Hybrid Technique for Posterior Lumbar Interbody Fusion: A Combination of Open Decompression and Percutaneous Pedicle Screw Fixation

Abstract

The authors describe a hybrid technique that involves a combination of open decompression and posterior lumbar interbody fusion (PLIF) and percutaneously inserted pedicle screws. This technique allows performance of PLIF and decompression via a midline incision and approach without compromising operative time and visualization. Furthermore, compared to standard open decompression, this approach reduces post-operative wound pain because the small midline incision significantly reduces muscle trauma by obviating the need to dissect the paraspinal muscles off the facet joint complex and by avoiding posterolateral fusion, thus requiring limited lateral muscle dissection off the transverse processes. A series of patients with Grade I-II spondylolisthesis at L4-5 and moderate-severe canal/foraminal stenosis underwent midline PLIF at L4-5, with closure of the midline incision. Percutaneous pedicle screws were inserted, thereby minimizing local muscle trauma, reduction of the spondylolisthesis being performed by using a pedicle screw construct. Rods were inserted percutaneously to link the L4 and L5 pedicle screws. Image intensification was used to confirmed satisfactory screw placement and reduction of spondylolisthesis. The results of a prospective study comparing a standard open decompression and fusion technique for spondylolisthesis versus the minimally invasive hybrid technique are discussed. The minimally invasive technique resulted in shorter hospital stay, earlier mobilization and reduced postoperative narcotic usage. The long-term clinical outcomes were equivalent in the two groups.

Surgical management of thoracolumbar junction fractures: An evidence-based algorithm

“…Additional hybrid techniques, such as percutaneous fixation combined with open decompression and debridement, have been tested for several thoracolumbar spinal pathologies. 49 , 50 , 51 …”

The “TFP” Fusion Technique for Posterior 360° Lumbar Fusion: a Combination of Open Decompression, Transforaminal Lumbar Interbody Fusion, and Facet Fusion with Percutaneous Pedicle Screw Fixation

“…Our posterior fusion technique has evolved from the previously described “80:20”technique to the current “TFP” technique, which incorporates unilateral TLIF and facet fusion. The rationale for the TFP technique involves unique advantages at each step of the procedure.…”

“…There is no definition of “adequate rigidity” in regard to interbody fusion; although no published studies have substantiated this, additional augmentation would likely be beneficial. Facet fusion can be added to posterior or posterolateral fusion by careful curettage of the joint followed by insertion of bone graft, thus augmenting stability and possibly eliminating facetogenic back pain. Both biomechanical and clinical studies have proven that facet fusion is equivalent to pedicle screws.…”

“…Proponents of minimally invasive posterior fusion techniques cite reduced destruction of soft tissues, leading to reduced postoperative pain, analgesia and length of stay. One option is medio‐latero‐superior trajectory of pedicle screw insertion.…”

“…Next, pedicle screws are inserted percutaneously and the spondylolisthesis reduced. The senior author (RJM) has also previously described the “80:20 technique” and “50:50 technique”. Details of the TFP technique are as follows.…”