Decision Making in Degenerative Spinal Surgery A Case Based Appr

NEUROSCIENCE RESEARCH PROGRESS
DECISION MAKING IN DEGENERATIVE

SPINAL SURGERY
A CASE BASED APPROACH
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DECISION MAKING IN DEGENERATIVE

SPINAL SURGERY
A CASE BASED APPROACH
SHEERAZ A. QURESHI, MD, MBA

THE MOUNT SINAI MEDICAL CENTER, NEW YORK
AND
KERN SINGH, MD
RUSH UNIVERSITY MEDICAL CENTER, CHICAGO, IL
EDITORS
New York
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Contents
Preface ix
Case Vignette 1: Cervical Disc Herniation 1
Chapter 1 Anterior Cervical Discectomy and Fusion 3
Mark F. Kurd, MD
Chapter 2 Cervical Disc Replacement 9
Jonathan Rasouli, MD, Branko Skovrlj, MD
and Sheeraz A. Qureshi, MD
Chapter 3 Minimally Invasive Posterior Laminoforaminotomy
and Microdiscectomy 19
Ehsan Tabaraee, MD, Junyoung Ahn, Andrew J. Park
and Kern Singh, MD
Case Vignette 2: Multilevel Cervical Myelopathy 27
Chapter 4 Posterior Cervical Laminectomy and Fusion 29
Samuel C. Overley, MD, Steven J. McAnany, MD
and Andrew C. Hecht, MD
Chapter 5 Cervical Laminoplasty 39
Daniel Park, MD
Chapter 6 Anterior Cervical Decompression and Fusion 49
Shah-Nawaz M. Dodwad, MD and Alpesh A. Patel, MD
Case Vignette 3: Cervical Pseudoarthrosis 57
Chapter 7 Anterior Approach 59
Krzysztof B. Siemionow, MD and Piotr Janusz, MD
Chapter 8 Posterior Approach for an Anterior Cervical Pseudoarthrosis 71
Abhishek Kannan and Wellington K. Hsu, MD
vi Contents
Case Vignette 4: Thoracic Disc Herniation 81

Chapter 9 Anterior Approach 83
Sleiman Haddad, MD, Paul W. Millhouse, MD,
John D. Koerner, MD and Alexander R. Vaccaro, MD, PhD
Chapter 10 Minimally Invasive Retropleural Discectomy 91
Junyoung Ahn, Ehsan Tabaraee, MD, Vincent J. Rossi,
Andrew J. Park, Khaled Aboushaala, MD and Kern Singh, MD
Case Vignette 5: Lumbar Disc Herniation 99
Chapter 11 Open Microdiscectomy 101
Islam M. Elboghdady, Hamid Hassanzadeh, MD
and Howard An, MD
Chapter 12 Minimally Invasive Microdiscectomy 109
Steven McAnany, MD, Jun Kim, MD
and Sheeraz A. Qureshi, MD, MBA
Chapter 13 Full Endoscopic Discectomy for Recurrent Lumbar Disc Herniation 117
Pablo J. Diaz-Collado, MD and James J. Yue, MD
Case Vignette 6: Lumbar Spinal Stenosis 129
Chapter 14 Open Laminectomy 131
Safdar N. Khan,MD, Jordan Kapke, Vincent J. Alentado,
Daniel Lubelski and Thomas E. Mroz, MD
Chapter 15 Minimally Invasive Tubular Decompression 141
Xin Feng Li, MD, Ji Hyun Lee, PA-C
and Larry T. Khoo, MD
Chapter 16 Interspinous Process Distraction 151
Ehsan Saadat, MD and Thomas D. Cha, MD
Case Vignette 7: Degenerative Lumbar Stenosis with Spondylolisthesis 159
Chapter 17 Open Posterior Decompression and Fusion 161
Christopher C. Gillis, MD, Paul A. Anderson, MD,
Jason W. Savage, MD and John E. O’Toole, MD
Chapter 18 Minimally Invasive Transforaminal Lumbar Interbody Fusion 171
Islam M. Elboghdady, Junyoung Ahn, Khaled Aboushaala, MD,
Vincent J. Rossi and Kern Singh, MD
Chapter 19 Lateral Interbody Fusion 183
Ehsan Tabaraee, MD, Junyoung Ahn
and Frank M. Phillips, MD
Contents vii
Case Vignette 8: L5-S1 Isthmic Spondylolisthesis 193

Chapter 20 Open Posterior Approach 195
Isaac L. Moss, MD, MASC, FRCSC
Chapter 21 Minimally Invasive Posterior Approach 205
Saad B. Chaudhary, MD
Chapter 22 Anterior Lumbar Interbody Fusion 215
Cliff Tribus, MD
Case Vignette 9: Lumbar Degenerative Disc Disease 225
Chapter 23 Minimally Invasive Lumbar Interbody Fusion 227
Branko Skovrlj, MD and Sheeraz A. Qureshi, MD, MBA
Chapter 24 Anterior Lumbar Interbody Fusion 233
Jim Youssef, MD, Douglas Orndorff, MD,
Sue Lynn Myhre, PhD, Rachel Ebner and Emily Barney
Chapter 25 Lumbar Disc Replacement 243
Jack E. Zigler, MD, FACS, FAAOS
Chapter 26 Pre-Sacral Lumbar Interbody Fusion 255
Ehsan Tabaraee, MD, Vincent J. Rossi,
Andrew J. Park, and Kern Singh, MD
Case Vignette 10: Degenerative Lumbar Scoliosis 265
Chapter 27 Open Posterior Approach 267
Blaine T. Manning, Khaled M. Kebaish, MD
and Hamid Hassanzadeh, MD
Chapter 28 Minimally Invasive Posterior Approach 277
Jordan Glaser, MD and Nomaan Ashraf, MD
Chapter 29 Lateral Approach 287
Yu-Po Lee and Jessica Lee, MD
Editors' Contact Information 297
Index 299
Preface
Decision Making in Degenerative Spinal Surgery: A Case Based Approach brings

together the thought processes of the world‟s leading spine surgeons for the management of
disc herniation, spondylolisthesis, deformity, myelopathy, and non-union. Advancements in
spine surgery are reflected in the summary of the most up-to-date literature while the pearls
and pitfalls and the surgical techniques portray the personal experiences of the authors. The
purpose of this compilation is to allow the reader to increase his or her familiarity with the
decision-making process in the treatment of spinal disease encountered by spine surgeons,
neurosurgeons, and orthopedics surgeons.
The surgical approaches and techniques may indicate that the book was designated as a
resource for surgeons and surgeons-in-training. However, the case vignette presentations
describe typical presentation as well as appropriate evaluation for a variety of spinal
pathology. As such, we hope that this book not only informs surgeons, but also physicians
and healthcare professionals who may treat spine patients in a non-operative setting.
Case Vignette 1:
Cervical Disc Herniation
In: Decision Making in Degenerative Spinal Surgery ISBN: 978-1-63482-094-3
Editors: Kern Singh and Sheeraz Qureshi © 2015 Nova Science Publishers, Inc.
Chapter 1
Anterior Cervical Discectomy

and Fusion
Mark F. Kurd, MD
Department of Orthopaedic Surgery, The Rothman Institute at Thomas Jefferson
University Hospital, Philadelphia, PA, US
Case Summary
37-year-old male presents with 4 months of worsening left upper extremity pain and
numbness that radiates down the back of his arm and into his left hand. He reports minimal
neck pain. Physical examination reveals a positive Spurling‟s on the left with slight weakness
in the left triceps. There are no findings of myelopathy. Radiographs demonstrate loss of disc
height at C6-7 (Figure 1). MRI of the cervical spine reveals a left paracentral/foraminal C6-7
disc herniation (Figure 2).
4 Mark F. Kurd
Pre-Operative Imaging
(A) (B)
Figure 1. (A) AP and (B) lateral cervical spine radiographs demonstrating maintenance of coronal and
sagittal alignment with loss of disc height at C6-7.
(A)
(B)
Figure 2. (A) Sagittal and (B) axial T2-weighted MRI demonstrating a left C6-7 paracentral disc
herniation causing compression of the left C7 nerve.
Anterior Cervical Discectomy and Fusion 5
Surgical Approach
An anterior cervical discectomy and fusion (ACDF) was chosen for this patient. ACDF is
well tolerated utilizing the surgical dissection originally described by Smith and Robinson in
1955 [1]. This approach uses anatomic tissue planes minimizing tissue trauma. Once the spine
is exposed, an ACDF provides visualization of the intervertebral disc and allows direct
decompression of the neural elements by removing the compressive pathology.
In comparison to a posterior laminoforaminotomy, ACDF is less disruptive to the soft
tissues as muscle is neither split nor stripped from the spine. ACDF is generally considered a
technically easier procedure to perform and consistently allows direct visualization and
removal of the herniated disc fragments. Furthermore, complications after ACDF are
extremely rare [2].
Surgical Procedure
As with all surgical procedures, patient positioning is critical. The patient is placed
supine on a standard or a flat Jackson table. The arms are tucked at the patient‟s side. The
neck is gently extended using a bump underneath the shoulders. Tape is used to provide
gentle traction depressing the shoulders in order to allow for intraoperative imaging.
The level of the incision is determined using lateral imaging or anatomic landmarks. A
left or right-sided (surgeon preference in primary cases) 2-3 cm transverse incision is made at
the pre-determined level. The subcutaneous tissue is dissected exposing the platysma. A
supra-platysmal plane is developed. The platysma is incised in line with the skin incision. A
sub-platysmal plane is then developed.
The deep cervical fascia is split in order to develop the plane between the
sternocleidomastoid and the strap muscles. The pre-tracheal fascia is then divided in order to
develop the plane between the trachea and the carotid sheath. Finally, the pre-vertebral fascia
is split and dissected from the anterior aspect of the spine. A hemostat is anchored to the spine
and a lateral image is obtained to determine the exposed cervical level.
After clearly identifying the surgical level, the soft tissues are stripped from the anterior
aspect of the vertebral bodies and the longus coli muscles are elevated bilaterally. Self-
retraining retractors are placed and anchored beneath the longus coli muscles. Caspar pins
may be placed in the vertebral bodies and gentle distraction is placed across the disc space.
A 15-blade is used to make an annulotomy in line with the endplates. A total discectomy
is then performed. After completion of the discectomy, the uncovertebral joints should be
visible bilaterally, the posterior longitudinal ligament (PLL) should be visible posteriorly and
the endplates should be denuded of all cartilage. The endplates are then leveled using a high-
speed burr.
The PLL should then be removed. This removal is most easily accomplished by finding
the tear from the herniated disc if the fragment was subligamentous or by developing a plane
with a nerve hook. A #2 Kerrison rongeur can then be used to resect the PLL. Careful
attention should be paid to the side of the disc herniation. A nerve hook should be utilized to
ensure there is no further retrovertebral disc material and that the foramen is patent to the
lateral aspect of the caudal pedicle.
6 Mark F. Kurd
The disc space is then sized using a trial interbody device (Figure 3). A structural
allograft or polyetheretherketone (PEEK) cage with the preferred biologic is then placed in
the disc space and recessed 1-2 mm from the anterior aspect of the vertebral bodies. Any local
autograft that has been collected can be placed lateral to the graft or in the cage. An anterior
plate is then placed with two screws in each of the vertebral bodies (Figure 4).
Figure 3. Intra-operative photograph demonstrating sizing of the disc space utilizing a trial interbody
device.
Figure 4. Intra-operative photograph demonstrating placement of the anterior plate.

Anterior Cervical Discectomy and Fusion 7
Pearls and Pitfalls

 The head must rest on the table after placing the bump under the shoulders. Leaving
the head “hanging” may result in neurologic injury. Excessive extension of the
cervical spine should be avoided.
 Traction on the shoulders is necessary to allow intraoperative x-ray or fluoroscopic
imaging. However, excessive traction can lead to a brachial plexus palsy. Limiting
traction is particularly difficult in larger patients and when performing an ACDF at
C6-7.
 Most surgeons approach from the left side because the course of the recurrent
laryngeal nerve is more predictable. There is very little scientific evidence to suggest
that the side of approach has a factor in post-operative dysphagia or dysphonia.
 Palpate the carotid artery to ensure it has been safely retracted laterally.
 Do not expose too far cranially or caudally as to disrupt the adjacent level
intervertebral discs. This is also important when placing the plate and screws.
 Visualize the esophagus and ensure that it is entirely behind the retractor.
 The herniated disc fragment will often be removed with the discectomy prior to
taking down the PLL.
 Over-distraction of the disc space can lead to facet joint distraction and resultant
neck pain.
Literature Summary
Since its description in the 1950s, ACDF has been the most studied and scrutinized
cervical spine procedure. For a single level ACDF, the fusion rate, neurologic outcome and
clinical results have consistently been demonstrated as excellent [3,4,5]. Additionally,
complications after ACDF are uncommon, particularly in single-level cases [2].
In comparing ACDF to a posterior laminoforaminotomy, both procedures have
demonstrated satisfactory results. However, ACDF has been demonstrated to provide better
long-term clinical improvement [6]. An ACDF is a commonly performed procedure that most
surgeons are very comfortable performing. Unlike a posterior laminoforaminotomy, the
sequelae of neck pain or repeat surgery are minimal.
Most of the surgical literature comparing ACDF to total disc replacement (TDR) is
derived from industry funded investigational device exemption (IDE) trials. Despite a
potential funding bias in favor of TDR, results have demonstrated no significant differences
in clinical outcomes or adjacent segment degeneration [7,8]. Both procedures have also been
found to be cost-effective. Due to the higher initial cost of TDR, an implant must last 14 years
to be more cost effective than ACDF [9]. Furthermore, at this point, the longevity of TDR
remains an unknown.
8 Mark F. Kurd
References
[1] Robinson, R.A., Smith, G. (1955). Anterolateral cervical disc removal and interbody
fusion for cervical disc syndrome. Bull Johns Hopkins Hosp. 96, 223-224.
[2] Smith, J.S., Fu, K.M., Polly, D.W. Jr, Sansur, C.A., Berven, S.H, Broadstone, P.A., …,
Shaffrey, C.I. (2010). Complications rates of three common spine procedures and rates
of thromboembolism following spine surgery based on 108,419 procedures: a report
from the Scoliosis Research Society Morbidity and Mortality Committee. Spine. 35(24),
2140-9.
[3] Brodke, D.S., Zdeblick, T.A. (1992). Modified Smith-Robinson procedure for anterior
cervical discectomy and fusion. Spine. 17(10), 427-30.
[4] Bohlman, H.H., Emery,S.E., Goodfellow, D.B., Jones, P.K. (1993). Robinson anterior
cervical discectomy and arthrodesis for cervical radiculopathy. Long-term follow-up of
one hundred and twenty-two patients. J. Bone Joint Surg Am. 75(9), 1298-307.
[5] Gao, Y., Liu, M., Li, T., Huang, F., Tang, T., Xiang, Z. (2013). A meta-analysis
comparing the results of cervical disc arthroplasty with anterior cervical discectomy and
fusion (ACDF) for the treatment of symptomatic cervical disc disease. J. Bone Joint
Surg Am. 95(6), 555-61.
[6] Herkowitz, H.N., Kurz, L.T., Overholt, D.P. (1990). Surgical management of cervical
soft disc hernation. A comparison between the anterior and posterior approach. Spine.
15(10), 1026-30.
[7] Verma, K., Gandhi, S.D., Maltenfort ,M., Albert, T.J., Hilibrand, A.S., Vaccaro, A.R.,
Radcliff, K.E. (2013). Rate of adjacent segment disease in cervical disc arthroplasty
versus single-level fusion: meta-analysis of prospective studies. Spine. 38(26), 2253-7.
[8] Jawahar, A., Nunley, P. (2012). Total disc arthroplasty and anterior cervical discectomy
and fusion in cervical spine: competitive or complimentary? Review of the literature.
Global Spine J. 2(3), 183-6.
[9] Qureshi, S.A., McAnany, S., Goz, V., Koehler, S.M., Hecht, A.C. (2013). Cost-
effectiveness analysis: comparing single-level cervical disc replacement and single-
level anterior cervical discectomy and fusion: clinical article. J. Neurosurg. Spine.
19(5), 546-54.
Chapter 2
Cervical Disc Replacement
Jonathan Rasouli, MD, Branko Skovrlj, MD

