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We’re passionate about
• Putting patients first
• Quality, safety and patient experience
• Transforming services to meet the health needs of future generations
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Missed Screw Technique for
Lumbar Fusion
Shoaib Khan
Mr Bhatia
Mr Krishna
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Opening of the Stockton and Darlington RailwayPainting in 1880’s, crowds are watching the inaugural train cross the Skerne Bridge in Darlington.
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Congreve Matchbox (1827)First Friction match developed by John Walker
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Lumbar Spine Disease
• Major public health concern
• Leading cause of disability
• Middle-age working population
• Multiple avenues of treatment
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Lumbar Spine Disease
• Degenerative disc disorders
• Secondary changes: Stenosis, Spondylolisthesis, Facet joint OA
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Conservative Measures
• Analgesia
• Exercise
• Education
• Physiotherapy
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Lumbar Spine Disease
• Surgical treatment stabilization/fusion
• The primary goal of treatment is pain relief and improve function
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History of Procedure
• Lumbar Fusion: 7 decades
• Symptomatic Lumbar Spine disease
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History of PLIF• 1944, Briggs and Milligan : Laminectomy
• 1946, Jaslow: Spinous Process
• 1953, Cloward: Iliac Crest Autograft
• 1961, Humphreys: Ant lumbar plate
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History of PLIF
• 1990’s Interbody Implants and Instruments
• Presently: Synthetic Cages/ Premilled Allograft
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Evolution of Technique
• Augmentation with Pedicle Screws
• Stability of Construct
• Increased Fusion rate
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History of TLIF
• 1982, Harms and Rolinger• Transforaminal route• Less retraction on thecal sac and nerves• Spares contralateral lamina, facet and pars• Safe for revision cases b/c of its PL trajectory
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Indications• Spinal Instability• Spinal Stenosis• Spondylolisthesis• Degenerative scoliosis• Discogenic low back pain• Recurrent Lumbar Disc Herniation • Postdiscectomy collapse with neuroforaminal
stenosis• Pseudoarthrosis
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Techniques
• ALIF• PLIF• TLIF• PLF• Circumferential fusion
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Biomechanics
• High fusion potential : Grafts are placed under compression
• Interbody fusions place the bone graft in the load-bearing position spinal columns
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Spinal Loads and Articular Surface in Lumbar Spine
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• Pedicle screw-rod constructs increase biomechanical rigidity and decrease pseudoarthrosis rates
• Interbody fusion devices: Restore intervertebral height and segmental lordosis
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Interbody fusion PL fusion
Interbody Grafts Compression
80% 20%
Intervertebral surface area
90% 10%
Vascularity More Less
Sagittal Balance Better Less Better
Interbody vs PL fusion
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Relative Contraindications
• Three Level DDD
• Single level disc disease causing radiculopathy without back pain/instability
• Severe osteporosis
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Interbody Grafts
• Autologous Illiac crest graft• Structural Allograft• Metallic cages with bone chips• Titanium Mesh Cages• Carbon Fiber Cages• PEEK cages
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Interbody Cages
• Provide stability, fills the disc space, require less structural bone graft
• Maintain spinal alignment, neuroforaminal height, prevent graft dislodgement and collapse, enhance fusion rates
• Carriers for osteoinductive or osteoconductive materials
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PLIF Technique
• Laminectomy and Facetectomy
• Reveals rostral exiting and caudal traversing nerve roots and disk spaces
• Thecal sac and nerve roots retracted medially
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PLIF Technique
• Discectomy
• Interbody graft placement
• Pedicle screw-rod compression: restore lumbar lordosis and maintain disk height
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PLIF Technique
• Risks of incidental durotomy/nerve injury• Cages : Postoperative Radiculopathy• Bilateral facetectomy to achieve adequate graft
placement• Postoperative Instability and failure if pedicle
screw instrumentation is not added
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TLIF Technique
• Unilateral laminotomy and complete facetectomy on the symptomatic side or bilaterally
• Full laminectomy and contralateral foraminotomy
• Discectomy
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TLIF Technique
• Posterior bony lips of the end plates may be removed
• Interbody graft placement
