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- 1. Lumbar Interbody Fusion- Indications,Techniques, And Complications Dr Praveen K Tripathi 27-Jan-16 1
- 2. Introduction Spinal fusion • Theultimate goal of a fusion is the elimination of pathologic segmental motion and its accompanying symptoms • Achieved by the formation of osseous bridging across the previously mobile level. • Successful fusion is known as arthrodesis; nonunion is referred to as pseudarthrosis . • Three basic requirements for a successful fusion: ▫ Immobilization, ▫ Fusion bed, and ▫ Bone graft 27-Jan-16 2
- 3. Landmarks in theHistory of Fusion • 1911 -Albee First use of tibial graft • 1911 -Hibbs First use of Iliac crest graft • 1953 -Watkins First posterolateral fusion (bilateral transverse process fusion) • 1950- Harrington Development of instrumentation (used to treat pediatric scoliosis from polio) • 2002 -FDA approval of recombinant human bone morphogenetic protein-2 27-Jan-16 3
- 4. Indications Degenerative spondylolisthesis, isthmic spondylolisthesis, spinalstenosis, lumbar spondylosis intervertebral disc herniation. Patients with deformity, Spinal trauma, and Oncologic conditions 27-Jan-16 4
- 5. Summary of Evidence-BasedIndications for Fusion 27-Jan-16 5
- 6. Relative Contraindications forLumbar Interbody Fusion • Three level DDD (except in spinal deformity) • Single level disc disease causing radiculopathy w/o symptoms of mechanical low-back pain or instability • Severe osteoporosis (possible subsidence of interbody grafts through the end plates) 27-Jan-16 6
- 7. Types of SpinalFusion •Interbody Fusion •Posterolateral Fusion Types of fusion are 27-Jan-16 7
- 8. Interbody Fusion (IF) •Removal of the intervertebral disc (discectomy) and replacement with a bone graft and/or a device (spacer or cage) to maintain alignment and disc height. • The devices usually contain bone graft material which facilitates fusion. 27-Jan-16 8
- 9. Approaches Interbody Fusion Anteriorapproach Anterior lumbar interbody fusion (ALIF) Transpsoas lumbar interbody fusion (DLIF/direct or XLIF/eXtreme) Oblique lumbar interbody fusion (OLIF) Posterior approach Posterior lumbar interbody fusion (PLIF) Midline LIF (MidLIF or MLIF) • “open” TLIF • minimally invasive techniques (MasTLIF or MisTLIF) Transforaminal lumbar interbody fusion (TLIF) 27-Jan-16 9
- 10. Posterolateral fusion (PLF) •Posterolateral fusion places the bone graft between the transverse processes 27-Jan-16 10
- 11. Fusion for DDD-goals Interbodytechniques • Remove pain generator • Large surface area for fusion where majority of spinal load bearing occur ▫ 90% of the surface area ▫ 80% of the load • Compressive force through graft • Correction coronal and sagittal alignment 27-Jan-16 11
- 12. Anterior Techniques Anterior lumbarinterbody fusion (ALIF): disc is approached from an anterior (abdominal) incision. Advantage - avoidance of cutting muscles of the back. Disadvantage is the risk of injury to structures in the abdomen. 27-Jan-16 12
- 13. Indications -Anterior lumbarinterbody fusion Degenerative disc disease with or without radiculopathy Spondylolisthesis Failed posterior fusion Scoliosis 27-Jan-16 13
- 14. Criteria -associated witha good outcome after ALIF (1) Axial back pain aggravated by spinal loading and fusion, (2) Radiographic studies consistent with disc degeneration, (3) Provocative discography that produces pain only at the affected levels, and (4) Dynamic studies demonstrating motion/sagittal deformity on sagittal views. 27-Jan-16 14
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- 19. 80% Anterior 20% Posterior The 80-20 ruleof Spine loading Biomechanics RATIONALE FOR ALIF 27-Jan-16 19
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- 21. • With ALIF,an interbody fusion device is used to redistribute the weight-bearing distribution to the original ratio. • According to the Woolf law, the fusion potential increases if grafts are placed under the direct compression that supports the placement of the graft in the anterior column. Mummaneni PV, Haid RW, Rodts GE. Lumbar interbody fusion: state-of the-art technical advances. J Neurosurg Spine. 2004;1(1):24-30. RATIONALE FOR ALIF 27-Jan-16 21
- 22. • Radiological outcomes,including height restoration and focal and lumbar lordosis, were superior in anterior approach, whereas cost, blood loss, and operative time were greater in ALIF compared with transforaminal lumbar interbody fusion. Jiang SD, Chen JW, Jiang LS. Which procedure is better for lumbar interbody fusion: anterior lumbar interbody fusion or transforaminal lumbar interbody fusion? Archives of Orthopaedic and Trauma Surgery. 2012;132(9):1259-1266. RATIONALE FOR ALIF 27-Jan-16 22
