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34 Minimally Invasive Wiltse Approaches for Posterolateral Fusion
ab
cd
357
Fig. 34.8 ( a ) The lamina and inferior articular process of
L4 are exposed, with the retractor engaging the tendon
inserting to the articular process of L5 and traversing to
sacral insertions. The multifi dus arising from the spinous
process is seen caudally. The retraction suture holds the
cephalad margin of the exposure open, retracting the ESA
medially. The dorsolumbar fascia has been freed along the
spinous process and refl ected laterally over the ESA. ( b )
The inferior articular process is removed. The medial
reliable surface anatomy to assist in screw
placement (Fig. 34.9 ). There is an arcuate fossa
between the lateral margin of the pars and the
accessory process that I fi nd critical for anatomic
placement of screws. Richard Hynes has used it
to assist in his screw placement and for reasons of
superior articular process has been removed. The foraminal venous complex overlying the disk is seen with a window for discectomy and fusion with minimal or no
retraction of neural elements. ( c ) Screw construct is in
place after interbody work is complete. The suture retaining the ESA has been removed allowing the tendons to
relax towards normal position. ( d ) AP x-ray view demon-
strating preservation of midline muscles
description and history I consider it Rick’s fossa.
The fossa defi nes the inferior dorsum of the
pedicle, with a transition to the accessory process
and longissimus lateral, and transition to the pars
interarticularis and lamina medial. Approach
over the surface of the lamina to the edge of
358
S. Ritland
Fig. 34.9 Landmarks for medial screw placement
traversing pars. There is a keel of cortical bone running
from the mammillary process to the of inferior articular
process that defi nes the transition from dorsal surface to
lateral margin of the pars interarticularis. There is an
arcuate fossa between the keel and lateral pars and the
accessory process that defi nes the dorsal and inferior mar-
the pars elevates the overlying muscle and
neurovascular supply. Identifying the lateral
margin of the pars defi nes a screw entry slightly
medial that maintains the course of the screw in
bone while accessing a relatively cortical trajectory to traverse the pars into the pedicle. Palpating
over the margin of the pars into Rick’s fossa
defi nes the plane of transition from pars to pedicle, with relatively certain defi nition of craniocaudal placement of the screw entry point to
avoid an inferior breach of the screw on the pedicle to pars transition.
I use a high-speed burr to make the initial
entry through the pars and convert to a tap once
the burr reaches the cancellous bone in the pedicle. I feel the margin of the pars and into Rick’s
fossa to defi ne the trajectory of the screw in the
sagittal plane and then rotate the trajectory to
place the screw entry on the dorsum of the pars
for a much stronger and more cortical screw
placement than starting in the fossa would
gin of the pedicle (Rick’s fossa). Palpation of the surface
of the fossa defi nes a plane of transition for screw trajectory across the pedicle. Moving medial on the surface of
the pars shifts the screw course to a tract through more
cortical bone and one that places the construct adjacent to
the spinous process, better underlying the muscle from
segment above
provide. The trajectory approximates 25° cranial
and 15° lateral to the axial and sagittal plane,
respectively (Fig. 34.10 ). Full dimension tapping
is important to avoid fracturing out the cortical
pars with an oversized screw. A cortical thread
screw of 4.5–5.5 mm diameter optimizes thread
pitch and minor diameter to most effectively
engage the bone and maximize screw strength.
Screw length is typically 25–35 mm.
In advanced degenerative cases, a combination of factors may obscure surface anatomy.
Settling of the disk brings the superior articular
process into contact with the inferior margin of
the pedicle and Rick’s fossa. Hypertrophic
arthropathy with capsular and bony overgrowth
of the joint further obscures the keel of lamina
and pars. Opening the facet joint allows one to
follow the inferior articular process to the keel of
the pars and Rick’s fossa.
The caudal screw presents slightly different
limitations. With a short exposure, I use a
34 Minimally Invasive Wiltse Approaches for Posterolateral Fusion
ab
359
Fig. 34.10 ( a ) A lateral x-ray demonstrates the sclerotic
cortical surface of the accessory process and Rick’s fossa
and defi ning a transition to pedicle. The white lines indicate margins of the sclerotic bone visualized on image.
