Posterior lumbar interbody fusion

This paper reports the posterior lumbar interbody fusion (PLIF) that has been performed on fourteen patients. It includes 6 cases of spondylolytic spondylolisthesis, 3 cases of degenerative spondylolisthesis, 2 cases of postoperative recurrence of lumbar disc protrusion, 2 cases of unstable prolapse of intervertebral disc, 1 cases of consequent spinal canal stenosis after lumbar lamina fusion. As a result 92 per cent of the operations are successful. The method of operation and it's modification are reported in detail. The indication of operation and the evaluative criteria of interbody bone union discussed. The intact of lumbar posterior structures, the condition of bone grating bed, the quality and disperse of bone graft are main factors that influencing bone union. Bleeding from venous plexus of spinal canal and from vertebral cancellous bone, injury of lumbosacral nerve root and cauda equina are the main surgical complications that should be stressed.     

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.     

Posterior lumbar interbody fusion updated

Based on over 45 years' experience in the surgical treatment of lumbar disc disease, it is recommended that the following operations be eliminated: the simple discectomy, which may cure the sciatica but not the back pain; the "decompressive laminectomy," which leaves the patient with painful instability and nerve-root scarring; and chemonucleolysis, which does not provide permanent relief of either low-back or leg pain. The PLIF technique is the answer to treatment of diseases of the lumbar spine and may be the operation of the future.     

Posterior and anterior lumbar interbody fusion

Posterior Lumbar Interbody Fusion (PLIF) may be indicated for intractable back pain, as it maintains adequate distraction of the intervertebral space thus relieving pressure on the nerve root. Iliac crest autografts, allografts and porous metallic cages are used.Success rates of above 90% have been reported, but complications due to the operative approach have been described. While biomechanically PLIF is superior to simple disc excision in relieving intractable back pain, the procedure is technically difficult in the presence of scar tissue from previous surgery. A proper understanding of operative principles and appropriate patient selection is essential to achieve good results. As an alternative technique, Anterior Lumbar Interbody Fusion (ALIF) has advocates.     

Posterior lumbar interbody fusion and segmental lumbar lordosis

Introduction

The sagittal plane of body produces a convex curve anteriorly referred to as the lordotic curve. Malalignment of lordotic curve leads to low back disorders and lumbar spinal surgery has been known to cause this. This study was a retrospective analysis of the effects of posterior lumbar interbody fusion using cages on segmental lumbar lordosis.

Materials and methods

We conducted a retrospective study involving 27 patients of which 16 were females and 11 were males. All patients underwent single level posterior lumbar interbody fusion with insertion of non-wedged intervertebral cage and pedicle screw fixation. Intraoperatively, all patients had a change from knee chest position to prone to augment their lumbar lordosis. The minimum follow up was 2 years and fusion was achieved in 21 patients.

Results

Segmental lordotic angles increased from 15.2° to 20.6° at L4/5 level and from 17.8° to 24.5° at L5/S1 level, preoperative to postoperative, respectively (P < 0.01 at both levels).

Conclusion

Thus apparently, posterior lumbar interbody fusion with insertion of non-wedged intervertebral cage and pedicle screw fixation results in creation and maintenance of lumbar lordosis.     

Posterior lumbar interbody fusion using rhBMP-2

The use of biological technologies for the treatment of degenerative spinal diseases has undergone rapid clinical and scientific development. BMP strategies have gained wide support for an inherent potential to improve the ossification process. It has been extensively studied in combination with various techniques for spinal stabilisation from both anterior and posterior approach. We studied the fusion process after implantation of rhBMP-2 in 17 patients with degenerative lumbar spine diseases in combination with dorsal fixation with pedicle screws and poly-ether-ether-ketone (PEEK) interbody cages. We used 12 mg rhBMP-2 carried by collagen sponge, 6 mg in every cage. Patient follow up consisted of pre-operative radiographic and clinical evaluation. Similar post-operative evaluations were performed at 3 and 6 months. Clinical assessment demonstrated clear improvement in all patients despite evidence of vertebral endplate osteoclastic activity in the 3-month radiographs. The 6-month radiograph, however, confirmed evidence of fusion, and no untoward results or outcomes were noted. While previous studies have shown exclusively positive results in both fusion rates and process, our study demonstrated an intermediate morphology at 3 months during the ossification process using Induct Os in combination with peek-cages using a PLIF-technique. The transient resorption of bone surrounding the peek cage did not result in subsidence, pain or complication, and fusion was reached in all cases within a 6-month-controlled evaluation. Although there was no negative influence on clinical outcome, the potential for osteoclastic or metabolic resorption bears watching during the post-surgical follow up.     