• Pedicle screw-rod compression: restore lumbar
lordosis and maintain disk height
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PLIF and TLIF ApproachBottom :TLIF
PL Appraoch for TLIF
Posterior Approach for PLIF
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Graft Placement
PL for TLIF
Posterior for PLIF
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PLIF Outcome
• Good outcome in properly selected pt
• Fusion rates: 85%
• Comparison of low back fusion techniques: TLIF and PLIF approaches
• Chad D. Cole Todd D. McCall Meic H. Schmidt .Andrew T. Dailey
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TLIF Fusion Rate
• Single-level TLIF: More than 90%
• Multilevel procedure: Less than 90%
• Villavicencio AT, Burneikiene S, Bulsara KR, et al: Perioperative complications in transforaminal lumbar interbody fusion versus anterior-posterior reconstruction for lumbar disc degeneration and instability. J Spinal Disord Tech 2006
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TLIF vs PLIF
STUDIES HAVE SHOWN THAT THE THERE IS NO STATISTICAL DIFFERENCE IN THE
FUSION RATES OF TLIF Vs PLIF
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• Zhang, Qunhu et al. “A Comparison of Posterior Lumbar Interbody Fusion and Transforaminal Lumbar Interbody Fusion: A Literature Review and Meta-Analysis.”BMC Musculoskeletal Disorders 15 (2014): 367. PMC. Web. 22 Oct. 2015
• Park JS, Kim YB, Hong HJ, Hwang SN. Comparison between posterior and transforaminal approaches for lumbar interbody fusion. J Korean Neurosurg Soc.2005;37:340–344.
• Yan DL, Li J, Gao LB, Soo CL. Comparative study on two different methods of lumbar interbody fusion with pedicle screw fixation for the treatment of spondylolisthesis. Zhonghua Wai Ke Za Zhi. 2008;467:497–500.
• Zhuo X, Hu J, Li B, Sun H, Chen Y, Hu Z. Comparative study of treating recurrent lumbar disc protrusion by three different surgical procedures. Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi. 2009;23:1422–1426.
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PLIF Complications
• Transient/ Permanent Nerve Injury• Graft Displacement• Intervertebral space collapse with
neuroforaminal stenosis • Loosening• Subsidence• Pseudoarthrosis
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TLIF Complications
• Pedicle screw misplacement• Transient Neurological deficit• Dural/Neural injury• Graft extrusion
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Other Complications
• Blood loss• Durotomy• Arachnoiditis • Wound infection• Delayed wound healing• Haematoma• Screw misplacement
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Other Complications
• Intraoperative pedicle fracture• Urinary retention• Pulmonary embolism• Seroma• Epidural fibrosis/scar
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Our Study
• Rate of interbody fusion using PLIF/TLIF with a missed screw technique.
• Fusion was performed at two levels with no intervening screw at the middle pedicle
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Methods
• Retrospective radiological analysis
• Fusion at 2 levels with missed screw technique
• Radiographs were assessed independently by Radiologist and Spinal Surgeon
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Assessment Criteria
• Brantigan-Steffee fusion:
-Denser and more mature bone fusion area than originally achieved at surgery
-No interspace between the cage and the vertebral body
-Mature bony trabeculae bridging the fusion area.
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Demographics
• Total No: 40• Males: 24• Females: 16 • Avg Age: 44.7 years• Time period: 3 years & 6 months• Mean Follow up: 19.8 months
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Cages Used
CARBON FIBER CAGES PEEK CAGES
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Results
• Fusion achieved (assessed by Independent Observer)
• 29 patients (76%) at both levels• 3 patients (7%) at one level • No definite fusion was observed in the remaining
6 patients (15%)• 2 excluded from study- inadequate follow up.
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• 57 yr old female
• Back pain &
radiculopathy
• L3/4 Spondy
Spondy L3/4Disc DegenerationReduced Disc Height
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• MRI L Spine• Disc Degeneration
L3/4,4/5,L5/S1• Minor Disc bulge
L4/5
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• 2 level fusion
• Spondy reduced
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• 44 yr old male
• Chronic Back Pain
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• MRI L Spine• Modic changes
L4/5, L5/S1• Disc bulges
L4/5, L5/S1
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• 2 level fusion
• Disc heights maintained
• Lordosis restored
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• 64 yr old female
• Chronic Back Pain
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• 2 level fusion
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Conclusion
Fusion can be achieved without middle pedicle screw while performing PLIF/TLIF
at two levels
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THANKS VERY MUCH
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UNIVERSITY HOSPITAL OF NORTH TEES