Original Article

PLIF With Total Facetectomy

R Koç

Citation

R Koç. PLIF With Total Facetectomy. The Internet Journal of Minimally Invasive Spinal Technology. 2010 Volume 4 Number 1.

Abstract


Fusion surgery in lumbar spine may be performed as followsInterbody fusionAnterior lumbar interbody fusion (ALIF)Posterior lumbar interbody fusion (PLIF)Transforaminal lumbar interbody fusion (TLIF)Extreme lateral lumbar interbody fusion (XLIF) AxiALIFPosterior or posterolateral fusionInterbody fusion is believed to be superior to posterolateral fusion in terms of biomechanical stability, safety and efficiency. Interbody space has more vascularity than posterolateral space, which increases potential for a solid fusion. Interbody fusion helps to restore disc space height, lumbar lordosis, and coronal and sagittal balance of the spine. Postoperatively, the differentiation between a fusion and a pseudarthrosis is easier after an interbody fusion. The rate of fusion was reported to be higher with interbody fusion than with posterolateral fusion (some series have reported fusion rates up to 96%).Indications for PLIF - Spondylolisthesis (usually Grade I or II)- Postdiscectomy collapse with neural foraminal stenosis and radiculopathy- Pseudarthrosis- Postlaminectomy kyphosis- Lumbar deformity with coronal or sagittal imbalance - Recurrent lumbar disc herniation with significant mechanical back pain - 3rd-time or greater recurrent lumbar disc herniation with radiculopathy (w/ or w/o back pain)- DDD causing discogenic low-back painRelative contraindication for PLIF - Severe osteoporosis (possible subsidence of interbody grafts through the endplates)TLIF or PLIF ?PLIF requires significant retraction on the thecal sac and nerve roots, which may cause dural tear, dysesthetic nerve root pain syndromes, nerve root injury, epidural fibrosis . Some authors have modified the PLIF approach to reduce thecal sac retraction by removing almost the entire facet complex.To avoid the complications of PLIF, Harms and Rolinger described the TLIF technique in which bone graft and titanium mesh are placed via a posterolateral transforaminal route into a distracted disc space in conjunction with a supplemental pedicle screw construct.PLIF: Vertebrae are reached through a posterior midline incision.TLIF: An approach from lateral to medial is obtained through posterior paramedian incision.Advantages of TLIF compared with PLIF - Decreasing epidural bleeding and scarring - Less destruction of the posterior elements - Less gross destabilization of the spine- Being able to be performed safely above L3 Advantages of PLIF compared with TLIF - Offering direct neural decompression - Reducing the risk of nerve root injury due to minimal root retraction- Being easier and familiar for all spine surgeons - Being able to be performed safely at all levels - Lowering radiation Technique of PLIF with total facetectomy - Skin incision is made midline, 7-10 cm.- Decompression of neural elements are performed.- Unilateral total facetectomy is performed by removing the facet and lamina in large pieces with Kerrison punch, osteotomes and rongeurs. It is used as a local autograft.- Excessive retraction of neural elements must be prevented during discectomy, bone grafting and cage inserting.- Pedicle screws are placed.- Distraction of interspace is performed by pedicle screw distraction, interbody wedge distracters, interlaminar distractor or intervertebral body spreader.- Endplate lips are removed by Chisel, drill or Kerrison rongeur.- Discectomy is performed by curettes and discector.- Endplate preparation is done by curettes and osteotome.- Interbody spacer placement is performed by PEEK cage and bone graft inserting through transforaminal area. Collapsed disc space shouldn’t be over distracted.- Pedicle screw construct compression is done.- Posterior fusion over contralateral lamina and facet is optional.Outcome in PLIF with cage and posterior instrumentationThe fusion rate was 90%. Satisfied outcome was 67%. Radiographically demonstrated fusion was not statistically related to clinical outcome (p=0.2).Complications of PLIF with total facetectomy Intraoperative dural tear %7.6 pedicle screw malposition %2.8Early postoperative brain infarction %0.4 infection %0.4Neurological no motor loss, increased leg pain (MMT Score 5) %0.8 slight motor loss (MMT Score 3-4) %2.4 severe motor loss (MMT Score 3) %3.6 permanent motor loss %1.6Late postoperative hardware failure %1.2 nonunion %1.2adjacent-segment degeneration %14.4ConclusionsThe rates of fusion are higher in interbody techniques.Radiographically demonstrated fusion is not related to good clinical outcome.Use of autogenous bone grafts is better. So local autogenous bone grafts should be preferably used.PLIF with total facetectomy is better than PLIF with cage. PLIF with total facetectomy and TLIF have similar outcomes.

 

References

Author Information

Rahmi Kemal Koç, Prof. Dr.
Department Of Neurosurgery, Erciyes University, Faculty Of Medicine, Kayseri, Turkey

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