Posterior lumbar interbody fusion with facet-screw fixation

The optimal surgical construct for lumbar fusion remains controversial. The posterior lumbar interbody fusion (PLIF) operation offers advantages including total nuclear disc excision, restoration of disc-space height, root decompression, limited muscle retraction and injury, and solid mechanical arthrodesis. Major disadvantages have included graft displacement, neurologic injury and nonunion. The use of posterior fixation as an adjunct to PLIF reduces the probability of these complications and increases the chances of fusion. This study examines 35 patients who underwent PLIF and facet-screw fixation. Indications for surgery included disabling low-back pain with discographic/MRI-demonstrated disc derrangement, recurrent disc herniation, and failed inter-transverse process fusions. Follow-up ranged from 6 to 18 months. There were no patients with significant neurologic injury or functional root loss. One patient developed graft displacement and failure of fixation (laminar fracture in markedly obese patient). Three patients had subcutaneous hematomas (no surgical treatment required). None of the cases required blood replacement. The authors have concluded that the addition of facet fixation/fusion to the PLIF operation substantially reduces the complication rate of the procedure.     

Posterior lumbar interbody fusion with specialized instruments

Posterior lumbar interbody fusion (PLIF) has been performed in 100 individuals by use of specialized surgical instruments and allogeneic preserved bone grafts from 1979 to March 1982, after the advantages of performing PLIF in 342 individuals from 1965 to 1978 were noted. No deaths occurred, nor any infections or thrombophlebitis postoperation. Eleven (11%) reoperations were required: six for proven pseudarthrosis, three for gradual bone graft extrusion (of six extrusions total), one for bone graft fracture (with manifestations of nerve root compression), and one for hematoma. Operative results were excellent in 35%, good in 39%, fair in 17%, and poor in 9%. Specialized surgical instruments used for the operation included mortising chisels with cannulated reamers, right-angled curettes, and depth-limited impactors. PLIF is technically demanding; however, it establishes a mortise-graft interbody fusion to stabilize and restore the spinal architecture.     

后路腰椎椎体间融合术治疗腰椎滑脱的临床疗效

目的：探讨后路腰椎椎体间融合术（posterior lumbar interbody fusion,PLIF）治疗腰椎滑脱的中期疗效,对腰椎滑脱症的临床治疗提供指导意见。方法回顾性分析采用PLIF治疗的腰椎滑脱40例,所有病例随访观察＞3年,对手术前后影像学资料、Oswestry功能障碍指数（Oswestry disability index,ODI）、视觉模拟量表（visual analog scale ,VAS）评分及日本骨科学会（Japanese Orthopaedic Association ,JOA）腰背痛手术治疗评分标准的评分变化情况进行比较分析。结果椎间隙高度、椎间孔高度术后1年、3年与术前比较差异均有统计学意义（P＜0．05）;术后1年与术后3年测量值比较差异不具有统计学意义（P＞0．05）。 ODI、腰痛VAS评分、腿痛VAS评分及JOA评分术前和术后1年、3年比较差异具有统计学意义（P＜0．05）;术后1年与术后3年比较差异不具有统计学意义（P＞0．05）。结论 PLIF手术能够恢复腰椎序列稳定性,改善临床症状,是治疗腰椎滑脱的理想术式,中期随访疗效满意。     

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。     

后路减压内固定融合治疗退变性腰椎侧凸

目的探讨后路减压内固定植骨融合治疗退变性腰椎侧凸的临床疗效。方法后路减压内固定植骨融合治疗19例退变性腰椎侧凸患者。手术前后进行JOA、VAS评分评估临床疗效,影像学测量比较手术前后的Cobb角、骨盆倾斜角(PT)、腰椎前凸角(LL)。结果所有患者均获得随访,时间11~23(15.7±2.2)个月。JOA评分:术前为12.2分±1.7分,术后3个月为22.7分±3.1分,末次随访为24.0分±2.8分。VAS评分:术前为8.4分±0.5分,术后3个月为1.9分±0.8分,末次随访为1.8分±0.6分。Cobb角:术前为23.9°±4.2°,术后3个月为3.1°±1.4°,末次随访为3.3°±1.1°。LL:术前为31.6°±5.9°,术后3个月为42.5°±6.6°,末次随访为44.3°±6.0°。PT:术前为21.5°±7.3°,术后3个月为18.9°±9.4°,末次随访为18.5°±7.8°。以上各项指标术后3个月与术前比较差异均有统计学意义(P0.05),末次随访与术后3个月比较差异均无统计学意义(P0.05)。结论后路减压内固定植骨融合治疗退变性腰椎侧凸可充分减压,缓解症状,重建腰椎矢状面和冠状面的序列并维持脊柱稳定。     

Posterior lumbar interbody fusion versus intertransverse fusion in the treatment of lumbar spondylolisthesis

