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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_583_Библиотеки_им_академика_М_И_Перельмана
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69 Microsurgical Monosegmental Fusion withInternal Fixator andTransforaminal Interbody Fusion (TLIF)
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a b
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Fig. 69.18 Fixing of the rod (a) intraoperative X-ray (b) illustration
Fig. 69.19 Contralateral pedicle screw instrumentation. (With permis-
sion of Aescupap AG, Tuttlingen, Germany)
• After closure of the fascia and skin, an identical procedure is carried out on the contralateral side (see
Figs.69.19, 69.20, and 69.21).
69.7 Tips andTricks
• The K-wires should remain securely in position throughout the entire procedure and must not slip out before the
screws are inserted. The wires are long enough to be held
in place by hand during the different surgical steps.
• The tip of the K-wire should be monitored uoroscopically to ensure that it does not penetrate the anterior wall
of the vertebral body.
• The K-wires should be kept parallel to one another during
insertion.
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Fig. 69.20 Patient with spondylolytic spondylolisthesis: preoperative X-ray at L4/L5 (a) and postoperative AP (b) and lateral (c) X-rays
Fig. 69.21 Length of the two scin incision (3–4cm) postoperatively
References
1. Ge DH, Stekas ND, Varlotta CG, etal. Comparative analysis of two
transforaminal lumbar interbody fusion techniques: open TLIF versus Wiltse MIS TLIF.Spine. 2019;44:E555–60.
2. Foley KT, Holly LT, Schwender JD. Minimally invasive lumbar
fusion. Spine. 2003;28(Suppl):26–35.
3. Harms JG, Jeszensky D.The posterior lumbar interbody Fusion in
a unilateral technique. Oper Orthop Traumatol. 1998;10:90–102. In
German
4. Jong JS, Lee SH.Minimally invasive transforaminal lumbar interbody fusion with ipsilateral pedicle screw and contralateral facet
screw xation. J Neurosurg Spine. 2005;3:218–23.
5. Khoo LT, Palmer S, Loich OT.Minimally invasive percutaneous
posterior lumbar interbody fusion. Neurosurgery. 2005;51(Suppl
2):166–81.
6. Park Y, Lee SB, Seok SO, etal. Perioperative surgical complications and learning curve associated with minimally invasive transforaminal lumbar interbody fusion: a single-institute experience. Clin
Orthop Surg. 2015;7:91–6.
7. Wimmer C, Pfandlsteiner T, Walochnik N. Less invasive spine
fusion. A comparison study. Eur Spine J. 2006;10:179–82.
Posterior Lumbar Interbody Fusion with
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anInterbody Fusion Spacer orCage
UweVieweg andSteenSola
70
70.1 Introduction and Core Messages
Posterior lumbar interbody fusion (PLIF) is a treatment option currently used for degenerative disk diseases [1] and was introduced by Cloward in the 1940s
[2]. Interbody fusion probably results in the most stable construction for intersegmental spinal fusion.
Anterior column support is provided via a posterior
approach, and the disk height is restored in order to
open the neural foramen. A PLIF procedure is especially attractive in cases where a posterior approach is
needed anyway, for example, for nerve root or spinal
canal decompression. Different devices are available
including allograft spacers, titanium spacers with or
without a Plasmapore coating, tantalum spacers, and
titanium or PEEK cages. This chapter describes the
posterior technique for implanting an interbody spacer
or cage. These implants are used to obtain 360° fusion.
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
S. Sola
Department of Neurosurgery, University of Rostock,
Rostock, Germany
e-mail: solastef@med.uni-rostock.de
70.2 Indications
• Degeneration of lumbar segments (L2 to sacrum)
• Discogenic low-back pain
• Degenerative spondylolisthesis
• Pseudarthrosis of a posterolateral fusion
• Isthmic spondylolisthesis grade I–II (III)
70.3 Contraindications
• Severe osteoporosis
• Infection
• Severe epidural scarring
• Unstable burst fractures and compression fractures
• Destructive tumors
70.4 Technical Prerequisites
Fluoroscopy, positioning device (e.g., Wilson frame), adequate instruments, and implants to meet the following
requirements: primary stability, restoration of natural lordosis, and long-term maintenance of spinal balance.
Intersomatic devices: allograft spacers (Vertigraft VG2 PLIF,
DePuy Spine; ProSpace spacer, Aesculap; PLIF allograft
spacer, Synthes), titanium cages (CONTACT Fusion Cage,
Synthes; Ray cage, Surgical Dynamics, LT cage, Medtronic;
OIC PL, Stryker), titanium Plasmapore-coated spacers
(ProSpace, Aesculap) (see Fig. 70.1a), tantalum spacers
(Zimmer Spine), and PEEK cages (ProSpace, Aesculap, see
Fig. 70.1b; Plivios, Synthes; Coda, Mercy Health System;
Tetris, Signus; Oria Natura/Adonys, Alphatec Spine/
Scient’X; Pezo-P, Ulrich; Luna Cage, Bricon; OIC PL,
Stryker; Lumbo-Space PLIF, Intromed).
