Transforaminal lumbar interbody fusion: surgical technique and results in 24 patients

OBJECTIVE: The advantage of anterior column support and fusion in addition to pedicle fixation in patients with degenerative spinal disorders has become increasingly clear. With the increase in popularity of this treatment, a variety of techniques have been used to achieve the goal of anterior column support, fusion, and segmental instrumentation. Posterior lumbar interbody fusion has been used since the late 1940s in the treatment of degenerative lumbar spine. We evaluated a modification to posterior lumbar interbody fusion called transforaminal lumbar interbody fusion (TLIF). METHODS: A retrospective analysis was performed on 24 patients (9 women, 15 men) who underwent TLIF. The approach involved a unilateral laminectomy and inferior facetectomy at the level of fusion. The interbody fusion was achieved from this unilateral approach by performing discectomy, arthrodesis, and insertion of one or two titanium cages packed with autologous bone. The average age of the patients in this study was 42.6 +/- 12.5 years. Five patients were smokers. Five cases were related to workmen's compensation. Seventeen patients' original symptoms were a combination of low back pain and radiculopathy. Ten patients had had a previous spine operation. RESULTS: Eleven patients had L4-S1 TLIFs. The rest of the patients had a single-level TLIF (L2-S1). Average intensive care unit and floor days were 1.1 +/- 1.0 and 5.8 +/- 2.2 days, respectively. The number of days to ambulation was 2.8 +/- 1.6 days. There were a total of six self-limited complications in 24 patients (including one transient neurological complication). The average follow-up time was 16.9 +/- 9.1 months. Twenty-two patients had solid fusions. A modified Prolo scale (4 worst, 20 best) was used to evaluate the clinical outcome. The average score was 16.1 +/- 4.1. CONCLUSION: TLIF is a reliable and safe technique for interbody support that can be performed with excellent clinical outcome. In the authors' experience, TLIF offers excellent exposure with minimal risk. This applies particularly in cases of repeat spine surgery, in which the presence of scar tissue makes traditional posterior lumbar interbody fusion techniques difficult or impossible. In addition, TLIF seems to be a viable alternative to anteroposterior circumferential fusion and/or anterior lumbar interbody fusion.     

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.     

Transforaminal Thoracic Interbody Fusion (TTIF) for Treatment of a Chronic Chance Injury

Multiple anterior and posterior approaches to the thoracic disc space have been reported. However, we are not aware of any previous reports describing a transforaminal approach for thoracic disc release and interbody cage placement. In this case report, we describe a method to perform transforaminal thoracic interbody fusion (TTIF), which is an adaptation of an established lumbar fusion technique (transforaminal lumbar interbody fusion). Key differences between the two procedures are discussed. A 24-year-old woman presented after sustaining a T11-12 Chance fracture that had been treated in a brace. She had severe, debilitating pain and a rigid segmental kyphotic deformity of 38°. The patient was treated 3 months post-injury with T10-L1 fusion with anterior release and interbody fusion with cage placement at T11-12. Anterior column release and fusion were performed via a transforaminal approach. The patient had anatomic reduction of deformity, solid arthrodesis, and relief of pain at 1-year follow-up. The TTIF approach permits access to the anterior column of the thoracic spine for the purpose of reduction of deformity and interbody fusion with reduced morbidity compared to anterior–posterior surgery.     

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.     

