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65 Correction ofSpondylolisthesis
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Optimal
Placement
“Parallel”
Fig. 65.4 Optimal parallel placement of the pedicle screws in the
sacrum. (With permission from Aesculap AG, Tuttlingen, Germany)
Fig. 65.3 Standard Gill procedure. (With permission from Aesculap
AG, Tuttlingen, Germany)
65.6.2 Instrumentation
• Perform a standard Gill procedure (see Fig.65.3).
• Using the awl, the cortex is penetrated under C-arm con-
trol. The drilling angle is determined. Use the ball-tipped
probe to make sure the pedicle is intact.
• Screws in the sacrum are best placed parallel to its supe-
rior end plate and as parallel to each other as possible (see
Fig. 65.4, see pedicle access, pedicle preparation, and
screw placement, Chap. 46).
• Place the caudal screws so that they are parallel to the
cephalad vertebra screws in both planes. This differs from
the standard convergent manner (see Fig.65.5).
• An alternative technique—instrumentation with polyax-
ial screws—allows a standard convergent positioning
and easier attaching of the S4 SRI.
• In the case of an L5/S1 reduction, the chosen length at S1
should achieve bicortical purchase. In most cases, this is
45mm in length and 7mm diameter.
• During the decompression, perform a complete resection
of the pars interarticularis defects to fully decompress the
exiting nerve roots. This may include removal of the Gill
fragment.
Optimal
Placement
“Parallel”
Fig. 65.5 Parallel placement of the caudal vertebral screws to the
cephalad vertebra screws in both planes and complete decompression
of the exiting nerve roots. (with permission from Aesculap AG,
Tuttlingen, Germany)
• Perform a complete resection of the residual superior
articular processes in preparation for the PLIF. A wide
decompression allows access to the intervening disk
space, lateral to the thecal sac.
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U. Vieweg
Fig. 65.6 Insert the mounting post into the tulip of the screw and nger
tighten. Attach the cephalad component rst. (With permission from
Aesculap AG, Tuttlingen, Germany)
• On the caudal components, make sure the distraction nuts
are of a point of minimal distraction (toward the most
caudal position of the S4 SRI).
• On the caudal components, make sure the reduction bolts
are backed out to the point of minimal reduction.
• Attach the cephalad component rst (see Fig.65.6).
• Insert the mounting post into the tulip of the screw and
nger tighten (Fig.65.7).
• The caudal components are labeled “R” for right and “L”
for left. For alternative placement of SRI medially to the
pedicle screws, (see Figs.65.8 and 65.9).
• Ensure that the articulated head is positioned inferiorly
and insert the distraction spindle (caudal component) into
the articulated head of the cephalad component. At the
same time, insert the mounting post into the tulip of the
pedicle screw of the caudal vertebra and nger tighten.
• Once the instrument is attached and positioned properly,
tighten the caudal and cephalad components using the
T-handles.
Fig. 65.7 The instrument is attached and positioned properly. Tighten
the caudal and cephalad components using the T-handles. (With permission from Aesculap AG, Tuttlingen, Germany)
• Hold the smaller inner T-handle and use it to apply countertorque while tightening with the larger outer T-handle.
• The mounting post on polyaxial screws should be tightened enough to lock slightly the polyaxial head.
• The mounting post on monoaxial screws needs to be
tightened enough to cover the break-off tabs and part of
the screw head.
• Using the distraction forceps, slowly spread the SRI device
to achieve the desired distraction. Then, lock the distraction
nut on the threaded distraction spindle (see Fig.65.10).
• Using the larger outer T-handle on the reduction bolt, turn
clockwise to carefully reduce the spondylolisthesis under
uoroscopy control (see Fig.65.11).
• Monitor the nerve root tension during reduction. Typically,
a decrease in the nerve root tension will be observed.
• Remove the SRI from one side if required to provide
room to work and perform a routine PLIF (TLIF). If the
decompression is great enough, the SRI can be left in
place.