- 23. Anterior lumbar interbodyfusion (ALIF) (A) ALIF interbody device with integral fixation. (B) ALIF implant with anterior plate fixation. (C) ALIF implant with posterior instrumentation. 27-Jan-16 23
- 24. Lateral lumbar interbodyfusion (LLIF) • Transpsoas lumbar interbody fusion (DLIF/direct or XLIF/eXtreme): the disc is approached through the psoas muscle, from an extreme lateral incision (retroperitoneal) on the patient’s side. • The advantage is the avoidance of back muscles and abdominal structures required in traditional fusion procedures. • The disadvantage is that L5-S1 is not accessible with this procedure 27-Jan-16 24
- 25. Indications and Contraindications-lateral lumbar interbody fusion (LLIF) • LLIF is most suitable for interbody access from L2 to L4 for degenerative disc disease with or without instability • Adjacent segmental disease • Degenerative spondylolisthesis (grade I or II) • Complex degenerative scoliotic deformity contraindications • LLIF at L5-S1 is generally contraindicated due to obstruction by the iliac wing. • Other relative contraindications include grade III or greater degenerative spondylolisthesis, greater than 30-degree lumbar deformities • Bilateral retroperitoneal scarring • LLIF is generally not used alone when direct posterior decompression is necessary, such as with lumbar stenosis or disc rupture 27-Jan-16 25
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- 27. Oblique lumbar interbodyfusion (OLIF): • Oblique lumbar interbody fusion (OLIF): the disc is approached from a lateral incision on the patient’s side. • The procedure is done "obliquely" (in front of the iliac crest) which gives access to L5-S1 27-Jan-16 27
- 28. Anterior Approaches -Contraindications ALIF - Contraindications • Calcified aorta • Prior vascular reconstructive surgery • Prior intra-abdominal or retroperitoneal surgery • History of severe pelvic inflammatory disease • Prior anterior spinal surgery Transpsoas -Contraindications • At L5/S1 and sometimes at L4/5 because of obstruction from iliac crest • Prior retroperitoneal surgery or scarring 27-Jan-16 28
- 29. Advantages of OLIFthan direct anterior approach • Anterior to psoas muscle-avoids injury to psoas muscle and lumbar plexus there by less incidence of cruralgia • Away from peritoneum and vasculature ( beware of ileolumbar vein and transitional bifircation of great vessels) • Preserves sympathetic plexus- decreased incidence of retrograde ejaculation 27-Jan-16 29
- 30. Advantages of OLIF.... •Direct visualisation and discectomy, easy to do end plate preparation • Can be performed L2-L3 to L4-L5 • Upto 3 level fusion can be done using 4 cm incion by “sliding window” technique Rodgers WB, Gerber EJ, Patterson J. Intraoperative and early postoperative complications in extreme lateral interbody fusion: an analysis of 600 cases. Spine (Phila Pa 1976) 2011;36:26-32. 27-Jan-16 30
- 31. Advantages of OLIF •Lesser incidence of hernias and ileus • Decreased blood loss • Increased surface area of the OLIF cage which is 3 times more than TLIF cage gives better and strong arthodesis 27-Jan-16 31
- 32. Advantages of anteriorapproach • nerve root retraction and entrance into the spinal canal are unnecessary, thereby eliminating epidural scarring and perineural fibrosis Chung SK, Lee SH, Lim SR, et al. Comparative study of laparoscopic L5-S1 fusion versus open mini-ALIF, with a minimum 2-year follow-up. Eur Spine J. 2003;12 (6):613-617 27-Jan-16 32
- 33. Advantages Anterior Approaches •Larger graft placement without manipulation of nerve roots • Deformity correction • Indirect decompression • Greater fusion surface area 27-Jan-16 33
- 34. Advantages Anterior Approaches •Preservation of posterior stabilizing structures ▫ Interspinous ligaments ▫ Facet capsules • No muscle disruption & Postop muscle atrophy ▫ Chronic pain 27-Jan-16 34
- 35. ALIF - Complications •Retrograde ejaculation ▫ Most series < 1% to 7% ▫ Much higher (10 times) with transperitoneal approaches and with laparoscopic approaches • Blunt dissection versus electrocautery • Large majority of patients recover within 6 – 12 months • Bowel & Ureter injury 27-Jan-16 35