显微内窥镜下椎管减压椎间融合治疗腰椎失稳症的近期疗效观察

目的:探讨显微内窥镜下椎管减压、椎间植骨融合治疗腰椎失稳症的临床疗效。方法:2006年7月～2008年12月共收治退变性腰椎失稳症患者48例,患者均有持续性腰痛,伴有双侧臀部、双侧或一侧下肢疼痛、麻木,均有间歇性跛行、腰部屈伸活动受限。腰椎动力位X线片示均为单节段失稳,椎间水平移位≥4mm或椎间角度变化≥11°,但滑移不超过Ⅰ度。均采用显微内窥镜下经椎板间隙入路椎管减压、经椎间孔入路椎体间自体骨粒、椎间融合器置入椎体间融合术。术后2周(出院时)拍腰椎正侧位X线片,术后每3个月复查X线片。按照Macnab标准评价疗效,随访观察近期治疗效果。结果:手术时间70～150min,平均95min;出血量110～210ml,平均150ml。随访6～18个月,平均12个月。术后症状及体征均有不同程度缓解,术中、术后均无任何并发症发生。末次随访时按照Macnab标准,优24例,良20例,可4例。X线检查未见cage移位、下沉,37例随访超过9个月的患者均见椎间隙变模糊,过伸过屈侧位X线片示椎体间无移位,但所有患者均未观察到椎间隙消失和骨小梁完全通过椎体间上下终板。结论:显微内窥镜下椎管减压及椎间融合术治疗退变性椎间失稳症具有创伤小、早期疗效满意等优点,长期疗效及融合情况需进一步随访观察。     

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.     

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。     

单侧椎弓根螺钉内固定联合椎体间融合治疗腰椎退行性疾病的临床研究

目的探讨腰椎后路单侧椎弓根螺钉内固定联合经椎间孔椎体间融合术(transforaminallumbar interbody fusion,TLIF)治疗腰椎退行性疾病的临床疗效。方法回顾性分析35例腰椎退行性疾病患者,采用经后路单侧椎弓根螺钉内固定联合TLIF并单枚Cage手术进行治疗,其中男性20例,女性15例,年龄29～68岁(平均53.3岁),病程0.5～5年。使用使用Oswestry(ODI)功能障碍指数和日本JOA评分法评估术后疗效,依据SUK法对术后脊柱融合情况进行评估。结果所有患者手术前后Oswestry功能障碍指数之间比较差异有统计学意义,根据日本JOA评分法评估优25例(71.4%)、良8例(22.8%)、可1例(2.9%)、差1例(2.9%),依据SUK标准证实本组病例椎体间植骨融合率为97.1%。有1例患者节段间有明显间隙,椎间植骨有不同程度的吸收,但动态片上节段间相对活动<4 mm。内固定未见松动、拔出、断钉。结论单侧椎弓根螺钉内固定联合椎间植骨并Cage支撑治疗腰椎退行性疾病融合率高,临床疗效良好。     

Comparison of posterior and transforaminal approaches to lumbar interbody fusion

STUDY DESIGN: A study of the transforaminal lumbar interbody fusion and the posterior lumbar interbody fusion techniques was performed. OBJECTIVES: To describe the transforaminal lumbar interbody fusion technique, and to compare operative data, including blood loss and operative time, with data from posterior lumbar interbody fusion technique. SUMMARY OF BACKGROUND DATA: The evolution of posterior lumbar fusion combined with anterior interbody fusion has resulted in increased fusion rates as well as improved reductions and stability. The transforaminal lumbar interbody fusion technique pioneered by Harms and Jeszensky offers potential advantages and provides a surgical alternative to more traditional methods. METHODS: In 13 consecutive months, two spinal surgeons performed 40 transforaminal lumbar interbody fusions and 34 posterior lumbar interbody fusion procedures. Data regarding blood loss, operative times, and length of hospital stay were recorded. These data were analyzed using analysis of variance to show any significant differences between the two techniques. To determine whether differences in measured variables were dependent on patient gender or number of levels fused, epsilon(chi2) analysis was used. RESULTS: No significant differences were found between transforaminal and posterior lumbar interbody fusions in terms of blood loss, operative time, or duration of hospital stay when a single-level fusion was performed. Significantly less blood loss occurred when a two-level fusion was performed using the transforaminal approach instead of the posterior approach (P < 0.01). Differences in measured variables for the two procedures were independent of patient age, gender, and the number of levels fused. There were no complications with the transforaminal approach, but the posterior approach resulted in multiple complications. CONCLUSIONS: In this comparison of patients receiving transforaminal lumbar interbody fusion versus posterior lumbar interbody fusion, no complications occurred with the transforaminal approach, whereas multiple complications were associated with the posterior approach. Similar operative times, blood loss, and duration of hospital stay were obtained in single-level fusions, but significantly less blood loss occurred with the transforaminal lumbar interbody approach in two-level fusions. The transforaminal procedure preserves the interspinous ligaments of the lumbar spine and preserves the contralateral laminar surface as an additional surface for bone graft. It may be performed at all lumbar levels because it avoids significant retraction of the dura and conus medullaris.     

