Unilateral transforaminal posterior lumbar interbody fusion (TLIF): indications, technique, and 2-year results

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.     

Posterior lumbar interbody fusion

Posterior lumbar interbody fusion (PLIF) and transforaminal lumbar interbody fusion (TLIF) create intervertebral fusion by means of a posterior approach. Both techniques are useful in managing degenerative disk disease, severe instability, spondylolisthesis, deformity, and pseudarthrosis. Successful results have been reported with allograft, various cages (for interbody support), autograft, and recombinant human bone morphogenetic protein-2. Interbody fusion techniques may facilitate reduction and enhance fusion. The rationale for PLIF and TLIF is biomechanically sound. However, clinical outcomes of different anterior and posterior spinal fusion techniques tend to be similar. PLIF has a high complication rate (dural tear, 5.4% to 10%; neurologic injury, 9% to 16%). These findings, coupled with the versatility of TLIF throughout the entire lumbar spine, may make TLIF the ideal choice for an all-posterior interbody fusion.     

Unilateral transforaminal posterior lumbar interbody fusion.

A prospective analysis of consecutive patients who had lumbar fusion using the unilateral transforaminal posterior lumbar interbody fusion with pedicle screw fixation is presented to assess the clinical and radiographic outcomes of the transforaminal posterior lumbar interbody fusion procedure and describe the technique and indication in the treatment of degenerative disease of the lumbar spine. Forty patients treated with transforaminal posterior lumbar interbody fusion for degenerative diseases of the lumbar spine (with anterior column deficiency) were followed up for a minimum of 3 years (mean, 3.4 years; range, 3-3.9 years). Radiographic assessment included plain and flexion and extension radiographs. Clinical outcome was based on pain relief, ability to do activities of daily living, and return to work. Thirty-six patients (90%) had solid fusions and at latest followup, segmental lordosis has increased in all patients. Eighty-five percent of patients had excellent or good clinical outcome(s). The unilateral transforaminal posterior lumbar interbody fusion provides bilateral anterior column support through a unilateral approach. The patients had high fusion rates and patient satisfaction as reported with similar complications found in other methods commonly used for spinal decompression and stabilization.     

The impact of interbody approach and lumbar level on segmental,adjacent, and sagittal alignment in degenerative lumbar pathology: a radiographic analysis six months following surgery

BACKGROUND CONTEXTInterbody fusion, including: transforaminal (TLIF), posterior (PLIF), anterior (ALIF), and lateral (LLIF); effectively treat lumbar degenerative pathology and provide spinopelvic balance. Although the decision on surgical approach and technique are multifactorial and patient specific, the impact of the interbody approach on segmental and adjacent level lordosis could be an important factor to consider during pre-operative planning to achieve pre-specified alignment goals.PURPOSEThe purpose of this study is to compare the 6-month postoperative radiographic outcomes in the lumbar spine following 1 to 2 level transforaminal (TLIF), posterior (PLIF), anterior (ALIF), and lateral (LLIF) interbody fusions at the L3-4, L4-5, and L5-S1 levels. As our primary outcome, we evaluated the change in segmental lordosis at the level of fusion in ALIF/LLIF approaches compared to TLIF/PLIF. Secondarily, we evaluated the pelvic incidence to lumbar lordosis (PI-LL) mismatch and examined the compensatory lordotic changes at the adjacent levels 6 months following surgery.STUDY DESIGNRetrospective cohort.PATIENT SAMPLEThis retrospective study included 18 centers of various practice settings across the United States. Patients were included in the study if they underwent a one- or two-level primary lumbar fusion for degenerative pathology.OUTCOMES MEASURESMeasurements of the pre-operative and 6-month post-operative lumbar AP and lateral lumbar plain radiographs included: pelvic incidence (PI), pelvic tilt, lumbar lordosis from L1-S1 (LL), as well as segmental lordosis (SL) of each segment between L1-S1.METHODSDue to there being 2 evaluated time points, patients were then grouped based on alignment into categories of preserved, restored, not corrected, and worsened.RESULTS474 patients underwent 608 levels of fusion. ALIF/LLIF resulted in significantly more segmental lordosis compared to TLIF/PLIF procedures at both L4-5 and L5-S1 (p<.001). Overall, ALIF/LLIF resulted in significantly more global lumbar lordotic alignment change compared to TLIF/PLIF (p=.01). Whether patients’ alignment was preserved versus worsened was not significantly predicted by type of procedure. Similarly, whether patients’ alignment was restored versus not corrected was not significantly predicted by type of procedure. Finally, anterior approaches resulted in decreased lordosis at adjacent levels, thus resulting in a more neutral position.CONCLUSIONIn this large multicenter retrospective study of 1 to 2 level interbody fusion surgeries, we identified that A/LLIF procedures at L4-L5 and L5-S1 resulted in greater segmental lordosis restoration and PI-LL mismatch improvement compared to T/PLIF procedures. A/LLIF may also significantly reduce lordosis (compared to T/PLIF) at the adjacent levels in a fashion that serves to reduce the lumbar lordosis that may have been increased at the fused level.     

