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Conventional Posterior Lumbar Interbody Fusion versus Mini-open Posterior Lumbar Interbody Fusion using the New Percutaneously Inserted

Spinal Transpedicular Screwing System

1Hurisarang Hospital, Department of Neurosurgery, Daejeon, Republic of Korea

2Mokpo Hankook Hospital, Department of Neurosurgery, Mokpo, Republic of Korea

3Korea Hospital, Department of Orthopedic Surgery, Jeonju, Republic of Korea

4College of Medicine, Chosun University, Department of Neurosurgery, Kwangju, Korea, Republic of

1Hurisarang Hospital, Department of Neurosurgery, Daejeon, Republic of Korea

2Mokpo Hankook Hospital, Department of Neurosurgery, Mokpo, Republic of Korea

3Korea Hospital, Department of Orthopedic Surgery, Jeonju, Republic of Korea

4College of Medicine, Chosun University, Department of Neurosurgery, Kwangju, Korea, Republic of

Hyeun Sung Kim([email protected])1

S.K. Park2, H. Joy2, I.H. Park2, J.K. Ryu2K.H. Park3

C.I. Ju4, S.W. Kim4, S.M. Lee4, H. Shin4


Historical ReviewDisadvantages of posterior fusion

– large skin incisions

– extensive muscle dissection

– trauma to the lumbar musculoligamentous complex

– long operation time

– significant blood loss

– significant postoperative pain

– postoperative paraspinal muscle denervation

Goals of Mini-open Posterior Decompression & Fusion => To reduce the approach-related morbidity associated with traditional lumbar fusion

– minimal skin incision and anatomic dissection

– minimal operation time

– minimal blood loss & minimal transfusion

– minimal postoperative pain

– minimal hospital stay period

– better cosmetic benefits

Hyeun Sung Kim ([email protected], www.ilovespine.com)


Material and Methods

Period : January 2004 to February 2007

Materials

Group A Group B

Mean Age (years) 56.3 (34 – 73) 59.1 (23 – 78)

Number 86 145

Men follow-up period (months) 23.7 (6 – 43) 25.3 (6 - 43)

Cases of fusion level

1 level 73 117

2 level 11 22

3 level 4 6

Groups

Group A (n=86) Microscopic conventional PLIF + open transpedicular screw fixation

Group B (n=145) Microscopic Modified mini-open PLIF + percutaneous transpedicular screw fixation



Methods : Device

Newly designed percutaneous transpedicular screw fixation system

Name Apollon System

Manufactured by Solco medical, South Korea

Characteristics Detachable screw extender system Easy to rod manipulationCan use thoracolumbar area percutaneouslyCan use multi-level screwing

vertical axis Easier to achieve compression and distraction

Threaded screw joint Firm and secure fixation

Rimmed screw head Decrease screw head loosening

One-touch rod locking system Easy & quick operation

Unique alignment guidePoly-axial screw heads

Easy to rod insertion



Methods : Operation Methods

Apollon System Application

Total Foraminal Decompression

Spine Classics MLD



Modified midline total decompressed Mini-open PLIF techniqueModified midline total decompressed Mini-open PLIF technique

Methods : Operation Methods



Methods : Low Back Outcome ScaleThe Low-Back Outcome Scale of Greenough and Fraser

Parameter Finding Points

Parameter

Finding Points

Current pain 7 to 10 cm VAS 0 Sex life Severely affected impossible 0

5 to 6 cm VAS 3 Moderately affected difficult 2

3 to 4 cm VAS 6 Mildly affected 4

O to 2 cm VAS 9 Unaffected 6

employment Unemployed because of back pain 0 Sleeping Severely affected impossible 0

Part time 3 Moderately affected difficult 1

Full time lighter 6 Mildly affected 2

Full time original 9 Unaffected 3

Domesticchores odd

jobs

None 0 Walking Severely affected impossible 0

A few but not many 3 Moderately affected difficult 1

Most or all but more slowly 6 Mildly affected 2

normally 9 unaffected 3

Sport or activesocial activities

None 0 Sitting Severely affected impossible 0

Some but much less than before 3 Moderately affected difficult 1

Back to previous level 9 Mildly affected 2

resting Resting more than half the day 0 unaffected 3

Little rest needed occasional 4 Travelling Severely affected impossible 0

No need rest 6 Moderately affected difficult 1

Treatment orconsultation

More than once per month 0 Mildly affected 2

About once per month 2 unaffected 3

Rarely 4 Dressing Severely affected impossible 0

Never 6 Moderately affected difficult 1

Analgesia Several times each day 0 Mildly affected 2

unaffected 3Almost every day 2

Occasionally 4

Total 75Never 6

Score Status

>= 65 Excellent

50 – 64 good

30 – 49 Fair

0 - 29 poor



Results

Results

Group A(n=86) Group B(n=145)