微创单侧椎弓根螺钉固定、椎体间融合治疗腰椎疾患所致腰痛的临床观察

目的:评价微创单侧椎弓根螺钉固定、椎间融合治疗腰椎疾患所致腰痛的临床疗效。方法:2003年12月～2006年8月,共收治不同原因所致腰痛患者29例,其中腰椎间盘突出症13例,腰椎不稳8例,椎间盘源性腰痛5例,MED术后复发3例,均采用可扩张管道系统经椎间孔行椎体间植骨融合、单侧椎弓根螺钉固定术治疗。应用视觉模拟评分系统(VAS)评估患者术前、术后疼痛情况,应用Kim方法评价临床效果,应用Schulte方法观察植骨融合情况。结果:1例患者术后出现对侧下肢放射性疼痛,保守治疗无效,再次手术行神经根管减压和内固定后症状缓解。随访21～36个月,平均31.5个月,术前VAS评分为7.7±0.6分,术后3个月时为1.9±0.9分,两者比较有显著性差异(P0.001),术后3个月时Kim优良率为89.7%,末次随访时Kim优良率为96.6%,满意率为96.6%。末次随访时椎间融合率为93.1%,1例可能融合和1例假关节形成。结论:微创单侧椎弓根螺钉固定是治疗腰痛的一种有效方法,但需要严格把握手术适应证。     

后路腰椎间融合与经椎间孔腰椎间融合治疗单纯腰椎不稳的对比研究

[目的]对后路腰椎间融合(Posterior Lumbar Interbody Fusion,PLIF)及经椎间孔腰椎间融合(Transforami-nal Lumbar Interbody Fusion,TLIF)治疗单纯腰椎不稳的手术创伤、并发症及术后疗效进行比较。[方法]将2006年2月～2009年7月收治的单纯腰椎不稳患者采用随机数字表法将患者分为PLIF组(110例)、TLIF组(108例)。术前评估两组患者一般资料差异无统计学意义,具有可比性。分别对两组患者的手术创伤、术中并发症及功能恢复情况进行比较。[结果]术后随访时间14～36个月,平均21个月。手术时间:PLIF组为(125.6±45)min,TLIF组为(124.9±44)min(P>0.05);失血量:PLIF组为(1 000±450)ml,TLIF组为(995±405)ml(P>0.05);术中并发症:PLIF组为3例,TLIF组为0例(P<0.05);术后优良率:PLIF组为93.6%,TLIF组为94.4%(P>0.05);术后融合率:PLIF组为96.4%,TLIF组为98.1%(P>0.05);JOA评分:PLIF组为14.5...     

经椎间孔椎体间植骨治疗下腰椎爆裂性骨折

目的 探讨在下腰椎爆裂性骨折中应用单一后路经椎间孔椎体间植骨融合术重建椎体前中柱的有效性.方法 2009年1月～2011 年6月,采用单一后路切开复位椎弓根内固定经椎间孔椎体间植骨融合术治疗下腰椎爆裂性骨折19例.分别评价术前、术后、末次随访时的影像学指标变化,及术前与术后末次随访时神经功能变化.结果 19例患者平均随访15.6 个月.所有患者术后未发生切口感染、神经功能损伤及内固定器松动断裂等并发症.末次随访时18例患者证实椎间融合,19例患者术前平均伤椎高度为正常椎体高度的（40.62±12.32）%,术后恢复至（96.52±10.62）%,末次随访时为（95.43%9.54）%.腰椎前凸角术前32.2°±5.1°,术后38.4°±5.2°,末次随访时为38.4°±7.2°.末次随访时伴有神经功能障碍的患者均有1级以上的恢复.结论 下腰椎爆裂性骨折行后路椎弓根螺钉内固定经椎间孔椎体间植骨融合术,能完成短节段三柱固定,同时修复了前柱及矫正脊柱后凸,取得满意的骨性融合率.     

