Objective To analyze the effectiveness of transforaminal lumbar interbody fusion (TLIF) for failed back surgery syndrome (FBSS). Methods Between October 2003 and December 2007, 36 patients with FBSS were treated with TLIF. There were 19 males and 17 females with an average age of 52.6 years (range, 46-68 years) and an average disease duration of 1.6 years (range, 3 months-15 years). Of 36 patients, reoperation was performed in 25, 10 received 3 operations,and 1 had 5 operations. A total of 50 segments were involved in fusion, including L4, 5 in 12 cases, L5, S1 in 10 cases, L3, 4 and L4, 5 double segments in 8 cases, and L4, 5 and L5, S1 double segments in 6 cases. According to X-ray films, CT, and MRI examination, 12 patients were diagnosed as having lumbar instabil ity secondary to total laminectomy, 18 as having recurrence of lumbar disc protrusion, and 6 as having recurrence of lumbar spondylol isthesis. Results Dural rupture occurred in 1 case and was repaired by suturing without cerebrospinal fluid leakage was observed; 1 had deep incision infection of Staphylococcus; and 1 had transient single irritation sign because of hematoma formation and was cured after symptomatic treatment. The other incisions healed by first intention. No patients had permanent nerve injury or deterioration. Thirty-three cases were followed up 18-72 months (mean, 35.2 months). At 12 months, all the operated segments reached interbody fusion, and no breakage of screw or Cage dislocation occurred. Japanese Orthopaedic Association (JOA) scores showed significant difference (t=2.45, P=0.01) between before operation (14.2 ± 4.1) and 18 months after operation (23.9 ± 2.6). The rate of cl inical improvement was 90.9% (23 cases of excellent, 7 cases of good, 3 cases of acceptable). Conclusion The TLIF simpl ifies the manipulation of lumbar revision surgery and decreases the operation risk and the operative compl ications for the treatment of FBSS.
Objective To analyze the cl inical effects of modified transforaminal lumbar interbody fusion (TLIF) for the treatment of lumbar degenerative disease. Methods From October 2003 to December 2006, 33 patients with lumbar degenerative disease (L3-S1) were treated by modified TLIF. There were 14 males and 19 females with an average age of 52.2 years(33 to 70 years). The median disease course was 1.8 years (4 months to 15 years). A total of 42 levels were fused, including 24 cases of single level and 9 cases of double levels. The results of preoperative diagnosis were lumbar degenerative spondylol isthesis with stenosis (8 cases), isthmic spondylol isthesis (5 cases), degenerative lumbar stenosis (16 cases), huge herniated disc with segmental instabil ity (3 cases) and failed back surgery syndrome (1 case). During the modified TLIF procedure, total inferior facet process and inner half summit of superior facet process of TLIF side were resected to make the posterior wall of foramen opened partly. After the bone graft (3 to 5 mL) was placed into the interbody space, a single rectangle Cage was inserted obl iquely from 30° to 40° toward the midl ine. Combined with pedicle screw instrumentation, TLIF was accompl ished. Middle canal and opposite side nerve root decompression were performed simultaneously when necessary. Results Intraoperative dura mater rupture, postoperative cerebral spinal fluid leakage, deep wound infection and transient nerve root stimulation occurredin 1 case respectively, and were all recovered after treatment. No patients had permanent neurologic deficit or aggravation. All patients were followed up for 20 to 58 months (mean 27.2 months). At the follow-up after 1 year postoperatively, all the operated segments achieved fusion standard and no broken screw or Cage dislocation occurred. All 13 cases of spondylol isthesis were reduced thoroughly and maintained satisfactorily. Nineteen patients remained sl ight chronic back pain. There was significant difference (P lt; 0.05) in JOA score between preoperation (14.9 ± 5.1) and postoperation (25.9 ± 3.0). The rate of cl inical improvement was 80.5% (excellent in 24 cases, good in 7 cases, and fair in 2 cases). Conclusion The modified TLIF carries out the less invasive principles in opening operations, simpl ifies the manipulation and expands the indication of TLIF to some extent, and the cl inical results for the treatment of lumbar degenerative disease is satisfactory.