The tap is seen with tip projecting across cortical density
into pedicle but is rotated to traverse the pars rather than
the cortical surface of the fossa. ( b ) AP x-ray image with
initial tap placement demonstrating trajectory to pedicle.
medialized trajectory entering through the
articular surface. The capsule of the facet provides some protection to the segmental nerve and
vessel just inferior to the joint, supplying the
adjacent multifi dus. I enter typically at the base of
the articular surface between middle and lateral
third, with an AP or slightly lateral trajectory that
allows the screw to engage the vertebral endplate
and lateral body junction for maximal security
(Fig. 34.11 ). If the canal has been decompressed,
direct confi rmation of the medial pedicle confi rms
anatomy. If the muscle has been detached for
exposure, placement analogous to the cephalad
screw is straightforward but requires a slightly
longer incision to achieve the desired trajectory.
On the left , the line segments defi ne the lateral border of
the pars transitioning to Rick’s fossa and a segment with
ends defi ning the entry to laminar surface and tip position
corresponding to tap. On the right , a line segment defi nes
a direct placement trajectory. Rotating the trajectory to a
medial entry over the laminar surface corresponds to the
alignment of the tap
L5 is unique in that the pars interarticularis is
foreshortened relative to cephalad levels, with a
less well-developed cortical portion than levels
above and with a transition to the pedicle and
body providing somewhat less margin to inferomedial pedicle compromise. In surgery it is frequently not easy to directly palpate the lateral
pars and into Rick’s fossa directly. Opening the
sacral facet joint allows one to follow the inferior
articular process of L5 to the fossa and inferior
pedicle and defi ne screw entry.
Sacrum presents a different issue. An analogous trajectory lacks the same cortical development seen at levels above, which relates to the
stresses across the lamina and pars associated
360
S. Ritland
with the dynamics of the motion segment disk
complex. I frequently place a pedicle screw
directly, or through the muscle with a medial
trajectory, to optimize placement in the better
bone under the sacral endplate and to engage the
sacral apex anteriorly. A short side connector
facilitates lining up with the cephalad construct,
if necessary. A sacral alar screw provides an
elegant and secure solution in many cases and
places the head of the screw in relatively better
alignment with a medial construct.
With two or three segments, it is possible to
Fig. 34.11 Medializing a pedicle screw at the caudal
segment, with entry at the lower margin of the articular
surface, provides adequate fi xation with a trajectory minimizing skin incision. When the segmental muscle origins
are preserved, this avoids extending across the medial
ramus and artery just below the facet
ab
pass the rod under or through the segmental
multifi dus; however detachment of the midline
muscles may facilitate and optimize surgery
while still preserving the neurovascular integrity
of the muscles (Fig. 34.12 ).
Fig. 34.12 ( a ) Medial screw construct with laminar
exposure L4 to sacrum. Detachment of midline muscle
attachments provides generous access for decompression
and bone harvest while still preserving the neurovascular
integrity of the muscles. The screws are placed deep to the
muscle arising on the L3 spinous process and remain
medial to tendon and neurovascular constraints along the
articular processes. Placing a sacral alar screw avoids disrupting multifi dus insertions to the sacrum ( b ) A lateral
view of the construct shows the cephalad trajectory traversing the pars interarticularis and pedicle
34 Minimally Invasive Wiltse Approaches for Posterolateral Fusion
361
34.6 Discussion
Anatomic approach about the muscles of the
back provides a muscle sparing, naturally minimal approach to the back. Historically, many
approaches simply disconnected muscles of the
spine for exposure as desired. Caspar [ 2 ] intro-
duced the use of the operating microscope to
lumbar discectomy, with a slightly paramedian
approach through the ESA, and retraction of the
multifi dus from the cephalad segment to avoid
local muscle compromise. Ritland [ 5 , 6 ]
described a microsurgical intermuscular fusion
or micro-TLIF, working about the muscle constraints with an intermuscular approach to construct placement, and a segmented intermuscular
approach to the lamina for decompression and
interbody fusion. Foley [ 3 ] initiated a parallel
approach to MISS with percutaneous screw fi xation and a transmuscular approach to the spine.
This provided a limited approach but one frequently extra-anatomic in regard to the tendon
and neurovascular elements in the back.
To the extent that MISS involves not just the
skin incision, but preservation of the muscular
integrity of the back, there is a compelling argument for approaches that respect the integrity of
the back muscles and work about rather than
through muscle fascicles. Engaging and respecting the segmental muscles in the back has the
potential to preserve muscle integrity at risk with
transmuscular or expanding retraction. In the situation of deformity and multisegmental correction, an intermuscular approach provides a
muscle-sparing approach to placing fi xation and
seats the construct between the major back muscles. Combined with a segmented approach to
facet or interbody fusion, it is possible to fully
preserve the back muscle integrity. It places the
construct between muscle groups with minimal
impact on segmental muscle function. A midline
approach for fi xation with medialized screw
placement is similarly anatomic. Midline muscle
detachment may provide a more generous
approach to the spine and spinal canal while still
preserving the neurovascular integrity of the
midline back muscles.