Transforaminal interbody fusion versus anterior-posterior interbody fusion of the lumbar spine: a financial analysis

Lumbar interbody fusion can be performed anteriorly or posteriorly. An anterior approach generally requires an access surgeon and often is combined with a posterior fusion. A traditional posterior interbody fusion can destabilize the spinal motion segment and requires neural retraction. A new surgical technique, a transforaminal lumbar interbody fusion (TLIF), was recently described. It requires minimal neural retraction, and the disk space is exposed posterolaterally with removal of only one facet joint. This study compares the cost of an anterior-posterior one-level lumbar fusion with the cost of the same procedure performed using the TLIF technique. Table 1 lists the specific demographics. A retrospective review of the hospital charges of 80 patients undergoing interbody lumbar stabilization was conducted. The two groups consisted of 40 patients with an anterior-posterior fusion and 40 patients who were fused circumferentially using the TLIF technique. A cost analysis with normalization of 1998 dollars between the two groups was performed. The TLIF group had an average operative time of 213 minutes, compared with 269 minutes for the anterior-posterior group. In addition, an average additional 38 minutes were required to turn the patient from the anterior or posterior position. The average blood loss for the anterior-posterior procedure was 969 mL, compared with 489 mL for the TLIF group. Twenty-three of the anterior-posterior patients received an average of 2.2 units of blood and six of the TLIF patients received an average of 1.3 units. Use of the surgical intensive care unit was much lower in the TLIF group (38 of 40 patients versus 2 of 40 patients). The average length of stay was 6.1 days for the anterior-posterior group compared with an average of 3.3 days for the TLIF group. The average cost of the anterior-posterior patients was $49,085, compared with $33,784 for the TLIF group. Cost analysis between the two groups show the TLIF patients had an average savings of approximately $15,000 per admission. This cost comparison was conducted only for the time of the operative procedure. No attempt was made to analyze rates of fusion between the two groups or ultimate clinic outcome. There were no major complications in either group, and no patient returned to surgery for a lumbar spinal problem at the authors' hospital within 1 year of the index procedure.     

经单侧椎间孔椎体间融合术在退变性腰椎疾病中的应用

目的 探讨单侧经椎间孔腰椎体间融合术（TLIF）在退变性腰椎疾病的应用。方法采用经单侧椎间孔人路椎体间融合结合椎弓根短节段固定治疗退变性腰椎疾病30例。使用自体三面皮质髂骨或钛网作为融合材料。结果患者术后随访6～20个月,根据腰椎X线片作为评判椎间融合的标准,融合率为93％。未发生内置物断裂、松动移位和椎间隙高度丧失,疗效评定按日本骨科学会（JOA）下腰痛评分15分法评定：优20例,良8例,可2例,总优良率为93％。结论TLIF治疗退变性腰椎疾病,手术创伤小,融合率高,并发症少。     