Objective To compare the therapeutic effect of conventional discectomy, posterior lumbar interbody fusion (PLIF), and transforaminal lumbar interbody fusion (TLIF) on the recurrent lumbar disc protrusion (RLDP). Methods From January 2000 to January 2008, 65 patients with RLDP underwent different surgical procedures, namely conventional discectomy (group A, 25 cases), PLIF (group B, 22 cases), and TLIF (group C, 18 cases). There were 44 males and 21 females aged 26-65 years old (average 41 years old). All the patients were single-level protrusion, including 33 cases at the L4, 5 level and 32 cases at the L5, S1 level. The primary procedure included laminectomy discectomy in 39 patients, unilateral hemilaminectomy discectomy in 15 patients, and bilateral laminectomy and total laminectomy discectomy in 11patients. The recurrent time to the primary operation was 13-110 months (average 64 months). The location of recurrent disc protrusion was at the ipsilateral side in 47 cases and the contralateral side in 18 cases. No significant differences among three groups were evident in terms of basel ine data (P gt; 0.05). Results The incision all healed by first intention. The incidence of perioperative compl ication in group A (24.0%) and group B (22.3%) was significantly higher than that of group C (5.6%) (P lt; 0.05), and there was no significant difference between group A and group B (P gt; 0.05). The operation time and bleed loss during operation of group B were obviously higher than that of group A and group C (P lt; 0.05), and there was no significant difference between group A and group C (P gt; 0.05). There were no significant differences among three groups in terms of the length of hospital ization (P gt; 0.05). Six-one patients were followed up for 12-36 months (average 20 months). At 1 week after operation, the satisfied rate of patients was 84.0% in group A, 81.8% in group B, and 88.9% in group C (P gt; 0.05). All the patients in group B and group C achieved fusion uneventfully. There were no significant differences among three groups in terms of visual analogue scale (VAS) and Oswestry disabil ity index (ODI) when compared the preoperative value with the final follow-up value (P gt; 0.05). There was significant difference within group A, B, and C in terms of VAS and ODI when compared the preoperative value with the final follow-up value (P lt; 0.05), but there were no significant differences among three groups in the improvement rate (P gt; 0.05). The intervertebral space grading method proposed by Roberts et al. was adopted to evaluate the intervertebral space height (ISH), the preoperative value was 2.04 ± 0.93 in group A, 2.18 ± 0.91 in group B, and 2.11 ± 0.90 in group C, andat the final follow-up, the value was 2.64 ± 0.58 in group A, 1.05 ± 0.59 in group B, and 1.06 ± 0.42 in group C. There were significant differences among three groups in the ISH when compared the properative value with the final follow-up value (P lt; 0.05). Conclusion All of the three surgical procedures are effective for RLDP, but conventional discectomy and PLIF have more compl ications than TLIF. Conventional discectomy may result in the further narrow of the intervertebral space and the occurrence of segment instabil ity, whereas TLIF is safer, more effective, and one of the ideal methods to treat RLDP.
Objective To study the clinical application ofheterogenous bone graft combined with auto-marrow. Methods Deproteinated and degreased heterogenouscancellous bone combined with auto-marrow was used in 21 cases of anterior cervical interbody fusion. Among them, 2 cases were treated by bone graft only, and the other 19 cases were further treated by anterior plate fixation. Results The follow-up time was 12-36 months with an average of 21 months. After operation, posteroanterior and lateral radiograph of all the cases revealed that the reduction and the position of the grafting bone were good without inflammation or other complications. After 6 months of operation, the radiograph of 2 cases of cervical disk herniation, which were treated by bone graft only, showed the bones lost their height and the curve of the cervical spine returned to the state of preoperation. For the other cases, the grafting bonesremained their original figure without dislocation of the bone or fracture of the plate or the screw. The nervous function recovered variously. Before operation, 10 cases were ranked as grade A,7 cases grade C, 4 cases grade D according to Frankel classification. After operation, in grade A cases, 5 cases did not recover, 3 cases recovered to grade B, 2 cases to grade C; in grade C cases, 5 to grade D, 2 to grade E; all ofgrade D 4 cases to grade E. Conclusion Heterogenous bone combined with auto-marrow can be used as grafting material in the anterior cervical interbodyfusion, but its mechanical rigidity need to be improved or the fusion shouldbe aided with rigid internal fixation.