Department of Orthopaedic Surgery, Mount Sinai Medical Center
New York, NY, US
Case Summary
10 Jonathan Rasouli, Branko Skovrlj and Sheeraz A. Qureshi
(A) (B)
Figure 1. Radiographs taken in the neutral (A) AP and (B) lateral position demonstrating normal
cervical lordosis and absence of spondylolisthesis.
(A) (B)
Figure 2. T2-weight (A) sagittal and (B) axial MRI demonstrating a left broad-based, para-central disc
protrusion causing neuroforaminal stenosis at C6-7 and C7 nerve root compression. Note the absence of
T2-signal changes within the spinal cord.
Surgical Approach
Cervical disc replacement (CDR), also known as cervical arthroplasty, was chosen as the
surgical approach to best address this patient‟s clinical symptoms and radiologic findings.
Compared to traditional anterior cervical discectomy and fusion (ACDF), this approach
allows for direct nerve root decompression without the need for an interbody fusion. Given
the patient‟s normal cervical lordosis, single-level pathology, absence of static or dynamic
instability, and minimal degenerative changes he was felt to be an excellent candidate for
motion-preservation surgery [1].
Cervical Disc Replacement 11
CDR is considered an acceptable alternative to ACDF in the treatment of neck and arm
pain caused by a cervical disc herniation [1]. By eliminating the need for fusion at the
selected level, CDR is thought to lead to a decreased incidence of adjacent segment disease
compared to ACDF [2]. In addition, several studies have suggested decreased surgical
morbidity and faster return-to-work in highly-selected patients who receive CDR over ACDF
[3, 4, 5].
Surgical Procedure
The patient is placed supine on a radiolucent surgical table and the target level is
identified under fluoroscopic guidance (Figure 3). To aid with the approach, the neck is
positioned in slight extension with the shoulders secured to the side with surgical tape.
Additional neck extension and interbody distraction can be achieved with the placement of
Gardner-Wells Tongs or head-halter device, usually with 5-10 lbs of traction. It is important
to keep the level being operated on in a neutral position as far as end-plate alignment is
concerned, despite extending the neck for help with visualization.
Figure 3. Intra-operative radiographs obtained after positioning the patient for a C6-7 disc replacement.
Note that the inferior endplate of C6 and the superior endplate of C7 are parallel allowing for proper
positioning of the arthroplasty device.
Figure 4. Horizontal incision made for approach to anterior cervical spine.
A scalpel is used to make a horizontal incision in the skin close to midline, identical to
the style of incision utilized in an ACDF (Figure 4). The surgical approach can be on the left
or the right side of the patient depending on surgeon preference. Most authors advocate for a
left-sided approach given the consistent location of the recurrent laryngeal nerve.
Electrocautery and self-retaining retractors are utilized to dissect down to the platysma. The
platysma can then be incised with a vertical or horizontal incision depending on surgeon
preference. The superficial layer of the deep cervical fascia is then undermined cranially and
caudally with blunt dissection.
Once the deep cervical fascia is exposed, the medial edge of the sternocleidomastoid is
identified and mobilized laterally along with the carotid sheath with Cloward retractors. The
trachea and esophagus are then mobilized medially to expose a surgical plane down to the
prevertebral fascia and longus coli. Hemostasis along the way is achieved with bipolar
electrocautery. Once the prevertebral fascia is reached, it is bluntly dissected away with a
Kitner dissector, exposing the anterior face of the vertebral body. Bovie electrocautery is then
used to release the medial edge of the longus coli muscle overlying the lateral margin of the
vertebral body, creating a trough to insert the blades of the self-retaining retractor. Of note,
aggressive electrocautery of the longus muscle must be avoided to prevent damage to the
cervical sympathetic chain, which is located postero-medial to the carotid sheath and over the
belly of the longus coli. Particular care must be taken at the lateral edge of the C6 vertebral
body, where the cervical sympathetic chain takes its most medial course. Inadvertent injury to
the sympathetic chain may result in a Horner‟s syndrome.
Once the target level is reached, a hemostat clamp is placed at the edge of the
intervertebral disc to confirm radiographic location. Caspar screws are placed into the
vertebral bodies above and below the target interspace to assist with parallel distraction
(Figure 5).
Figure 5. Caspar distraction pins placed into vertebral bodies to assist with parallel distraction of the
disc space.
Figure 6. Bilateral compression to the uncovertebral joints was performed. When performing an
arthroplasty, it is critical to removal all uncovertebral osteophytes and to perform a thorough
decompression of the thecal sac and nerve roots in order to avoid persistent radicular symptoms.
A 10 blade is used to incise the anterior intervertebral disc and a standard discectomy is
performed utilizing a combination of curettes and pituitary/Kerrison rongeurs. Care is taken
to only excise the cartilaginous endplates and to preserve the sub-chondral bone. The uncinate
process should also be preserved; only the posterior 1/3 should be removed for
decompression [6] (Figure 6). A matchstick burr is used to drill down to reach the posterior
annulus. Once the posterior longitudinal ligament is reached, a nerve hook is used to carefully
penetrate through to allow for sub-ligamentous disc removal with either a 1 or 2-mm Kerrison
rongeur.
A footprint trial prosthesis is selected and gently tapped into the disc space with
fluoroscopic guidance. Patient-specific adjustments are made in regards to the prosthestic size
and location, ensuring midline placement, which is critical for adequate prosthesis
functioning [6]. Keel preparation (if a keeled implant is being used) is accomplished using
guides that are prosthesis specific. Under fluoroscopy, the milling bits are inserted through
the guides and drilled into the vertebral body until it reaches the positive stop in the guide [6].
The guide and trial are ultimately removed and copious irrigation is used to remove bone
debris. The implant is then placed “en-bloc” into the cavity and secured. A final fluoroscopic
image is taken to ensure satisfactory prosthesis placement (Figure 7).
Early mobilization is encouraged in the post-operative period to avoid the development of
bridging bone across the intervertebral disc space [7]. In addition, some surgeons advocate for
the post-operative use of NSAIDs to theoretically reduce the risk of heterotopic ossification
[7]. Physical therapy should be delayed for approximately six weeks following surgery in
order to allow for bony ingrowth on the prosthesis.
Figure 7. Lateral intra-operative radiograph of arthroplasty placed at C6-7.

Pearls and Pitfalls

 Major intra-operative complications include carotid, tracheal, or esophageal injury.
These complications can be avoided with careful exposure and blunt dissection.
 The risk of injury to the recurrent laryngeal nerve injury can be theoretically
minimized with a left-sided approach and by avoiding aggressive retraction to the
trachea and esophagus.
 Aggressive discectomy is essential to mobilize the disc space to allow for full range
of motion. A disc space with limited motion may encourage an autofusion of the
implant. Furthermore, unlike a fusion, arthroplasty requires continued motion across
the disc space and uncovertebral joints as such any residual compressive pathology
may result in persistent radiculopathy.
 Maximal bone-prosthesis contact ensures a secure, functional construct. Optimal
bone-prosthetic contact can be achieved by flattening the endplates above and below
the prosthesis; however, care must be taken not to remove too much cortical bone
resulting in endplate compromise and subsidence of the prosthesis.
 It is critical to choose the largest implant footprint size that will allow for the greatest
distraction of the endplates without adversely affecting the patient‟s anatomic
curvature. Overdistraction of the endplates can inadvertently lead to the placement of
an oversized implant, which may result in hyper-lordosis and increased risk of
implant failure.
Literature Summary
The best indication for cervical disc replacement is for the treatment of neck pain,
radiculopathy, or myelopathy caused by a single-level soft disc herniation in the subaxial
cervical spine of a young adult [1]. Contraindications to arthroplasty include severe
degenerative cervical spondylosis (more common in older adults) and dynamic or static
cervical instability as seen on flexion/extension x-rays [1]. The major advantage of disc
replacement versus traditional anterior cervical discectomy and fusion is the preservation of
motion at the treated level potentially decreasing the incidence of adjacent segment disease.
Despite this theoretical advantage, it should be noted that no study to date has demonstrated a
significant reduction in the incidence of adjacent segment disease when comparing ACDF to
CDR [8].
Currently, the standard of care for a one-level cervical spondylotic radiculopathy or
myelopathy is an ACDF [5,8,9]. Early studies comparing clinical outcomes of ACDF and
CDR did not demonstrate a significant difference between the groups [10]. More recently,
several authors have suggested a decreased incidence of post-operative complications and
faster recovery time with cervical arthroplasty in comparison to traditional ACDF [3,4]. For
example, Sasso et al. and Vaccaro et al. were able to demonstrate superior outcomes in long-
term Neck Disability Index scores, visual analog scale, and Short Form-36 physical
component scores when comparing CDR to ACDF [3,4]. Although the results of these studies
are promising, further data is required before routine use of CDR over ACDF is supported
[5].
The historical clinical success for ACDF is quoted to be 68%, with a 9.8% reoperation
rate [9]. Although more long-term data is required, the overall clinical success rate for CDR
appears to be similar to that of ACDF. For example, Goffin et al. demonstrated a clinical
success rate of 86% and 90% with the Bryan prosthesis at 6- and 12-months, respectively
[11].
In conclusion, CDR remains a valuable therapeutic alternative to an ACDF in highly
selected patients with similar clinical and radiographic pre-operative characteristics. Current
evidence suggests the primary difference between the two procedures is a faster return to
activity in patient‟s undergoing CDR compared to ACDF [5]. With the growing number of
patients receiving CDR over ACDF, further long-term and larger population studies will be
needed to elucidate key differences in clinical outcomes.
References
[1] Auerbach JD, Jones KJ, Fras CI, Balderston JR, Rushton SA, Chin KR. (2008). The
prevalence of indications and contraindications to cervical total disc replacement. Spine
J. 8(5), 711-716.
[2] Dmitriev AE, Cunningham BW, Hu N, Sell G, Vigna F, McAfee PC. (2005). Adjacent
level intradiscal pressure and segmental kinematics following a cervical total disc
arthroplasty: an in vitro human cadaveric model. Spine. 30(10), 1165-1172.
[3] Sasso RC, Anderson PA, Riew KD, Heller JG. (2011). Results of Cervical Arthroplasty
Compared with Anterior Discectomy and Fusion: Four-Year Clinical Outcomes in a
Prospective, Randomized Controlled Trial. J. Bone Joint Surg. Am. 93(18), 1684-1692.
[4] Vaccaro A, Beutler W, Peppelman W, Marzluff JM, Highsmith J, Mugglin A, DeMuth
G, Gudipally M, Baker KJ. (2013). Clinical Outcomes With Selectively Constrained
SECURE-C Cervical Disc Arthroplasty: Two-Year Results From a Prospective,
Randomized, Controlled, Multicenter Investigational Device Exemption Study. Spine.
38(26), 2227-2239.
[5] Fallah A, Akl EA, Ebrahim S, Ibrahim GM, Mansouri A, Foote CJ, Zhang Y, Fehlings
MG. (2012). Anterior Cervical Discectomy with Arthroplasty versus Arthrodesis for
Single-Level Cervical Spondylosis: A Systematic Review and Meta-Analysis. PLoS
One. 7(8), e43408.
[6] Synthes Spine, (2008). ProDisc-C Total Disc Replacement. For single level spinal
arthroplasty from C3 to C7. Technique Guide.
[7] Mehren C, Suchomel P, Grochulla F, Barsa P, Sourkova P, Hradil J, Korge A, Mayer
HM. (2006). Heterotopic ossification in total cervical artificial disc replacement. Spine.
31(24), 2802-6.
[8] Nunley PD, Coric D, Jawahar A, Kerr, E.J. Gordon, C. Utter, P.A. (2011). Total Disc
replacement in Cervical Spine: 4-7 years follow-up for primary outcomes and
symptomatic adjacent segment disease. Cervical Spine Research Society 2011 Annual
Meeting. Scottsdale, Arizona, United States.
[9] Pettine KA, Eiserman L. (2012). Meta-analysis of Class I Results of Anterior Cervical
Decompression and Fusion with Allograft and Plating. American Academy of
Orthopaedic Surgeons 2012 Annual Meeting. San Franciso, California, United States.
[10] Bohlman HH, Emery SE, Goodfellow DB, Jones PK., (1993). Robinson anterior
cervical discectomy and arthrodesis for cervical radiculopathy. Long-term follow-up of
one hundred and twenty-two patients. J. Bone Joint Surg. Am. 75(9), 1298-1307.
[11] Goffin J, Casey A, Kehr P, Liebig K, Lind B, Logroscino C, Pointillart V, Van
Calenbergh F, van Loon J. (2012). Preliminary clinical experience with the Bryan
cervical disc prosthesis. Neurosurgery. 51(3), 840-847.
Chapter 3
Minimally Invasive Posterior

Laminoforaminotomy and
Microdiscectomy
Ehsan Tabaraee, MD, Junyoung Ahn, Andrew J. Park

and Kern Singh, MD
Department of Orthopaedic Surgery, Rush University Medical Center
Chicago, IL, US
Case Summary
20 Ehsan Tabaraee, Junyoung Ahn, Andrew Park et al.
(A) (B)
Figure 1. (A) AP and (B) lateral radiographs demonstrating loss of disc height at C6-7. Note
maintenance of sagittal alignment and the absence of spondylolisthesis.
(A)
Figure 2.A. Sagittal T2-weighted MRI demonstrating a para-central disc protrusion at C6-7 causing C7
nerve root compression.
(B)
Figure 2.B. Axial T2-weighted MRI demonstrating a left, para-central disc protrusion at C6-7 causing
C7 nerve root compression.
Minimally Invasive Posterior Laminoforaminotomy and Microdiscectomy 21
Surgical Approach
Minimally invasive laminoforaminotomy has become a popular operation for cervical
nerve root decompression. This muscle splitting approach allows for motion preservation
while avoiding the risks of anterior instrumentation (dysphagia, adjacent level ossification
disease) and traditional posterior approaches (periosteal stripping, pain, infection, instability).
The paraspinal muscle splitting tubular approach preserves vital cervical stabilizers and
minimizes dissection. The indications for the procedure include unilateral radiculopathy from
bony foraminal stenosis or herniated cervical nucleus pulposus.
Surgical Procedure
Following successful intubation with general anesthesia, Mayfield tongs are placed. The
arms are padded and folded. The patient can be placed in either the traditional prone position
(Figure 3) or the sitting position with the head holder attached to the bed via extensions.
Benefits of the sitting position include improved fluoroscopic and surgical visualization. If
the sitting position is undertaken, the patient is turned to face the anesthesia equipment with
the cervical spine positioned perpendicular to the floor. The C-arm is positioned in the lateral
position under, over, or in front of the patient. Prepping and draping follows standard
protocol.
Figure 3. Photograph demonstrating prone positioning with Mayfield head-holder in place.
The appropriate level is localized with fluoroscopic imaging. The incision is centered on
the inferior half of the rostral facet. A 12-18 mm vertical incision is made approximately 1-
1.5 cm lateral to the midline. Bovie electrocautery is utilized for deep dissection and
hemostasis. The paraspinal fascia is identified and generously incised in line with the
incision. Sequential cannulated dilators are placed onto the bony posterior elements up to the
diameter of the tubular retractor that will be utilized for the procedure (Figure 4-5). The
appropriate tubular retractor is secured over the dilators and the light source is attached. The
residual soft tissue is removed sub-periosteally and the laminofacet junction is defined.
Ideally, the tubular retractor is centered over the disc space on lateral imaging with the
lamina-facet junction on the medial 1/3rd of the visual field (Figure 6).
Figure 4. Intra-operative lateral fluoroscopic image demonstrating the initial dilator locating the target
level. Note: Intra-operative image represents dilator location at C4-5.
Figure 5. Intra-operative lateral fluoroscopic image demonstrating the placement of tubular dilators
(18 mm).
Figure 6. Intra-operative tubular image demonstrating exposure of the superior and inferior articular
processes.
Figure 7. Intra-operative tubular image demonstrating removal of the medial third of the inferior
articular process utilizing a high-speed burr.
A curved microcurette can be utilized to identify the interlaminar space and detach the
superolateral flavum from the cephalad lamina. This allows a small Kerrison rongeur to be
utilized to initiate the laminotomy. Alternatively, a high-speed burr can be utilized to remove
bone from the laminofacet junction. A laminotomy is only necessary to identify the lateral
spinal canal and the medial aspect of the pedicle. A high-speed drill is utilized to thin the
medial facet (Figure 7). A Kerrison rongeur is utilized for final decompression to expose the
nerve root from its origin off the thecal sac to the lateral aspect of the pedicle (Figure 8). A
nerve hook can then be utilized to palpate and help extract herniated disc material by entering
the canal below the nerve root and rotating the nerve hook. A micro pituitary rongeur can be
utilized to extract disc material. However, great care must be taken to avoid overzealous
retraction of the cervical nerve roots, as these are less forgiving than the lumbar nerve roots.
Pulsation of the root often indicates adequate decompression.
Figure 8. Intra-operative tubular image demonstrating exposure of the nerve root following partial
resection of the inferior and superior articular processes.
Pearls and Pitfalls

