacity, the two most common spacers are polyetheretherketone (PEEK) cages and femoral cortical allografts (FCAs). The authors compared the clinical and radiographic outcomes of patients who underwent TLIF with pedicle screw fixation, in whom either a PEEK cage or an FCA was placed as an interbody spacer.

METHODS

The charts and x-ray films obtained in 39 patients (age range 33-68 years, mean 44.7 years) who underwent single-level TLIF between October 2001 and April 2004 and in whom either a PEEK cage (18 patients) or FCA (21 patients) was placed as an interbody spacer were evaluated in a retrospective study. Radiological outcome was based on fusion rate and a comparison of the initial postoperative lordotic angle on standing lateral radiographs with that at long-term follow up (mean follow up 15.1 months, minimum 12 months). To control for variations in radiographic magnification, the authors used lordotic angle as an indirect measure of disc space height. Clinical outcome was assessed using the Oswestry Disability Index (ODI). There were no major complications in either group. Radiographically documented fusion occurred in all patients in the PEEK group and 95.2% of those in the FCA group. Pseudarthrosis developed in one patient in the FCA group, and this patient underwent additional surgery. In both groups, the mean lordotic angle changed by less than 2.20 degrees during the postoperative period, and the mean postoperative ODI score was more than 40 points lower than the mean preoperative score. There was no significant difference between the two groups in mean change in lordotic angle (p = 0.415) and mean change in ODI score (p = 0.491).

CONCLUSIONS

Both PEEK cages and FCAs are highly effective in promoting interbody fusion, maintaining postoperative disc space height, and achieving desirable clinical outcomes in patients who undergo TLIF with pedicle screw fixation. The advantages of PEEK cages include a lower incidence of subsidence and their radiolucency, which permits easier visualization of bone growth.