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10 T. Scarabino et al.
reach its full extent. IDET might also cause
destruction of sensitized nociceptors in the
annular wall. Denervation by thermal energy is
used widely for peripheral and central nervous
system lesioning and might contribute to partial
and initial pain relief following the procedure
[3, 4].
IDET is minimally invasive and has a low
complication rate. Although initial clinical
studies suggest that IDET might be effective in
approximately 70 % of patients with chronic
unremitting low back pain, its efficacy has not
been assessed in randomized controlled clinical
trials [5–8].
2.1.2 Chemonucleolysis
Chemonucleolysis is a minimally invasive
interventional procedure characterized by
destruction of the nucleus by the injection in the
intervertebral disk of papain, enzyme which
destroys nucleus without damaging the neighboring structures. Papain is injected percutaneously with posterolateral approach in the
intervertebral space, until the level of the hernia.
This technique should be preceded by allergy
test to papain and for radiological examinations
(CT, MRI) to confirm diagnosis of hernia. Procedure is performed under light anesthesia
(analgesics and neuroleptics), takes about
20 min, and requires 3–4 days of hospitalization. In 40 % of cases, the healing occurs three
days after the treatment, but sometimes later.
Therapy is considered failed if a month after
there was no sign of remission. Percentage of
success is about 70 % [9, 10]. This percutaneous
treatment, very popular in the 1980s, was phased
out for possible adverse reactions to chemical
parts.
2.1.3 Coblation
This minimally invasive interventional procedure is performed for ‘‘contained’’ hernia that
irritates nerve root causing pain in absence of
massive muscular deficits. This percutaneous
technique involves the insertion of a needle into
the disk space under radiological control. At this
level, a series of cold ablations are produced to
loose the disk tension, vaporize part of the
nucleus pulposus, and reduce pressure on the
irritated root. It is a cold disk lysis without
irritating effects of the other traditional techniques of aspiration. By this decompression, the
nerve root regains the lost space and is no longer
marked by protruding disk, and thus not subjected to mechanical irritation responsible for
the pain [11, 12]. Treatment takes about 30 min
and is performed under local anesthesia or with
patient mildly sedated in order to verify immediately the disappearance of pain. No surgical
wound is practiced and the patient can be dismissed the same day or, in special cases, the
immediately following. There are no risks,
thanks to the use of not high temperatures (max
70), which are not able to cause irritation or
damage to the adjacent spinal cord.
2.1.4 Laser Diskectomy
In the last 5 years, this minimally invasive
technology has improved particularly through
the use of highly precise and safe surgical laser,
making the procedure without risk, as long as
performed in hospitalized structures and experienced hands.
Under fluoroscopic or CT guidance, a fine
needle (less than 1 mm) is introduced in herniated intervertebral disk with interlaminar or
transforaminal or extraforaminal approach. Once
checked the correct position, a thin optical fiber
of 360 uM is introduced inside the needle,
connected to the laser, whose action towards the
herniated disk is partial vaporization with consequent retraction of the hernia, reduction of
intradiskal pressure, and improvement of disk
radicular conflict [13]. Laser also alters the
chemical and physical structure of the nucleus
pulposus and thus can change the chemical origin of pain by interfering with the mediators of
the inflammatory process. After laser treatment,
both macroscopic and histological characteristics are different for effect of depolymerization
2 Interventional Radiology 11
of condromucoproteine of the nucleus pulposus.
This process can have a positive influence on the
progression of the degenerative process and in
the stabilization of the segment.
The procedure, normally performed under
local anesthesia and sometimes a slight analgesic, takes 15–20 min for a single level treatment.
It is normally devoid of significant pain symptoms unlike other techniques that utilize heat
(coblation, nucleus plastic, radio frequency),
since the laser allows to concentrate very high
powers without dissipation of heat into the surrounding tissues. The physical characteristics of
the optical fibers (pure silicon) and their emission mode allows in fact to concentrate the
energy in just a few mm with energy absorption
rate greater than 90 %.
Patient can be dismissed within the day (day
surgery). There is no surgical wound or any
instability after the procedure. Antibiotic prophylaxis with analgesics to need is carried out
for 3 days. A day of rest is recommended and
returning to the normal working life occurs
within 1 week.
Results are satisfying in about 80 % of cases
with a significant reduction of complications
conversely present in traditional surgery [14, 15].