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。     

PLIF与TLIF治疗腰椎不稳症的疗效比较

目的对比研究后路腰椎椎体间植骨融合术(posteriorlumbarinterbodyfusion,PLIF)与经腰椎间孔入路腰椎椎间植骨融合术(transforaminallumbarinterbodyfusion,TLIF)治疗腰椎不稳症的疗效。方法1999年2月~2006年3月,217例重度退变性腰椎不稳症患者接受腰椎后路椎间植骨融合,辅以相应节段椎弓根钉内固定术,其中76例经腰椎间孔椎体间植骨融合(TLIF组),另外141例经腰椎管内(硬脊膜外)椎体间植骨融合(PLIF组),比较两组手术方式的临床疗效、植骨融合率及手术并发症。结果217例患者手术切口均一期愈合,无椎间隙感染、下肢深静脉栓塞等并发症。PLIF组128例患者经6~82个月随访,平均64个月,发生硬脊膜撕裂4例,脑脊液漏1例,马尾神经及神经根一过性牵拉损伤3例。TLIF组67例经4~56个月随访,平均36个月,未发生神经损伤等并发症。两组平均手术时间、术中平均出血量、平均住院时间均无明显差异。TLIF组与PLIF组的临床优良率分别为89.86%和86.72%,两者无显著性差异(P>0.05),植骨融合率分别为92.75%和93.75%,两者无显著性差异(P>0.05)。结论经腰椎间孔入路椎间植骨融合术治疗腰椎不稳症,不但技术操作可行,而且能明显降低因侵入椎管而带来的各种并发症,是治疗重度退变性腰椎不稳症的有效手术方式。     

单侧椎弓根钉结合对侧关节突螺钉内固定与双侧椎弓根钉固定治疗下腰椎退行性疾病的比较

目的比较后路减压椎间融合器植骨后行单侧椎弓根钉结合对侧椎板关节突螺钉固定与双侧椎弓根螺钉固定治疗下腰椎退行性疾病的优缺点。方法2010年1月至2012年1月采用后路减压椎间融合器植骨内固定治疗80例下腰椎退行性疾病患者,均为单节段病变。其中40例在可扩张管微创系统（Quadrant系统）辅助下行椎弓根钉结合对侧椎板关节突螺钉固定（微创组）,40例采用开放后路腰椎体间融合双侧弓根螺钉内固定（常规组）。使用0s—westry功能障碍指数（oswestry disability index,ODI）、疼痛视觉模拟评分（visual analogue score,VAS）评定临床疗效,并比较两组患者手术切口长度、手术时间、术中出血量、术后引流量、住院时间、并发症等指标。结果术后1周微创组腰痛VAS评分优于常规组（P〈0．05）。而其他时间相比两组VAS评分与ODI评分相比,差异均无统计学意义（P〉0．05）。两组患者手术切口长度、手术时间、术中出血量、术后引流量、住院时间比较差异均有统计学意义,微创组少于常规组。随访过程中两组病例均未出现内固定物松动、移位、断裂等。融合率差异无统计学意义（P〉0．05）。结论与传统后路开放减压双侧椎弓根螺钉内固定术相比,微创通道下单侧椎弓根钉结合对侧椎板关节突螺钉内固定方法具有操作简单、创伤出血少、稳定可靠、疗效确切等优点,更加符合微创原则。     