 If the patient is placed in the sitting position, an arterial line can assist in detailed
monitoring of the blood pressure to prevent hypotension and a Doppler may be
utilized to detect air embolus.
 If 2 levels are being decompressed, center the incision over the middle lamina.
 If bilateral foramina are being decompressed, make a midline skin incision and create
subcutaneous flaps. This allows mobilization of the skin laterally for the paramedian
fascial incision.
 The fascial incision must be generous enough to avoid excess force required during
dilator placement.
 The initial docking onto the bony elements should be performed with great care to
avoid direct trauma to the spinal cord that may result from penetration of the
interlaminar space.
 Dock the tubular retractor system over the disc space via lateral fluoroscopic
imaging. Center the lamina-facet junction on the medial third of the surgical corridor.
 After drilling the medial 1/3 of the facet, identify the medial and cephalad aspect of
the pedicle below for proper orientation.
Literature Summary
Despite a significant number of publications regarding laminoforaminotomies, most
studies lack validated outcomes as the majority of studies have been classified as level of
evidence III [1]. However, improvements in radicular pain, numbness, weakness, and overall
satisfaction have been reported to be as high as 90-98% in large series with long-term follow
up [2,3,4].
Over the past decade, multiple publications have advocated minimally invasive
foraminotomies over the traditional open technique. The reported benefits of the minimally
invasive foraminotomy include decreased blood loss, shorter operative time, decreased
narcotic utilization during the hospitalization period, and shorter length of hospitalization
while maintaining similar clinical improvements when compared to the open approach
[5,6,7].
However, complications associated with MIS posterior foraminotomy have been
reported. Damage to the dural covering has been reported as the most common complication
[6,8,9]. In addition, the potential remains for catastrophic spinal cord injury with improper K-
wire placement during the initial localization. The possibility of nerve palsies and
development of hematomas should also be considered [9].
The evidence suggests that MIS posterior foraminotomy and microdiscectomy may be an
efficacious treatment for cervical nerve root compression. This approach aims to preserve the
stabilizing musculature while minimizing the operative time, estimated blood loss, and post-
operative narcotic requirements. However, in considering this approach to cervical
decompression, caution must be observed in the setting of radiographic evidence of
instability, kyphosis, myelopathy, or a central disc herniation.
References
[1] Heary RF, Ryken T, Matz PG, Anderson PA, Groff MW, Holly LT, Kaiser MG,
Mummaneni PV, Choudhri TF, Vresilovic EJ, Resnick DK. (2009). Cervical
Laminoforaminotomy for the Treatment of Cervical Degenerative Radiculopathy. J.
Neurosurg. Spine. 11(2), 198-202.
[2] Henderson CM, Hennessy RG, Shuey HM Jr., Shackelford EG., (1983). Posterior-
lateral Foraminotomy as an Exclusive Operative Technique for Cervical Radiculopathy:
a Review of 846 Consectutively Operated Cases. Neurosurgery. 13(5), 504-512.
[3] Zeidman SM, Ducker TB. (1993). Posterior Cervical Laminoforaminotomy for
Radiculopathy: Review of 172 cases. Neurosurgery. 33(3), 356-362.
[4] Davis RA. (1996). A Long-Term Outcome Study of 170 Surgically Treated Patients
with Compressive Cervical Radiculopathy. Surg. Neurology. 46(6), 523-33.
[5] Fessler RG, Khoo LT. (2002). Minimally Invasive Cervical Microendoscopic
Foraminotomy: an Initial Clinical Experience. Neurosurgery. 51(5 Suppl.), S37-S45.
[6] Kim KT, Kim YB. (2009). Comparison Between Open Procedure and Tubular
Retractor Assisted Procedure for Cervical Radiculopathy: Results of a Randomized
Controlled Study. J. Korean Med. Sci. 24(4), 649-653.
[7] Winder MJ, Thomas KC. (2011). Minimally Invasive Versus Open Approach for
Cervical Lamionforaminotomy. Can. J. Neurol. Sci. 38(2), 262-267.
[8] Jodicke A, Daentzer D, Kastner S, Asamoto S, Boker DK. (2003). Risk factors for
outcome and complications of dorsal foraminotomy in cervical disc herniation. Surg.
Neurol. 60(2):124–129.
[9] Skovrlj, B, Gologorsky, Y, Haque, R, Fessler, RG, Qureshi SA. (2014). Complications,
outcomes, and need for fusion after minimally invasive posterior cervical foraminotomy
and microdiscectomy. Spine J. 14(10), 2405-11.
Case Vignette 2:
Multilevel Cervical Myelopathy
Chapter 4
Posterior Cervical Laminectomy

and Fusion
Samuel C. Overley, MD, Steven J. McAnany, MD

and Andrew C. Hecht, MD
The Mount Sinai Medical Center
New York, New York
Case Summary
64-year-old female presents with progressively worsening bilateral hand numbness and
gait imbalance. She describes mild neck pain but increasing difficulty using her hands for
activities involving fine motor control. Physical examination is significant for radiating pain
down the arms and legs with flexion and extension of the neck and an inability to perform a
tandem gait. She has a poor grip release test. Imaging evaluation reveals a neutral cervical
alignment with multilevel cervical spondylosis and spinal cord compression most severe at
C3-4 and C6-7 (Figures 1, 2, 3).
30 Samuel C. Overley, Steven J. McAnany and Andrew C. Hecht
(A) (B)
(C) (D)
Figure 1. Neutral (A) AP and (B) lateral radiographs and (C, D) dynamic lateral radiographs of
flexion/extension views demonstrating multilevel spondylosis without listhesis or instability on
dynamic films and lack of cervical lordosis on neutral films.
Posterior Cervical Laminectomy and Fusion 31
(A) (B)
(C) (D)
(E) (F)
Figure 2. (A) Sagittal and (B-F) axial representative CT sections demonstrating multi-level cervical
spondylosis and stenosis with neutral cervical lordosis.
(A) (B)
(C) (D)
(E)
Figure 3. (A,B) Sagittal and (C-E) axial T2-weighted MRI sections of C3-4, C4-5, C6-7. Sagittal
sections demonstrate both anterior and posterior cord impingement, greatest at C3-4, C4-5, and C6-7.
Surgical Approach
A posterior approach was utilized for direct exposure of the posterior elements of the
cervical spine. This approach is useful for establishing a wide decompression via
laminectomy and multi-level foraminotomies while also providing full exposure of the lateral
masses for placement of lateral mass screw fixation. The lamina and spinous process also
serves as a rich supply of local autogenous bone for grafting purposes.
A midline skin incision is made after establishing the location of the affected cervical
levels via fluoroscopy. It is important to maintain meticulous hemostasis as the dissection is
carried down to the level of the cervical fascia in order to improve visualization. The fascia is
split in the midline and a subperiosteal dissection is carried out bilaterally to the lateral edges
of the lateral masses via electrocautery. The surgeon should take care not to violate the facet
capsule of the most cephalad level. It is of utmost importance that the lateral edges of the
lateral masses be clearly identified if screws are to be placed in order to avoid a lateral screw
cut out or a less commonly medially errant screw which can violate the vertebral artery [1].
Surgical Procedure
The patient is positioned supine on the Jackson table and placed into 20 lbs. of Gardner -
Wells traction. The patient is then sandwiched between the 2 well-padded boards of the
Jackson table and spun rotisserie style into the prone position in traction. Alternatively, the
patient can be placed into a prone position on a regular OR table with a Mayfield head holder
(Figure 4).
Figure 4A. Intra-operative photograph of posterior view of patient positioned in prone position with
Mayfield head holder in place.
Figure 4B. Intra-operative photograph demonstrating lateral view of prone patient positioning with
Mayfield head holder in place.
After exposing the posterior elements of the cervical spine, the levels are confirmed by
using the C2 vertebra as a reference point. An exposed facet joint is identified on fluoroscopy
by placing a Penfield 4 directly onto the mid-portion of the lateral mass.
Our preference is to first drill pilot holes for all lateral mass screws prior to performing
the laminectomy in order to minimize the passing of instruments over an exposed thecal sac.
Positioning of the pilot holes and the lateral mass screws remains a debated topic. We use the
technique described by An et al. with the screw position aiming 25-30° lateral and 15°
cephalad to midline (Figure 5) following the sagittal inclination of the facet joint [2]. A 2mm
burr is used to make pilot holes in the lateral masses bilaterally, followed by drilling with a
stop set to 12mm -14mm to create a unicortical screw track. The integrity of the drill hole is
confirmed with a ball-tip probe and then each drill hole is subsequently tapped. We prefer
unicortical screws as these have shown equal clinical results to bicortical fixation while
minimizing risk of injury to adjacent neurovascular structures [3].
Figure 5. Intra-operative image demonstrating the cephalad and lateral directed trajectory of lateral
mass screw placement.
After all the lateral mass screw tracts have been tapped, attention is turned to the
laminectomy. We use a high-speed burr to create troughs in the lamina just medial to the
medial edge of the lateral masses. The trough is carried down to the level of the ligamentum
flavum/inner cortex after which a small nerve hook or 2 mm Kerrison rongeur is used to
elevate the lamina while the flavum is resected with a Kerrison rongeur. Once the troughs
have reached full thickness through the lamina and ligamentum flavum, the laminae are
removed en-bloc. Care must be taken to provide equal and constant upward pressure in order
to avoid inadvertent compression of the spinal cord. Additionally, any adhesions from the
dura to the lamina to should be carefully dissected in order to avoid an incidental durotomy or
excessive traction on the neural elements.
If the cervicothoracic junction is to be crossed, as in this case, T1 pedicle screws are
placed. We instrument and fuse into the thoracic spine in most cases that require laminectomy
of C7 secondary to a high reported rate of post laminectomy kyphosis when a construct
terminates at C7 [4]. The medial aspect of the T1 pedicle is exposed via a
laminoforaminotomy. The starting point for the T1 pedicle screw is at the intersection of
midline of the transverse process and lateral edge of the pars. A gearshift or awl is then
advanced with the curve of the probe aimed laterally. After the probe tip has reached 20mm,
the gearshift is removed and the curvature is aimed medially into the vertebral body. A ball-
tip probe is used to assess the integrity of the tract. Finally, a 4.0mm screw of appropriate
length is inserted. 3.5mm lateral mass screws are then placed into their previously drilled
tracts. We also utilize intra-operative 3-dimensional fluoroscopy to confirm accurate
placement of hardware to minimize any complications related to hardware malpositioning.
Once all screws are in place, the high-speed burr is used to decorticate the facet joints and
lateral masses and morsilized autograft from the laminectomy is placed laterally to achieve an
appropriate fusion mass. When increased lordosis is desired, as in this case, an air pump
(inflation of an IV compression bag) can be placed beneath the face padding and inflated
under lateral fluoroscopy until suitable lordosis is achieved. Finally, appropriately sized rods
are placed bilaterally into the heads of the screws and screw caps tightened.
Pearls and Pitfalls

 Draping the C-arm to allow for intra-operative use can greatly aid in assuring a
correct-level surgery. Failure to confirm levels intra-operatively after dissection may
lead to wrong level surgery.
 A thorough dissection with meticulous hemostasis allows visualization of the lateral
masses and identification of the correct starting point. The tendency is for the screws
to break through the superior lateral portion of the lateral mass.
 Establishing pilot holes and drilling / tapping the screw tracts for the lateral mass
screws prior to performing the laminectomy can minimize work performed over an
exposed spinal cord.
 A lateral and cephalad directed trajectory, such as that employed in the An technique,
is critical to avoiding the facet joint, exiting nerve root and the vertebral artery.
(Figure 5).
 When decompression and fusion to the level of C7 is indicated, crossing the