显微内镜辅助经皮微创椎间孑L入路腰椎椎体间融合术治疗腰椎退行性疾病

背景：传统开放椎间孔入路腰椎椎体间融合术（transforaminal lumbar interbody fusion,TLIF）由于剥离肌肉广泛及长时间牵拉,可导致部分患者持续性腰背痛。随着脊柱微创技术的发展,采用微创手段实施TLIF技术取得了良好的临床效果,但小切口经扩张通道系统的微创TLIF仍不可避免存在肌肉剥离,需探索更加微创的手术方式。 目的：探讨显微内镜辅助经皮微创TLIF治疗腰椎退行性疾病的近期疗效及安全性。 方法：2010年9月至2011年7月,72例腰椎退行性疾病患者接受了单节段TLIF手术,腰椎失稳症36例,腰椎管狭窄症25例,复发型腰椎间盘突出症11例。采用VIPER经皮椎弓根螺钉系统结合椎间盘镜下TLIF手术32例（微创组）,传统开放TLIF手术40例（开放组）,对两组患者近期临床疗效、并发症、术中射线暴露指标等进行比较。 结果：所有患者均获随访,随访时间6-15个月,平均9个月。两组手术时间无明显统计学差异（P〉0．05）,微创组术中出血量、伤口引流量、住院天数、术后应用镇痛药剂量均明显低于开放组（P〈0．01）;微创组术中射线暴露时间及剂量高于开放组（P〈0．01）;微创组术后疼痛（VAS评分）及ODI功能指数较开放组明显降低（P〈0．01）。微创组出现术中减压错误1例,置钉位置错误1例,导针穿透椎体前壁1例,硬膜撕裂1例;开放组出现术中硬膜撕裂3例,术后伤口浅表感染1例。两组患者均未出现神经损伤并发症。 结论：显微内镜辅助经皮微创TLIF较传统开放手术具有创伤小、出血少、恢复快、住院时间短等优点,具有良好的近期疗效,是治疗腰椎失稳症值得推荐的微创手术方式。     

经椎间孔椎间融合术治疗腰椎退变性疾病的临床研究

目的分析经椎间孔椎间融合术（transforaminal lumbar interbody fusion,TLIF）手术治疗腰椎退变性疾病的临床资料与手术疗效。方法对2004年1月-2008年6月经TLIF手术治疗的26例病例进行回顾性分析。均采用TLIF方法通过一侧椎间孔抵达椎间盘间隙摘除椎间盘,处理椎间隙后置入椎间融合器。结果所有患者术后平均下床活动时间为4．5d。1例患者术后出现切口皮缘坏死,经清创缝合后愈合;1例患者出现健侧神经根牵拉伤,门诊随访4个月后恢复;其余患者均获得6～36个月随访,平均18．3个月。采用改良MaeNab标准评价随诊结果显示优良率达到92．3％。采用JOA下腰痛评分显示优良率达到92．24％。结论TLIF手术技术具有手术创伤小、恢复活动能力快、术后并发症少及疗效好等优点,是治疗腰椎退行性疾病非常有效的方法之一。     

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

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 7.2 days, for minimally invasive TLIF 3.1 days, and open TLIF 4.1 days. The total rate of complications was 76.7% for AP reconstruction, including 62.8% major and 13.9% minor complications. The minimally invasive TLIF patients group had the total 30.1% rate of complications, 21.9% of which were minor and 8.2% major complications. There were no major complications in the open TLIF patients group, with 35.3% 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.     

