Minimally Invasive Percutaneous Posterior Lumbar Interbody Fusion

Abstract

OBJECTIVE The wide exposure required for a standard posterior lumbar interbody fusion (PLIF) can cause unnecessary trauma to the lumbar musculoligamentous complex. By combining existing microendoscopic, percutaneous instrumentation and interbody technologies, a novel, minimally invasive, percutaneous PLIF technique was developed to minimize such iatrogenic tissue injury (MIP-PLIF). METHODS The MIP-PLIF technique was validated in three cadaveric torsos with six motion segments decompressed and fused. Preoperative variables measured from imaging included interpedicular distance, pedicular height and width, interspinous distance, lordosis, intervertebral height, Cobb angle, and foraminal height and volume. Using the METRx and MD spinal access systems (Medtronic Sofamor Danek, Memphis, TN), bilateral laminotomies were performed using a hybrid of microsurgical and microendoscopic techniques. The intervertebral disc spaces were then distracted and prepared with the Tangent (Medtronic Sofamor Danek) interbody instruments. Either a 10 or 12 by 22 mm interbody graft was then placed. Using the Sextant (Medtronic Sofamor Danek) system, percutaneous pedicle screw-rod fixation of the motion segment was completed. We then applied MIP-PLIF in three patients. RESULTS For segments with preoperative intervertebral/foraminal height loss, MIP-PLIF was effective in restoring both heights in all cases. The amount of improvement (9.7 to 38% disc height increase; 7.7 to 29.9% foraminal height increase) varied directly with the size of the graft used and the original degree of disc and foraminal height loss. Segmental lordosis improved by 29% on average. Graft and screw placement was accurate in the cadavers, except for a single Grade 1 screw violation of one pedicle. The average operative time was 3.5 hours per level. In our three clinical cases, the MIP-PLIF procedure required a mean of 5.4 hours, estimated blood loss was 185 ml, and inpatient stay was 2.8 days, with no intravenous narcotic use after 2 days in any of the patients. All screw and graft placements were confirmed. CONCLUSION A complete PLIF procedure can be safely and effectively performed using minimally invasive techniques, thereby potentially reducing the pain and morbidity associated with standard open surgery. Prospective, randomized outcome studies will be required to validate the efficacy of this exciting new surgical technique.

Multifidus muscle changes and clinical effects of one-level posterior lumbar interbody fusion: minimally invasive procedure versus conventional open approach

“…Preliminary results suggested that the MI posterior lumbar fusion procedures hold the promise of decreased iatrogenic muscle injury and approach-related morbidity, while allowing the surgeon to perform the operation as effectively as the conventional open surgery [8,11,13,20,22,25]. However, there was no long-term evaluation of changes in multifidus muscle and their potential effects.…”

“…Later, with modifications of the tubular retractor system, this approach was utilized for posterior lumbar interbody fusion (PLIF), transforaminal LIF, and posterolateral LF. Preliminary results suggested that the minimally invasive approach is superior to the conventional open approach in terms of reduced intramuscular pressure and paraspinal muscle edema, [25] less blood loss, [8,11,20,22] lower serum creatinine kinase (CK) and inflammatory cytokine levels, [13] and less postoperative back pain [20,22]. Particularly, all of the midline supporting musculo-ligamentous structures are left intact with this technique.…”

A minimally invasive posterior lumbar interbody fusion for degenerative lumbar spine instabilities

“…Ongoing technological progress led to the development of specific percutaneous surgical techniques to treat lumbar degenerative diseases [7][8][9][10].…”

Editorial: Comparing minimally invasive, hybrid, and open surgical techniques for adult spinal deformity

“…Minimally invasive spine surgery techniques generally cause less "collateral damage" resulting in decreased blood loss, lower infection rates, quicker recovery, and shorter hospital stays. 5,8,9,11 Unfortunately, minimally invasive and open spine deformity surgeries have largely remained as two distinct subspecialties in spine surgery, with few surgeons who consider themselves proficient in both disciplines. Thus, until recently, the principles of minimally invasive surgery (MIS) were rarely applied to the treatment of ASD.…”

“…The benefits of minimally invasive techniques (that is, MIS vs open transforaminal lumbar interbody fusion) have been demonstrated for degenerative disease over a short segment of the spine. 5,8,9 However, the indications, efficacy, and complications of minimally invasive techniques when applied to the treatment of spinal deformity have not been adequately compared with open procedures.…”