cervicothoracic junction with the fusion construct should be strongly considered to
avoid junctional breakdown.
 Using a device such as a hand air pump (iv compression bag) or a pacing a blanket
under the face pad can help restore a desirable amount of cervical lordosis. Other
alternatives include bivector traction and a Mayfield head holder.
 A watertight, layered closure is vital in order to prevent a postoperative seroma and
the sequela of wound complications.
Literature Summary
Cervical degenerative disease is the most common cause of acquired disability in patients
over the age of 50 [5]. Despite the condition‟s high incidence and disabling symptoms, there
is no consensus regarding the most effective form of treatment.
Herkowitz compared posterior laminectomy without fusion, laminoplasty and anterior
cervical discectomy and fusion. Patients who underwent laminectomy without fusion had
significantly lower clinical success rates than those who underwent laminoplasty or anterior
cervical discectomy and fusion [6]. These results may be largely attributed to a lack of
concomitant posterior stabilization with the laminectomy. Post-laminectomy kyphosis is a
well-documented phenomenon following an un-instrumented laminectomy [7].
The posterior approach to multi-level degenerative cervical disease has undergone many
advances over the past several decades and current lateral mass screw-rod constructs have
shown clinical success and longevity, with radiographic fusion rates that approach 98-100%
[8]. Sekhon et al. examined the placement of lateral mass screws using the An technique with
postoperative CT scan, and concluded that only 1.9% of 1026 screws breached the transverse
foramen; no patients had any subsequent radiculopathy and or vascular injuries [9].
The posterior laminectomy with fusion facilitates wide decompression while providing
adequate exposure of the lateral masses for screw fixation. A study comparing the outcomes
between laminoplasty and posterior laminectomy with fusion by Highsmith et al.
demonstrated significantly higher improvements in neck pain in patients who underwent
fusion [10]. The authors concluded that patients with significant neck pain prior to surgery
should be strongly considered for fusion rather than a laminoplasty. However, although lateral
mass screw-rod fixation has proven to be a safe and extremely efficacious procedure, it
cannot be used for all cases of multilevel degenerative cervical disease. It is best utilized in
patients with a neutral or lordotic cervical spine, and is absolutely contraindicated in patients
with greater than 13° of kyphosis. In cases in which a fusion is not recommended,
laminoplasty remains a viable option for patients with multilevel degenerative myelopathy
and has shown comparable clinical results with a higher cost-effectiveness ratio, though at the
expense of theoretically increased long-term post-operative neck pain [10].
References
[1] Heller, J.G., Silcox, D.H., Sutterlin, C.E. (1995). Complications of posterior cervical
plating. Spine. 20(22), 2442-2448.
[2] An, H.S., Gordin, R., Renner, K. (1991). Anatomic considerations for plate-screw
fixation of the cervical spine. Spine. 16(10 Suppl.), S548-S551.
[3] Seybold, E.A., Baker, J.A., Criscitiello, A.A., Ordway, N.R., Park, C.K., Connolly, P.J.
(1999). Characteristics of unicortical and bicortical lateral mass screws in the cervical
spine. Spine. 24(22), 2397-2403.
[4] McGirt, M.J, Sutter, E.G., Xu, R., Sciubba, D.M., Wolinsky, J.P., Witham, T.F.,
Gokaslan, Z.L., Bydon, A. (2009). Biomechanical comparison of translaminar versus
pedicle screws at T1 and T2 in long subaxial cervical constructs. Neurosurgery 2009;65
(6, suppl):167-172.
[5] Law, M.D. Jr., Bernhardt, M., White, A.A. (1995). Evaluation and management of
cervical spondylotic myelopathy. Instr Course Lect. 44, 99-110.
[6] Herkowitz, H.N. (1988). A comparison of anterior cervical fusion, cervical
laminectomy, and cervical laminoplasty for the surgical management of multiple level
spondylotic radiculopathy. Spine. 13(7), 774-780.
[7] Park, Y., Riew K.D., Cho, W. (2010). The long-term results of anterior surgical
reconstruction in patients with postlaminectomy cervical kyphosis. Spine J. 10(5), 380-
387.
[8] Katonis, P., Papadakis, S.A., Galankos, S., Paskou, D., Bano, A., Sapkas, G.,
Hadjipavlou, A.G. (2011). Lateral mass screw complications: Analysis of 1662 screws.
J. Spinal Disord. Tech. 24(7), 415-420.
[9] Sekhon, L.H. (2005). Posterior cervical lateral mass screw fixation analysis of 1026
consecutive screws in 143 patients. J. Spinal Disord Tech. 18(4), 297–303.
[10] Highsmith, J.M., Dhall, S.S., Haid, R.W. Jr., Rodts, G.E. Jr., Mummaneni, P.V. (2011).
Treatment of cervical stenotic myelopathy: a cost and outcome of laminoplasty versus
laminectomy and lateral mass fusion. J. Spinal Disord Tech. 14(5), 19-625.
Chapter 5
Cervical Laminoplasty
Daniel Park, MD
Department of Orthopaedic Surgery, Oakland University School of Medicine
Royal Oak, MI, US
Case Summary
tandem gait. She has a poor grip release test. Imaging evaluation reveals a neutral cervical
alignment with multilevel cervical spondylosis and spinal cord compression worst between
C3-4 and C6-7 (Figures 1,2,3).
40 Daniel Park
(A) (B)
(C) (D)
Figure 1. (A) AP, (B) lateral, and (C, D) flexion-extension radiograph demonstrating multi-level
spondylosis without listhesis or cervical lordosis.
Cervical Laminoplasty 41
(A) (B)
(C) (D)
(E) (F)
Figure 2. (A) Sagittal and (B-F) axial CT demonstrating multi-level cervical spondylosis and stenosis.
42 Daniel Park
(A) (B)
(C) (D)
(E)
Figure 3. (A) Sagittal and axial T2-weighted MRI sections of C3-4, C4-5, and C6-7 demonstrating
spinal cord impingement.
Surgical Approach
There are three possible treatment options for this patient. These options include: multi-
level anterior cervical discectomy and fusion, posterior laminectomy and fusion, and posterior
laminoplasty.
Due to spinal cord compression at C3-4, C4-5, and C5-6, surgical decompression is
required at these three levels. A posterior approach would be the best treatment for several
reasons. First, the axial MRI images demonstrate evidence of congenital spinal stenosis and
circumferential compression (Figure 3). Lateral pre-operative radiographs also demonstrate
this congenital stenosis as the distance between the spinolaminar line and the posterior margin
of the facet joints is narrowed (Figure 1). It is our belief that a posterior approach allows for a
more adequate decompression of multiple levels in the setting of congenital stenosis.
Additionally, the plain radiographs demonstrate significant C6-7 spondylosis in the setting of
maintained cervical sagittal alignment. Given that the C3-4, C4-5, and C5-6 levels require
formal decompression, I would have significant concern for placing a three level cervical
fusion (ACDF C3-6) adjacent to a degenerated disc (C6-7).
Surgical Procedure
For this procedure, Mayfield Tongs are utilized to position the patient prone (Figure 4).
Fluoroscopic imaging is obtained to ensure appropriate positioning of the cervical spine.
Unlike a laminectomy and fusion, the head can be flexed slightly in a laminoplasty procedure
to aid in the spinal canal exposure and decompression. The slight flexion decreases the
shingling effect of the laminae allowing for improved visualization of the adjacent levels.
Multi-modal neurophysiologic monitoring is utilized to ensure safe decompression of a
compromised cord (as evidenced by the cord edema on MRI; Figure 3). Mean arterial
pressures should be maintained above 75 mm Hg to ensure adequate cord perfusion especially
during the decompressive portion of the surgical procedure.
During exposure, one should be careful not to detach the posterior cervical extensor
muscles that insert on the spinous process of C2. Furthermore, lateral dissection, in contrast to
fusion procedures, does not need to extend past the lateral mass-lamina junction (Figure 5).
Once the spine is exposed, the spinous processes can be removed. Next, the interspinous
ligaments connecting the surgical levels to the cranial and caudal interspace are detached.
Some surgeons favor preserving the interspinous ligaments in order to increase stability of the
hinge, but our preference is to remove it in its entirety to aid in a controlled expansion. Next,
a burr is utilized to create a trough at the junction of the lateral mass and lamina. It should be
noted the cephalad portion of the lamina is thicker than the caudal portion at each level.
Furthermore, the caudal end of the lamina does not have ligamentum flavum attached, thus,
leaving no protection from the burr. The opening side is burred through the outer cortex,
cancellous bone, and inner cortex. The “hinge” side is then burred at the same junction. It is
critical to maintain the integrity of the inner cortex such that a greenstick fracture can be
created.
44 Daniel Park
Figure 4. Mayfield Tongs utilization in prone positioning.
Figure 5. Intra-operative photograph demonstrating lateral dissection and visualization of the spinous
processes.
Once each level is burred down on the “hinge” side, a currette can be utilized to create
dorsal pressure to observe whether the posterior lamina will expand dorsally. If difficulty is
experienced while elevating the hinge, the opening side should be re-examined to verify
completion.
Lastly, a plate, allograft rib, machined cortical allograft, or the posterior spinous process
can be used to secure the hinge (Figure 6,7).
Figure 6. Post-operative AP and lateral radiograph demonstrating bridging plate at C3-6 following
cervical laminoplasty.
Figure 7. Post-operative axial CT images demonstrating positioning of the bridging plate following
cervical laminoplasty.
46 Daniel Park
Pearls and Pitfalls

 It is important to preserve the muscle attachments to the spinous process of C2 .
 The lateral exposure to the lateral mass-lamina junction should be minimized.
 When opening the laminoplasty door, ensure careful, controlled expansion in order to
prevent spinal cord injury.
 Ensure the caudal and cephalad levels are free from the ligamentum flavum
attachments prior to opening the laminoplasty to allow for smooth expansion.
 If there is difficulty opening the hinge, check the opening side to make sure the bone
trough is complete.
Literature Summary
The causes of cervical myelopathy include cervical spondylosis, disc herniation, and
ossification of the posterior longitudinal ligament. Cervical spondylosis is the predominant
cause of cervical myelopathy in patients over 55 years of age. As the cervical discs
degenerate, there is a resultant loss of disc height and bulging of the annulus resulting in cord
compression. Furthermore, the overall spinal column shortens leading to redundancy and
thickening of the ligamentous flavum which contributes to spinal cord compression [1].
Non-operative treatment can be utilized for patients with mild myelopathy [1,2,3]. In
regards to surgical management options, studies have demonstrated similar neurological
recovery independent of the technique. Emery et al. reviewed 108 patients who underwent
anterior surgery with autogenous bone graft for cervical myelopathy. Although 16 (14.8%)
patients demonstrated pseudarthrosis, the anterior technique was associated with high rates of
neurological recovery, functional improvement, and pain relief [4].
The aim of posterior based techniques is to indirectly decompress the spine via a drifting
mechanism. The two common posterior techniques are laminoplasty and laminectomy with
fusion. Edwards et al. compared 13 patients who underwent multilevel corpectomy to 13
patients who underwent laminoplasty for multilevel cervical myelopathy [5]. The Nurick
grade improvements were greater for the laminoplasty patients, but the difference was not
statistically significant. Complications for anterior surgery were more common and included
progression of myelopathy, nonunion, persistent dysphagia and/or dysphonia, and subjacent
motion segment ankylosis. Radiographic evidence of adjacent level degeneration was
demonstrated in 38% of patients following corpectomy and 8% of patients following
laminoplasty. The authors concluded that in the absence of pre-operative kyphosis,
laminoplasty may be the treatment of choice for multilevel myelopathy [5]. In another study,
Yonenobu et al. compared laminoplasty and anterior fusion for the treatment of two, three,
and four-level cervical stenosis. Laminoplasty was associated with lower complication rates
while maintaining similar rates of functional recovery when compared to anterior fusion [6].
Despite demonstrating neurological improvement, complications following cervical
laminoplasty have been described. Recurrent kyphosis can lead to failed surgery and
recurrence of pre-operative symptoms as the cord cannot drift posteriorly from the existing
anterior compression. Hirai et al. found that anterior decompression achieved a more adequate
maintenance of lordosis and a faster rate of neurological recovery than laminoplasty at 5 years
following surgery [7]. In addition, despite its description as “motion preserving”,

laminoplasty can result in 30-50% loss of motion which is less than with multilevel
arthrodesis. Also, laminoplasty has been demonstrated to be inconsistent in providing relief of
axial neck pain [8].
To eliminate potential post-operative kyphosis and residual neck pain, some surgeons
employ a posterior based laminectomy and fusion. Heller et al. demonstrated that
improvements in Nurick scores, strength, dexterity, sensation, pain, and gait were greater for
laminoplasty than fusion, but not statistically significant [9]. However, the authors reported
complications including progression of myelopathy, nonunion, instrumentation failure,
kyphosis, bone graft harvest pain, adjacent degeneration requiring reoperation, and deep
infection were associated with laminectomy and fusion while no complications were noted in
the laminoplasty patients.
In conclusion, while an anterior approach has some advantages in the management of
multi-level disc disease and resultant myelopathy, a posterior approach allows for direct
decompression of the spinal cord and nerve roots as well as indirect decompression by
allowing the cord to drift off of the anteriorly-based offending pathology. While posterior
fusion should be considered in patients who have significant axial neck pain, in the absence of
neck pain a laminoplasty procedure can be extremely reliable to decompress the neurologic
elements, while preserving motion and reducing complications.
References
[1] Rao, R. D., Currier, B. L., Albert, T. J., Bono, C. M., Marawar, S. V., Poelstra, K. A., &
Eck, J. C. (2007). Degenerative cervical spondylosis: clinical syndromes, pathogenesis,
and management. J. Bone Joint Surg. Am., 89(6), 1360-1378.
[2] Kadanka, Z., Bednarik, J., Novotny, O., Urbanek, I., & Dusek, L. (2011). Cervical
spondylotic myelopathy: conservative versus surgical treatment after 10 years. Eur.
Spine J., 20(9), 1533-1538.
[3] Rhee, J. M., Shamji, M. F., Erwin, W. M., Bransford, R. J., Yoon, S. T., Smith, J. S.,
Kalsi-Ryan, S. (2013). Nonoperative management of cervical myelopathy: a systematic
review. Spine (Phila Pa 1976), 38(22 Suppl 1), S55-67.
[4] Emery, S. E., Bohlman, H. H., Bolesta, M. J., & Jones, P. K. (1998). Anterior cervical
decompression and arthrodesis for the treatment of cervical spondylotic myelopathy.
Two to seventeen-year follow-up. J. Bone Joint Surg. Am., 80(7), 941-951.
[5] Edwards, C. C., 2nd, Heller, J. G., & Murakami, H. (2002). Corpectomy versus
laminoplasty for multilevel cervical myelopathy: an independent matched-cohort
analysis. Spine (Phila Pa 1976), 27(11), 1168-1175.
[6] Yonenobu, K., Hosono, N., Iwasaki, M., Asano, M., & Ono, K. (1992). Laminoplasty
versus subtotal corpectomy. A comparative study of results in multisegmental cervical
spondylotic myelopathy. Spine (Phila Pa 1976), 17(11), 1281-1284.
[7] Hirai, T., Okawa, A., Arai, Y., Takahashi, M., Kawabata, S., Kato, T., Shinomiya, K.
(2011). Middle-term results of a prospective comparative study of anterior
decompression with fusion and posterior decompression with laminoplasty for the
48 Daniel Park
treatment of cervical spondylotic myelopathy. Spine (Phila Pa 1976), 36(23), 1940-

1947.
[8] Hosono, N., Yonenobu, K., & Ono, K. (1996). Neck and shoulder pain after
laminoplasty. A noticeable complication. Spine (Phila Pa 1976), 21(17), 1969-1973.
[9] Heller, J. G., Edwards, C. C., 2nd, Murakami, H., & Rodts, G. E. (2001). Laminoplasty
versus laminectomy and fusion for multilevel cervical myelopathy: an independent
matched cohort analysis. Spine (Phila Pa 1976), 26(12), 1330-1336.
Chapter 6
Anterior Cervical Decompression

and Fusion
Shah-Nawaz M. Dodwad, MD and Alpesh A. Patel, MD

Department of Orthopaedic Surgery, Northwestern University Feinberg
School of Medicine, Chicago, IL, US
Case Summary
tandem gait. She has a poor grip release test. Imaging evaluation reveals neutral cervical
alignment with multilevel cervical spondylosis and spinal cord compression worst between
C3-4 and C6-7 (Figures 1,2,3).
50 Shah-Nawaz M. Dodwad and Alpesh A. Patel
Figure 1. Radiographs taken in the AP, neutral lateral, and flexion/extension lateral demonstrating loss
of normal cervical lordosis with disc space narrowing and osteophyte formation most significant from
C4 to C7. Flexion/extension radiographs are useful to evaluate for dynamic cord compression due to
any subtle instability at a specific level.
Anterior Cervical Decompression and Fusion 51
Figure 2. Sagittal and axial CT images demonstrating multi-level cervical spondylosis and stenosis.
(A)
(B)
Figure 3. (A) Sagittal T2-weighted MRI sections also demonstrate cord impingement at C3-4, C4-5,
and C6-7. (B) Axial T2-weighted MRI sections of C4-5, Retrovertebral C5, C5-6, and C6-7.
Surgical Approach
A standard anterior cervical or Smith-Robinson approach was chosen as this provides the
most direct access to treat this patient‟s anterior compressive pathology. This approach allows
direct anterior decompression of the spinal cord and cervical roots. There are multiple
variables that must be assessed prior to determining anterior versus posterior cervical
decompression: number of levels, location of cord compression (ventral vs. dorsal, disc space
vs. retrovertebral), sagittal alignment, dynamic instability, and the presence of ossification of
the posterior longitudinal ligament [1]. Additionally, each approach has unique complications
and this needs to be accounted for in every patient. Anterior approaches, especially multilevel
and upper cervical levels, carry a greater risk of dysphagia, dysphonia and nonunion.
Posterior approaches have been associated with greater blood loss, longer hospital length of
stay, and a higher infection or wound complication rate.
This patient has a neutral cervical spine, allowing for either posterior or anterior
procedures. Although there are multiple factors involved, in general, anterior approaches are
used for up to 3 segment fusions. Beyond 3 segments, posterior procedures are typically used.
The most compelling reason for an anterior approach in this patient is the ventral location of
the compressive pathology both at each individual disc space but also retrovertebral at C5. An
anterior approach allows for a direct decompression of these structures while also avoiding
complications of posterior procedures.
Surgical Procedure
The patient is placed supine on a radiolucent table. If the patient is myelopathic,
fiberoptic intubation or an awake intubation may be necessary. In myelopathic patients, intra-
operative neuromonitoring is performed, with baseline motor evoked and somatosensory
evoked potentials obtained prior to positioning. A padded bump is placed between the
shoulder blades posteriorly. This bump extends the shoulders and neck to facilitate surgical
dissection but must be done carefully in the setting of myelopathy so as to avoid iatrogenic
cord injury. The arms and shoulders are secured to the side of the patient. Rather than a direct
transverse incision, an oblique incision along the anterior border of the sternoclediomastoid
muscle is used to facilitate multilevel cervical exposure and instrumentation.
A 2-3 cm incision is made on the left or right side of the neck; the incision is typically
made on the contralateral side of maximal neurological compression/symptoms. There has
been no definitive data to suggest surgical laterality relates to recurrent laryngeal nerve injury
[2,3]. The platysma muscle layer is identified and carefully dissected using blunt dissection to
elevate the platysma while electrocautery is used to carefully transect the muscle. The
superficial fascia is then bluntly dissected. The plane between the sternocleidomastoid muscle
laterally and the strap muscles medially is then developed through blunt dissection directed
towards the midline. The pre-tracheal fascia is identified and dissected down to the level of
the vertebral body. Once the appropriate level is identified using fluoroscopy, electrocautery
is used to dissect through the anterior longitudinal ligament and elevate the longus coli
muscles sub-periosteally out to the width of the uncovertebral joints. Wide exposure out to
the uncovertebral joints is the most critical part of the exposure: it orients the surgery to the
midline as well as identifies the left and right extent of the vertebral bodies. This technique
facilitates a thorough and symmetric decompression while protecting the vertebral arteries.
An initial discectomy is performed by incising the anterior annulus and removing the
initial disc material using curettes and rongeurs. Caspar pins are advanced into the vertebral
bodies and are distracted appropriately. The discectomy or corpectomy is then fully
performed using pituitary/Kerrison rongeurs, curettes, and high-speed burr. In cases of
myelopathy, the posterior longitudinal ligament should be removed to fully decompress the
cord. A nerve hook is used to develop a plane between the dura and the posterior longitudinal
ligament and is then followed by the use of a 1mm Kerrison rongeur to remove the posterior
longitudinal ligament. Decompression is confirmed with a nerve hook in the central canal and
neuroforamina bilaterally. Direct palpation of the medial, superior, and lateral borders of the
pedicle ensures a thorough decompression. In corpectomy procedures, a minimum width of
15 mm is required to adequately decompress the cord. This width is confirmed with the use of
a ruler or caliper.
Once the disc space or corpectomy site has been prepared, trial interbody and/or
corpectomy grafts are used to identify the appropriate graft size. Structural graft is augmented
with local bone, bone graft extenders or iliac crest autograft. Once the appropriately sized
graft is placed, plate fixation is performed. Plate fixation is used to prevent graft kick-out and
subsidence, as well as facilitate lordosis and fusion, most notably in multilevel procedures [4].
Pearls and Pitfalls

