Unilateral Transforaminal Posterior Lumbar Interbody Fusion (TLIF): Indications, Technique, and 2-Year Results

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Abstract

A prospective analysis of consecutive cases of lumbar fusion using the unilateral transforaminal posterior lumbar interbody fusion (TLIF) technique with pedicle screw fixation. The objective of the study was to assess the clinical and radiographic outcome of TLIF and describe the technique and indications in the treatment of degenerative disease of the lumbar spine. Forty patients treated with TLIF for degenerative diseases of the lumbar spine were followed up for a minimum of 2.5 years (mean: 36 months; range: 30-42 months). Twenty-three patients had degenerative disc disease alone, 13 had associated isthmic or degenerative spondylolisthesis, and 4 had recurrent disc herniations at the L4-L5 level. Thirty-six (90%) had solid fusions radiographically at latest follow-up. Seventy-nine percent had excellent or good clinical outcomes. Our patients demonstrated high fusion rates and patient satisfaction.

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Most cited references 14

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The treatment of ruptured lumbar intervertebral discs by vertebral body fusion. I. Indications, operative technique, after care.

R Cloward (1953)

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Adding posterior lumbar interbody fusion to pedicle screw fixation and posterolateral fusion after decompression in spondylolytic spondylolisthesis.

Chien-Te Lee, S. I. Suk, Brian J. Lee … (1997)

This is a retrospective study analyzing 76 patients treated by decompression, pedicle screw instrumentation, and fusion for spondylolytic spondyiolisthesis with symptomatic spinal stenosis. To verify the advantages of adding posterior lumbar interbody fusion to the usual posterolateral fusion with pedicle screw instrumentation. Stabilization after decompression of spondylolytic spondylolisthesis is difficult because of a lack of fusional bone bases, gap between the transverse process bases, and incompetent anterior disc support. Posterior lumbar interbody fusion offers anterior support, reduction, and a broad fusion base. Forty patients were treated with posterolateral fusion, and 36 were treated with additional posterior lumbar interbody fusion. They were compared for union, reduction of the deformity, and clinical results. The patients were followed up for more than 2 years. Nonunion was observed in three patients who underwent posterolateral fusion (7.5%), and no cases of nonunion was found in patients who underwent posterior lumbar interbody fusion. Reduction of slippage was 28.3% in those who underwent posterolateral fusion and 41.6% in those who had posterior lumbar interbody fusion (P = 0.05). In the posterolateral fusion group, eight patients (20%) had recurrence of deformity, with loss of reduction more than 50%. Hardware failures occurred in two patients who had posterolateral fusion. There was no major neurologic complications in both groups. Both groups had satisfactory results in more than 90% of patients, with marked improvement of claudication. However, subjective improvement of back pain by Kirkaldy-Willis criteria revealed differences in the excellent results. An excellent result was reported by 45% in the posterolateral fusion group and by 75% in posterior lumbar interbody fusion group. The addition of posterior lumbar interbody fusion to posterolateral fusion after a complete decompression and pedicle screw fixation is a recommended procedure for the treatment of spondylolytic spondylolishesis with spinal stenosis.

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Threaded titanium cages for lumbar interbody fusions.

Adrian Ray (1997)

This study evaluated safety, fusion success rate, and clinical outcome of a new lumbar interbody hollow, threaded titanium fusion cage in a multicenter, prospective 236-case program adhering to a United States Food and Drug Administration Investigational Device Exemption controlled protocol. The results were evaluated to demonstrate the safety and effectiveness of this new method to achieve solid lumbar interbody fusions. Interbody fusions have certain distinct mechanical advantages over lateral or posterolateral ones. Autologous, cancellous bone is the preferred graft material, but is too soft to maintain the space during fusion without mechanical support. Various methods have been used in the past to maintain the graft integrity during fusion development. An initial pilot study began on 10 patients (followed for 84 months, average 80 months). Two years after that investigation started, the multicenter United States Food and Drug Administration Investigational Device Exemption study began, with cases followed for 28-46 months (average, 32). Ninety-six percent of the investigational Device Exemption study cases had severe, disabling back pain; in addition, 74% had major annular degeneration; 57% had herniations; 21% had osteophytes; and 43% had disc height reduced by greater than 10%. Forty-five percent of cases had previous spinal surgeries, and none were posterior lumbar interbody fusions. Titanium fusion cage pairs were screwed into bored and threaded, parallel intradiscal holes, and 3-8 ml autologous cancellous bone was packed inside each. Fusion success was judged by absence of motion on flexion-extension radiographs, absence of bone halo around the implants, and maintenance of visible bone inside the cages on Ferguson view radiographs. Segments fused rapidly; the pilot study cases fused at 10 (91%) of 11 levels, with a reported 80% average clinical improvement. Ninety-six percent of the 208 2-year follow-up Investigational Device Exemption cases had fusion, and the Prolo socioeconomic/ functional improvement scale showed: 40% excellent, 25% good, 21% fair, and 14% poor results. Less than 1% of Investigational Device Exemption cases had complications that persisted beyond the average 5 days of hospitalization, and none were serious. The Ray titanium fusion cage (Surgical Dynamics, Norwalk, CT) implant method has been found to be an effective, rapid, safe procedure for lumbar spine fusions, demonstrating a high fusion rate and clinical success with rare, serious, or permanent complications.