- 36. Extreme Lateral -Complications • Reporting of complications has been inconsistent 3% - 60%) • Genitofemoral, ilioinguinal or lateral femoral cutaneous nerve injuries -Thigh numbness, paresthesias • Femoral nerve -Leg weakness • Damage to lumbosacral plexus which progressively migrates anteriorly beginning at L1/2 level • Psoas muscle injury and pain • Traction injury to plexus postop dysesthesias 27-Jan-16 36
- 37. Posterior Lumbar InterbodyFusion (PLIF) • The first successful report of a posterior lumbar interbody fusion (PLIF) dates to 1940 by Cloward Indications • Recurrent disc herniation • Failed back surgery syndrome • Spondylolisthesis • Bilateral midline disc herniation • Segmental instability • Degenerative disc disease 27-Jan-16 37
- 38. Posterior Lumbar InterbodyFusion (PLIF) Contraindications to performing PLIF include • Osteoporosis, • Discitis, • Subchondral sclerosis, and • Adhesive arachnoiditis. 27-Jan-16 38
- 39. The classic PLIFtechnique consists of three surgical steps: (1) Laminectomy or laminotomy with partial or complete facetectomy, (2) Removal of the intervertebral disc, and (3) Fusion Posterior interbody techniques (PLIF) 27-Jan-16 39
- 40. Posterior interbody techniques(PLIF) 27-Jan-16 40
- 41. Posterior interbody techniques(PLIF) A, The nerve root and dural sac are retracted medially, creating maximal exposure of the interbody space. B, The interbody device is inserted bilaterally and packed with bone for maximal fusion. C, A pedicle screw is used to distract the disc space. The trajectory and depth of the screw are important for successful fusion. D, Next, using either a screw or a rod construct, the final arthrodesis is reinforced until biologic fusion is achieved. 27-Jan-16 41
- 42. Complications of PLIF PLIFis a technically challenging and demanding procedure and consequently is associated with complications. • Nerve root injury ▫ The nerve root that exits at the level above the disc space often lies near the interbody graft as it is being placed and can easily be injured. • Incidental durotomy • Wrong -level surgery, • Adjacent-level disease, • Graft retropulsion, and pseudarthrosis in the case of instrumentation with PLIF. 27-Jan-16 42
- 43. Lumbar – TransforaminalLumbar Interbody Fusion (TLIF) • Transforaminal lumbar interbody fusion (TLIF) reestablishes anterior column support while allowing for posterior fixation, thereby imparting improved fusion rates because of circumferential support. 27-Jan-16 43
- 44. Lumbar – TransforaminalLumbar Interbody Fusion (TLIF) Indications • Degenerative disc disease, • Low-grade spondylolisthesis • Synovial cysts (when fusion is required) • Multiply recurrent disc herniations, and foraminal stenosis associated with deformity. • TLIF is ideal for grade I or II spondylolisthesis with unilateral symptoms. Contraindicated in • Complete disc desiccation • Presence of extensive osteophytes- limits disc distraction. • Extensive scarring from prior posterior surgery serves as a relative contraindication. 27-Jan-16 44
- 45. TLIF utilizes animagined quadrangular space between the transverse processes of the vertebral bodies adjacent to the affected disc space and the traversing nerve root medially Lumbar – Transforaminal Lumbar Interbody Fusion (TLIF) 27-Jan-16 45
- 46. Lumbar – TransforaminalLumbar Interbody Fusion (TLIF) • TLIF is performed to remove a portion of a disc that is the source of back or leg pain. • Bone graft is used to fuse the spinal vertebrae after the disc is removed. • However, the TLIF procedure places a single bone graft between the vertebrae from the side, rather than two bone grafts from the rear as in the PLIF procedure. 27-Jan-16 46
- 47. Lumbar – TransforaminalLumbar Interbody Fusion (TLIF) Decompression Removing the facet joint and disc relieves pressure on the compressed spinal nerve, allowing it to return to the proper position. 27-Jan-16 47
- 48. Lumbar – TransforaminalLumbar Interbody Fusion (TLIF) Graft Placement A single bone graft is placed in the disc space from the lateral Preparing for Fusion a motorized instrument is used to remove the top (cortical) layer of the transverse processes 27-Jan-16 48
- 49. Lumbar – TransforaminalLumbar Interbody Fusion (TLIF) The rod and screw instrumentation provides stability to the spine Bone Graft Bone grafting can be done with pieces of a patient’s own bone (autograft), processed bone from a bone bank (allograft), or a bone graft substitute (demineralized bone,ceramic extender, or bonemorphogenetic protein). 27-Jan-16 49