 Pre-operative imaging should be scrutinized for aberrant vertebral artery anatomy
that may preclude anterior cervical surgery.
 Most patients will have post-operative dysphagia to some degree which usually
improves with time. Patients should be clearly counseled preoperatively.
 Dissection should include full exposure of the uncus on each side of the vertebral
body. Final retractors should not be placed until both uncinate processes are
visualized.
 Once deep retractors are placed, the endotracheal tube should be deflated and then re-
inflated to the appropriate pressure to help decrease excessive esophageal pressure
and potential excessive recurrent laryngeal nerve pressure.
 Failure to appropriately protect the esophagus during surgical dissection or aberrant
retractor placement can have devastating long-term complications secondary to
esophageal injury.
 The sympathetic chains lay on top of the longus coli muscles and appropriate
retractor placement and meticulous lateral dissection is critical to help reduce injury
to these structures.
 Anterior osteophytes should be debrided prior to Caspar pin placement to clearly
identify the superior/inferior disc margins.
 The surgical procedure should be performed with high efficiency to decrease
operative/retractor time to potentially decrease post-operative complications such as
dysphagia.
Literature Summary
Cervical degenerative myelopathy is the most common pathology that results in spinal
cord dysfunction in the world and remains primarily a clinical diagnosis supported by
radiographic findings [5]. Surgical intervention in myelopathic patients halts progression or
improves symptoms and is usually dependent on the degree of pre-operative symptoms.
Anterior cervical decompression involves fusion with corpectomy or discectomy. Posterior
cervical decompression usually involves laminectomy and fusion or laminoplasty.
While both anterior and posterior approaches have demonstrated success, each has its
own unique advantages and disadvantages that need to be addressed for each individual
patient. Critical factors include anterior or posterior compression of the spinal cord, number
of surgical levels, sagittal alignment, instability, prior surgical procedures, and the presence of
ossification of the posterior longitudinal ligament. If the cervical spine is kyphotic and 3 or
fewer segments of disease are involved, anterior surgery is usually performed. Corpectomy is
often performed for retrovertebral compression. For multilevel cervical myelopathy in the
absence of kyphotic deformity, laminoplasty is gaining popularity as the recommended
treatment [6,7]. Furthermore, adjacent segment degeneration is reported to be about 2.9% for
anterior procedures and 1% for posterior procedures [8,9]. Additionally, the rate of C5 palsies
with anterior and posterior cervical surgery are equal [10].
Anterior and posterior surgical techniques have equivalent efficacy in the treatment of
degenerative cervical myelopathy. However, there is some data to show a potentially higher
complication rate with posterior surgery compared to anterior surgery, notably wound
complications and infection [11]. Regardless of whether an anterior or posterior surgical
approach is used to treat cervical spondylotic myelopathy, the goal remains the same – to
decompress the neural structures, prevent disease progression, and, hopefully, improve
neurological function.
Figure 4. Post-operative lateral radiograph demonstrating re-establishment of disc height and cervical
lordosis, with C5 corpectomy and ACDF at C6-7 with spanning plate fixation from C4-7.
References
[1] Lawrence, B. D., & Brodke, D. S. (2012). Posterior surgery for cervical myelopathy:
indications, techniques, and outcomes. Orthop. Clin. North Am., 43(1), 29-40, vii-viii.
doi: 10.1016/j.ocl.2011.09.003
[2] Beutler, W. J., Sweeney, C. A., & Connolly, P. J. (2001). Recurrent laryngeal nerve
injury with anterior cervical spine surgery risk with laterality of surgical approach.
Spine (Phila Pa 1976), 26(12), 1337-1342.
[3] Kilburg, C., Sullivan, H. G., & Mathiason, M. A. (2006). Effect of approach side during
anterior cervical discectomy and fusion on the incidence of recurrent laryngeal nerve
injury. J. Neurosurg. Spine, 4(4), 273-277. doi: 10.3171/spi.2006.4.4.273.
[4] Oh, J. K., Kim, T. Y., Lee, H. S., You, N. K., Choi, G. H., Yi, S., . . . Shin, H. C.
(2013). Stand-alone cervical cages versus anterior cervical plate in 2-level cervical
anterior interbody fusion patients: clinical outcomes and radiologic changes. J. Spinal
Disord Tech., 26(8), 415-420. doi: 10.1097/BSD.0b013e31824c7d22.
[5] Young, W. F. (2000). Cervical spondylotic myelopathy: a common cause of spinal cord
dysfunction in older persons. Am. Fam. Physician, 62(5), 1064-1070, 1073.
[6] Edwards, C. C., 2nd, Heller, J. G., & Murakami, H. (2002). Corpectomy versus
laminoplasty for multilevel cervical myelopathy: an independent matched-cohort
analysis. Spine (Phila Pa 1976), 27(11), 1168-1175.
[7] Seng, C., Tow, B. P., Siddiqui, M. A., Srivastava, A., Wang, L., Yew, A. K., . . . Yue,
W. M. (2013). Surgically treated cervical myelopathy: a functional outcome
comparison study between multilevel anterior cervical decompression fusion with
instrumentation and posterior laminoplasty. Spine J., 13(7), 723-731.
[8] Sekhon, L. H. (2006). Posterior cervical decompression and fusion for circumferential
spondylotic cervical stenosis: review of 50 consecutive cases. J. Clin. Neurosci., 13(1),
23-30.
[9] Hilibrand, A. S., Carlson, G. D., Palumbo, M. A., Jones, P. K., & Bohlman, H. H.
(1999). Radiculopathy and myelopathy at segments adjacent to the site of a previous
anterior cervical arthrodesis. J. Bone Joint Surg. Am., 81(4), 519-528.
[10] Gandhoke, G., Wu, J. C., Rowland, N. C., Meyer, S. A., Gupta, C., & Mummaneni, P.
V. (2011). Anterior corpectomy versus posterior laminoplasty: is the risk of
postoperative C-5 palsy different? Neurosurg. Focus, 31(4), E12.
[11] Fehlings, M. G., Barry, S., Kopjar, B., Yoon, S. T., Arnold, P., Massicotte, E. M., . . .
Gokaslan, Z. L. (2013). Anterior versus posterior surgical approaches to treat cervical
spondylotic myelopathy: outcomes of the prospective multicenter AOSpine North
America CSM study in 264 patients. Spine (Phila Pa 1976), 38(26), 2247-2252. doi:
10.1097/brs.0000000000000047
Case Vignette 3:
Cervical Pseudoarthrosis
Chapter 7
Anterior Approach
Krzysztof B. Siemionow, MD and Piotr Janusz, MD

Department of Orthopaedic Surgery, University of Illinois at Chicago
Chicago, IL, US
Case Summary
A 53-year-old male presents with a chief complaint of severe neck pain two years
following a C5-6 and C6-7 anterior cervical discectomy and fusion (ACDF). The pain is
constant, burning, and localized to the axial cervical spine without radicular symptoms. The
pain is aggravated with neck movements. While the procedure relieved his pre-operative
radicular symptoms, one year following surgery he developed progressive axial neck pain. On
physical examination, he is neurologically intact, but has limited and painful neck range of
motion in flexion, extension, and lateral bending. His voice is normal without hoarseness. He
smokes one pack of cigarettes per day. Plain radiographs demonstrate anterior
instrumentation at C5-7 and evidence of pseudarthrosis at C6-7 (Figure 1). Computed
tomographic (CT) imaging reveals non-union at C6-7 (Figure 2).
60 Krzysztof B. Siemionow and Piotr Janusz
(A)
(B)
Figure 1. (A) AP and (B) lateral radiographs of the cervical spine demonstrate C5-C7 anterior
instrumentation and evidence of arthrodesis at C5-C6 with a pseudarthrosis at C6-C7. There is no
evidence of lucency around the screws. The plate encroaches on the C4-C5 disc space.
Anterior Approach 61
Figure 2. Sagittal CT demonstrates a non-union at C6-C7 and solid fusion at C5-C6. The plate
encroaches on the C4-C5 disc space.
Surgical Approach
Revision surgery for pseudarthrosis following an ACDF may be performed via anterior,
posterior, or a circumferential approach. The anterior approach has been associated with
decreased rates of complications, lower intra-operative blood loss, shorter length of recovery,
and lower complication rates when compared to the posterior approach for the treatment of
cervical pseudarthrosis. [1]
If an anterior approach is selected, the surgeon must decide whether to approach the
pseudarthrosis from the same side as the original surgery or from the contralateral direction.
Contralateral surgery decreases approach-related risks, but requires a pre-operative
otolaryngology consult to prevent possible bilateral recurrent laryngeal nerve injury.
Surgical Procedure
The patient was placed on the operating room table in the supine position. A shoulder roll
was placed under the patient‟s shoulders, and the head was gently extended on a foam
doughnut. Gentle traction was placed on the shoulders (with cloth tape) to increase
visualization (Figure 3). The previously used right-sided incision was marked and the level
was confirmed by fluoroscopy. A transverse incision on the opposite side at the level of the
old incision was performed. After dissecting through the skin and underlying soft tissue, the
platysma was incised in line with the incision. The deep cervical fascia was exposed. A
standard Smith-Robinson approach was performed (Figure 4,5). The anterior plate was
identified and the adhesions were carefully dissected. The screws and the plate were removed.
The C5-C6 level was fused. The C6-C7 disc space was explored and carefully debrided. The
burr was used to remove the prior fusion attempt as well as any associated cartilaginous tissue
(Figure 6). The pseudarthrosis mass and bone was removed completely until the dura was
exposed (Figure 7). The nerve probe was used to ensure that there was no residual central or
foraminal compression (Figure 7). The endplates were prepared with rasps and a burr after
which a 6 mm stand-alone cage filled with iliac crest autograft was placed. Screws were
placed into the new holes (Figure 8). The implant position was confirmed with fluoroscopic
imaging (Figure 9).
Pearls and Pitfalls

 Consider a pre-operative otolaryngology consultation to assess the status of the vocal
cords.
 Approaching the spine from the opposite side of the index procedure is technically
less demanding but requires both vocal cords to be functioning properly.
 Obtain a copy of the prior operative report and review for any potential
complications and the type of implants utilized.
 Have an implant removal set available and understand how the screw removal
mechanism functions.
Figure 3. Image of patient positioning. The neck is gently extended and the shoulders are strapped
down to increase visualization. Care should be taken to ensure that there is no pressure on the brachial
plexus.
Figure 4. Intra-operative image demonstrating the standard Smith-Robinson approach.
 Have a backup plan for removing the plate and screws.

 An oral-gastric tube can aid in identifying the esophagus in the setting of significant
scar tissue formation.
 Identify the midline. Use the old instrumentation as a reference (know where it is on
preoperative imaging in relation to midline). Traditional landmarks such as the
longus coli and the uncinate process may not be available in revision settings. During
endplate preparation use a burr to remove the prior allograft or PEEK cages. Try to
avoid excessive endplate bone removal to prevent settling of the new graft.
 Consider utilizing an iliac crest autograft.
 Choose the shortest plate possible and stay at least 5 mm away from the adjacent disc
space.
Figure 5. Surgical approach demonstrating exposed 1) m. longus coli, 2) carotid sheath and 3) SCM.
Figure 6. Intra-operative microscope image demonstrating resection of the pseudarthosis with a high-
speed burr.
Figure 7. Intra-operative microscope image demonstrating the exposed spinal cord and nerve probe
evaluation of neuroforaminal stenosis.
Figure 8. Intra-operative microscope image demonstrating interbody screw placement.

(A)
(B)
Figure 9. Intra-operative fluoroscopic (A) AP and (B) lateral image confirming implant and screw
placement. Interbody device is properly positioned.
(A)
(B)
Figure 10. Post-operative AP (A) and lateral (B) radiographs demonstrating proper instrumentation and
interbody cage placement. Disc height and cervical lordosis have been restored.
Figure 11. One year post-operative sagittal CT demonstrating no loosening of instrumentation or cage
migration. Bone growth can be visualized.
Literature Summary
The advantages of anterior revision surgery include direct visualization and removal of
the pseudarthrosis, direct decompression of the neural elements, and avoidance of the
morbidity associated with a posterior approach. However, the reported outcomes for the
anterior approach for the treatment cervical pseudarthrosis have been variable.
Zdeblick et al. analyzed thirty-five patients with pseudarthrosis treated with an anterior
approach and revision fusion with autograft. [2] The authors demonstrated excellent clinical
results in 29 (82.9%) patients, good results were reported in 1 (2.9%), fair in 4 (11.4%), and
poor in 1 (2.9%) patient. One patient reported temporary recurrent laryngeal-nerve palsy
while two patients reported wound draining, and one demonstrated a cerebrospinal fluid leak.1
Tribus et al. demonstrated 75% improvement in clinical symptoms in patients with one- or
two-level pseudarthrosis treated via an anterior approach utilizing autograft and anterior
instrumentation. [3] Furthermore, Coric et al. reported on nineteen patients following an
anterior approach revision fusion with allograft and anterior instrumentation for 1- to 3-levels
of pseudarthrosis. [4] The authors demonstrated that 94.7% of patients achieved solid fusion.
A study by Carreon et al. demonstrated that the posterior approach incurred increased
estimated blood loss, longer recovery period, and a higher complication rate than the anterior
approach.4 However, the patients who underwent revision via the posterior approach were
significantly less likely to require additional revision surgery. [1]
The decreased incidence of procedure-associated morbidity may compel the surgeon to
elect to perform the revision surgery via the anterior approach. However, the literature
appears to demonstrate that the standard posterior approach may offer higher rates of
arthrodesis following revision. The surgeon should be cognizant of the known risk factors in
each patient for non-union including smoking status, obesity, age, and comorbidities (e.g.
diabetes) prior to the procedure. [5] It may be imperative to determine whether avoiding the
peri-operative morbidities associated with the posterior approach may outweigh the
seemingly long-term benefits of a posterior approach for the management of cervical
pseudarthrosis on a case-by-case basis. Specifically, the patient preference as well as the
pathology (e.g. levels of involvement) should be closely scrutinized to determine whether the
patient may be a viable candidate for revision via the anterior approach following cervical
pseudarthrosis.
References
[1] Carreon, L., Glassman, S. D. & Campbell, M. J. (2006). Treatment of anterior cervical
pseudoarthrosis: posterior fusion versus anterior revision. The spine journal : official
journal of the North American Spine Society., 6, 154-6.
[2] Zdeblick, T. A., Hughes, S. S., Riew, K. D. & Bohlman, H. H. (1997). Failed anterior
cervical discectomy and arthrodesis. Analysis and treatment of thirty-five patients. J
Bone Joint Surg Am., 79, 523-32.
[3] Tribus, C. B., Corteen, D. P. & Zdeblick, T. A. (1999). The efficacy of anterior cervical
plating in the management of symptomatic pseudoarthrosis of the cervical spine. Spine.,
24, 860-4.
[4] Coric, D., Branch, C. L. & Jenkins, J. D. (1997). Revision of anterior cervical
pseudoarthrosis with anterior allograft fusion and plating. J Neurosurg., 86, 969-74.
[5] Stauff MP, Knaub MA. (2006). Pseudoarthrosis Following Anterior Cervical Surgery:
Diagnosis, Treatment Options, and Results. Seminars in Spine Surgery., 18, 235-44.
Chapter 8
Posterior Approach for an Anterior