In case of failure, it can be repeated without any
compromise for the use of traditional surgery.
Laser energy is safer with the endoscopic
technique that allows to see clearly the surgical
field, to dose more appropriate energy, to irrigate
and aspire. Focus of the energy on the herniated
disk allows material removal in a more effective
and safe way [16].
Laser energy can be applied at a reduced dose
(Low Level Laser) in thermodiskoplasty, which
does not aim to remove disk material, but only to
change the intradiskal physical and chemical
environment [17]. The thermodiskoplasty acts
both on diskal pain, both on disk radicular
conflict in small dimension hernia. With non
ablative doses, laser energy causes a contraction
of the disk tissue by about 15 % (photocoagulation effect).
2.1.5 Oxygen Ozone Therapy
It is a minimally invasive interventional procedure extremely reliable and competitive. It has
recently developed much more respect than
other percutaneous techniques because it is
considered as a valid alternative to surgery. It
consists of periganglionic intradiskal injection of
a mixture of O
30 mg/ml) in order to have lytic action, antiinflammatory, and analgesic effects [18–20]. This
result is obtained thanks to three mechanisms:
(1) Direct action on mucopolysaccharides of the
nucleus with release of H
size of the disk that compresses the root, (2)
improved oxygenation and reduction of inflammation at the site of the disease for oxidizing
action on algogenic mediators of pain (in herniated disk there is increase in chondrocytes,
cytokines, prostaglandin E2, and sensitivity to
bradykinin), and (3) improved micro circulation
for rising venous stasis and loss of oxygenated
blood caused by mechanical compression.
The chronic reduction of oxygen is partly
responsible for the pain, because nerve roots are
susceptible to hypoxia. Patient, pretreated with
antibiotic therapy, is placed in prone position
with use of the pillow, in order to reduce the
physiological lumbosacral lordosis. The procedure is performed in a comfortable and sterile
setting, with mild sedation and local anesthesia.
The interbody space is identified under scopic or
CT control, then a needle is placed in the nucleus
pulposus where is introduced a mixture of O
Mostly it is includes the injection of steroids and
anesthetics, as long as patients are not already
treated for recurrent disk herniation and scarring
following surgery. By this way, the appearance of
any transient paraplegia (lasting 2 h) is avoided
due to postsurgical inflammatory processes in the
epidural space. Headache is caused instead due to
epidural anestheticdiffusion. It isrecommended a
48 h postoperative period of no absolute rest with
the beginning of specific physiokinesitherapy
after a week.
(3–10 cc, concentration of
2–O3
O and reduction of
2
2O3
.
12 T. Scarabino et al.
2.2 Percutaneous Techniques
in Vertebral Collapses
Percutaneous interventional techniques currently
used in treating various nature collapses (osteoporotic, traumatic, and neoplastic) are represented by vertebroplasty and kyphoplasty. Both
reach a similar result, with specific advantages
and disadvantages (mainly the lower cost in
vertebroplasty).
2.2.1 Vertebroplasty
Vertebroplasty is a minimally invasive interventional procedure specified for the treatment
of painful osteoporotic vertebral fractures
refractory to medical therapy, for risk of neoplastic fractures (hemangioma, metastases,
myeloma, and lymphoma) and for osteonecrosis
(Kummell’s disease). It is also useful in patients
with multiple fractures where possible, and further collapses would lead to respiratory compromission, in unconsolidated fractures in
healthy bone and in treatment of cystic degeneration [21–23]. Absolute contraindictions are
stable asymptomatic fractures, effective medical
therapy, osteomyelitis in fractured vertebra,
uncorrectable coagulopathy, allergy to components, and local or systemic infections such as
spondylodiscitis. Relative contraindications are
radicular pain or radiculopathy caused by compressive syndrome not related to vertebral fracture, fragment displaced posteriorly with
compromission [20 % of the spinal canal,
tumor extended into the epidural space, acute
traumatic fracture of not osteoporotic vertebra,
severe compression of the vertebral body, and
stabilized fracture without pain lasting more
than a year. This technique developed in France
in the mid-1980s and has only recently been
widely circulated in other European countries
(including Italy) and United States, favored
above all by lower costs of DRG (diagnosis
related group) compared to other similar techniques (kyphoplasty).