Mean Surgical Time (minutes) 163.7 (120-280) 142.6 (100-240)

Blood loss (ml) 753 (350-1200) 438 (160-850)

LBOS 56.2 63.8

Skin Incision Length (Cm) : Midline Skin Incision

Group A Group B

1 level 6.23 3.71

2 level 11.28 6.27

3 level 15.26 8.35

Complications

Group A Group B

Dural tear 5 cases(5.8%) 8 cases (5.5%)

Deep wound infection 4 cases(4.7%) 4 cases (2.7%)

Device failure 4 cases(4.7%) 5 cases (3.4%)



Results : Skin Incision LengthConventional Skin Incision

Mini-open Skin Incision

1 level

2 level 3 level1 level



Discussion : Evolution of Minimal Invasive Lumbar Fusion1. Leu HF, Hauser RK. Percutaneous endoscopic lumbar spine fusion. Neurosurg Clin N Am 1996:7;107-17 2. Foley KT, Smith MM. Microendoscopic dicectomy. Tech Neurosurg 1997:3;301-3073. Mathews HH. Percutaneous interbody fusions. Orthop Clin North Am 1998:29:647-53.4. Foley KT, Gupta SK, Justis JR, Sherman MC. Percutaneous pedicle screw fixation of the lumbar spine. Neurosurg

Focus 2001:10;1-9.5. Foley KT, Gupta SK. Percutaneous pedicle screw fixation of the lumbar spine: preliminary clinical results. J Neurosurg

2002:97;7-12.6. Kim DH, Jaikumar S, Kam AC. Minimally invasive spine instrumentation. Neurosurgery 2002;51:S15-25.7. Khoo LT, Palmer S, Laich DT, Fessler RG. Minimally invasive percutaneous posterior lumbar interbody fusion.

Neurosurgery 2002;51:S166-81.8. Foley KT, Holly LT, Schwender JD. Minimally Invasive Lumbar Fusion. Spine 2003:28:S26-S359. Lee SH, Choi WG, Lim SR, et al. Minimally invasive anterior lumbar interbody fusion followed by percutaneous

pedicle screw fixation for isthmic spondylolisthesis. The Spine Journal 2004:4;644-64910. Mummaneni PV, Rodts GE Jr.. The mini-open transforaminal lumbar interbody fusion. Neurosurgery 2005:57;256-61.11. Schwender JD. Holly LT. Rouben DP. Foley KT. Minimally Invasive Transforaminal Lumbar Interbody Fusion

(TLIF): Technical Feasibility and Initial Results. J Spinal Disord Tech 2005:18;S1-6.12. Holly LT, Schwender JD, Rouben DP, Foley KT. Minimally invasive transforaminal lumbar interbody fusion:

indications, technique, and complications. Neurosurg Focus 2006:20;E6.13. Deutsch H. Musacchio MJ Jr.. Minimally invasive transforaminal lumbar interbody fusion with unilateral pedicle

screw fixation. Neurosurg Focus 2006:20;E10.14. Anand N, Baron EM, Thaiyananthan G, et al. Minimally invasive multilevel percutaneous correction and fusion for

adult lumbar degenerative scoliosis: a technique and feasibility study. J Spinal Disord Tech 2008:21;459-67.15. Gepstein R, Shabat S, Reichel M, et al. Treatment of postdiscectomy low back pain by percutaneous posterior lumbar

interbody fusion versus open posterior lumbar fusion with pedicle screws. The Spine Journal 2008:8;741-46.



Discussion : Mini-open PLIF Versus TLIF

Mini-open Posterior Lumbar Interbody Fusion(PLIF)

Mini-open Posterior Lumbar Interbody Fusion(PLIF)

Transforaminal Lumbar Interbody Fusion(TLIF)Transforaminal Lumbar Interbody Fusion(TLIF)

The PLIF technique requires significant bilateral retraction on the thecal sac and nerve roots, whereas TLIF provides less extensive neural retraction and injury by accessing the spinal canal and disc via a path that runs through the far-lateral portion of the vertebral foramen.