椎间盘镜辅助 X-Tube下椎体间融合术治疗退变性腰椎间盘疾病

 目的 探讨椎间盘镜辅助 X-Tube下腰椎后路椎体间融合术(posterior lumbar interbody fusion, PLIF)和经椎间孔腰椎椎体间融合术(transforaminal lumbar interbody fusion, TLIF)治疗退变性椎间盘疾病的临床疗效。方法 2007年 11月至 2008年 4月, 采用椎间盘镜辅助 X-Tube下 TLIF和 PLIF治疗退变性椎间盘疾病 32例: PLIF 13例, TLIF 19例。单节段腰椎间盘突出症伴相应节段腰椎不稳定 21例, 腰椎滑脱症 11例(玉度 6例, 域度 5例)。病变节段: L3-4 2例, L4-5 18例, L5S1 12例。年龄 38~72岁, 平均 51.2岁;男 19例, 女 13例。术后进行定期随访和影像学检查, 并进行 Oswestry功能障碍指数评定以评价术后康复情况。结果手术时间 90~180 min, 平均 120 min;手术出血量 100~400 ml, 平均 190 ml。切口均为甲级愈合, 未见切口及椎管、椎间隙感染、内固定失败等并发症发生。所以患者均获随访, 随访时间 13~41个月, 平均 21个月。 Oswestry功能障碍指数由术前 40.1%±4.1%下降到术后 3个月的 9.5%±3.7%。疗效评价: 优 19例, 良 10例, 可 3例;优良率为 90.6豫。骨融合均取得成功。结论椎间盘镜辅助 X-Tube下 TLIF和 PLIF治疗退变性椎间盘疾病具有切口小, 创伤小, 术后恢复快等优点。     

经神经根孔入路腰椎融合加椎弓根固定治疗腰椎间盘源性下腰痛

目的研究经神经根孔入路腰椎融合(transforaminal lumbar interbody fusion,TLIF)加椎弓根固定治疗腰椎间盘源性下腰痛的手术疗效。方法26例腰椎间盘源性下腰痛,选择行后路TLIF手术加椎弓根固定治疗。分别于术前、术后对患者的腰痛情况进行VAS评分,同时评估术后腰椎融合率。结果术后随访时间8~24个月,平均16个月。25例术后腰腿痛症状基本消失,1例仍有轻度腰痛,融合率为100%。结论严格掌握手术适应证,后路腰椎椎体间融合术是治疗腰椎间盘源性下腰痛的有效方法。     

Transforaminal lumbar interbody fusion: a safe technique with satisfactory three to five year results

The unilateral transforaminal approach for lumbar interbody fusion as an alternative to the anterior (ALIF) and traditional posterior lumbar interbody fusion (PLIF) combined with pedicle screw instrumentation is gaining in popularity. At present, a prospective study using a standardized tool for outcome measurement after the transforaminal lumber interbody fusion (TLIF) with a follow-up of at least 3 years is not available in the current literature, although there have been reports on specific complications and cost efficiency. Therefore, a study of TLIF was undertaken. Fifty-two consecutive patients with a minimum follow-up of 3 years were included, with the mean follow-up being 46 months (36–64). The indications were 22 isthmic spondylolistheses and 30 degenerative disorders of the lumbar spine. Thirty-nine cases were one-level, 11 cases were two-level, and two cases were three-level fusions. The pain and disability status was prospectively evaluated by the Oswestry disability index (ODI) and a visual analog scale (VAS). The status of bony fusion was evaluated by an independent radiologist using anterior–posterior and lateral radiographs. The operation time averaged 173 min for one-level and 238 min for multiple-level fusions. Average blood loss was 485 ml for one-level and 560 ml for multiple-level fusions. There were four serious complications registered: a deep infection, a persistent radiculopathy, a symptomatic contralateral disc herniation and a pseudarthrosis with loosening of the implants. Overall, the pain relief in the VAS and the reduction of the ODI was significant (P<0.05) at follow-up. The fusion rate was 89%. At the latest follow-up, significant differences of the ODI were neither found between isthmic spondylolistheses and degenerative diseases, nor between one- and multiple-level fusions. In conclusion, the TLIF technique has comparable results to other interbody fusions, such as the PLIF and ALIF techniques. The potential advantages of the TLIF technique include avoidance of the anterior approach and reduction of the approach related posterior trauma to the spinal canal.     