© Springer-Verlag GmbH Germany 2023
U. Vieweg, F. Grochulla (eds.), Manual of Spine Surgery, https://doi.org/10.1007/978-3-662-64062-3_70
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Fig. 70.1 ProSpace titanium spacer with Plasmapore coating (a) and ProSpace PEEK cage (b). (Aesculap AG, Tuttlingen, Germany)
U. Vieweg and S. Sola
70.4.1 Plasmapore-Coated Spacer
The heart of the disk implant is a solid core. The core is
coated with Plasmapore to increase the area of contact
between the implant and the end plates. The implant is made
of ISOTAN F, a titanium alloy, which also has a Plasmapore
coating. Plasmapore is a well-established pure titanium coating material, which offers an optimal foundation for the
ingrowth of bone due to its balanced relationship among
pore depth, porosity, and roughness. Plasmapore promotes
osteointegration and osteoconduction without requiring
additional bone graft material [1].
The aim of the Plasmapore coating is to achieve both primary and secondary stability. The increased surface
roughness of the Plasmapore coating, in combination with a
posterior xation device, ensures immediate primary stability of the motion segment. Bone growth into the coating is
rapid, owing to the optimal properties of Plasmapore. This
results in bone fusion between vertebrae and implant (secondary stability).
70.4.2 PEEK Cages
cic stiffness encourages load sharing between implant
material and natural bone, thereby stimulating bone-healing activity (see Fig.70.2).
70.5 Planning, Preparation, andPositioning
The patient is placed in a prone position. A radiolucent operating table is recommended to ensure unobstructed intraoperative uoroscopic visualization in the anteroposterior (AP)
and lateral planes. The elbows and knees are appropriately
padded. The abdomen must be free. The lumbar spine should
be in natural lordosis.
70.6 Surgical Technique
70.6.1 Approach
A midline incision is performed over the levels to be instrumented. The muscle should not be stripped more laterally
than the lateral aspects of the facet joints unless posterolateral fusion between transverse processes is planned.
PEEK stands for polyetheretherketone. The use of PEEK
as an orthopedic device material has become increasingly
popular in recent years owing to the material’s unique
combination of characteristics. Its properties include
radiolucency, high mechanical strength, biocompatibility,
and compatibility with standard sterilization methods. The
intrinsic radioscopic transparency of the material gives it
permeability on X-rays and CT scans, making it possible
to view bone growth adjacent to the implant. Of particular
interest is the modulus of elasticity of PEEK, which is
3.6GPa and thus similar to that of cortical bone. This spe-
70.6.2 Instrumentation [1–7]
70.6.2.1 With aPlasmapore-Coated Titanium
Spacer
• Bone resection
• The bone is resected using an osteotome and Kerrison bone
punch to gain access to the intervertebral space. Alternatively,
bone can be removed at the joints using a chisel or highspeed burr. The bone that has been removed is stored in a
container under gauze to serve as graft material.
70 Posterior Lumbar Interbody Fusion withanInterbody Fusion Spacer orCage
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Fig. 70.3 After appropriate laminectomy, the nerve root and dura
mater should be protected and the disk sufciently exposed. Retraction
of the dura and upper nerve root with nerve root retractors
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Fig. 70.2 Load sharing between PEEK implant material and natural
bone stimulates bone-healing activity. (With permission from Aesculap
AG, Tuttlingen, Germany)
• Revealing the disk space
• The dura and upper nerve root are carefully retracted in
the desired direction using the nerve root retractors (see
Fig.70.3). Often, large epidural veins need to be cauterized to permit visualization of the posterolateral disk
annulus. This must be done carefully, using bipolar cautery to prevent damage to the nerve roots.
• Restoration of disk height
• In order to make room for the insertion of the distractor,
the disk material is now resected using rongeurs and forceps. Distraction can be set to the required height using
the distractors (see Fig.70.4). The distractors are inserted
one after the other on alternate sides of the disk until the
desired distraction is obtained (see Fig.70.5).
• Clearance of the intervertebral space
• Besides rongeurs and curettes, reamers and rasps can also
be used to prepare the intervertebral space. Turning the
instrument will remove disk material (see Fig. 70.6).
Using the rasps, the cartilaginous end plates are refreshed
(see Fig.70.7). The annulus has to be cleaned out as completely as possible, and the end plates need to be freed
from cartilage, taking care not to perforate the bone.
• Preparation of the implant bed
Fig. 70.4 Restoration of the disk height using different distractors.
(With permission from Aesculap AG, Tuttlingen, Germany)
• Any unevenness of the borders of the implant bed can be
smoothed using the broach. The sharp leading edge of the
instrument permits simple bone resection to the dimensions required (see Figs.70.7 and 70.8). The implant bed
is now prepared, and the implant can be inserted.