PURPOSE: To compare 2 methods of fusion in the treatment of lumbar spondylolisthesis: posterior lumbar interbody fusion (PLIF) and intertransverse fusion (ITF). METHODS: 20 patients with lumbar spondylolisthesis were randomly allocated to one of 2 groups: decompression, posterior instrumentation, and PLIF (n=10) or decompression, posterior instrumentation, and ITF (n=10). The Oswestry low back pain disability questionnaire was used for clinical assessment. Radiography was performed preoperatively and postoperatively to assess the reduction of spondylolisthesis or slip. RESULTS: In the PLIF and ITF groups, 87.5% and 100% had a satisfactory clinical result, and 48% and 39% had reduced spondylolisthesis, respectively. Both had a fusion rate of 100%. PLIF showed better reduction of spondylolisthesis, although ITF achieved a better subjective and clinical outcome. CONCLUSION: Morbidity and complications are much higher following PLIF than ITF. ITF is recommended because of the simplicity of the procedure, lower complication rate, and good clinical and radiological results.     

后路减压植骨融合内固定术治疗高位腰椎间盘突出症

[目的]探讨后路减压植骨融合内固定术治疗高位腰椎间盘突出症目的临床疗效.[方法]对26例高位腰椎间盘突出症患者行后路减压植骨融合内固定手术治疗,术前进行腰痛VAS及腰腿痛评分,术后平均随访20.8个月(8个月～3年),末次随访时进行VAS评分及腰腿痛评分,通过配对比较t检验,比较术前及术后VAS及腰腿痛功能评分.[结果]26例患者全部获得随访,术后VAS评分较术前明显减少,(P＜0.05);术腰腿痛评分较术前明显增加,下肢功能明显改善,(P＜0.05).本组22例获得优良手术效果,优良率为84.6%.[结论]后路减压植骨融合内固定治疗高位腰椎间盘突出症是一种切实可行目的手术治疗方式,手术疗效明确.术中操作轻柔、仔细,避免医源性损伤是手术成功目的关键.     

Posterior lumbar interbody fusion technique: complications and pitfalls

To assure a high degree of lumbar interbody fusion, four biomechanic principles should be observed: preservation of posterior portion of the motion segment (this would stabilize and compress the grafts); near total discectomy to render a larger area for recipient graft site; maximum impaction of mixed cancellous and unicortical peg grafts; and partial decortication to avoid invasion into the soft vascular cancellous bone in a deeper area. The result of 465 cases of PLIF over a ten-year period showed 82% clinical satisfactory results and a 88% satisfactory fusion rate. Various complications and pitfalls related to this procedure suggest that with meticulous technique and close adherence to the established protocol, PLIF can be performed safely with a high success rate of fusion.     

Posterior lumbar interbody fusion with restoration of lamina and facet fusion

STUDY DESIGN: To report the techniques and surgical results of posterior lumbar interbody fusion with restoration of the lamina and facet fusion. OBJECTIVES: To present a technique to reconstruct the posterior construct in posterior lumbar interbody fusion. SUMMARY OF BACKGROUND DATA: Successful arthrodesis in posterior lumbar interbody fusion requires both a large amount of graft and maximal graft filling, it also requires an excessive distraction of neural structures and excessive removal of the facet-lamina structure, which plays a significant mechanical role, especially in rotatory stability. METHODS: This study consisted of 36 surgery patients comprising 27 cases of chronic herniated lumbar disc, 4 caused by failed back surgery syndrome, 3 by recurrent lumbar disc herniation, and 2 by apophysis fracture with disc avulsion. The facetolaminotomy was performed by osteotomizing bilateral pars interarticularis with a Gigli saw. Posterior lumbar interbody fusion was performed through the more widely exposed intervertebral space by inserting a pair of carbon fiber cages and medial iliac bone blocks between the cages. The facetolaminotomy flap was returned to the previous site and fixed by translaminar and transisthmic screw fixation. Bilateral facet arthrodesis was also performed. RESULTS: There were no neural complications related to facetolaminotomy by using the Gigli saw, nor were there any complications related to the screw fixation for the restoration of the posterior construct. Of the 22 patients available for more than a 6-month postoperative follow-up period, radiologic union at the interbody fusion site and at both pars interarticularis was noted in 18. An incomplete union at unilateral pars interarticularis was noted in the other 4 patients. CONCLUSIONS: The technique of posterior lumbar interbody fusion with restoration of the lamina and facet fusion not only provides a wide interspace for safe and effective posterior lumbar interbody fusion but also restores the posterior constructs, thereby preserving its important mechanical roles and often even achieving natural circumferential arthrodesis.     

Posterior lumbar interbody fusion using spinous process and laminae

Posterior lumbar interbody fusion (PLIF) is indicated for many patients with pain and/or instability of the lumbar spine. We performed 36 PLIF procedures using the patient's lumbar spinous process and laminae, which were inserted as a bone graft between two vertebral bodies without using a cage. The mean lumbar lordosis and mean disc height to vertebral body ratio were restored and preserved after surgery. There were no serious complications. These results suggest that this procedure is safe and effective.