SB Charité disc replacement: report of 60 prospective randomized cases in a US center

Sixty patients with one-level discogenic pain confirmed by plain radiography, magnetic resonance imaging, and provocative discography for degenerative disc disease were randomized: one-third BAK anterior interbody fusion and two-thirds anterior SB Charité artificial disc replacement. The mean age was 40.3 years (range 21-56 years). Nineteen cases were at L4-L5 and 41 cases were at L5-S1. Nineteen cases had BAK anterior interbody fusion and 41 cases were randomized as SB Charité disc replacement. The length of surgery was mean 88.4 minutes (range 54-137 minutes) for both groups. The estimated blood loss was mean 289.5 mL (range 50-1800 mL). The length of hospital stay was a mean of 3.03 days (range 2-6 days). Oswestry Disability Index scores for the SB Charité disc (aggregate study group) were 50.0 +/- 14.3 preoperatively and 25.0 +/- 20.1 at 1-3 years' follow-up (P < 0.001). This is the first study that shows improvement of functional outcome measures in a prospective randomized design with disc arthroplasty treating primarily mechanical back pain and achieving comparable successful results to lumbar fusion-interbody fusion cage and BMP or interbody autograft and pedicle screw instrumentation.     

Minimally invasive surgery for the lumbar spine

Minimally invasive spine surgery is a rapidly developing field that has the potential to decrease surgical morbidity and improve recovery compared to traditional spinal approaches. Minimally invasive approaches have been developed for all regions of the spine, but have been best documented for degenerative conditions of the lumbar spine. Lumbar decompression and lumbar interbody fusion are two of the most well-studied minimally invasive surgical approaches. This article will review both the rationale and technique for minimally invasive lumbar decompression and for a minimally invasive transforaminal lumbar interbody fusion (TLIF).     

经椎间孔入路与经后方入路椎间融合术治疗退变性腰椎失稳症的疗效比较

目的回顾性研究经后方入路椎体间融合术（posterior lumbar interbody fusion,PLIF）和切除上、下关节突的经椎间孔入路椎体间融合术（transforaminal lumbar interbody fusion,TLIF）治疗腰椎失稳症的疗效及并发症情况。方法采用PLIF和TLIF治疗2004年1月至2008年1月本院收治的退变性腰椎失稳症患者78例,其中PLIF31例,TLIF47例。比较两组手术时间、术中出血量、平均卧床时间、Nakai评分优良率、融合时间（按Suk标准）及术后并发症发生率。对两组术前及末次随访时的椎间隙高度及椎间孔高度进行对比研究。结果 78例患者均获随访,随访时间1.5～4.5年,平均3.5年。所有患者均获椎间骨性融合。对两组卧床时间、Nakai评分优良率、融合时间、同时间点椎间隙高度和椎间孔高度进行比较,差异无统计学意义（P〉0.05）;而在手术时间、出血量以及术后并发症发生率方面,两组之间的差异有统计学意义（P〈0.05）。两组末次随访时的椎间隙高度和椎间孔高度均较术前有明显改善（P〈0.05）。结论 TLIF和PLIF治疗退变性腰椎失稳症效果良好;与PLIF相比,TLIF操作简单,出血量小,并发症少。     

Lumbar Alignment and Clinical Outcome after Single Level Asymmetrical Transforaminal Lumbar Interbody Fusion for Degenerative Spondylolisthesis with Local Coronal Imbalance

Transforaminal lumbar interbody fusion (TLIF) is widely accepted for the treatment of lumbar arthrodesis. However, the exact characteristics of TLIF depend on the number, location, shape, or materials of the interbody implants, and the type of posterior instrument. Clinical and biomechanical characteristics of each TLIF procedure are still unclear. The present study investigated the clinical and radiological improvements after single level asymmetrical TLIF, in which a single box-shaped spacer was obliquely inserted into the intervertebral space, for lumbar degenerative spondylolisthesis in patients with or without local coronal imbalance (LCI) at the operated level. The clinical records of 60 patients who underwent single level asymmetrical TLIF augmented with the pedicle screw fixation system from January 2005 to January 2011, were retrospectively reviewed. The patients were divided into the LCI group (n = 19) and non-LCI group (n = 41), based on segmental lateral translation or disc wedging at the operated site. Clinical recovery was significantly good in both groups at 2 years after surgery, but improvement of low back pain was significantly worse in the LCI group. Radiological examination revealed that the mean lumbar scoliotic angle was significantly worse in the LCI group postoperatively. Preoperative greater scoliotic angle and coronal off balance of the lumbar spine were related to unfavorable radiological outcomes. The present study showed that single level asymmetrical TLIF is an acceptable method for achieving good clinical and radiological outcomes for patients with symptomatic degenerative spondylolisthesis, however, the clinical benefits and realignment are limited if the patient has LCI at the operated site with greater scoliotic angle or coronal off balance of the lumbar spine.     