An understanding of the segmental muscles of
the back enables and facilitates anatomic
approaches to the back which preserve or minimally impact the functional integrity of the back.
It is reasonable to consider approaches which
detach muscles only as required to optimize
deformity correction, neurologic decompression,
or as necessitated for fusion.
Acknowledgments The artwork has been developed
with Scott Bodell over a period of years. It is meant to
illustrate the most relevant surgical anatomy. For purposes
of illustration and clarity, some details such as interspinales and intertransversarii have been variably omitted. It
expands on work previously published with Hoh [
erence Bogduk [
1 ] for anatomic nomenclature.
4 ]. I ref-
References
1. Bogduk N. Clinical anatomy of the lumbar spine and
sacrum. 4th ed. Edinburgh: Churchill-Livingstone;
2005.
2. Caspar W. A new surgical procedure for lumbar disk
herniation causing less tissue damage through a
microsurgical approach. In: Wullenweber R, Brock M,
Hamer JN, editors. Advances in neurosurgery. Berlin:
Springer; 1977. p. 74–7.
3. Foley KT, Holly LT, Schwender JD. Minimally
invasive lumbar fusion. Spine. 2003;28(15):S26–35.
4. Hoh DJ, Wang MY, Ritland S. Anatomic features of the
paramedian muscle-splitting approaches to the lumbar
spine. Neurosurgery. 2010;66(3 Suppl Operative):13–24.
5. Ritland, S. Microsurgical intermuscular lumbar arthrod-
esis. Poster Session, Congress of Neurological Surgeons,
Annual Meeting, San Antonio, Texas, September, 2000.
6. Ritland, S. Micro-TLIF™ a mini-open and intermus-
cular transforaminal lumbar interbody fusion. DePuy
AcroMed Inc, Surgical Technique, October, 2002.
7. Ritland S. Intermuscular approaches for lumbar fi xation
and arthrodesis. Semin Spine Surg. 2003;15(4):420–9.
8. Santoni BG, Hynes RA, et al. Cortical bone trajectory
for lumbar pedicle screws. Spine J. 2009;5:366–73.
9. Wiltse LL, Hutchinson RH. Surgical treatment of spon-
dylolisthesis. Clin Orthop Relat Res. 1964;35:116–35.
Minimally Invasive Thoracolumbar Facet Joint Fusion
Oliver Tannous, Kelley Banagan,
and Steven C. Ludwig
3 5
35.1 Introduction
For minimally invasive spine surgery to be
successful, it is mandatory that it achieves the
same goals that open surgical procedures achieve.
By avoiding collateral damages to anatomic
structures, the purported advantages of minimally invasive techniques include reduction in
postoperative pain, length of hospitalization,
blood loss, and medical and surgical complications. During the past several years, surgeons
have been expanding the indications for minimally invasive techniques from degenerative procedures to more complex spinal disorders,
including thoracolumbar deformity, trauma,
tumor, and infections. Paramount to successful
results of treatment of many thoracolumbar pathological conditions is achieving a solid biological
fusion.
A variety of techniques have been advocated
for achieving the fusion goal, including minimally invasive posterior interbody fusions, lateral interbody fusions, and anterior interbody
fusions. With the advent of implementing minimally invasive techniques for more complex
disorders, performing interbody approaches can
become an arduous task when spanning multiple
spinal segments. A different option for minimally
O. Tannous , M.D. • K. Banagan , M.D.
S. C. Ludwig , M.D. (*)
Department of Orthopaedics,
University of Maryland, 22 S. Greene Street,
Suite S11B, Baltimore, MD 21201, USA
e-mail: sludwig@umoa.umm.edu
invasive fusion would thus take advantage of
fusing the facet joint with the addition of
pedicular fi xation to stabilize and fuse the thoracolumbar segments.
Lumbar transfacet fi xation was fi rst introduced by King [ 1 ] in 1948. He described the
fusion technique with the use of short screws
inserted horizontally across the facet joint. The
screw member entered the inferior articular process and crossed the joint into the ipsilateral
superior articular process [ 2 ]. In 1959, Boucher
[ 3 ] described a modifi cation of King’s technique.