Cervical Pseudoarthrosis
Abhishek Kannan and Wellington K. Hsu, MD

Department of Orthopaedic Surgery,
Northwestern University Feinberg School of Medicine
Chicago, IL, US
Case Summary
A 33-year-old female presents with a 15-year history of left-sided intrascapular pain.
Over the past 2-3 years, her symptoms have worsened in severity. She characterized the pain
as burning in nature, and localized it to her left intrascapular, deltoid, and anterior chest wall
region. She also complained of numbness and tingling in her fifth digit as well as in the distal
aspect of her second and third fingers in her left hand. She denied any right-sided symptoms
or weakness. Her prior conservative treatment included physical therapy, corticosteroid
injections, acupuncture, and medications such as gabapentin and tramadol. Physical exam
demonstrated decreased sensation to light touch in left C6 dermatomes, and a positive left-
sided Spurling‟s test. MRI demonstrated mild spondylotic changes throughout the cervical
region with significant broad-based disc protrusions at the C5-C6 levels associated with
foraminal stenosis (Figure 1).
The patient was offered and then underwent anterior cervical discectomy and fusion
(ACDF) at the level of C5-C6 with machined corticocancellous allograft without
postoperative complications. She reported resolution of her preoperative symptoms beginning
at the 6-week follow-up and was released to activity without restrictions. Plain radiographic
evaluation at the 3-month time point demonstrated interval bony incorporation of the allograft
(Figure 2A). Beginning at the 6-month and continuing to the 9-month follow-up, subsequent
plain radiographs demonstrated resorption of the allograft (Figure 2B). Clinically, the patient
reported continued resolution of her symptoms and did not have complaints. When the patient
reached the 13-month postoperative mark, she began to develop neck and recurrent left-sided
intrascapular pain. Work-up included CT, MRI, and flexion-extension radiographs. The
72 Abhishek Kannan and Wellington K. Hsu
patient was diagnosed with a non-union with resorption of vertebral endplates at the C5-6
level. CT scan demonstrated no evidence of hardware loosening. MRI ruled out associated
adjacent segment disease. Patient was diagnosed with C5-C6 pseudoarthrosis, and extensive
discussion was carried out with the patient regarding non-operative and surgical options.
Figure 1. Mid-sagittal T2-weighted MRI of the cervical spine demonstrating overall mild multilevel
degenerative changes resulting in mild central spinal canal stenosis.
Posterior Approach for an Anterior Cervical Pseudoarthrosis 73
Figure 2A. Post-operative lateral radiograph at 3 months demonstrating anterior plate and screw
construct following ACDF.
Figure 2B. Post-operative lateral radiograph at 9 months following ACDF demonstrating allograft
resorption. The arrow denotes retrolisthesis of C5 on C6.
Surgical Approach
Given the patient‟s failed fusion via a previous anterior approach, a C5-C6 posterior
foraminotomy and fusion with instrumentation was decided upon for the pathology. It stands
to reason that because the inherent anterior biology did not allow for a successful fusion
during the index procedure, as such a posterior procedure would lead to a higher revision
fusion rate. A posterior approach also avoids revision dissection through scar tissue and the
potential risks of injury to the recurrent laryngeal nerve, carotid and vertebral arteries, as well
as the esophagus and trachea. [1] Finally, the evidence-based literature supports the use of
posterior surgery to treat cervical pseudarthroses because of the good clinical outcomes and
successful fusion rates. [1,2,3] Surgically correcting this patient with a posterior technique
enhances potential for subsequent fusion, avoids the challenges posed by anterior revision,
and serves to minimize patient symptoms by enhancing early stability.[4] Because of the
patient‟s residual radicular complaints, a posterior foraminotomy was performed to fully
decompress the exiting C6 nerve root. [5]
Surgical Procedure
After general anesthesia and endotracheal intubation, the patient is placed in the prone
position on a standard radiolucent table and Mayfield head holder. Gardner-Wells tongs with
15 pounds of traction utilized with a footplate at the caudal end of the table can be used to
secure the head during the operation (Figure 3). Fluoroscopic guidance is then used to
localize the incision over the C5-C6 spinous processes. After standard dissection of soft tissue
over the spinous processes with Bovie cauterization, the lateral edge of the lateral masses is
exposed. After re-confirmation of the level with fluoroscopic guidance, we recommend
performing the foraminotomy initially because of the preservation of the bony anatomic
landmarks (Figure 4A). After the microscope is properly positioned, the inferior articular
facet of the C5 level is removed followed by the superior articular process of the C6 vertebrae
with an oscillating burr. A #1 Kerrison rongeur can be used to complete the decompression.
Utilizing a micronerve hook, the lateral edge of the C6 pedicle is palpated to ensure
decompression of lateral border of the cervical foramen. Visualization of the exiting nerve
root confirms successful foraminotomy.
Attention is then directed towards the lateral masses for screw fixation. An oscillating
burr is used to mark the starting position just medial to the midpoint of the lateral mass both
in the medial-lateral and cephalad-caudad planes (Figure 4B). Utilizing a Magerl technique
(30 degree cephalad and 25 degree lateral trajectory) (Figure 5), the longest possible lateral
mass screw is inserted. A variable-length drill guide with 2-mm increments can be used to
maximize screw lengths at each cervical level. Bilateral placement of 3.5 mm x 14 mm
screws at the C5 and C6 level is confirmed using fluoroscopy (Figure 6). Bilateral
facetectomy with an oscillating burr is performed to increase the surface area for fusion. If the
lamina is intact, decortication can also be done here to supplement the fusion. Local bone
graft from either a facectectomy or laminectomy can serve as the osteoinductive portion of
the bone graft. After bone graft placement, a titanium rod is then fitted within the lateral mass
screws with final tightening of the set-screws. Use of an instrumentation system with a wide
arc of motion from the tulip head can aid in rod placement. Furthermore, offset connectors
can be helpful when instrumentation must extend across the cervicothoracic junction. We
routinely use 1-2 grams of vancomycin powder subfascially and prophylactically followed by
a medium Hemovac drain. Meticulous multilayer closure of the fasical planes with vicryl
sutures is essential to prevent wound dehiscence and infection
Figure 3. Patient positioning with Gardner-Wells tongs to secure the head, footplate at the caudal end,
and table in reverse Trendelenburg.
Figure 4A. Image demonstrating bony landmarks. Black arrow denotes “intralaminar V”.
Figure 4B. An oscillating burr is used to mark the starting position just medial to the midpoint of the
lateral mass both in the medial-lateral and cephalad-caudad planes.
Figure 5. Cervical lateral mass fixation with the use of the Magerl technique. This technique utilizes a
starting placement at the midpoint of the lateral mass in both the cephald-caudad and medial-lateral
planes; the Magerl screw is inserted in a 30° superior and 20° lateral orientation.
Figure 6. Intra-operative image demonstrating bilateral placement of 3.5 mm x 14 mm screws at the C5

and C6 level.
Figure 7. Post-operative (A) AP and (B) lateral radiographs demonstrating proper instrumentation.
Arrowhead denotes graft incorporation anteriorly within the disc space.
Pearls and Pitfalls

 In clinical situations in which a foraminotomy and lateral mass fixation is required,
we recommend performing the decompression first since the anatomic landmarks are
best visualized at this time.
 Before bony resection with an oscillating burr, visualization of the entire facet joint is
necessary to prevent destabilization during the foraminotomy. After identification of
the point where the caudad and cephalad lamina meet and the lateral edge of the
lateral mass, the surgeon then knows to avoid removing the lateral 50% width of the
facet joint.
 Palpation of the lateral edge of the caudad pedicle (C7 during a C6-7 foraminotomy)
in the foramen is necessary to ensure adequate decompression in a medial to lateral
direction. If the decompression reaches lateral to this point, then the rest of the facet
can be preserved.
 Visually marking the medial, lateral, cephalad, and caudad borders of the lateral
mass can aid in the identification of the starting point of screw fixation. While the
Magerl technique is the most common protocol taught in the United States, other
trajectories have also been published that may be more appropriate based on patient-
specific characteristics.
 Use of a variable-length drill guide can help utilize the full length of the lateral mass
during screw placement. Because this area cannot typically accommodate screws
longer than 16 mm, the technique chosen should attempt to use the longest screw
possible.
Literature Summary
Cervical pseudarthrosis is a well-established complication of ACDF marked by a lack of
solid arthrodesis at the 12-month period. Non-union rates vary with bone graft type, number
of vertebral levels fused, and the surgical procedure. [1] Various contributors to fusion rate
have been identified, including patient age, obesity, smoking status, medical comorbidities,
and patient compliance post-operatively. [6] The pseudarthrosis rate following an ACDF has
been reported in the range of 3%-20% for single level fusions and has high as 21% and 46%
for two- and three- level fusions, respectively. [7, 8]
In comparison to the anterior approach, the posterior revision, as seen in this vignette,
affords increased stability while avoiding the risk of dissection through anterior scar tissue.
Posterior procedures allow for additional stabilization of the spine by providing fixation of
the posterior column.[6] Among a group of 34 patients with symptomatic pseudarthrosis post
anterior cervical fusion, Brodsky et al. demonstrated “excellent” or “good” clinical results in
88% of the posterior fusion group.[3] Of the 17 patients who underwent anterior repair, only
59% achieved the same success. The posterior repair group showed 94% radiologic fusion
compared to 76% in the anterior repair group. After anterior revision, 24% had persistent
pseudoarthrosis. [3] Similarly, in another comparative study of anterior versus posterior
approaches for cervical nonunion, Carreon et al. demonstrated that 44% of 27 patients who
underwent anterior revision required a second revision surgery. On the other hand, the
posterior fusion group had a revision rate of 2%. [1] In a case series study, Kuhns et al.
presented a retrospective review of 33 patients who underwent posterior revision for
pseudoarthrosis following ACDF. With an average follow-up period of 46 months, 100% of
patients demonstrated successful fusion and noted significant improvement in preoperative
symptoms. Outcome measures including the Cervical Spine Outcomes Questionnaire (CSOQ)
and the Arthritis Impact Measurement Scales 2 (AIMS2) demonstrated 72% patient
satisfaction with surgical results. [2]
With respect to anterior revisions, a posterior revision poses fewer complications and
lower risk of injury to vital structures. Carotid and vertebral artery injury, glosspharyngeal
lesion and facial nerve paresis have been reported.[9, 10] Post-operative edema of the
pharynx, esophagus, and trachea can result in temporary dysphagia and hoarseness, and are
known complications of ACDF as well as anterior revision. Edwards et al. reported a variable
range of postoperative dysphagia and dysphonia (from 1% to 60%), with surgeon
underreporting as high as 80%.[11] While posterior fusion procedures are associated with
increased blood loss and longer recovery time, the higher fusion rate and lower incidence of
repeat revision surgery make it the preferred option in properly selected patients. [5]
When planning a posterior revision for cervical pseudoarthrosis, a surgeon should

consider multiple factors including sagittal alignment, the type and extent of the pathological
involvement, and patient preference. [5] Posterior cervical decompression and fusion for
treatment of symptomatic cervical pseudoarthrosis affords patients the potential for relief of
symptoms secondary to compression of neural elements. Surgical intervention for cases
involving myelopathy, radiculopathy, or any combination of these conditions can produce
excellent clinical outcomes and ultimately an improvement in patient quality of life.
References
[1] Carreon, L., Glassman, S. D. & Campbell, M. J. (2006). Treatment of anterior cervical
pseudoarthrosis: posterior fusion versus anterior revision. Spine J, 6(2), 154-156.
[2] Kuhns, C. A. G., Matthew, J. & Wang Jeffrey, C. Delamarter, Rick B. (2005). An
Outcomes Analyssi of the Treatment of Cervical Pseudoarthrosis With Posterior
Fusion. Spine (Phila Pa 1976), 30(21), 2424-2429.
[3] Brodsky, A. E. K., Momtaz, A., Sassard Walter, E. & Newman Bernard, P. (1992).
Repair of Symptomatic Pseduoarthrosis of Anterior Cervical Fusion: Posterior Versus
Anterior Repair. Spine (Phila Pa 1976), 17(10), 1137-1143.
[4] Lindsey, R. W. N., Kenneth E., Leach, John, & Murphy, Michael J. . (1986). Nonunion
Following Two-Level Anterior Cervical Discectomy and Fusion. Clinical Orthopaedics
and Related Research, (223), 155-163.
[5] Hsu, W. K. (2011). Advanced Techniques in Cervical Spine Surgery. The Journal of
Bone and Joint Surgery. 93(8), 780-8.
[6] Stauff, M. P. & Knaub, M. A. (2006). Pseudoarthrosis Following Anterior Cervical
Surgery: Diagnosis, Treatment Options, and Results. Seminars in Spine Surgery, 18(4),
235-244.
[7] Mutoh, N. S. K., Yamaura, I. & Satoh, H. (1993). Pseudoarthrosis and delayed union
after anterior cervical fusion. International Orthopaedics, (17), 286-289.
[8] Simmons, E. H. (1970). Anterior Cervical Discectomy and Fusion. Journal of Bone and
Joint Surgery, 44, 897-898.
[9] Bertalanffy, H. E. & H. R. (1989). Complications of Anterior Cervical Discectomy
Without Fusion in 450 Consecutive Patients. Acta Neurochir, 99, 41-50.
[10] Schroeder, G. D. & Hsu, W. K. (2013). Vertebral artery injuries in cervical spine
surgery. Surgical Neurology International, 4(Suppl 5), S362-367.
[11] Edwards II, C. C. K., Yekaterina, Cha., Chuck, Heller., John, G., Yoon, Timothy &
Riew, Daniel. (2004). Accurate Identification of Adverse Outcomes After Cervical
Spine Surger. The Journal of Bone and Joint Surgery, 86A(2), 251-256.
Case Vignette 4:
Thoracic Disc Herniation
Chapter 9
Anterior Approach
Sleiman Haddad, MD1, Paul W. Millhouse, MD2,