微创通道结合经皮椎弓根螺钉固定治疗腰椎退变的个体化方案选择

目的探讨应用微创通道减压融合结合经皮椎弓根螺钉固定治疗腰椎退行性疾病的初步临床效果及手术方案选择。方法收集2009年8月至2011年7月第四军医大学唐都医院运用微创通道减压融合结合经皮椎弓根螺钉固定治疗并获得随访的64例腰椎退变患者的临床资料。采用Quadrant、Pipeline或Luxor通道系统,经椎间孔腰椎间融合（TLIF）或后路TLIF（PTLIF）入路,行髓核摘除或椎间处理并植入椎间融合器,通道内行椎弓根螺钉固定并安装连接棒。于对侧相应椎体处行椎弓根经皮植入Sextant、vipor或Mantis螺钉固定。微创策略的选择：（1）单侧通道下减压椎间植骨融合,常规椎弓螺钉内固定;（2）一侧通道下减压植骨融合通用螺钉固定 ＋ 对侧通道下通用螺钉固定;（3）一侧通道下减压植骨融合通用螺钉固定 ＋ 对侧经皮螺钉固定;（4）一侧通道下减压椎间植骨融合＋双侧经皮螺钉固定。融合方式包括单节段融合、双节段融合和跨节段融合。观察患者术中出血量、手术时间、术后下床活动时间、住院天数、内固定位置以及术后症状改善情况。结果随访3～22 个月（平均 16 个月）。术中出血量 70～230 mL（平均 90 mL）、手术时间 70～210 min（平均 100 min）、下床活动时间为术后3～10 d（平均5 d）、住院天数5～15 d（平均7 d）。腰痛视觉模拟评分（VAS）和腿痛VAS分别由术前的（9.2 ± 1.4）分和（7.4 ± 1.2）分减少到末次随访的（2.6 ± 0.5）分和（2.2 ± 0.6）分,Oswestry功能障碍指数（ODI）由术前的（57.4 ± 6.4）%降至末次随访的（25.8 ± 4.3）%,差异均有统计学意义（P 〈0.05）。术中、术后X线片和/或 CT 检查显示内固定及融合器位置良好。结论一侧采用微创通道 TLIF 或 PTLIF 入路行单节段或双节段椎间处理融合,或在此基础上行对侧通道下通用螺钉/经皮椎弓根螺钉固定或双侧经皮螺钉固定等个体化方案治疗腰椎退行性疾病,术中出血少,手术时间短,术后可早期下床进行功能锻炼,初步临床效果优良。     

经椎间孔椎体间融合治疗退行性腰椎间盘病

目的探讨退行性椎间盘病（degenerative disc disease，DDD）的诊疗要点和经椎间孔椎体间融合治疗的临床效果。方法2004年9月-2006年8月，收治DDD患者共15例，采用经椎间孔椎体间融合术（transforaminal lumbar interbody fusion，TLIF）治疗。其中男8例，女7例；年龄33～46岁。病程2～10年。病变间隙均为单节段，其中L3,4 1例，L4、58例，L5、S1 6例。术前视觉模拟疼痛评分（visual analogue scale，VAS）为（8．94&#177;1．8）分，Oswestry功能障碍指数（Oswestry disability index，ODI）为（51．4&#177;8.3）分。患者均经至少3个月正规非手术治疗，无明显疗效。结果手术时间120～180min，平均150min：术中出血量200～500mL，平均360mL。1例患者术后椎间孔开放侧胫前肌力下降至3级，3个月后恢复至5-级，余患者未见严重并发症。15例获随访12～24个月，平均18个月。术后12个月内椎体间均骨性融合，融合率100％。术后VAS和ODI评分分别为（2．84&#177;1．6）分和（19．1&#177;3．2）分，与术前比较差异有统计学意义（P〈0．05）；VAS评分改善率为61．8％&#177;7.3％，ODI评分改善率为64.3％&#177;5．5％。疗效评价：优6例，良8例，可1例，优良率93．3％。患者均恢复正常工作和生活。结论TLIF是治疗DDD的一种有效方法，但应严格掌握手术适应证。     

