1. 2010.9.30 AOSpine Advance Course Yokohama 2010 Indications and techniques of PLIF & TLIF Okayama University Masato Tanaka

3. 1. History of PLIF & TLIF Tibial grafts between spinal processes for Tb 1911 Hibbs (NY) Local dorsal spinous processes for Tb spine Posterior fusion Bony union rate 20% 1911 Albee (NY)

4. 1. History of PLIF & TLIF 1925 Campbell (Memphis) Concept of PLF 1963 Roy-Camille (Paris) Pedicle screw Bony union rate 80-90% Bony union rate 90-95%

5. 1. History of PLIF & TLIF Popularized TLIF (Transforaminal Lumbar Interbody Fusion) 1943 Cloward (USA) First performer of PLIF (Posterior Lumbar Interbody Fusion) 1985 Harms (Germany) Bony union rate 95-98%, Good reduction & maintain

6. 2. Indication of PLIF & TLIF

7. 2. Indication of PLIF & TLIF DDD lumbago, massive extrusion, insta. Satoh 2006 J Spinal Disord Tech Spinal stenosis (<1/2 resect of facet, recurrent) Foraminal stenosis (TLIF) Spinal instability 3mm slip, translation, 10 deg . ang. Kanemura 2009 J Spinal Disord Tech Deg. spondylolisthesis especially high grade Spondy. spondylolisthesis Degenerative scoliosis Arthritis & Arthroplasty (Saunders 2010) AAOS Instructional Course Lecture 2009-10

8. 2010.9.30 AOSpine Advance Course Yokohama 2010 Indication of PLIF & TLIF Decompression will result in short time pain relief . Decompression and stabilization is recommended. Choice of technique is at the discretion of surgeon. Surgery for degenerative spondylolisthesis There is no clear consensus. Most studies suggest surgery do better with fusion . Fusion is more robust and solid with instrumentation . ? Collapsed disc and no motion, osteoporotic bone

9. Do we need fusion or instrument? 1. Decompression without fusion (Mardjetko Spine 1994) Total No. Satisfactory Unsatisfactory Progressive slip 216 140 ( 69%) 75 (31%) 67 ( 31% ) 2. Decompression with noninstrumented fusion Total No. Satisfactory Unsatisfactory Fusion 74 67 ( 90%) 7 (10%) 64 ( 86% )

10. Do we need fusion or instrument? NASS guideline (Watter Spine J 2009) Surgical decompression with fusion is recommended for the treatment of patients with symptomatic spinal stenosis and degenerative lumbar spondylolisthesis to improve clinical outcomes compared with decompression alone. (Grade B) The addition of instrumentation is recommended to improve fusion rates , … The addition of instrumentation is not recommended to improve clinical outcomes ,…(Grade B)

11. Do we need PLIF or TLIF? NASS guideline (Watter Spine J 2009) Q #17 How do outcomes of decompression with posterolateral fusion compare with those for 360 fusion ? A #17 Because of the paucity of literature addressing this question, the work group was unable to generate a recommendation to answer Q #18 What is the role of reduction with fusion in the treatment of degenerative lumbar spondylolisthesis? A #18 Reduction with fusion and internal fixation of patients with low-grade degenerative lumbar spondylolisthesis is not recommended to improve clinical outcomes. (Grade I)

12. Contraindication of PLIF & TLIF Arthritis & Arthroplasty (Saunders 2010) AAOS Instructional Course Lecture 2009-10 Contraindication L2/3 level and more cranial segments (for PLIF) Retract of conus medullaris Severe dural adhesion Possibility of dural tear, so ALIF is better Spinal infection Risk of contamination Narrow disc space and kyphotic deformity ALIF is better for this condition

13. 3. Anatomy of lumbar spine 2010.9.30 AOSpine Advance Course Yokohama 2010

14. Anatomy of back muscle Latissimus dorsi ( 広背筋 ) Thoracolumbar fascia ( 腰背筋膜 ) Trapezium ( 僧帽筋 ) 1.Spinalis ( 棘筋 ) 2.Mutlifundus ( 多裂筋 ) 3.Longissimus ( 最長筋 ) 4.Iliocostalis ( 腸肋筋 ) Erector spinae ( 脊柱起立筋 )