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Fig. 65.8 Lateral placement of the reduction instrument. (With per-
mission from Aesculap AG, Tuttlingen, Germany)
Fig. 65.10 First perform distraction with spreading of the SRI device
with distraction forceps or with the distraction nut. Then, lock the distraction in place with the distraction nut on the threaded distraction
spindle. (With permission from Aesculap AG, Tuttlingen, Germany)
Fig. 65.9 Medial placement of the reduction instrument (alternative).
(With permission from Aesculap AG, Tuttlingen, Germany)
Fig. 65.11 Reduction progress using the larger outer T-handle. (With
permission from Aesculap AG, Tuttlingen, Germany)
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U. Vieweg
Fig. 65.12 Interbody fusion with PLIF cage. (With permission from
Aesculap AG, Tuttlingen, Germany)
• Retract the dura and upper nerve root carefully in the
desired direction using the nerve root retractors.
• Besides retracting, the nerve root retractor provides protection for the surrounding tissues during the following
operative steps.
• In order to make room for the insertion of the distractor of
the PLIF instruments, resection of disk material is now
carried out using rongeurs and forceps on both sides of
the disk.
• The PLIF implant (see Prospace Titan Spacer) should be
inserted in the disk space 2–3mm beyond or anterior to
the rear edge of the vertebral body (Fig.65.12).
• During insertion of the spacer or cage, the provided
retractor can be used to ensure that the dura and nerve
roots are carefully protected.
• Position the rod, and then lock in place with the setscrews
(Figs.65.13 and 65.14).
Fig. 65.13 Placement of the rod and locking into place with setscrews.
(With permission from Aesculap AG, Tuttlingen, Germany)
65.7 Tips andTricks
• In the event that the space lateral to the pedicle screws is
not sufcient for introduction of the distraction spindle,
both SRI components (right/left) can also be transposed
laterally.
• Medial placement of the reduction instruments is the preferred method. This usually allows for easier reduction
and less soft tissue impingement from the device itself.
Lateral placement sometimes allows an easier interbody
placement, but can make the reduction maneuver more
difcult.
• In order to avoid breaking of the tab during reduction,
make sure to fully tighten the SRI device to the pedicle
screw prior to performing the reduction.
• Prepare the small pedicle L5 with cannulated instruments
and use cannulated screws in L5.
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487
Fig. 65.14 (a) Lateral
radiological X-ray of a
spondylolytic
spondylolisthesis at L5/S1,
(b) lateral postoperative
radiograph after repositioning
with the S4 SRI and interbody
fusion with the PLIF cage
ab
References
1. Harrington PR, Dickson JH. Spinal instrumentation in the treatment of severe progressive spondylolisthesis. Clin Orthop.
1976;117:157–63.
2. La Rosa G, Germano A, Conti A, etal. Posterior fusion and implantation of the SOCON-SRI system in the treatment of adult spondylolisthesis. Neurosurg Focus. 1999;7(6):E2.
3. La Rosa G, Cacciola F, Conti A, etal. Posterior fusion compared
with posterior interbody fusion in segmental spinal xation for adult
spondylolisthesis. Neurosurg Focus. 2001;10(4):E9.
4. Majcher P, Fatyga M, Skwarcz A.Internal xation systems in the
surgical treatment of spondylolisthesis. Ortop Traumatol Rehabil.
2000;30:65–8.
5. Periasamy K, Shah K, Wheelwright EF.Posterior lumbar interbody
fusion using cages, combined with instrumented posterolateral
fusion: a study of 75 cases. Acta Orthop Belg. 2008;74:240–8.
Transforaminal Lumbar Interbody
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Fusion
StefanKroppenstedt andUweVieweg
66
66.1 Introduction and Core Messages
Interbody fusion performed by placing spacers or graft
materials via a transfacetar route is named transarticular lumbar interbody fusion (TLIF). TLIF is typically
performed via a unilateral approach and can be performed via a standard open approach with a midline
lumbar incision or in a less invasive miniopen fashion).
Because the TLIF approach uses a unilateral facetectomy, it is typically combined with screw xation (see
Fig.66.1). Advantages compared to bilateral PLIF are
as follows: contralateral facet joint and posterior laminar arch are preserved, and iatrogenic contralateral
scar formation is eliminated. Further, exposure of the
disk space requires less or no medial dural retraction.