In Mini-open PLIF and TLIF

Not easy to resolve the lateral recess stenosisNot easy to decompress central stenosisNot easy to restore the spinal balanceNot easy to operate on multi-level fusion



Discussion : Modified Mini-open PLIF

Modified midline total decompressed Mini-open PLIFModified midline total decompressed Mini-open PLIF

the Modified Mini-open PLIF + Newly Designed Pedicle Screwing

Minimized the skin incisionMinimized the muscle retraction and surround structural damageMaximized the spinal decompressionMore familiar to spine surgeonMore easy to compression and distraction procedureBenefit of a multilevel PLIF



Discussion : Bone Cement Augmentation for Osteoporosis

1. Burval DJ, McLain RF, Milks R, Inceoqlu S. Primary pedicle screw augmentation in osteoporotic lumbar vertebrae: biomechanical analysis of pedicle fixation strength. Spine 2007:32:1077-83.

2. Frankel BM, Jones T, Wang C. Segmental polymethylmethacrylate-augmented pedicle screw fixation in patients with bone softening caused by osteoporosis and metastatic tumor involvement: a clinical evaluation. Neurosurgery. 2007:61:531-7.

3. Kim HS, Park IH, Ryu JK, Kim SW, Shin H. Bone Cement Augmentation of Pedicular Screwing in severe Osteoporotic Spondylolisthetic Patients. J Korean Neurosurg Soc 2007:42;6-10.

4. Tan JS, Balley CS, Dvorak MF, et al. Cement augmentation of vertebral screws enhances the interface strength between interbody device and vertebral body. Spine 2007:32;E317-24.

5. Chang MC, Liu CL, Chen TH. Polymethylmethacrylate augmentation of pedicle screw for osteoporotic spinal surgery: a novel technique. Spine 2008:33;334-341.

6. Kim HS, Park SK, Joy H, Ryu JK, Kim SW, Ju CI. Bone Cement Augmentation of Short Segment Fixation for Unstable Burst Fracture in Severe Osteoporosis. J Korean Neurosurg Soc 2008:44;8-14



Cases : One Level – Non-osteoporotic

70/F : Isthmic Spondylolisthesis L5 on S1 6Months F/U

51/F : Isthmic Spondylolisthesis L4 on L5 1yrs F/U

58/F : Spinal stenosis L4 on L5 6Months F/U



Cases : One Level - Osteoporotic

62/F :Degenerative Spondylolisthesis L4 on L5, L2 osteoporotic VCFs 6Months F/U

59/F : Isthmic Spondylolisthesis L4 on L5 1yrs F/U

65/M : Isthmic Spondylolisthesis L4 on L5 1yrs F/U



Cases : Two Level – Non-osteoporotic

60 /M : Spinal stenosis and instability L3-4-5 1yrs F/U

60/F : both foraminal stenosis L4-5-S1 6Months F/U

56/F : Isthmic Spondylolisthesis L4 on L5 on S1 1yrs F/U

Hyeun Sung Kim ([email protected])


Cases : Two Level –Osteoporotic

78/F : degenerative Spondylolisthesis L3 on L4 on L5, osteoporotic VCFs L4 6Months F/U

71/F : spinal stenosis L4-5-S1 1 yrs F/U



Cases : Three Level – Non-osteoporotic 53/F : Degenerative Spondylolisthesis L3 on L4 on L5, Foraminal stenosis L5-S1



Cases : Three Level – Non-osteoporotic

60/F : Spinal stenosis L3-4-5-S1 1yrs F/U

68/F : spinal stenosis L3-4-5-S1 6Months F/U

51/F : Spinal stenosis and instability L3-4-5-S1 6Months F/U



Cases : Three Level – Non-osteoporotic

67/F : Spinal stenosis L3-4-5-S1 and instability, Spondylitis

6Months F/U

68/M : Spinal stenosis and Instability L3-4-5-S1, HNP L5-S1 6Months F/U



Cases : Three Level – Osteoporotic

59/M : Spinal stenosis and instability L2-3-4-5 9Months F/U

51/F : Spinal stenosis L4-5-S1 and Iatrogenic intraoperative joint damage L3-4 6Months F/U

Metal failure



Conclusion

A vertical axis and detachable screw extender system makes it easier to perform rod manipulation as well as compression and distraction. As compared with conventional PLIF, it can decrease the length of the midline skin incision. It is therefore useful in reducing operative time and intra-operative blood loss, thus minimizing the postoperative occurrence of back pain and complications. Accordingly, a prompt recovery and a good clinical outcome can be expected.


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