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. 2016:2016:2518394.
doi: 10.1155/2016/2518394. Epub 2016 Jun 28.

Minimally Invasive Transforaminal Lumbar Interbody Fusion at L5-S1 through a Unilateral Approach: Technical Feasibility and Outcomes

Won-Suh Choi  1 , Jin-Sung Kim  1 , Kyeong-Sik Ryu  1 , Jung-Woo Hur  1 , Ji-Hoon Seong  1
Affiliations

Minimally Invasive Transforaminal Lumbar Interbody Fusion at L5-S1 through a Unilateral Approach: Technical Feasibility and Outcomes

Won-Suh Choi et al. Biomed Res Int. 2016.

Abstract

Background. Minimally invasive spinal transforaminal lumbar interbody fusion (MIS-TLIF) at L5-S1 is technically more demanding than it is at other levels because of the anatomical and biomechanical traits. Objective. To determine the clinical and radiological outcomes of MIS-TLIF for treatment of single-level spinal stenosis low-grade isthmic or degenerative spondylolisthesis at L5-S1. Methods. Radiological data and electronic medical records of patients who underwent MIS-TLIF between May 2012 and December 2014 were reviewed. Fusion rate, cage position, disc height (DH), disc angle (DA), disc slope angle, segmental lordotic angle (SLA), lumbar lordotic angle (LLA), and pelvic parameters were assessed. For functional assessment, the visual analogue scale (VAS), Oswestry disability index (ODI), and patient satisfaction rate (PSR) were utilized. Results. A total of 21 levels in 21 patients were studied. DH, DA, SLA, and LLA had increased from their preoperative measures at the final follow-up. Fusion rate was 86.7% (18/21) at 12 months' follow-up. The most common cage position was anteromedial (15/21). The mean VAS scores for back and leg pain mean ODI scores improved significantly at the final follow-up. PSR was 88%. Cage subsidence was observed in 33.3% (7/21). Conclusions. The clinical and radiologic outcomes after MIS-TLIF at L5-S1 in patients with spinal stenosis or spondylolisthesis are generally favorable.

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Figures

Figure 1
Figure 1
a: segmental lordotic angle (SLA), b: SLA of level L5-S1, and y: lumbar lordotic angle (LLA).
Figure 2
Figure 2
a: disc slope angle (DSA), b: disc angle (DA), c: sacral slope (SS), d: pelvic incidence (PI), and e: pelvic tilt (PT).
Figure 3
Figure 3
A: anterior, M: medial, L: lateral, and P: posterior.
Figure 4
Figure 4
By angulating the tubular retractor so that its distal end is facing more towards the opposite side of the surgeon, visualization and access to the contralateral side are improved. Tilting the table towards the opposite side, as seen in the figure, can help the surgeon maintain a more natural posture, as the retractor would be more perpendicular to the floor.
Figure 5
Figure 5
VAS for back and leg pain.
Figure 6
Figure 6
ODI scores.
Figure 7
Figure 7
Because of the orientation of the L5-S1 disc space, the tubular retractor when placed in line with the disc space can often be slanted. Resultant unnatural posture of the surgeon can cause fatigue to the surgeon. To avoid this, we tilt the operating table caudally so the tubular retractor is almost perpendicular to the floor.
Figure 8
Figure 8
Posterior tip of caudal endplate of L5 was drilled slightly to widen the opening for cage insertion.
See this image and copyright information in PMC

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