微创经多裂肌间隙单侧腰椎椎弓根钉固定椎间融合术式的探讨

目的 探讨应用直视下可扩张管微创系统(Quadrant系统)经多裂肌间隙入路单侧椎弓根螺钉固定单枚cage椎间植骨融合术的疗效.方法 2008年4月至2009年4月应用Quadrant系统对47例患者采取多裂肌间隙入路单侧椎弓根螺钉固定,单枚cage椎间植骨融合术治疗,其中男性22例,女性25例;年龄46～74岁,平均5 8.2岁..极外侧型椎间盘突出12例,椎间盘开窗摘除术后复发7例,退变性腰椎不稳28例;37例经椎间孔入路,10例行后侧入路.术后通过X线片观察固定融合情况,按Nakai标准评定临床疗效.结果 切口长度3.0～3.5 cm,平均3.2 cm;手术时间70～160 min,平均90 min;术中出血量90～360 ml,平均130 ml.随访8～20个月,无椎弓根钉断裂、松动、拔出、cage移位等严重并发症发生;43例获骨性融合,4例可疑融合.末次随访时患者VAS腿痛评分从术前平均(7.4±1.1)分降至(2.4±1.3)分,VAS腰痛评分从术前平均(6.7±1.3)分降至(1.8±1.5)分.临床疗效评定:优31例,良11例,可5例,优良率89.4%.结论 经多裂肌间隙入路单侧椎弓根螺钉固定,单枚cage椎间植骨融合术具有手术创伤小、时间短、出血少、并发症低、疗效确切等优点,在合理选择适应证的情况下是一种理想的下腰椎融合方法.     

Anterior lumbar interbody fusion using a hybrid graft

This prospective study evaluates the clinical and radiological results of anterior lumbar interbody fusion using a femoral cortical ring allograft (FCA) packed with cancellous autologous bone (hybrid graft), combined with posterior pedicular fixation but without posterior fusion, for symptomatic degenerative disease of the lumbar spine. Twenty-eight out of 30 consecutive adult patients were followed up for a minimum period of 2 years. Intra- and postoperative complications were seen in 2 out of 28 patients (7%); no complications resulted from the allografts. Clinically, 24 out of 28 patients (85%) had a good to excellent result, one patient (4%) a fair result, and 3 patients (11%) a poor result. Radiologically, the overall fusion rate by the level was 98% in 28 patients.     

Anterior interbody arthrodesis with percutaneous posterior pedicle fixation for degenerative conditions of the lumbar spine

This is a retrospective case series to evaluate clinical variables, complications and outcome of 50 patients who underwent anterior lumbar interbody fusion (ALIF) supplemented with posterior percutaneous pedicle screw fixation for degenerative conditions of the lumbar spine. Twenty-four patients underwent single-level fusion and 26 patients had a two-level fusion for a total of 76 levels fused. The mean lengths of the anterior and posterior (including repositioning) portions of the procedure were 131 and 102 min, respectively. The mean estimated blood loss for the entire procedure was 288 ml. The overall adverse event rate was 12%. The mean VAS score for leg pain, VAS score for back pain and mean ODI all improved postoperatively. This study found that ALIF using allograft bone and rhBMP-2 combined with percutaneous pedicle screw fixation had a high fusion rate and a low incidence of perioperative complications. Patient outcomes showed significant improvements in back and leg pain and physical functioning.     

Minimally invasive lumbar spinal fusion

Minimally invasive techniques for lumbar spine fusion have been developed in an attempt to decrease the complications related to traditional open exposures (eg, infection, wound healing problems). Anterior minimally invasive procedures include laparoscopic and mini-open anterior lumbar interbody fusion as well as the lateral transpsoas and percutaneous presacral approaches. Posterior techniques typically use a tubular retractor system that avoids the muscle stripping associated with open procedures. These techniques can be applied to both posterior and transforaminal lumbar interbody fusion procedures. Many initial reports have shown similar clinical results in terms of spinal fusion rates for both traditional open and minimally invasive posterior approaches. However, the anterior minimally invasive procedures are often associated with significantly greater incidence of complications and technical difficulty than their associated open approaches. There is a steep learning curve associated with minimally invasive techniques, and surgeons should not expect to master them in the first several cases.