Early Clinical Results of Percutaneous Endoscopic Transforaminal Lumbar Interbody Fusion: A New Modified Technique for Treating Degenerative Lumbar Spondylolisthesis

Abstract

Introduction Lumbar interbody fusion is used to treat degenerative lumbar spondylolisthesis with instability. We developed a device that safely expands a percutaneous path through Kambin's triangle and used it via a new technique: percutaneous endoscopic transforaminal lumbar interbody fusion (PETLIF). We report in this study the details and outcomes of this procedure after a one year follow-up. Methods Twenty-five patients requiring interbody fusion for degenerative spondylolisthesis of the L4 vertebra were enrolled in this study. The procedure involved percutaneous posterior pedicle screw placement to correct spondylolisthesis. After the exterior of the L5 vertebra superior articular protrusion was shaved with a percutaneous endoscopic drill in order to expand the safe zone, the oval sleeve was inserted through Kambin's triangle and was rotated to expand the disk height and create a path toward the vertebral disk. The interbody cage was inserted against the J-shaped nerve retractor, with the exiting nerve root retracted. Indirect decompression of spinal canal stenosis was expected because the vertebral body spondylolisthesis had been corrected and the interbody distance was expanded. Thus, no direct decompression was performed posterolaterally. Results The mean follow-up period, surgery time, and blood loss were 22.7 months, 125.4 min, and 64.8 mL, respectively. The Japanese Orthopaedic Association score improved from 13.3 to 28.0. The Roland-Morris Disability Questionnaire score improved from 10.3 to 3.3. All items were evaluated both preoperatively and one year postoperatively. Bone fusion was observed one year postoperatively in 22 out of 25 patients. Conclusions These results demonstrate the feasibility and efficacy of PETLIF for treating degenerative lumbar spondylolisthesis. This minimally invasive procedure is useful and has wide applicability. To obtain safe and favorable results, necessary surgical techniques must be mastered, and surgical equipment, including that for neural monitoring, is required.

Full-Endoscopic Lumbar Interbody Fusion for Treating Lumbar Disc Degeneration Involving Disc Height Loss: Technical Report

“…As the operation time of endoscope-assisted LIF, a standard approach in our hospital, was 102 (range, 59–162) min [ 24 ], 109.4 min was not significantly different from the operative time for the conventional approach. Likewise, the mean operation time was not inferior to that reported in previous FELIF studies (84.5–285.7 min) [ 6 , 7 , 8 , 9 , 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 ]. Presently, we only perform FELIF for patients with LDD with disc height loss; the removal of the disc material is not a time-consuming step.…”

“…Recently, Nagahama et al reported excellent clinical outcomes following transforaminal LIF using a 3.9 mm working channel endoscope (SpineTIP ® Transforaminal Approach Kit, Karl Storz GmbH, Tuttlingen, Germany) [ 17 ]. They treated 25 cases of degenerative spondylolisthesis of the L4 vertebra; the spondylolisthesis was corrected using a PPS system before endoscopic manipulation.…”

“…Previously, LIF was performed using open, microscopic, or endoscope-assisted surgical approaches. In contrast, uniportal full-endoscopic spine surgery (FESS) was originally introduced for the treatment of lumbar disc herniation and has recently been performed during posterior, lateral, and transforaminal LIF [ 6 , 7 , 8 , 9 , 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 ]. Among these approaches, transforaminal LIF through Kambin’s triangle seems to be the most commonly used approach.…”

Methods and Early Clinical Results of Percutaneous Lumbar Interbody Fusion

“…24 Although we used standard sheaths in our procedure, they were removed, unlike any of the techniques described above, and retract-sliders that had been inserted beforehand were used for cage insertion (retract-slider group). 8,26 Our previous report 8 was the first to describe this technique. By using a retract-slider, our procedure enables the insertion of a cage larger than a sheath, while protecting the exiting nerve root.…”

“…Although the above-mentioned PPL-LIF could be regarded as a least invasive LIF, it is in the trial and development stage and there are unique techniques for this procedure, which we classified according to the grafting and insertion methods into the intervertebral space (Table 1). [8][9][10][11][12][13][14][15][16][17][18][19][20][21][22][23][24][25][26] Among the insertion techniques utilizing the usual sheath (usual sheath [US] group), the insertion technique of comminuted bone and/or other materials without using any cages (without cage subgroup) is the oldest technique, but it has been reported even recently. [9][10][11][12][13] Because of the lack of supporting structure in the intervertebral disk area, which is the main loading part of the lumbar spine, this technique appears to be principally inferior in terms of stability.…”