• Insertion of the cage
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U. Vieweg and S. Sola
Fig. 70.5 The distractors are inserted one after the other on alternate
sides. (With permission from Aesculap AG, Tuttlingen, Germany)
Fig. 70.6 Clearance of the intervertebral space with curettes, reamers,
and rasps. (With permission from Aesculap AG, Tuttlingen, Germany)
Fig. 70.7 Preparation of the implant bed using a broach. (With permis-
sion from Aesculap AG, Tuttlingen, Germany)
• Either a straight implant (0°) or a lordotic implant (5° or
8°) can be used, depending on the particular level and
anatomy. The implant is connected to the inserter by
engaging the thread using the Allen key connected to the
instrument (see Fig.70.9). The spacer is introduced on the
at side and turned clockwise in order to spread the disk
space. The implant is then brought into its nal vertical
position. The position of the implant can be corrected
with the impactor (see Fig.70.10).
Fig. 70.8 Preparation of the implant bed using a broach. (With permis-
sion from Aesculap AG, Tuttlingen, Germany)
• Insertion on the contralateral side
The operative steps described above are now repeated
for the contralateral side. Bone material can be packed
between both implants. Additional posterior stabilization
of the segment should be performed (see Figs.70.10 and
70.11).
70 Posterior Lumbar Interbody Fusion withanInterbody Fusion Spacer orCage
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Fig. 70.9 Insertion of the spacer with the insertion instrument and
impactor. (With permission from Aesculap AG, Tuttlingen, Germany)
70.6.2.2 With aPEEK Spacer
(Operating steps are comparable to those for the titanium
cages.)
• Bone resection
• The bone is resected using an osteotome and a Kerrison
bone punch to gain access to the intervertebral space.
Alternatively, bone can be removed at the joints using a
chisel or high-speed burr.
• Revealing the disk space
Fig. 70.10 Additional posterior stabilization of the motion segment is
necessary
• The dura and upper nerve root are carefully retracted in
the desired direction using the nerve root retractors (see
Fig.70.3).
• The sharp leading edge of the instrument permits simple
bone resection to the dimensions required.
• Restoration of disk height
• Distraction can be set to the required height using the distractors (see Figs.70.11 and 70.12). The distractors are
inserted one after the other on alternate sides of the disk
until the desired distraction is obtained.
• Clearance of the intervertebral disk
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Fig. 70.11 Restoration of
disk height using different
distractors. Positioning of
contralateral distractor. (With
permission from Aesculap Ag,
Tuttlingen, Germany)
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Fig. 70.12 (a, b) Clearance of the intervertebral space. (With permission from Aesculap AG, Tuttlingen, Germany)
Fig. 70.13 Determination of
the implant size using trial
implants. (With permission
from Aesculap AG,
Tuttlingen, Germany)
U. Vieweg and S. Sola
• The disk space is cleared using rongeurs, bone
curettes, and rectangular curettes. Bone rasps are used
to refresh the cartilaginous end plates (see Figs.70.12
and 70.13).
• Determination of implant size using trial implants
• Trial implants are available in different sizes and with different angulations. Trial implants are inserted in turn,
starting with the smallest size. Each is inserted horizontally and rotated clockwise (see Figs.70.13 and 70.14).
Progressively, taller trial implants are inserted until the
required distraction has been achieved. The trial implant
now in place indicates the height, angle, and length of the
implant to be inserted.
• Insertion of the PEEK cage
• After lling the PEEK implant with bone graft or articial
bone substitute, the implant is clamped to the PEEK
insertion instrument (see Figs. 70.14 and 70.15) and
inserted in the intervertebral space (see Figs.70.15 and
70.16). The cage is lled with nely milled autologous
bone (the resected bone from the spinous processes and
the facet joints will generally be sufcient).
• Insertion on the contralateral side.
• The operative steps described are now repeated for the
contralateral side. Bone material can be packed between
both implants.
• Posterior stabilization
• Additional posterior stabilization of the segment should
be performed.
70 Posterior Lumbar Interbody Fusion withanInterbody Fusion Spacer orCage
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Fig. 70.14 The implant is
clamped to the insertion
instrument. (With permission
from Aesculap AG,
Tuttlingen, Germany)
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Fig. 70.15 Insertion of the PEEK cage with the insertion instrument.
(With permission from Aesculap AG, Tuttlingen, Germany)
Fig. 70.16 Three-column stabilization with anterior column fusion
with PEEK cage and posterior column xation with internal xator.
(With permission from Aesculap AG, Tuttlingen, Germany)
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References
1. Bronsard JJ, Tropiano P, Louis C, etal. Three–column spinal fusion
using ProSpace intervertebral blocks. In: Kaech DL, Jinkins JR,
editors. Spinal restabilisation procedures. Amsterdam: Elsevier
Science; 2002. p.153–70.
2. Cloward RB.Spondylolisthesis: treatment by laminectomy and posterior lumbar interbody fusion. Clin Orthop. 1981;154:74–82.
3. Freemann BJ, Licina P, Mehdina SH. Posterior lumbar interbody
fusion combined with instrumented posterolateral fusion: 5 year
results in 60 patients. Eur Spine J. 2000;9:42–6.
4. 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.
5. 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.
6. 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.
7. Potel A, Welch WC.Posterior lumbar interbody fusion with metal
cages: current techniques. Oper Tech Orthop. 2000;10:311–9.
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