Incidences and Risk factors of Screw-related Superior Facet Articular Surface Violation at L4 and L5 levels in Transforaminal Lumbar Interbody Fusion

Abstract

Study Design. A retrospective comparative study with radiographic measurements.Objective. The aim of this study was to investigate incidences and risk factors of screw-related superior facet articular surface violation (FASV) and optimal pedicle screw angles (PSAs) to avoid FASV at L4 and L5 levels in transforaminal lumbar interbody fusion (TLIF) with either open surgery (OS) or minimal invasive (MIS) techniques with 3D C-arm navigation. Summary of Background Data. L4 to S1 are common levels in TLIF. Adjacent segment diseases (ASD) following TLIF is not uncommon. Screw-related FASV at the superior level is one of the potential risk factors for ASD. Methods. In the OS and MIS groups, 111 and 110 screws were included at L4 level, and 114 and 110 screws at L5 level, respectively. Postoperative computed tomography examined screw-related FASV at L3-4 and L4-5 facet levels. The entry point was the location where pedicle screws placed into the facet joints. Results. The OS technique and insertion at the L5 level increased the likelihood of FASV 2.56 and 1.81 times, respec-tively. Multivariate logistic regressions analysis determined PSA was a significant factor associated with FASV. Pearson r between PSA and the distance between midline and entry point was 0.905 (P < .0001). Adding one degree of convergence in PSA led to a mean 0.87 lower odds of an FASV event, regardless of surgical techniques. In 90% of patients in the OS and MIS groups, PSA with FASV was < 11.98 and <15.98 at L4 level, and <15.98 and <21.88 at L5 level, respectively. Conclusion. PSAs played an important role in FASV. MIS allowed greater PSAs and resulted in fewer incidences of FASV. To avoid FASV in 90% of patients, the PSAs might be at least 11. 98 and 15.98 at L4 level, and 15.98 and 21.88 at L5 level for OS and MIS techniques, respectively.

Superior facet joint violation between open and minimally invasive techniques in lumbar fusion surgery: An updated systematic review and meta-analysis

“…Lau et al used O-arm navigation and Huang et al used C-arm navigation rather than CT navigation adopted by the other three studies. 14,25 The sensitivity analysis removing the studies by Lau et al and Huang et al resulted in a reduced RR (0.29, 95% CI: 0.12-0.69) of superior FJV. Analysis of the two studies using robotic assistance in the MI group showed that the overall RR of superior FJV was 0.25 (95% CI: 0.08-0.72) for the MI surgery.…”

“…29,46 The possible risk factors associated with superior FJV are more depth of the spine, 12,23 higher BMI, 14,23,26 lumbar level from L2 to L5, 15,16 greater facet angle, 20,23 and larger pedicle screw angle. 25 More tissue needs to be traversed to place the guided wires and percutaneous screw in patients with obesity, high BMI, or a thick layer of subcutaneous fat. Any movement at the skin layer will increase the displacement of the entry point and subsequently lead to an incorrect trajectory.…”

“…After screening the titles and abstracts, 17 remained. [11][12][13][14][15][16][17][18][19][20][21][22][23][24][25][26][27] Of these 17 articles, one was excluded due to a lack of description of the exact number of FJV cases. 11 Among the 16 eligible studies, 13 reported superior FJVs in the text.…”

“…14,18,19 Seven studies enrolled only patients undergoing one-level lumbar fusion surgery. 13,18,19,23,[25][26][27] Yson et al did not describe the demographic data of patients. 15 Multiple FJV grading criteria were used.…”

“…10 Accordingly, the consensus is that maintaining integrity of superior facet joints is generally required to avoid ASD regardless of technique (MI or open), and several studies have highlighted the risk of superior FJV associated with different surgical techniques. [11][12][13][14][15][16][17][18][19][20][21][22][23][24][25][26][27] In a meta-analysis conducted in 2015, Wang et al found similar rates of superior FJV for MI and open methods (MI: 18.2%; open: 18.7%). 28 Innovative technologies and techniques have revolutionized MI spine surgery in the past decade.…”