John D. Koerner, MD2 and Alexander R. Vaccaro, MD, PhD2
Vall d‟Hebron University Hospital, Autonomous University of Barcelona, Spain
1
2
The Rothman Institute at Thomas Jefferson University Hospital, Philadelphia, PA, US
Case Summary
A 33-year-old female presented with worsening throbbing abdominal pain, lower
extremity weakness, and difficulties with balance. She described chronic lower back pain
since a motor vehicle accident 14 years prior to presentation. Her discomfort worsened over
the past year with progressive lower extremity pain, more pronounced on the left side. She
denied fevers or chills, unintentional weight loss or gain, and bowel or bladder changes. She
failed to improve with non-operative treatment including COX-2 inhibitors and spinal
injections.
On physical examination, she had tenderness over the lower thoracic spine. Lumbar range
of motion was preserved despite pain. Motor and sensory examination was within normal
limits except for hyperactive reflexes in the lower extremities. No other long tract signs were
present.
Radiographic examination demonstrated multilevel degenerative changes with a slight
decrease in thoracic kyphosis (Figure 1). An MRI of the thoracic spine revealed three disk
herniations: two were minor at the T7-8 and T8-9 levels with no signs of cord compression
while one was significant with cord compression at T10-11. The larger herniation was
calcified and occupied 50% of the spinal canal, more significant on the left side,
corresponding to the majority of the patient‟s symptoms (Figure 2).
84 Sleiman Haddad, Paul W. Millhouse, John D. Koerner et al.
Figure 1. 33 year-old female with back pain, lower extremity weakness, and gait imbalance. AP and
lateral thoracic spine radiographs demonstrate multi-level degenerative changes with slight decrease in
her kyphosis angle throughout the apex of her thoracic spine.
Figure 2. Sagittal STIR sequence: T7-8 and T8-9 minor TDHs, no signs of cord compression or
myelopathy, Giant T10-11 TDH occupying more than 50% of the canal with signs of calcifications.
Axial: Left paracentral large TDH, impeding on and displacing the spinal cord at the T10-T11 level.
Surgical Approach
In summary, the patient presented with a centrolateral large calcified thoracic disc
herniation (TDH) at the T10-T11 level. She was a candidate for surgical decompression due
to progressive myelopathy. Considering the level of the TDH (T10-T11), the size and the
centrolateral position, the anterior transthoracic approach was determined to be most
appropriate to properly visualize and completely resect the herniated fragment. For upper
thoracic levels (T1-T4), a right sided thoracotomy is recommended to help prevent injury to
the thoracic duct and the aortic arch [1,2]. For lower levels (T4-L2) we generally prefer a left
sided approach to avoid obstruction from the liver [1,2,3]. This left sided exposure also
facilitates ligation of the segmental arteries arising from the aorta, and greater ability to
manage inadvertent complications such as dural tears [1,2]. In addition the exposure is easily
enlarged and the field may be extended as necessary to manage multilevel pathology [1,2].
Surgical Procedure
The patient was placed in the right lateral decubitus position on a radiolucent Jackson
table and all bony prominences were padded. The spinal level was determined using
fluoroscopy by counting from the lumbosacral junction and confirmed with the preoperative
radiographs and MR images (sagittal view of entire spine). Again under fluoroscopy, the
appropriate level was marked parallel to the rib and the intercostal space.
The surgical field was then prepped widely so that the incision could be extended to a
regular thoracotomy if necessary. Through a 4- to 6-cm skin incision, centered over the
posterior edge of the disc space, the serratus muscle was exposed and split parallel to the
fibers. The underlying rib and intercostal space was then uncovered. In young patients with an
elastic rib cage an intercostal approach can safely be used for the thoracotomy, with no need
for rib osteotomy or resection. The intercostal muscles were accordingly split above the
superior margin of the caudal rib and the thoracic cavity was entered after incising the
visceral pleura. The intercostal space was further widened with a Finochetto retractor to
increase exposure.
The pleura over the target disc was cut longitudinally and a spinal needle inserted into the
disc. Lateral fluoroscopy was used to verify that the needle was over the appropriate disc. The
rib head overlying the T10-T11 disc was resected with a Leksell rongeur and a curette was
used to expose the underlying left pedicle. The pedicle was then thinned with a burr, moving
from caudal to cranial, while preserving the innermost cortex. The undersurface of the pedicle
was exposed using a curved curette, and removed with a Kerrison rongeur. This maneuver
allowed for identification of the exiting nerve root and thecal sac. Using a #15 blade, a
triangular annulotomy was performed and the disc space penetrated. The central disc
elements were then removed with a pituitary rongeur and curettes. A high-speed burr was
used running parallel to the vertebral endplates to remove the superior third of the caudal
vertebra and the inferior third of the cranial vertebra. The posterior cortex of the vertebral
bodies at these levels was thinned using the same burr and then gently brought into the
created cavity using curved curettes and a nerve hook, along with the annulus and herniated
elements. The entire width of the dural sac and posterior longitudinal ligament was exposed
and confirmed with the visualization of the contralateral pedicle. The posterior longitudinal
ligament was grasped with a micro nerve hook and sharply removed to complete the
decompression of the spinal cord. The thecal sac was palpated along its entire width, reaching
to the contralateral pedicle, to confirm adequate decompression.
The resultant cavity and the remaining vertebral body were prepared to receive an iliac
crest allograft. The graft was inserted and countersunk 2-3 millimeters. Intra-operative
imaging was obtained to confirm appropriate positioning of the interbody spacer. A #28 chest
tube was placed through a separate stab incision and directed to the posterior mediastinum.
The pleura, muscles and skin were then closed.
To enhance stability to the operative segment and prevent axial pain or collapse into
kyphosis, a posterior approach followed by pedicle screw instrumentation was completed at
T10 and T11. Intraoperative imaging confirmed the appropriate placement of the spinal
anchors and alignment of the instrumentation. Local bone graft and demineralized bone
matrix were placed over the decorticated posterior elements at the T10-11 level to further
enhance fusion (Figure 3).
Figure 3. Post-operative AP and lateral thoracic radiographs of the same patient after anterior
transthoracic decompression and posterior fusion.
Pearls and Pitfalls

 Disc herniation type, location, and biomechanical stability dictate the surgical
approach.
 Choice of an approach generally considers three elements: patient factors, the
herniated disc characteristics, and surgeon experience.
 A central laminectomy alone without wide facet resection for herniated discs has
been abandoned due to high morbidity rates.
 The open transthoracic approach is unique in that it affords safe spinal cord
decompression under direct visualization for central, large, calcified disc herniations.
 The open transthoracic approach is ideal for the treatment of multilevel pathology
and the management of intraoperative complications (i.e. dural tear or vessel injury)
if they should occur.
 Pre-operative imaging including X-rays and MRI should always be available in the
operating room, and the lumbar anatomy and number of ribs must be checked
preoperatively.
 The pre-operative sagittal scout MRI should be matched with intra-operative
fluoroscopy findings to properly identify the level of the pathology.
 Pre-operative CT scans may be of value in the operative planning by evaluating disc
calcification and for planning instrumentation.
 Special care should be taken to avoid injury to the costal neurovascular bundle.
 Rib resection provides better visualization but may increase intercostal neuralgia and
wound problems.
 If needed, the segmental arteries may be ligated at least 1cm away from the aorta to
prevent avulsion.
 Rib head removal permits direct access to the caudal pedicle, adjacent
neuroforamina, and posterior vertebral wall.
 Wrong level surgery may be avoided using imaging confirmation after reaching the
target disc space.
 The empty disk space as well as the trough created after partial vertebral body
resection is utilized as a “cavity” to allow deposition of bone and disk as needed.
This allows maneuvers to be directed away from the spinal canal at all times
 Dural tears and/or neurologic injury are more likely to occur if excision of the
posterior calcified disk material and OPLL is done prior to performing
decompression via hemicorpectomies.
 Adjacent partial hemicorpectomy aids in defining the “normal” spinal canal and cord.
 Non-symetrical hemicorpectomies can compromise interbody arthrodesis and lead to
iatrogenic sagittal or coronal deformities
 Fusion is indicated when stability is compromised by the decompression and in cases
associated with Scheuermann disease.
Literature Summary
Accepted surgical indications for a thoracic disc herniation (TDH) include: progressive
myelopathy, lower extremity weakness or paralysis, bladder or bowel dysfunction, and
radicular pain unresponsive to conservative treatment [1,2].
Surgical treatment of thoracic disc herniations was first performed via thoracic
laminectomy without wide facet resection in the early 19th century [2]. This technique is now
virtually contraindicated due to high morbidity rates, with neurologic compromise as high as
75% in some series, as well as high mortality, mainly due to the obligatory mobilization of
the spinal cord. As such, a number of alternative surgical approaches have been devised to
gain direct access to the herniated disc. These alternatives include the posterior, posterolateral
and anterior approaches. In brief, posterior and posterolateral approaches allow for an indirect
compression (unless the herniation is lateral) and therefore carry the inherent risk of spinal
cord injury [4,5]. On the other hand, the anterior approach offers excellent visualization
through a direct working field, although sometimes at the expense of pulmonary morbidity
[1]. Therefore, the most important goal when choosing a surgical approach is to achieve good
visualization of the herniation while minimizing manipulation of an already compromised
thoracic spinal cord.
Several factors are taken into consideration when selecting the surgical approach. These
factors are grouped into three general categories: patient characteristics, type and location of
the herniated disc, and surgeon experience. The patient‟s body habitus might increase the
difficulty of a transthoracic approach. Also, the patient‟s general health condition and
comorbidities can be relative contraindications to large anterior procedures as these patients
require single-lung ventilation, result in increased blood loss, necessitate a postoperative chest
tube and are associated with prolonged hospital stays. Next, the qualities of the disc
herniation itself must be taken into consideration. The location, size, consistency, and
possible intradural involvement of the disc hernation all play crucial roles. When a central
herniated disc is present, it is safest to use an anterolateral approach involving thoracoscopy
or thoracotomy [5,6,7]. Posterolateral approaches are reserved for paracentral or lateral
herniated discs that do not cross the midline [8]. Upper thoracic levels might be difficult to
reach through the chest and a costotransversectomy may be indicated. Finally, from a
surgeon‟s viewpoint, there is a steep learning curve for certain approaches, especially the less
invasive techniques.
The transthoracic, anterior approach is the most versatile, allowing for central exposure
and decompression from T4 to T12 [1,6,9]. This has been described as the “gold standard”
approach to treat TDHs [10]. However, despite excellent clinical results and neurological
safety profile, standard thoracotomy carries a significant risk of perioperative morbidity such
as post-thoracotomy syndrome and intercostal neuralgia due to rib osteotomies and soft tissue
retraction. Therefore, several modifications to the original technique have been described.
The technique used here minimizes the trauma to the thoracic cage and utilizes direct
visualization with an adequate field of vision. The working field, while smaller, has the
advantage of allowing simultaneous control of the pathology and the essential anatomical
structures. Surgical time is not significantly increased when compared to a conventional open
thoracotomy [1]. This approach also is associated with less postoperative morbidity (wound
problems, lung complications, neuralgic pain, post thoracotomy pain) and therefore generally
results in shorter hospital stays and faster return to function [1,9]. The proposed technique
does violate the pleura, and therefore necessitates a postoperative chest tube; generally the
chest tube may be removed within 48 hours.
The addition of an interbody fusion may be required for patients who have undergone
wide corpectomies, complete discectomy, or both during the thoracic decompression [5].
Patients with multilevel discectomies, a discectomy at the thoracolumbar transition area, or
with concomitant Scheuermann disease may also require fusion [7]. If significant thoracic
spine pain is anticipated or severe osteoporosis is present, fusion may also be indicated.
Less invasive approaches have been developed from a desire to reduce postoperative pain
and recovery time while capitalizing on already excellent outcomes. However, the best
evidence regarding these approaches is confined to small retrospective series and descriptions
of operative techniques [4,5,10] These reports advocate use in select patients, and the clinical
evidence has yet to prove superiority of one approach over another. This is mainly due to the
infrequency of TDHs and the heterogeneity encountered in the patient population and
associated published studies.
To date, only five series have specifically reported results in large TDH, four of which
utilized a transpleural thoracotomy, with the last one using a transthoracic retropleural mini-
open technique [6]. In transthoracic transpleural approaches, most of the patients needed
further instrumentation due to extensive discectomies or corpectomies. In more than 75% of
the cases, patients improved at least one Frankel grade. Uribe et al. reviewed the literature on
open versus minimally invasive approaches for TDH (not restricted to large TDH) ﬁnding a
complication rate of 36.7% (Range 0-82%) and 28.4% (range 0–92.3%), respectively, with no
differences in overall outcome [10].
Finally, the decision on which approach to select will ultimately depend on the pathologic
features of the patient and TDH as well as the training and expertise of the operating surgeon.
References
[1] Harrod, C. C., Simpson, A. K. & Vaccaro, A. R. (2012). Anterior Thoracic Diskectomy
and Corpectomy. In A. R. Vaccaro, Baron, E. M. (Ed.), Operative Techniques: Spine
Surgery (2nd Edition ed., Vol. 1, 144-157). Philadelphia: Elsevier Saunders.
[2] Eck, J. C., Green, B. A. & Eismont, F. J.(2011). Thoracic Disc Disease. In H. N.
Herkowitz, Garfin, S. R., Eismont, F. K., Bell, G. R. & Balderston, R. A. (Ed.),
Rothman-Simeone The Spine (828-845): Saunders - Springer.
[3] Fernandez, M. & Gidvani, S. N. (2014). Thoracic Disc Herniation. In V. V. Patel, Patel,
A., Harrop, J.S., Burger, E (Ed.), Spine Surgery Basics (193-201). Heidelberg, New
York, Dordrecht, London: Springer.
[4] Snyder, L. A., Smith, Z. A., Dahdaleh, N. S. & Fessler, R. G. (2014). Minimally
invasive treatment of thoracic disc herniations. Neurosurg Clin N Am, 25(2), 271-277.
[5] Yoshihara, H. (2014). Surgical treatment for thoracic disc herniation: an update. Spine
(Phila Pa 1976), 39(6), E406-412.
[6] Quraishi, N. A., Khurana, A., Tsegaye, M. M., Boszczyk, B. M. & Mehdian, S. M.
(2014). Calcified giant thoracic disc herniations: considerations and treatment
strategies. Eur Spine J, 23 Suppl 1, S76-83.
[7] Oppenlander, M. E., Clark, J. C., Kalyvas, J. & Dickman, C. A. (2014). Indications and
Techniques for Spinal Instrumentation in Thoracic Disc Surgery. J Spinal Disord Tech.
[8] Oppenlander, M. E., Clark, J. C., Kalyvas, J. & Dickman, C. A. (2013). Surgical
management and clinical outcomes of multiple-level symptomatic herniated thoracic
discs. J Neurosurg Spine, 19(6), 774-783.
[9] Yoshihara, H. & Yoneoka, D. (2014). Comparison of in-hospital morbidity and
mortality rates between anterior and nonanterior approach procedures for thoracic disc
herniation. Spine (Phila Pa 1976), 39(12), E728-733.
[10] Uribe, J. S., Smith, W. D., Pimenta, L., Hartl, R., Dakwar, E., Modhia, U. M. &
Deviren, V. (2012). Minimally invasive lateral approach for symptomatic thoracic disc
herniation: initial multicenter clinical experience. J Neurosurg Spine, 16(3), 264-279.
Chapter 10
Minimally Invasive Retropleural