Vertebroplasty consists of the injection in the
center of the vertebral body of few cc (may also
be enough 2–5 cc) of low viscosity bone cement,
called polymethyl-methacrylate (PMMA), which
diffuses within the fractured vertebral body,
distributing itself along the lines of failure
(regardless of the outcome of imaging). This
material solidifies quickly, resulting in the
immediate consolidation of the bone and preventing further collapses. It results in reduction
of pain that definitively disappears within maximum 24 h so that patients can repurchase regular
mobility. A specifically conformed metal needle
(10–15 cm in length with a gauge of 10–15 G) is
introduced under the double combined guide of
CT and digital fluoroscopy, in order to minimize
the execution time (20–30 min) and then the
related risks. Approach is usually transsomatic
(with small and unique surgical breech to reach
the center of the body), sometimes transpedicle
(for levels L4 and L5). This procedure is performed with patient awake, in presence of the
anesthetist that monitors vital functions, usually
under local anesthesia, preferably in day surgery.
After the procedure, patient can stand up after
2 h, then after 4 h can be dismissed with muscle
relaxants therapy. The pre-treatment evaluation
should first include clinical examination in order
to focus the level of pain (pain must be treated,
not the image !!). Preliminary PT, PTT, platelets
and INR examinations are necessary to have the
certainty that the patient can be submitted to
surgery, for which is significant evaluate
breathing capacity and if patient can stay prone.
Diagnostic algorithm pre-treatment involves
X-ray that documents the collapse, sometimes
associated with a targeted CT scan. MR is still
the gold standard because it is able to clearly
identify the vertebra to be treated. MR particular
sequences (fast field eco T2 weighted with fat
suppression or STIR) document edema pattern
in the cancellous bone of the fractured vertebrae,
even in the absence of clear vertebral collapse.
Conversely ld collapses, without edema pattern
should not be treated [24–26]. The choice of
vertebra to be treated is in fact based not only on
2 Interventional Radiology 13
the shape at X-ray but even in the presence of
edema on MRI proving that fracture is recent.
This finding should be related to the precise site
of pain reported by the patient with a targeted
digital pressure.
Vertebroplasty obtains excellent results in
treatment of pain caused mainly by osteoporosis
(with positive results up to 90 %), and in less
measure in treatment of vertebral metastases
(approximately 70 % efficacy) [27]. One-third of
all vertebral fractures is attributable to osteoporosis and in Italythere are approximately 100,000
vertebral fractures each year (1/3 of them with
significant pain). Conventional treatment
involves a long immobilization (30–60 days) and
analgesic with the risk of complications (thrombophlebitis or pneumonia). Multiple osteoporosis
fractures can also be treated in the same session
(up to three) when symptomatic and white edema
pattern (if there is no pain, no treatment shouldbe
carried out) [28]. Sometimes it is advisable to
treat the clinically most affected vertebra and then
treat the other collapses at a later time. The
majority of patients (80–85 %), which benefited
from this therapy reported a reduction or resolution of pain during the first 14 days, with an
average of 72 h, which made it possible to stop
wearing thebust, to reduceanalgesics, and thusto
improve thequality of life. In vertebra affected by
metastases orprimary tumor (angioma, myeloma,
plasmacytoma) vertebroplasty allows to quickly
obtain the stabilization of the itself and the
reduction/resolution of pain within 12–24 h after
treatment in 96–98 % of cases (the radio and
chemotherapy reach analgesia in 2–4 weeks),
with significant improvement of quality of life. In
such cases, vertebroplasty is still a palliative
treatment and is not in any way considered as a
cancer treatment; patients should therefore continue to perform traditional therapies [29, 30].
Within this procedure it is also possible perform a
spine biopsy. Complications are iatrogenic damage due to puncture with temporary increase in
pain and possible passage of cement in unwanted
locations, usually modest and precocious thanks
to the double scopic and CT guidance (1–2 %
osteoporosis, 10.5 % in the case of metastases).
Carried out vertebroplasty moreover, there is the
risk that the adjacent vertebra, over or below,
might collapse. In the event of intradiscal dripping of cement the risk of a new fracture
increases.
2.2.2 Kyphoplasty
Kyphoplasty is a minimally invasive interventional procedure in the treatment of vertebral
thoracolumbar painful fractures caused by primary or secondary osteoporosis, by neoplastic
osteolytic metastases, vertebral hemangiomas,
and trauma [31]. Contraindications include
pregnancy, coagulation abnormalities, and pain
not associated with vertebral collapses. This
technique is performed in the majority of cases
with patient awake, under local anesthesia.