Objective To analyze the technical notes, effectiveness, and current issues of real-time three-dimensional CT navigation-guided full-endoscopic lumbar interbody fusion. Methods Between April 2020 and October 2021, a total of 27 patients received real-time three-dimensional CT navigation-guided full-endoscopic lumbar interbody fusion. There were 18 males and 9 females with an average age of 63.2 years (range, 48-84 years). There were 6 cases of lumbar spinal stenosis, 1 case of lumbar instability, 9 cases of lumbar spinal stenosis with instability, 3 cases of degenerative spondylolisthesis, 6 cases of isthmus spondylolisthesis, and 2 cases of recurrent lumbar disc herniation. All patients showed neurological symptoms before operation (ipsilateral symptom for 15 cases and bilateral symptom for 12 cases). The symptom duration was 1-300 months (median, 24 months). The operations were performed via transforaminal approach in 8 cases, trans-facet joint approach in 18 cases, and combined approaches in 1 case. A total of 32 levels were fused, including 23 single-level cases, 3 two-level cases, and 1 three-level case. Lumbar fusion segment was L2, 3 in 1 case, L3, 4 in 4 cases, L4, 5 in 20 cases, and L5, S1 in 7 cases. The operation time, intraoperative estimated blood loss (IEBL), and perioperative complications were recorded. The improvement of intervertebral space height at fusion level was measured, and the accuracy of percutaneous pedicle screw (PPS) and Cage placement was also evaluated based on CT images performed at 1 week postoperatively. Visual analogue scale (VAS) score for both low back pain and leg pain, Japanese Orthopaedic Association (JOA) score, and Oswestry disability index (ODI) were evaluated before operation, at 1 week postoperatively, and at last follow-up. Satisfaction to effectivenss were assessed by patients using modified MacNab criteria at last follow-up. Results The operation time was ranged from 255 to 805 minutes (mean, 424.9 minutes). IEBL was 150-290 mL (mean, 219.3 mL). All patients received follow-up with the duration from 4 to 22 months (mean, 12.4 months). At 1 week postoperatively and last follow-up, VAS scores of low back pain and leg pain, JOA score, and ODI were significantly improved when compared with those before operation (P<0.05). At last follow-up, the clinical indicators were similar in comparison with those at 1 week postoperatively (P>0.05). There were 26 patients and 1 patient who respectively ranked excellent and mild in terms of effectiveness according to the modified MacNab criteria, with the excellent and good rate of 96.3%. There was 1 patient who suffered from incomplete injury of L5 nerve root and partial neurological function recovered after 3-month conservative treatments. There were 118 implanted PPSs, and 116 of them were implanted under navigation. There were 33 Cages that were implanted under navigation. The accuracy of PPS and Cage placement was 99.1% and 97.0% respectively based on CT performed at 1 week postoperatively. The postoperative intervertebral space height was significantly increased in comparison with that before operation (P<0.05). During follow-up, mild Cage subsidence was observed in 1 patient, whereas no fixation loosing was found. Conclusion Real-time three-dimensional CT navigation-guided full-endoscopic lumbar interbody fusion has great safety and effectiveness with satisfactory preliminary clinical results. Design and further improvement of surgical equipment and instruments are expected to resolve the current technical difficulties.
ObjectiveTo analyze the restoration of intervertebral height and lordosis of fusion segment after open-transforaminal lumbar interbody fusion (Open-TLIF) and minimally invasive-TLIF (MIS-TLIF).MethodsBetween January 2013 and February 2016, patients who treated with TLIF due to lumbar degenerative diseases and met the selection criteria were selected as the study objects. Among them, 41 patients were treated with open-TLIF (Open-TLIF group), 34 patients were treated with MIS-TLIF (MIS-TLIF group). There was no significant difference between the two groups (P>0.05) in gender, age, body mass index, disease type, disease duration, pathological segment, and other general data. The intraoperative bleeding volume, hospital stay, visual analogue scale (VAS) score of waist and leg, and Oswestry disability index (ODI) were recorded before and after operation. The anterior disc height (ADH), posterior disc height (ADH), and segmental lordosis (SL) of fusion segment were measured by X-ray film before and at 6 months after operation. The differences of ADH, PDH, and SL between pre- and post-operation were calculated.ResultsThe intraoperative bleeding volume and hospital stay in Open-TLIF group were significantly higher than those in MIS-TLIF group (t=14.619, P=0.000; t=10.021, P=0.000). All incisions healed by first intention without early complications. All patients were followed up 6-24 months (mean, 12.6 months) in Open-TLIF group and 6-24 months (mean, 11.5 months) in MIS-TLIF group. The preoperative VAS scores of waist and leg and ODI of the two groups significantly improved (P<0.05). There was no significant difference in VAS scores and ODI between the two groups before operation and at 2 weeks and 6 months after operation (P>0.05). Imaging examination showed the good intervertebral fusion. There was no significant difference in ADH, PDH, and SL between the two groups before operation and at 6 months after operation (P>0.05). The differences of ADH, PDH, and SL between the two groups were not significant (P>0.05). The ADH, PDH, and SL after operation significantly increased in the two groups (P<0.05).ConclusionOpen-TLIF and MIS-TLIF show similar effectiveness and radiological change in the treatment of single lumbar degenerative diseases and the improved intervertebral height and lordosis, but MIS-TLIF can significantly reduce hospital stay and intraoperative blood loss.