15. 1.Spinalis ( 棘筋 ) 3.Longissimus throcis( 最長筋 ) 4.Iliocostalis ( 腸肋筋 ) Quadratus lumborum ( 腰方形筋 ) Iliopsoas ( 腸腰筋 ) 3.Longissimus throcis ( 最長筋 ) 2.Multifunds ( 多裂筋 ) Intertransversarii lumborum ( 横突起間筋 ) Anatomy of back muscle 2.Multifunds ( 多裂筋 ) Wiltse approach

16. Anatomy of thoracic & lumbar artery

17. Anatomy of thoracic and lumbar vein

18. Posterior branch facet, back muscle Anterior branch So called spinal nerve In facet joint, sensory nerves come from up and down. Anatomy of lumbar nerve

19. Spinous process T11 Anatomy of thoracolumbar vertebrae

20. 4. Technique of PLIF & TLIF 2010.9.30 AOSpine Advance Course Yokohama 2010

21. Positioning of the patient Hall frame Position of pads reduce abdominal pressure Do not compress femoral veins eyeballs Do not hyperextend the neck concomitant cervical myelopathy

22. Posterior approach 1. Muscle dissection

23. Posterior approach 2. Bleeding points

24. Roy-Camille method : medial of accessory process Weinstein method : just accessory process Margel method : base of the transverse process 3. Pedicle screw insertion

25. Magerl method 1984 The direction of Schanz screw is 10-20 deg. convergent The vertical line touches the lateral border of the superior articular process. The horizontal line bisects the base of the transverse process. （ Magerl F P, Clin Orthop 1984) Percutaneous

26. Axial Sagittal （ Zindrick M R, Spine 1987) Angulation of pedicles L5 30 deg. L3 15 deg. L4 20 deg. L1,2 10 deg. Almost horizontal

28. S1 pedicle screw 1. Superior & lateral of S1foramen 2. Just below L5 inferior articular process 3. Aim promontrium 4. Bicortical 5. Use special awl with stopper

29. Anterior aspect of sacrum Common iliac vessels are located laterally. Central portion is safer.

30. Strength of S1 pedicle screw Method Strength Monocortical purchase - Bicortical purchase 1.1-1.5 times (Zhu et al. Spine 2000) S1 endplate 1.6 times (Lehman et al. Spine 2002) Tricortical screw 2 times (Luk et al. Spine 2005) Bicortical Tricortical

31. PLIF vs TLIF PLIF has problems of distracting neural tissue 1. Nerve root or cauda equina injury 19% (Turner 1994) 2. Dural tear 10% (Ray 1997)

32. PLIF technique Laminectomy 1. Complete decompression of nerve roots are performed. 2. Medial facetectomy is recommended. Diskectomy 1. Epidural vessels are coagulated. 2. Rectangular curette and special shavers are useful.

33. PLIF technique PEEK (Synthes) Carbon (Depuy) Titanium (Medtronic) Bone graft & interbody cage 1. Vertebral spreader is used to widen the disk space. 2. Do not retract dural beyond midline of the spine. 3. Two cage is better results?.

34. Which is better for PLIF, one cage or two cages? 46 patients with degenerative lumbar spinal disease Single-level instrumented PLIF surgery using 1 (n 22) or 2 (n 24) Follow-up period was more than 7 years. Segmental stability, change in segmental height, foramen height, and segmental lordosis did not differ significantly between the 2 groups. Implantation of a single titanium closed-box cage in an instrumented PLIF seems to be adequate in case of degenerative lumbar disease. Kroppenstedt 2008 Spine

35. TLIF technique Unilateral facetectomy 1. Spinal canal is entered through facetectomy on the side of radiculopathy 2. Distract the contralateral side or special distractor 3. Remove the facet and identify L5 root inferiorly and L4 root superiorly

36. TLIF technique Total diskectomy & end plate preparation 1. Total disc resection using special curettes and angled pituitary forceps under image intensifier 2. Marginal resection of the dorsal edges of the end plates

37. TLIF technique Bone graft and cage insertion under image intensifier 1. Intervertebral bone graft using local bone, allograft or iliac bone 2. Insert beans type or rectangular cage under image intensifier

38. TLIF technique Final assembly of rod-screw system 1. The construct is compressed to establish an optimal cage bone interface and to reestablish lumbar lordosis 2. The rod-screw system is tightened and cross-linked 3. Perform PLF if needed

39. Three methods of TLIF technique One rectangular cage Two rectangular cage (Taneichi method) Beans type cage

40. Thank you for your attention