He used the same starting point but directed the
screw with a more vertical trajectory to penetrate
the base of the ipsilateral pedicle with the tip of
the screw to obtain greater body purchase.
Another modifi cation of transfacet fusion was
introduced by Magerl [
the use of a translaminar facet screw entering the
contralateral base of the spinous process, traversing through the lamina and entering the ipsilateral facet joint. With recent advances in minimally
invasive techniques, facet fusions can be accomplished with posterior pedicular fi xation as an
alternative to the use of transfacet screws to
achieve biological fusion.
4 ] in 1984, who described
35.2 Indications and
Contraindications
Indications for minimally invasive posterior
facet fusion with transfacet or transpedicular
fi xation include lumbar degenerative disorders,
M.Y. Wang et al. (eds.), Minimally Invasive Spinal Deformity Surgery,
DOI 10.1007/978-3-7091-1407-0_35, © Springer-Verlag Wien 2014
363
364
O. Tannous et al.
thoracolumbar fusions for deformity, trauma,
infection, and tumor reconstruction. Relative
contraindications to minimally invasive instrumentation include advanced osteoporosis and
active sepsis.
35.3 Surgical Technique Section
When performing minimally invasive posterior
facet fusions, the principles of minimally invasive posterior pedicle screw instrumentation are
applied and adhered to. The facet joints to be
fused are determined preoperatively. The pedicles associated with the chosen facets are cannulated in a minimally invasive manner. The
pedicles are visualized on a true anteroposterior
view intraoperative radiograph, with the endplates of the vertebral body parallel to the fl oor.
Once a true anteroposterior view radiograph has
been obtained, Kirschner wires (K-wires) are
placed over the skin and horizontal and vertical
lines are drawn on the skin through the center of
the pedicle. The intersection of the lines represents the approximate starting point for the pedicle screws. Based on the starting point, an
incision is made overlying the pedicle and vertebral body through skin, subcutaneous tissues, and
fascia. A Jamshidi needle is then introduced into
the incision and placed at the 3 o’clock and 9
o’clock positions of the pedicle. Placement of the
Jamshidi needle is confi rmed with intraoperative
fl uoroscopic imaging. Once the needle is in an
acceptable position, it is advanced to the pediclevertebral body junction and positioning is again
confi rmed with intraoperative imaging. A K-wire
is then introduced through the cannulated
Jamshidi needle. The K-wire is advanced into the
vertebral body.
K-wire placements at the respective levels are
confi rmed with fl uoroscopic guidance (Fig. 35.1 ).
Once the K-wires are deemed to be in acceptable
positions, the trajectories for the pedicle screws
are tapped over the K-wires (Fig. 35.2 ). The sizes
of the screws and the taps to be used are
determined based on preoperative CT. Once the
screw trajectory has been tapped, dilators are
placed over the K-wires in a sequential manner.
Fig. 35.1 Intraoperative fl uoroscopic image of K-wire
insertion into the pedicle and vertebral body with
overlying dilator
Fig. 35.2 Fluoroscopic image of screw placement after
facet fusion
The dilators are used not only to create a fi eld in
which to perform the facet fusion but, when used
in a wand-type manner, to clear the overlying soft
tissue from the facet joint (Fig. 35.3 ). Once the
appropriate sized dilator is placed over the facet
35 Minimally Invasive Thoracolumbar Facet Joint Fusion
365
joint, the surgeon should assess that optimal
visualization of the facet joint has been obtained
(Fig. 35.4 ). This often requires the use of a
headlight and loops if a microscope is not introduced into the fi eld. Bovie electrocautery is used
to clear the facet joint of overlying soft tissue and
capsule. This material is removed with a pituitary
rongeur. Once the facet joint is cleared of overlying soft tissue and is adequately visualized, a
high-speed cutting burr is introduced into the
tube. Lateral view intraoperative fl uoroscopic
imaging can be used with the burr in place to confi rm correct placement at the facet joint
(Fig. 35.5 ). The facet joint is then decorticated
with a high-speed burr. Next, bone graft material
of the surgeon’s choice is introduced through the
dilator and packed around the facet (Fig. 35.6 ).
The dilator tube is removed, and the screw is
inserted over the K-wire. The K-wire is then
Fig. 35.3 Intraoperative photograph of the dilator over
the facet joint
removed. This procedure is performed in
sequence, bilaterally, at all facet joints to be
addressed.
35.4 Clinical Data
Most of the clinical data regarding facet- mediated
fusions are based on open techniques [ 1 , 3 , 5 – 7 ].