Objective To compare the clinical outcomes of posterior lumbar interbody fusion（PLIF） using simple cage alone fusion with pedicle screw fixationand autogenous bone grafting and cage fusion with pedicle screw fixation in adult spondylolisthesis. Methods From March 2003 to March 2004，Twenty-seven patients with lumbar spondylolisthesis were divided in two groups. In group A, 15 patients were treated by PLIF using simple cage alone fusion with pedicle screw fixation, including 4 males and 11 females, aging 53-68 years. Isthmic defectswere located at L4 in 9 cases, at L5 in 6 cases. Four patients were smokers.Thepreoperative mean disc space height was 5.4±2.3 mm, the mean percentage of slip was 36.8％±7.2%. In group B, 12 patients were treated by PLIF using autogenous bone grafting and cage fusion with pedicle screw fixation, including 3 males and 9 females, aging 56 years. Isthmic defects were located at L4 in 8 cases, atL5 in 4 cases. Five patients were smokers. The preoperative mean disc space height was 5.7±2.5 mm, the mean percentage of slip was 37.8%±6.2%. Two groupswere compared in the amount of blood loss, duration of hospitalization, back pain, radiating pain, fusion rate, the intervertebral disc space height, the postoperative degree of slip and the fusion rate. Results All patientswere followed up for 24-38 months. The mean follow-up was 29(24-36) months in group A and26(24-38) months in group B. There were no statistically significant differences infollow-up period, age,sex, the location of isthmic defects, smoking, the preoperative disc space height and the percentage of slip between two groups (Pgt;0.05).There were no statistically significant differences in the amount of blood loss, the duration of hospitalization, the fusion time between two groups(Pgt;0.05). But there were statistically significant differences in the back pain score, the radiating pain score and the fusion rate between two groups(Plt;0.05).Thepo stoperative disc space height and the degree of slip of the last follow-up were5.8±2.2 mm and 25.6％±7.2% in group A, 6.2±2.5 mm and 24.1％±7.4 % ingroupB, showing statistically significant difference (Plt;0.05). Conclusion The PLIF using autogenous bone grafting and cage fusion with pedicle screw fixations ismore beneficial to improving the fusion rate and preventing longterm instabilities than simple cage alone fusion with pedicle screw fixation in adult spondylolisthesis.
ObjectiveTo compare the effectiveness and changes of sagittal spino-pelvic parameters between minimally invasive transforaminal lumbar interbody fusion and conventional open posterior lumbar interbody fusion in treatment of the low-degree isthmic lumbar spondylolisthesis. MethodsBetween May 2012 and May 2013, 86 patients with single segmental isthmic lumbar spondylolisthesis (Meyerding degree Ⅰ or Ⅱ) were treated by minimally invasive transforaminal lumbar interbody fusion (minimally invasive group) in 39 cases, and by open posterior lumbar interbody fusion in 47 cases (open group). There was no significant difference in gender, age, disease duration, degree of lumbar spondylolisthesis, preoperative visual analogue scale (VAS) score, and Oswestry disability index (ODI) between 2 groups (P>0.05). The following sagittal spino-pelvic parameters were compared between 2 groups before and after operation: the percentage of slipping (PS), intervertebral height, angle of slip (AS), thoracolumbar junction (TLJ), thoracic kyphosis (TK), lumbar lordosis (LL), sagittal vertical axis (SVA), spino-sacral angle (SSA), sacral slope (SS), pelvic tilt (PT), and pelvic incidence (PI). Pearson correlation analysis of the changes between pre- and post-operation was done. ResultsPrimary healing of incision was obtained in all patients of 2 groups. The postoperative hospital stay of minimally invasive group [(5.1±1.6) days] was significantly shorter than that of open group [(7.2±2.1) days] (t=2.593, P=0.017). The patients were followed up 11-20 months (mean, 15 months). The reduction rate was 68.53%±20.52% in minimally invasive group, and was 64.21%±30.21% in open group, showing no significant difference (t=0.725, P=0.093). The back and leg pain VAS scores, and ODI at 3 months after operation were significantly reduced when compared with preoperative ones (P<0.05), but no significant difference was found between 2 groups (P>0.05). The postoperative other sagittal spino-pelvic parameters were significantly improved (P<0.05) except PI (P>0.05), but there was no significant difference between 2 groups (P>0.05). The correlation analysis showed that ODI value was related to the SVA, SSA, PT, and LL (P<0.05). ConclusionBoth minimally invasive transforaminal lumbar interbody fusion and conventional open posterior lumbar interbody fusion can significantly improve the sagittal spino-pelvic parameters in the treatment of low-degree isthmic lumbar spondylolisthesis. The reconstruction of SVA, SSA, PT, and LL are related to the quality of life.