S. Kroppenstedt (*)
Department of Spinal Surgery, Center of Orthopedic Surgery, Sana
Hospital Sommerfeld, Kremmen, Germany
e-mail: s.kroppenstedt@sana-hu.de
U. Vieweg
Department of Conservative and Surgical Spine Therapy with
Interdisciplinary Spinal Deformities Centre and Rummelsberg
Sectional Center, Hospital Rummelsberg,
Schwarzenbruck, Germany
e-mail: uwe.vieweg@sana.de
This can be particularly advantageous in the face of
scarring after prior surgery and in the thoracolumbar
area, where the myelon restricts the retraction of the
thecal sac. Other potential advantages are less bleeding
and a shorter operation time. Compared to bilateral
PLIF, TLIF has potentially the following disadvantages. In case of high-grade spondylolisthesis, extended
segmental mobilization may be necessary to achieve a
proper reduction. This can be done worse. Although
contralateral decompression via undercutting is possible, it is technically more challenging. Since for TLIF
generally one cage is used theoretically, the risk for
cage migration and loss of correction is higher compared to bilateral PLIF using two cages, and thereby
having a larger cage contact area to only approach an
additional posterior decompression is possible in the
bone face.
66.2 Indications
The indications and contraindications for TLIF are similar to
those for posterior lumbar interbody fusion (PLIF).
• Degenerative diseases from the thoracolumbar area down
to S1
• Degenerative pathologies that require complete
facetectomies
• Isthmic spondylolisthesis
• Pseudoarthrosis after posterolateral fusion
© Springer-Verlag GmbH Germany 2023
U. Vieweg, F. Grochulla (eds.), Manual of Spine Surgery, https://doi.org/10.1007/978-3-662-64062-3_66
489
490
ab
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Fig. 66.1 Illustration of
the transarticular or
transforaminal interbody
fusion (TLIF). (a)
Preserved facet joint (b)
resected facet joint
S. Kroppenstedt and U. Vieweg
66.3 Contraindications
a
• High angulation of the level L5/S1
• Destruction of the end plates
66.4 Technical Prerequisites
Fluoroscopy, positioning device (e.g., Wiltse frame), adequate implants (e.g., kidney-shaped or banana-designed
PEEK or titanium cages or spacer; see Fig.66.2), and different instruments (Fig.66.3a–c).
b
66.5 Planning, Preparation,
andPositioning
The patient is positioned prone on a radiolucent operating
room table with chest and hip rolls/pillows in order to
enhance lumbar lordosis and to permit the abdomen to hang
freely. For L5–S1 fusions, the operating table is moved in
20–30° of reverse Trendelenburg to allow the surgeon to
have a more convenient view into the L5–S1 disk space.
The level of the incision is veried uoroscopically.
Fig. 66.2 Different TLIF cages T-Space PEEK (a) and titanium allow
(b) (Aesculap AG, Germany)
66.6 Surgical Technique [1–4]
66.6.1 Approach
A midline posterior approach to the spine is performed with
subperiosteal exposure of the posterior bony elements to the
level of the transverse processes.
66.6.2 Instrumentation
66.6.2.1 Pedicle Preparation
• The pedicle is instrumented using clinical and radiological landmarks.
• The pedicle screw entry points (junction of the midpoint
of the transverse process with the lateral facet) are identied and marked under uoroscopy.
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Fig. 66.3 (a–e) Different TLIF
instruments: angled bone curette
(a), angled curette (b), and trial
implant (c)
a
b
c
d
e
• The pedicles are probed and tapped, and screws are
inserted on the side ipsilateral to the decompression.
66.6.2.2 Decompression andEnd Plate Preparation
• On the symptomatic side, a total facetectomy is performed
using a combination of osteotomes, Kerrison rongeurs,
and a high-speed burr.
• Using a big bone rongeur, the top of the facet joint is
removed until the gap of the facet joint is clearly seen.
This is of importance for the later use of the osteotome.
• With an osteotome, the inferior articular facet is removed
(Fig.66.4). The direction of the osteotome is from medial
to lateral and from cranial to caudal orienting on the gap
of the facet joint. Care must be taken not to break the
pedicle or to injure the intraspinal structures.