King [ 1 ] described a fusion rate of 91 % in his
original series of 55 patients, with only one
patient experiencing nerve root irritation secondary to screw placement. Other surgeons [ 5 ], how-
ever, reported pseudarthrosis rates of up to 55 %
with transfacet screw fi xation using the King’s
technique. Boucher [ 3 ], with his modifi ed tech-
nique, reported a 100 % fusion rate in patients
undergoing single-level fusion for degenerative
disc disease and a 92 % fusion rate in patients
undergoing fusion for spondylolisthesis. In more
recent years, El Masry et al. [ 6 ] reported a 100 %
fusion rate, with 89 % of patients in this cohort
having excellent or good results and no neurological complications. Margulies and Seimon [ 7 ]
similarly reported that 91 % of their patients had
excellent clinical results after single-level fusion
with the open Boucher technique.
Magerl’s variation of open transfacet fi xation
using a translaminar facet screw has also been
shown to be a successful technique with few
complications and favorable clinical outcomes
[ 4 , 8 – 11 ]. Jacobs et al. [ 8 ] reported a 91 % fusion
rate with favorable clinical results in 93 % of
their cohort undergoing lumbosacral fusion.
Humke et al. [ 9 ] obtained a 94 % fusion rate
using translaminar facet screw fi xation for posterior fusion, achieving good or excellent clinical
results in 97 % of their patients. One of 173
patients in this series had temporary quadriceps
Fig. 35.4 View of the
decorticated facet joint
through the dilator tube
366
O. Tannous et al.
Fig. 35.5 Fluoroscopic image of the burr inserted
through the dilator to the level of the facet joint
resolved at minimum fi nal follow-up of 52
months. Other studies [ 10 , 11 ] using open
translaminar facet fi xation have reported fusion
rates exceeding 94 % with good or excellent
results achieved in a high percentage of patients.
Best and Sasso [ 12 ] also presented a cohort of
patients who underwent circumferential lumbar
fusion. The authors compared the reoperation
rate of translaminar facet screw fi xation with that
of pedicle screw fi xation. In this series, two of 43
patients (4.7 %) with translaminar facet fusion
and none of 24 patients (37.5 %) with pedicle
screw instrumentation required a second operation at the index level. Operative re-exploration
revealed that the pseudarthrosis rate was 2.3 % in
the translaminar facet screw population, compared with 4.2 % in the pedicle screw population.
Interestingly, the single patient in the translaminar facet screw group with pseudarthrosis had
additionally undergone an intertransverse process fusion, using pedicle screws, without
removal of the facet screws. All patients in the
pedicle screw group who underwent reoperation
required removal of the screws and rods.
To date, no study of open or minimally
invasive surgery has analyzed the results of performing thoracolumbar fusion with just a facet or
mediated fusions with pedicle screws. Whether
historical data regarding transfacet screw fi xation
with facet fusion is generalizable to minimally
invasive facet fusions with pedicle screws is
unknown. Thus, data to champion this technique
as a viable option is based on anecdotal
experiences.
Fig. 35.6 Intraoperative photograph showing placement
of bone graft through the dilator tube
weakness that resolved within 6 months after
fusion and decompression at L2−L3. Three of
173 had symptomatic nerve root irritation that
Conclusion
With advances in minimally invasive spine
surgery, percutaneous facet fusion is becom-
ing an attractive alternative for posterior lum-
bar fusion. The percutaneous procedures offer
numerous advantages compared with open
techniques, including less blood loss [ 13 – 15 ],
less soft-tissue disruption [ 16 – 18 ], less post-
operative pain [ 16 , 19 , 20 ], and less risk of
infection [ 14 , 21 , 22 ]. Radiation exposure is a
concern; however, it can be minimized with
virtual fl uoroscopy and CT-guided techniques
[ 23 , 24 ].
35 Minimally Invasive Thoracolumbar Facet Joint Fusion
367
Percutaneous facet fusion is a promising
technique. The clinical studies available to date,
however, are comparative and non-comparative
case series with no randomized controlled trials
with a different type of surgical technique.
Nevertheless, percutaneous facet fusion with
pedicular fi xation is a feasible alternative for
obtaining fusion through a minimally invasive
surgical approach.
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screw fi xation in circumferential interbody fusions as
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Tech. 2006;19:98–103.
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thoracolumbar region. Orthopedics. 2009;32.
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Grossterlinden L, Begemann PG, Baeumer T,
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