- 50. Complications -TLIF • Themost frequent include blood loss requiring transfusion • Lumbar wound infection • Postoperative radiculitis, • Cage subsidence or extrusion, and pseudoarthrosis 27-Jan-16 50
- 51. Posterior interbody techniques (PLIFTLIF) - Problems • Limited window to disc space • Thecal sac/nerve root retraction ▫ Weakness (2-7%) ▫ Postop neuralgia (5%) ▫ Dural tears (5-20%) 27-Jan-16 51
- 52. Posterior interbody techniques(PLIF TLIF) • Problems • Graft size vs. nerve root injury vs endplate fracture • Suboptimal restoration of disc height and surface area for fusion • Poor visualization of disc space/endplates • Limited endplate preparation for fusion • Endplate damage/fractures graft subsidence • Time • Blood loss 27-Jan-16 52
- 53. TLIF- advantages • TLIFobviates the morbidity from the retroperitoneal dissection and subsequent posterior fixation required from anterior lumbar interbody fusion (ALIF). • Unlike PLIF, TLIF requires minimal to no retraction on the thecal sac and nerve roots while still providing 360 degrees of support. • Because TLIF utilizes a more lateral trajectory, it can be performed in the setting of previous surgery with identifiable landmarks and a cleaner plane of dissection. • The average length of stay for both minimally invasive and open TLIF ranged between 3 and 6 days 27-Jan-16 53
- 54. Posterolateral fusion (PLF) •Posterolateral fusion places the bone graft between the transverse processes (the bony protuberances on the vertebrae) rather than the intervertebral disc space, which is left intact. • The approach is through a posterior (back) incision, and a laminectomy is typically required to gain access. • PLF is usually accompanied by fixation. 27-Jan-16 54
- 55. Posterolateral fusion (PLF) The landmarksused for cannulating the pedicles are the meeting point of the pars interarticularis, the superior articulating process, and the transverse process 27-Jan-16 55
- 56. Complications open posteriorlumbar fusion • Mortality rates have been found to be 0.15% to 0.29%. • The most common preventable cause of death- analgesia overuse Short term complications • Surgical site infections, are among the most common. • Incidental durotomy causing a cerebrospinal fluid leak, • Spinal epidural hematoma, • Cauda equina syndrome, • Neurologic injury, • Rhabdomyolysis, and sudden vision loss Long-term complications • Pseudarthrosis, • Chronic pain from the donor allograft site. 27-Jan-16 56
- 57. Advantages of LumbarInterbody Fusion Compared with Posterolateral Fusion • Interbody grafts are compressed by 80% of spinal loads, whereas posterolateral grafts are compressed by 20% • Interbody grafts occupy 90% of intervertebral surface area, whereas posterolateral grafts occupy only 10%. • The interbody space is more vascular than the posterolateral space, increasing chances for fusion. • Interbody grafts can better restore coronal and sagittal balance. 27-Jan-16 57
- 58. OLIF cage TLIF/PLIFcage 27-Jan-16 58
- 59. Cost of LumbarSpine Surgery in India 27-Jan-16 59
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- 61. Post op • VAS-1 Restoration of disc space height 27-Jan-16 61
- 62. Key points….. • Bothanterior and posterior approaches for interbody fusion are associated with good fusion rates and outcomes in patients with symptomatic lumbar degenerative disease. • Anterior approaches allow better access to and visualization of the disc and endplates which facilitate: ▫ More complete discectomy ▫ Larger surface area for fusion ▫ Better endplate preparation ▫ Larger graft placement for disc height restoration and lordosis • With a good access surgical team, the complications associated with ALIF are minimal • Extreme lateral interbody fusion is a relatively new procedure. As surgeons become more proficient in the operation and as surgical technique is refined, sensory dysesthesias and psoas trauma associated with the procedure are becoming less prevalent. 27-Jan-16 62
- 63. • OLIF isa minimally invasive fusion procedure • Lesser complication rate when compared to ALIF • Longterm follow up (5 and half years)of patients with OLIF showed similar outcome as that ALIF with lesser morbidity Saraph V, Lerch C, Walochnik N, Bach CM, Krismer M, Wimmer C. Comparison of conventional versus minimally invasive extraperitoneal approach for anterior lumbar interbody fusion. Eur Spine J 2004;13:425-31. Key points….. 27-Jan-16 63
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