• Using bone rongeurs, Kerrison punches, and/
or a drill, the superior articular facet is removed
(Fig.66.1a, b). Care must be taken not to injure the exiting nerve root.
• The working corridor is the space dened by the thecal
sac medially, exiting nerve root superiorly, and pedicle
wall inferiorly. Care should be taken to protect the exiting
and traversing nerve root during the remainder of the
surgery.
• The annulotomy and discectomy is performed in the standard technique with standard pituitary rongeurs.
• Distraction and if necessary removal of the posterior lip
of both end plates open a wider window to the posterolateral disk space and thereby facilitates extensive disk
excision.
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Fig. 66.4 Using a big bone rongeur, the top of the facet joint is
removed until the gap of the facet joint is clearly. With an osteotome,
the inferior articular facet is removed. The direction of the osteotome is
from medial to lateral and from cranial to caudal orienting on the gap of
the facet joint
• Special-angled rongeurs, bone curettes, shavers, and rasps
aid in cleaning of the disk space and end plates from the
cartilaginous surface (Fig.66.5a–d).
• Special care should be taken not to penetrate the anterior
part of the annulus with the curettes in order to avoid vascular injury.
66.6.2.3 Interbody Fusion
• The desired restoration of the natural disk height can be
set using distractors. They are available in heights from 7
to 17mm in 2-mm increments (see Fig.66.6).
• In addition to the osteoinductive graft material, a structural interbody spacer should be placed in the interbody
space to maintain intervertebral body and neuroforaminal
height and sagittal balance.
S. Kroppenstedt and U. Vieweg
• Depending on the shape of the end plates and the spinal
prole, it has been our practice to use either boomerang or
rectangular spacers in case of TLIF.For example, in case
of segmental kyphosis, we prefer to position a rectangular
cage laterally at the affected side.
• The appropriate size of the spacer is selected using specically designed trials.
• Before placement of a cage, milled local autograft from
the facet joint (and lamina) is inserted into the disk space
using a special funnel or a syringe (see Fig.66.7).
• After autograft insertion, the cage is inserted under distraction into the intended position. Distraction can be
achieved by placing a spreader under the screw heads of
the ispi- or contralateral pedicel screws. Placement of a
lamina spreader at the base of the spinous process is a
further option in case of a midline approach.
• Using a boomerang cage, it is impacted until it is completely inside the disk space and then it is gradually
rotated into position using an impactor (Fig.66.8). If the
cage is already in midline position and further anterior
placement is needed, a hockey-stick-shaped impactor is
placed onto the concave surface of the cage in order to
push the cage straight anterior.
• After the cage is placed, the distraction is released and the
rods are attached and xed.
• A further option is the placement of a translaminar facet
screw from the ipsilateral side. If lumbar lordosis needs to be
restored, mild compression of the screws can be performed
before nal xation of the rods. Overdo of the pedicle screw
compression may create a contralateral foraminal stenosis. A
standard closure in layers is performed (Fig.66.9).
66.7 Tips andTricks
• Cage position is an important factor to avoid cage migration. Mapping the structural properties of the lumbosacral
vertebral end plates has shown that the rigidity of the end
plates varies signicantly. In general, the strongest region is
located posterolaterally, just in front of the pedicles, with
more than twice the strength of the central end plate. Due
to difculties in preparation of the anterior end plates and
especially in case with anterior lips, it is often very difcult
to position a boomerang cage on the anterior cortical ring.
Thus, contrary to a rectangular cage, a frequent position of
a boomerang cage is in the “weaker” anterior- central end
ab
cd
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Fig. 66.5 Disk space and end plate preparation (a–d)
plate region. If this fact is associated with a higher rate of
cage migration, associated loss of correction has so far not
been investigated in the clinical setting. Using a long rectangular cage might overcome this potential problem.
• If too much autograft is packed ventrally into the disk
space, adequate anterior positioning of a boomerang cage
might not be possible. If it is intended to place an rh- BMP- 2
sponge into the disk space, the sponge should be placed
into the anterior disk space before cage placement to avoid
Fig. 66.6 Restoration of the disk height using a distractor
inducing of heterotopic bone formation near the dura mater.
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