Through an incision of 1 cm, an inflatable pad is
inserted into the fractured vertebral body. Balloon is then inflated to reduce the fracture and
restore the height of the body, subsequently it is
deflated and removed, leaving a cavity in the
vertebral body. The empty space is filled with
cement creating a sort of ‘‘internal plaster cast.’’
In this way there is the restoration of the height
and morphology of the vertebral body (not
always possible with vertebroplasty), the stabilization of the fracture, the alignment, and the
consolidation of spine [32]. Furthermore, with
the cavity created in the bone, there is the
reduction of the risk of cement leakage, greater
with vertebroplasty (incidence from 15 to 67 %).
Resulting benefits are the reduction of pain up
to 90 % with consequent improvement in the
functionality ofthe spine andquality of life. It has
recently been introduced a new system (VesselX) made following the principles of kyphoplasty,
which also reduce the risk of dispersion of
cement. The procedure involves the use of a
container made of double-layer network of telephthalate. This is a biocompatible and microporous material which allows slow and uniform
cement diffusion. Unlike traditional kyphoplasty,
in which the balloon is removed after having
created the cavity inside the vertebral body, with
this method the container filledwith cement is left
within.
14 T. Scarabino et al.
New minimally invasive percutaneous systems in treatment of osteoporotic vertebral collpases is OSSEOFIX, which consists in using a
titanium implant together with cement. Such
device, of cylindrical shape, once inserted into
the vertebral body, restores its height and
immediately stabilizes the fracture; subsequently
the space created in the vertebral body implant
(which remains on site) is filled with cement. The
use of the plant ‘‘stand-alone’’, is currently being
studied without insertion of cement, in treatment
of fracture of the posterior wall of the body.
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6. Assietti R, Morosi M, Migliaccio G et al (2011)
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8. Tsou HK, Chao SC, Kao TH, et al (2010) Intradiscal
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Neurol Int 4, 1:37
9. Javid MJ, Nordby EJ (1996) Lumbar chymopapain
nucleolysis. Neurosurg Clin N Am 7:17–27
10. Nordby EJ, Javid MJ (2000) Continuing experience
with chemonucleolysis. Mt Sinai J Med 67:311–313
11. Azzazi A, AlMekawi S, Zein M (2011) Lumbar disc
nucleoplasty using coblation technology: clinical
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12. Zhu H, Zhou XZ, Cheng MH et al (2011) The
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Int Orthop 35:1677–1827
13. Hao XL, Fu ZJ, Xu YJ et al (2012) Treatment of
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14. Singh V, Manchikanti L, Benyamin RM et al (2009)
Percutaneous lumbar laser disc decompression: a
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15. Menchetti PP, Canero G, Bini W (2011)
Percutaneous laser discectomy: experience and long
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16. Boult M, Fraser RD, Jones N et al (2000)
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Z J Surg 70:475–479
17. Chiu JC, Negron F, Clifford T et al (1999)
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Sciatica: treatment with intradiscal and
intraforaminal injections of steroid and oxygenozone versus steroid only. Radiology 242:907–913
19. Muto M, Andreula C, Leonardi M (2004) Treatment
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intraforaminal oxygen-ozone (O
J Neuroradiol 31:183–189
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Minimally invasive oxygen-ozone therapy for lumbar
disk herniation. AJNR 24:996–1000
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Oxygen-ozone therapy for degenerative spine disease
in the elderly: a prospective study. Acta Neurochir
108:137–142
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history, technique and current perspectives. Clin
Radiol 59:461–467
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Interv Radiol 14:S311–S315
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successful vertebroplasty. AJNR 26:1595–1600
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) injection.
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2 Interventional Radiology 15
29. Alvarez L, Perez-Higueras A, Granizo JJ et al (2003)
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Surgery
Tommaso Scarabino, Vincenzo Brandini, Michele Santoro
and Raniero Mignini
3
Surgery of spinal pathology should include: high
cure rates, possibility of simply intervening on
patients already treated, low recurrence rate,
absence of contraindications, minimal side
effects, no complications in the short, medium
and long term, no acute or chronic toxicity,
absence of requiring long hospitalization, short
convalescence, maximum conservativity of
spinal biomechanics in treated district, reduction
of the need of post-operative use of orthopedic
devices (busts, corsets etc.), low cost.
