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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
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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)
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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
Hyeun Sung Kim ([email protected], www.ilovespine.com)
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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
Hyeun Sung Kim ([email protected], www.ilovespine.com)
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Methods : Operation Methods
Apollon System Application
Total Foraminal Decompression
Spine Classics MLD
Hyeun Sung Kim ([email protected], www.ilovespine.com)
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Modified midline total decompressed Mini-open PLIF techniqueModified midline total decompressed Mini-open PLIF technique
Methods : Operation Methods
Hyeun Sung Kim ([email protected], www.ilovespine.com)
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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
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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%)
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Results : Skin Incision LengthConventional Skin Incision
Mini-open Skin Incision
1 level
2 level 3 level1 level
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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.
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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
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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
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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
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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
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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
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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
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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
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Cases : Three Level – Non-osteoporotic 53/F : Degenerative Spondylolisthesis L3 on L4 on L5, Foraminal stenosis L5-S1
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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
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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
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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
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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.
Hyeun Sung Kim ([email protected], www.ilovespine.com)