Reduction of spondylolisthesis by temporary adjacent segment distraction

AIM OF THE STUDY: Multiple instrument systems are currently available for the reduction of spondylolisthesis, where posteriorly oriented tensile forces are directly acting on the slipped vertebra. The aim of this clinical study was to evaluate the clinical efficacy of a new indirect reduction manoeuvre applied to the lumbar spine. METHOD: A total number of 32 patients (14 female, 18 male) suffering of spondylolisthesis were reduced by transpedicular instrumentation during June 2001 until October 2003. The cranial adjacent vertebra was temporarily instrumented and the reduction of the slipped vertebra was facilitated by the application of traction on the instrumentation leading to tension of the longitudinal ligaments. Posterior transforaminal lumbar interbody fusion (TLIF) or anterior lumbar interbody fusion (ALIF) was then carried out according to the degree of degenerative shortening of the anterior long. spinal ligament. On the last follow up (average 32 month postoperatively; min.: 22 month) both the reduction of the spondylolisthesis and the ossification of the interbody fusion was evaluated radiologically. Physical function and patients satisfaction was measured by means of the SF 36 questionnaire. RESULTS: The dislocation was reduced in all cases (81% on average). At the time of the last follow up bony fusion was depicted on the radiographs in all 32 patients. A distinct improvement in all categories of the SF 36 (in 5 out of 8 categories statistic significant) could be demonstrated. CONCLUSION: Temporary intraoperative instrumentation of the cranial adjacent segment proofs to be a simple an effective method for the sufficient reduction of spondylolisthesis.     

MRI Measurement of Neuroforaminal Dimension at the Index and Supradjacent Levels after Anterior Lumbar Interbody Fusion: A Prospective Study

Background

Anterior interbody fusion has previously been demonstrated to increase neuroforaminal height in a cadaveric model using cages. No prior study has prospectively assessed the relative change in magnetic resonance imaging (MRI) demonstrated neuroforaminal dimensions at the index and supradjacent levels, after anterior interbody fusion with a corticocancellous allograft in a series of patients without posterior decompression. The objective of this study was to determine how much foraminal dimension can be increased with indirect foraminal decompression alone via anterior interbody fusion, and to determine the effect of anterior lumbar interbody fusion on the dimensions of the supradjacent neuroforamina.

Methods

A prospective study comparing pre- and postoperative neuroforaminal dimensions on MRI scan among 26 consecutive patients undergoing anterior lumbar interbody fusion without posterior decompression was performed. We studies 26 consecutive patients (50 index levels) that had undergone anterior interbody fusion followed by posterior pedicle screw fixation without distraction or foraminotomy. We used preoperative and postoperative MRI imaging to assess the foraminal dimensions at each operated level on which the lumbar spine had been operated. The relative indirect foraminal decompression achieved was calculated. The foraminal dimension of the 26 supradjacent untreated levels was measured pre- and postoperatively to serve as a control and to determine any effects after anterior interbody fusion.

Results

In this study, 8 patients underwent 1 level fusion (L5-S1), 12 patients had 2 levels (L4-S1) and 6 patients had 3 levels (L3-S1). The average increase in foraminal dimension was 43.3% (p < 0.05)-19.2% for L3-4, 57.1% for L4-5, and 40.1% for L5-S1. Mean pre- and postoperative supradjacent neuroforaminal dimension measurements were 125.84 mm² and 124.89 mm², respectively. No significant difference was noted (p > 0.05).

Conclusions

Anterior interbody fusion with a coriticocancellous allograft can significantly increase neuroforaminal dimension even in the absence of formal posterior distraction or foraminotomy; anterior interbody fusion with a coriticocancellous allograft has little effect on supradjacent neuroforaminal dimensions.