Spinal surgery, as happens for the other districts, may present complications, for a large part
neurological (3–6 % incidence), which can be
classified according to the mechanism and the
time in which they occur [1, 2]. Causes of injury
are generally direct or indirect. Direct injuries
(tear, compression, traction and avulsion of the
neural elements) are most commonly the result
of a technical failure of the surgeon. Indirect
injury are due to the alteration of the blood
supply to the spinal cord and nerve roots, or to
the gradual compression of the neural elements,
for example in the correction of a deformity or
for a postoperative hematoma. This kind of
V. Brandini M. Santoro R. Mignini (&)
Department of Neurosurgery, ‘‘Lorenzo Bonomo’’
Hospital, Andria, Italy
e-mail: ranieromignini@libero.it
T. Scarabino
Department of Radiology—Neuroradiology,
‘‘Lorenzo Bonomo’’ Hospital, Andria, Italy
lesion is usually the result of ischemia or disruption of the vascular flow.
According to the timethey occur,complications
are classified into intra-operative, early postoperative (1–14 days), postoperative or later (after
14 days), whose gravity isrelated with complexity
ofsurgery.Intraoperativeeventsare usuallyrelated
to complications deriving from anesthesia, position of the patient, technique specific risks. Possible early complication of spinal surgery is
thromboembolism whose risks can be reduced but
not absolutely removed with anticoagulant prophylaxis. Risk of mortality from pulmonary
embolism at 30 days after surgery varies between
0.5 and 1.5 per 1,000 patients. In early postoperative, and up to 2 weeks after, neurological lesions
are most commonly secondary to direct compression of neural elements. This is often caused by
compression of a possible hematoma, epidural
abscess or pseudomeningocele.
Surgery should be done only in case of real need
and with minimum trauma and invasiveness. The
two most common surgical approach in lumbar
spine surgery are: decompression for the treatment
of hernia and fusion forthe degenerative pathology.
Decompression surgery involves removing a
small portion of the bone over the nerve root and
then of disk material to relieve pinching of the
nerve (microdiskectomy or laminectomy).
Lumbar spinal fusion involves using bone graft
to stop the motion at a painful vertebral segment
in order to decrease suffering. Several medical
devices with different techniques are available in
spinal fusion surgery [3, 4].
T. Scarabino and S. Pollice (eds.), Imaging Spine After Treatment,
DOI: 10.1007/978-88-470-5391-5_3, Springer-Verlag Italia 2014
17
18 T. Scarabino et al.
3.1 Surgery Techniques in Discal
Hernia
Intervertebral disk sinergically works with
interapophyseal joints forming thus a functional
unit. It has moreover, a close relationship with
neural adjacent structures and it is strongly
stimulated by pressure and torsion forces of head
and trunk. Its functionality therefore is important
in determining quality of life.
Spinal surgery should be effective and
respectful of original structure, easy execution
and low cost. Furthermore it should be justified
by consistent correlation between reported
symptoms (areas of pain irradiation, paresthesia,
functional limitation), examination (clinical trials and reflections) and imaging (CT, MRI) [5,
6], duration of symptoms more than six weeks,
pain unresponsive to analgesic, failure of conservative treatments.
Traditional techniques are microdiskectomy
(or small open surgery) and diskectomy (open
decompression), both carried out in order to solve
the compression and delete the material that
triggers the inflammatory process responsible for
the pain. Thechoice dependsfrom severalreasons
(for examplein the presence ofroot canal stenosis
diskectomy is preferred) and the duration of the
sciatic pain [7–11]. In cauda equine syndrome
surgery should be carried out urgently.
3.1.1 Microdiskectomy and Standard
Discectomy
Microdiskectomy consists in full or partial
removal of the nucleus pulposus, with the aid of
the surgical microscope that zoom neural structures (dural sack and nerve root). Approximately
90–95 % of patients will experience relief from
sciatic pain after this surgery. Standard diskectomy instead involves open air full or partial
removal of the herniated nucleus pulposus which
is causing compression on the neural elements.
When sciatic pain is due to lumbar spinal stenosis, surgery involves removal of disc and part
of the bone which is pinching nerve root.