Objective To review the research progress of Modic changes and its influence on lumbar interbody fusion. Methods The domestic and foreign literature related to Modic changes and its influence on lumbar interbody fusion was extensively reviewed. The etiology of Modic changes was summarized, and the treatment measures of Modic changes on lumbar interbody fusion were discussed. Results The etiology of Modic changes is not clear, which may be related to mechanical factors, autoimmune factors, low toxic infection factors, and genetic factors. Modic changes may lead to fusion failure and cage subsidence after lumbar interbody fusion. Preoperative evaluation of endplate sclerosis, reduction of iatrogenic endplate injury, fine operating of intervertebral space, management of osteoporosis, and selection of appropriate cage can prevent or reduce fusion failure or cage subsidence. Conclusion Modic changes may lead to fusion failure and cage subsidence after lumbar interbody fusion, and active perioperative intervention of Modic changes is helpful to improve the clinical prognosis.
Objective To compare the effectiveness of unilateral biportal endoscopic transforaminal lumbar interbody fusion (UBE-TLIF) and endoscopic transforaminal lumbar interbody fusion (Endo-TLIF) in the treatment of single-segment degenerative lumbar spinal stenosis with lumbar spondylolisthesis. Methods Between November 2019 and May 2023, a total of 81 patients with single-segment degenerative lumbar spinal stenosis with lumbar spondylolisthesis who met the selection criteria were enrolled. They were randomly divided into UBE-TLIF group (39 cases) and Endo-TLIF group (42 cases). There was no significant difference in baseline data between the two groups (P>0.05), including gender, age, body mass index, surgical segment, and preoperative visual analogue scale (VAS) scores for low back and leg pain, Oswestry Disability Index (ODI), and serum markers including creatine kinase (CK) and C reactive protein (CRP). Total blood loss (TBL), intraoperative blood loss, hidden blood loss (HBL), postoperative drainage volume, and operation time were recorded and compared between the two groups. Serum markers (CK, CRP) levels were compared between the two groups at 1 day before operation and 1, 3, and 5 days after operation. Furthermore, the VAS scores for low back and leg pain, and ODI at 1 day before operation and 1 day, 3 months, 6 months, and 12 months after operation, and intervertebral fusion rate at 12 months after operation were compared between the two groups. Results All surgeries were completed successfully without occurrence of incision infection, vascular or nerve injury, epidural hematoma, dural tear, or postoperative paraplegia. The operation time in UBE-TLIF group was significantly shorter than that in Endo-TLIF group, but the intraoperative blood loss, TBL, and HBL in UBE-TLIF group were significantly more than those in Endo-TLIF group (P<0.05). There was no significant difference in postoperative drainage volume between the two groups (P>0.05). The levels of CK at 1 day and 3 days after operation and CRP at 1, 3, and 5 days after operation in UBE-TLIF group were slightly higher than those in the Endo-TLIF group (P<0.05), while there was no significant difference in the levels of CK and CPR between the two groups at other time points (P>0.05). All patients were followed up 12 months. VAS score of low back and leg pain and ODI at each time point after operation significantly improved when compared with those before operation in the two groups (P<0.05); there was no significant difference in VAS score of low back and leg pain and ODI between the two groups at each time point after operation (P>0.05). There was no significant difference in the intervertebral fusion rate between the two groups at 12 months after operation (P>0.05). ConclusionUBE-TLIF and Endo-TLIF are both effective methods for treating degenerative lumbar spinal stenosis with lumbar spondylolisthesis. However, compared to Endo-TLIF, UBE-TLIF requires further improvement in minimally invasive techniques to reduce tissue trauma and blood loss.