Decompressive surgery is performed by laminotomy (bone resection limited to small segments of inferior margin of the cephalic lamina
and the superior margin of the caudal lamina),
laminectomy (bone resection of the entire width
of lamina), laminectomy and facetectomy (bone
resection of part or full facet joint in addition to
cephalic and caudal laminae).
Access to the spine occurs through maximum
3 cm incision focused on the vertebral body,
with dissection of the muscle and small opening
in the ligamentum flavum, sometimes with
minimal removal of part of the upper sheet (emilaminectomy).
After lumbar laminectomy approximately
70–80 % of patients typically experience relief
from sciatic nerve pain.
Surgical complications, such as wound
infections and nerve roots damage, are more
frequent than in microdiskectomy. These minimally invasive techniques allow to mobilize the
patient in the first day and generally dismiss in
the second. However, may occur instability and
spinal pain in a short time. With the lack of disk
and then its damping function, the disk above
and below will work harder with resulting risk of
other hernias, especially in patients performing
heavy physical activity or overweight.
Another consequence is the appearance of
scoliosis (lateral inclination of the spine from the
operated side where disk thickness is insufficient) with consequent pain syndrome (called
‘‘kissing spine’’), early facets arthrosis, narrowing of the canal, possible nerve entrapment and
then further return of pain. Friction of the vertebral bodies adjacent to the treated disk
involves formation of osteophytes causing low
back pain [12]. Moreover, there may be a
recurrence or a fibrous scar, that if hypertrophic
can compress and irritate the affected nerve and
require a second operation (the risk of reoperation is around 3–15 %). Most of the surgeons
therefore have almost left this type of intervention for the high risk of complaints for
‘‘malpractice’’ and statistical studies showing
that after four year there is a return back to
preoperative clinical conditions.
3 Surgery 19
3.2 Surgery in Degenerative
Disorders
It is used when conservative management has
failed, in spondylolisthesis, scoliosis or deformity, post-discectomy syndromes, segmental
instability adjacent to a previous fusion site,
unstable spine caused by infections, tumors or
fractures. It can be performed with traditional
stabilization (known as fusion surgery) or with
more recent ‘‘dynamic stabilization’’ (non-fusion
surgery) [3, 4].
Once stabilization consisted in weld the two
adjacent vertebrae with each other to abolish any
abnormal motion (traditional stabilization by
fusion) thanks to access to posterior surface of the
vertebrae with gouges, scalpels and rongeurs, to
activate a mechanism aiming to callus formation.
Over the years, with the development of materials
and surgical techniques, posterior arthrodesis was
replaced by the posterolateral (including the
articular apophyses and transverse processes), then
by the distraction and internal stabilization associatedwith arthrodesis;in the 70s finally, therewas
the emergence of stabilization with transpedicular
screws. Some limits like deterioration of the
instrumented arthrodesisin the years following the
operation and degenerative effects above and
belowarthrodesis obtainedwith rigid stabilization,
have recently developed a new surgical concept
which aims to abolish abnormal motions between
the bodies maintaining normal mobility of the
joints (called ‘‘dynamic’’ or ‘‘elastic’’ stabilization) using less rigid instrumentations and materials with bone-like elasticity in order to preserve,
at least partly, spinal micro movements.
Dynamic stabilization, by use of special
devices, allows to prevent the degenerative
cascade preserving the physiological rigidity and
stability of the functional unit and therefore
maintain natural mobility before degenerative
effects become irreversible. Recently emerged
the need to use a hybrid technique, with new
instrumentations able to respond in a modular
way, according to the pathology and the choice
of the surgeon, in order to abolish or preserve
the motions of each functional spinal unit.
3.2.1 Fusion Surgery
Fusion surgery consists of fusion of two or more
adjacent bodies and removal of the intervertebral
disk in order to stop the motion at painful vertebral segment (whit decreasing of pain generated from the joint), to stabilize the spine, to
replace resected components, to maintain anatomic alignment and to prevent pseudarthrosis.
Spinal fusion involves the insertion of a bone
graft (to stimulate bone growth) or bone graft
substitute (natural or synthetic material to
replace bone tissue and stimulate growth)
between two vertebral elements with or without
any material in the space left by disk removal.
Bone fusion occurs within 4–5 months after
surgery. Bone graft does not determine fusion at
the time of the surgery, but allow growing of new
bone to interfuse a section of the spine together
(into one long bone). For few moths after surgery
some devices are typically used to provide stability for that section; over the long term the solid
fusion occurred, provides itself to stability [13].
Devices commonly used are rods and plates,
translaminar or facet screws, transpedicular
screws, interbody spacers [14]. The choice of
these devices depends on clinical problem, anatomic location and surgeon preference [3, 4, 15].
Lumbar Spine Fusion
Traditionally there are different ways to fuse
lumbar spine. Anterior and posterior fusion
procedures are frequently complicated by persistent or recurrent low back pain that is probably multifactorial and caused by surgical
approach, pseudoarthrosis and development of
adjacent-level disease. Traditional surgery can
also result in complications like vascular and
bowel injury, sympathetic dysfunction and can
improve long-term clinical outcomes. Advanced
alternative minimally invasive approaches have
been developed to avoid these complications
[3, 4]. The recent innovative biologic osteoinductive materials like BMP (bone morphogenic
protein) are able to reduce adjacent-level
20 T. Scarabino et al.
disease. Motion-preserving devices moreover,
can be causes of complications [3, 4].
Lumbar spinal fusion surgery is more effective when involving only one vertebral segment,
not determining mostly any limitation in motion.
Multi-level fusion surgery may be considered
necessary in cases of scoliosis, kyphosis,
spondylolisthesis and lumbar deformity, fractures, tumors, infections, rarely in treatment of
only pain. Lumbar fusion spine therefore has a
small success rate in multi-level treatment.
Advances Lumbar Spinal Fusion
Advances minimally invasive fusion include
laparoscopic anterior lumbar interbody fusion
(ALIF), posterior lumbar interbody fusion
(PLIF), transforaminal lumbar interbody
fusion (TLIF), posterolateral gutter fusion, direct
lateral interbody (or fusion across the disk
space) fusion, extreme lateral interbody fusion
(XLIF) and trans-sacral fusion (axial lumbar
interbody fusion, AxialLIF) [3, 4]. Purpose of all
interbody fusion devices is to remove degenerate
disk material, restore and maintain disk space
height and normal sagittal contours (lordosis),
and increase stability of treated segment. Each
technique can stand alone or can be associated
with supplemental segmental instrumentation.
anterior approach alone. In cases where there is
not high instability, an ALIF alone can be sufficient especially in cases of one level degenerative disk disease and where disk space collapse is
not excessive.
Posterior Lumbar Interbody Fusion
PLIF is performed by using a posterior surgical
approach (bilateral partial laminectomies, caudal
and cephalic) followedby diskectomy. Bone graft
material is packed into the anterior disk space
before the insertion of an interbody spacer or two
interbody spacers placed side by side and packed
with graft material. Further bone graft material is
then packed into the remainder of the disk space.
Posterior instrumentation is performed toprovide
a rigid support until bone fusion occurs.
Posterior surgery has a higher potential for a
solid fusion rates than posterolateral because the
bone is inserted into the anterior portion of the
spine. Bone in the anterior portion fuses better
because there is more surface area than in the
posterolateral gutter, and also because the bone
is under compression. Conversely not as much
of the disk space can be removed with a posterior approach. Moreover, there is a small risk
that inserting a cage posteriorly will allow it to
retro pulse back into the canal and create neural
compression.
Anterior Lumbar Interbody Fusion
ALIF is performed by using an anterior approach
when pain is predominantly diskogenic and
posterior decompression is not required. This
approach is performed by using a lower abdominal incision or retroperitoneal approach through
the flank. An anterior approach provides for a
much more comprehensive evacuation of the
disk space and this leads to increase surface area
available for a fusion. A larger spinal implant can
be inserted with following superior stabilization.
These are supplemented by screws and rods or
plates, which may be placed either anteriorly or
posteriorly (depending on access) because of the
need to provide more rigid fixation than an
Transforaminal Lumbar Interbody Fusion
TLIF is similar to the posterior one but is performed by using a more lateral approach that
leaves the midline bone structures intact, minimizes central spinal canal disruption, and reduces dural tube traction and exposure.
A total facetectomy is generally performed to
gain access to the lateral disk space. Transforaminal interbody spacers are crescent shaped and
are placed anteriorly in the disk space. TLIF
procedure has several theoretical advantages
over some other forms of lumbar fusion. First of
all bone fusion is enhanced because bone graft is
placed both along the gutters of the spine