Discectomy
Junyoung Ahn, Ehsan Tabaraee, MD

Vincent J. Rossi, Andrew J. Park,
Khaled Aboushaala, MD and Kern Singh, MD
Chicago, IL, US
Case Summary
A 45-year old male presents with sudden severe thoracic back pain radiating bilaterally
into the chest. He also notes difficulty walking due to weakness in both legs and difficulty
emptying his bladder completely. Physical examination reveals decreased sensation below the
mid-thoracic spine, decreased rectal tone, and weakness in the bilateral lower extremities.
MRI of the thoracic spine shows a large central disc herniation at T8-9 causing severe
compression and deformation of the thoracic spinal cord (Figure 1).
92 Junyoung Ahn, Ehsan Tabaraee, Andrew Park et al.
(A)
(B)
Figure 1. Pre-operative (A) sagittal and (B) axial T1-weighted MRI demonstrating a large central disc
herniation at T8-9.
Minimally Invasive Retropleural Discectomy 93
Figure 2. Photograph demonstrating patient in the lateral decubitus position.
Surgical Approach
A minimally invasive (MIS) retropleural thoracic discectomy was chosen for the surgical
management of the thoracic disc herniation. In comparison to the traditional transthoracic
approach, the minimally invasive (MIS) retropleural thoracic discectomy has been associated
with increased surgical efficiency and lower complication rates [1,2]. In addition, the
retropleural approach affords the surgeon the most direct route to the herniated disc while
maintaining the integrity of pleura [3].
Surgical Procedure
The patient is placed in the left lateral decubitus position on a Jackson table with
appropriate padding of the bony prominences (Figure 2). Anteroposterior (AP) and lateral
fluoroscopic images are obtained to localize the level of spinal pathology.
A 2-5 cm skin incision is made parallel to the superior surface of the overlying rib and
centered over the target vertebral level. This rib is subperiosteally exposed, isolated, and
removed segmentally with the neurovascular bundle reflected inferiorly in the enveloped soft
tissue. The parietal pleura immediately beneath the thin fascia is bluntly reflected from the
ventral surface of the thoracic wall utilizing a sponge stick in a sweeping motion to create a
potential space for the dilators and final retractor system. The dissection is directed
posteriorly along the undersurface of the posterior thoracic cavity, sweeping the viscera
anteriorly.
Under fluoroscopic guidance and tactile feedback, the initial dilator is advanced until it
docks at the desired disc. Sequential dilation is performed. Once the final dilator is placed, an
expandable retractor is positioned over the dilators and secured onto the operating room table
with a self-retaining extension system (Figure 3). The dilators are removed and the retractors
blades are expanded.
Figure 3. Intra-operative photograph demonstrating tubular retractor system secured onto the operating
table.
Figure 4. Post-operative axial CT following the removal of the herniated thoracic disc. The trough
created in the vertebral body can be visualized.
Figure 5. Post-operative axial MRI demonstrating removal of the herniated thoracic disc and
restoration of the normal cord size.
Figure 6. Post-operative sagittal CT demonstrating removal of the herniated thoracic disc. The prior
attempted posterior laminectomy is also demonstrated.
After appropriate localization, the retractor system is subtly adjusted for adequate
visualization of the disc of interest. Exposure extends sub-periosteally from the disc space to
the adjacent vertebral bodies. The segmental arteries are avoided; however, if necessary they
can be cauterized.
The overlapping costovertebral joint immediately inferior to the disc space of interest is
resected to allow for visualization of the posterior vertebral body, pedicle, and intervertebral
disc. The pedicle is then partially resected with a combination of a high-speed burr, Kerrison
Rongeur, and curettes to gain access to the spinal canal. The lateral dural sac and the exiting
nerve root are identified. Troughs are created in the posterior aspects of the adjacent endplates
to create potential space for the posterior-to-anterior decompression of the disc material.
Great care is taken to avoid any pressure on the spinal cord. At this time, if a large portion of
the vertebral body and disc are removed, a fusion may be performed utilizing either autograft
(from previously resected rib), allograft, or an interbody device. Chest tubes are not routinely
used unless there is a disruption of the parietal pleura with exposed lung tissue.
Pearls and Pitfalls

 Pre-operative imaging (radiographs, MRI) should be available in the operating room
and matched with intra-operative fluoroscopy in order to ensure appropriate
localization.
 Resection of the rib facilitates expansion of the working tube while decreasing the
likelihood of a rib fracture. The rib portion may be re-approximated utilizing a
maxillofacial plate but this is rarely needed.
 A three-bladed retractor is most typically utilized. The retractor is oriented such that
there is no posterior blade allowing for visualization of the posterior vertebral body
and spinal canal.
 Cautious anterior to posterior decompression of thoracic discs require patience as
most discs will be calcified and adherent to the posterior longitudinal ligament.
Literature Summary
The transthoracic approach has traditionally provided excellent visualization in the
surgical management of thoracic disc herniations [4,5]. However, significant morbidity
associated with the approach (pneumothorax, pneumonia, significant blood loss, and post-
operative pain) has prompted interest in minimally invasive modifications [1,3,4,6].
The minimally invasive (MIS) retropleural thoracic discectomy has been associated with
reduced operative time, lower blood loss, shorter hospitalization, and lower rates of in-
hospital mortality when compared to the transthoracic approach [1,2]. In addition, lower rates
of complications including pleural effusions, pneumothorax, durotomy, and intercostal
neuralgia have been associated with the MIS retropleural thoracic discectomy [4,7]. The
retropleural approach also allows the surgeon to access the most direct route to a herniated
disc while maintaining the integrity of pleura [3].
Although the minimally invasive technique may decrease post-operative pain and
morbidity, the evidence is restricted to a relatively small number of case series with limited
follow-up. The largest series by Uribe et al. reviewed 75 retropleural thoracic discectomies.
The most common level was at T11 (18.7%). Anterior interbody fusion was performed in
90% of cases. Median operative time, length of stay, and estimated blood loss was 182
minutes, 5 days, and 290 ml respectively. There were 4 complications (6.7%) and 3 re-
operations (5%). At 11 month follow-up there was a 60% reduction in pain scores and 80%
excellent/good outcomes. Results have been consistently suggestive that the MIS retropleural
discectomy may offer similar final outcomes compared to traditional transthoracic anterior
approach while maintaining a lower incidence of complications [1,4,7]. However, reports
have differed in technique, outcomes studied, and follow-up. Future comparative studies
between MIS and traditional studies are warranted.
References
[1] Yoshihara, H. & Yoneoka, D. (2014). Comparison of in-hospital morbidity and
mortality rates between anterior and nonanterior approach procedures for thoracic disc
herniation. Spine (Phila Pa 1976), 39(12), E728-733.
[2] Snyder, L. A., Smith, Z. A., Dahdaleh, N. S. & Fessler, R. G. (2014). Minimally
invasive treatment of thoracic disc herniations. Neurosurg Clin N Am, 25(2), 271-277.
[3] Moran, C., Ali, Z., McEvoy, L. & Bolger, C. (2012). Mini-open retropleural
transthoracic approach for the treatment of giant thoracic disc herniation. Spine (Phila
Pa 1976), 37(17), E1079-1084.
[4] Uribe, J. S., Smith, W. D., Pimenta, L., Hartl, R., Dakwar, E., Modhia, U. M. &
Deviren, V. (2012). Minimally invasive lateral approach for symptomatic thoracic disc
herniation: initial multicenter clinical experience. J Neurosurg Spine, 16(3), 264-279.
[5] Quraishi, N. A., Khurana, A., Tsegaye, M. M., Boszczyk, B. M. & Mehdian, S. M.
(2014). Calcified giant thoracic disc herniations: considerations and treatment
strategies. Eur Spine J, 23 Suppl 1, S76-83.
[6] Burke, T. G. & Caputy, A. J. (2000). Treatment of thoracic disc herniation: evolution
toward the minimally invasive thoracoscopic technique. Neurosurg Focus, 9(4), e9.
[7] Smith, W. D., Dakwar, E., Le, T. V., Christian, G., Serrano, S. & Uribe, J. S. (2010).
Minimally invasive surgery for traumatic spinal pathologies: a mini-open, lateral
approach in the thoracic and lumbar spine. Spine. 35(26 Suppl), S338-346.
Case Vignette 5:
Lumbar Disc Herniation
Chapter 11
Open Microdiscectomy
Islam M. Elboghdady1, Hamid Hassanzadeh, MD2

and Howard An, MD1
1
Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, US
2
Department of Orthopaedic Surgery, University of Virginia, Charlottesville, VA, US
Case Summary
A 34-year old male presents to the office with a long-standing history of low back pain
radiating down the left lower extremity (LLE). The back pain has resolved; however, the
radiating pain down his LLE persists and now the patient complains of new-onset numbness
and weakness. Physical examination reveals left lower extremity weakness on plantar flexion
and decreased sensation to light touch on the plantar surface of the left foot. Plain radiographs
demonstrate decreased disc height at L5-S1 (Figure 1). MRI of the lumbar spine reveals disc
degeneration at L4-L5 and L5-S1 with a herniated disc at L5-S1 (Figure 2).
102 Islam M. Elboghdady, Hamid Hassanzadeh and Howard An
(A)
(B)
Figure 1. Pre-operative (A) AP and (B) lateral radiographs in the neutral position demonstrating
decreased L5-S1 disc height.
Open Microdiscectomy 103
(A)
(B)
Figure 2. Pre-operative (A) sagittal and (B) axial T2-weighted MRI demonstrating L4-5 disc
degeneration and a left-sided L5-S1 herniated disc.
Figure 3. Intra-operative photograph demonstrating medial retraction of the traversing nerve root and
removal of the herniated nucleus pulposus.
Surgical Approach
An open microdiscectomy (MD) was chosen as the approach that best addressed this
patient‟s pathology. Such an approach provides excellent lighting and magnification of the
operating field allowing for better visualization of the neural elements, herniated disc, and
bony structures. When compared to alternative approaches such as minimally invasive (MIS)
and micro-endoscopic techniques, open microdiscectomy offers superior pain relief and
decreased rates of recurrence and re-herniation [1,2].
In comparison to standard discectomy, microdiscectomy allows for smaller incisions of
the skin and fascia with reduced disruption of soft tissue allowing for a less traumatic
procedure. Furthermore, open microdiscectomy demonstrates comparable outcomes and
patient-reported satisfaction rates to traditional discectomy [3].
Surgical Procedure
The patient is positioned prone on the Jackson table and a lateral x-ray/radiograph is
obtained to localize L5 and S1. A longitudinal midline incision approximately 3 cm in length
is performed and the subcutaneous tissue is incised with Bovie cautery. The fascia is then
identified and incised just off the midline. Sub-periosteal dissection is carried out beneath the
fascia, over the L5 lamina. The sacrum is then palpated and the interlaminar space is
identified. McCulloch retractors are then placed to retract the fascia at the level of L5-S1.
At this point, the ligamentum flavum is detached from the superior aspect of the S1 and
slowly excised with a combination of curved curettes, Kerrison rongeurs, and Woodson
instrument. The McCulloch retractor is then adjusted such that the thin blade is between the
spinous processes and the thick blade is lateral against the fascia.
A microscope is then brought into the field once the exposure is complete. The
ligamentum flavum in the interlaminar space is then excised from the S1 lamina superiorly to
the inferior aspect of L5. The ligamentum flavum is then detached from the inferior aspect of
L5 with a combination of curettes. Upon entering the spinal canal, multiple-size Kerrison
rongeurs are used to remove a small portion of the ligamentum flavum. Woodson forceps are
used to create a stable working space between the dura and the overlying ligamentum flavum
by detaching the adhesions. The epidural fat and residual soft tissue are then removed.
The left-sided S1 nerve root is then visualized and freed from any adhesions and scar
tissue. Once the lateral aspect of the root is exposed, the root is retracted medially (Figure 3)
with a nerve root retractor as well as a Penfield 4, to allow for exposure of the L5-S1 disk on
the left side. The floor of the spinal canal, which is the dorsal aspect of the disc is then cleared
with a Penfield.
The discectomy is then begun with a Penfield to unveil the rent that is in the disk.
Sequestered disc material is removed with a pituitary. Any loose tissue is then forced out
through downward pressure on the middle aspect of the disk. Once the disk material is free, a
Woodson is placed in the central area anterior to the disk space, and anterior-directed force on
the disc space allows residual material to extrude out laterally through the annulotomy.
During the discectomy, the left S1 nerve root is retracted medially, visualized, and gradually
freed and mobilized.
Pearls and Pitfalls

 Pre-incisional and pre-decompression radiographs should be obtained to identify the
appropriate vertebral level.
 During decompression, refrain from extending too far laterally or entering the pars
interarticularis.
 Performing the annulotomy in-line with the fibers potentially decreases the rate of re-
herniation.
 In cases involving a large central disc herniation, performing a small discectomy
allows for mobilization and extrusion of the herniated disc portion without applying
excessive retraction of the dural sac and nerve root.
Literature Summary
The most prevalent modern approach for the treatment of lumbar disc herniation is open
microdiscectomy (MD) [1]. Studies have demonstrated significant improvements in Visual
Analogue Scale (VAS) scores for back pain and leg pain as well as mental well-being in
patients with lumbar disc herniation [4]. In comparison to minimally invasive (MIS) MD,
open MD demonstrates superior leg and low back pain relief at 6-month and 2-year follow up
[1]. Moreover, open approaches demonstrate significantly lower recurrence and re-operation
rates compared to MIS techniques for herniated discs [1,2]
The rate of dural tears and root injuries has been reported to be nearly three times more
common in micro-endoscopic techniques than in open approaches[5]. In addition to favorable
outcomes, open MD is associated with comparable operative time, length of hospitalization,
and neurologic outcomes to an MIS microdiscectomy [3,6]. MIS techniques may have the
potential advantage of a lower risk for surgical site infection.1 However, studies have
demonstrated no significant differences in bacterial counts in swabs of operative sites
between open and MIS MD, suggesting that the reported decreased rate of postoperative
infection in MIS cases to be related to other factors such as patient selection or post-operative
care [7].
MIS techniques for MD demonstrate reduced blood loss and decreased post-operative
narcotic utilization; however, the increased risk of severe complications and reoperation rates
associated with this approach may outweigh the benefits of reduced blood loss and opioid
consumption [5,8]. Lastly, overall costs are significantly lower in open MD which provides
an opportunity for cost-saving and reduction of hospital resource utilization [5].
References
[1] Rasouli, M. R., Rahimi-Movaghar, V., Shokraneh, F., Moradi-Lakeh, M. & Chou, R.
(2014). Minimally invasive discectomy versus microdiscectomy/open discectomy for
symptomatic lumbar disc herniation. Cochrane Database Syst Rev, 9, Cd010328.
[2] Cheng, J., Wang, H., Zheng, W., Li, C., Wang, J., Zhang, Z., . . . Zhou, Y. (2013).
Reoperation after lumbar disc surgery in two hundred and seven patients. Int Orthop,
37(8), 1511-1517.
[3] Porchet, F., Bartanusz, V., Kleinstueck, F. S., Lattig, F., Jeszenszky, D., Grob, D. &
Mannion, A. F. (2009). Microdiscectomy compared with standard discectomy: an old
problem revisited with new outcome measures within the framework of a spine surgical
registry. Eur Spine J, 18 Suppl 3, 360-366.
[4] Lebow, R., Parker, S. L., Adogwa, O., Reig, A., Cheng, J., Bydon, A. & McGirt, M. J.
(2012). Microdiscectomy improves pain-associated depression, somatic anxiety, and
mental well-being in patients with herniated lumbar disc. Neurosurgery, 70(2), 306-
311; discussion 311.
[5] Teli, M., Lovi, A., Brayda-Bruno, M., Zagra, A., Corriero, A., Giudici, F. & Minoia, L.
(2010). Higher risk of dural tears and recurrent herniation with lumbar micro-
endoscopic discectomy. Eur Spine J, 19(3), 443-450.
[6] Lau, D., Han, S. J., Lee, J. G., Lu, D. C. & Chou, D. (2011). Minimally invasive
compared to open microdiscectomy for lumbar disc herniation. J Clin Neurosci, 18(1),
81-84.
[7] Li, C. H., Yew, A. Y., Kimball, J. A., McBride, D. Q., Wang, J. C. & Lu, D. C. (2013).
Comparison of operating field sterility in open versus minimally invasive
microdiscectomies of the lumbar spine. Surg Neurol Int, 4(Suppl 5), S295-298.
[8] Harrington, J. F. & French, P. (2008). Open versus minimally invasive lumbar
microdiscectomy: comparison of operative times, length of hospital stay, narcotic use
and complications. Minim Invasive Neurosurg, 51(1), 30-35.
Chapter 12
Minimally Invasive Microdiscectomy
Steven McAnany, MD, Jun Kim, MD

Department of Orthopaedic Surgery, Mount Sinai Medical Center
New York, NY, US
Case Summary
A 40 year-old female presents with 4 months of worsening right lower extremity
radiculopathy. The pain is constant and radiates from the right buttock into the sole of the
right foot. Physical examination reveals a positive right straight leg raise, decreased sensation
in the plantar aspect of the foot, and slight weakness in the right gastroc-soleus complex. MRI
of the lumbar spine reveals a large right posterolateral L5-S1 herniated disc (Figure 1).
110 Steven McAnany, Jun Kim and Sheeraz A. Qureshi
Figure 1. Sagittal and axial T2-weighed MRI demonstrating large L5-S1 right sided paracentral disc
herniation with compression of the traversing nerve root.
Surgical Approach
Minimally invasive (MIS) tubular microdiscectomy was chosen as the approach to best
treat this patient‟s pathology. By means of tubular dilators, the paraspinal muscles are dilated
rather than subperiosteally dissected as is done in the open approach. A tubular retractor is
then placed directly over the interlaminar space in order to provide access to the epidural
space for removal of the offending disc fragment.
As an alternative to the standard open approaches, endoscopic and minimally invasive
techniques have resulted in reduced hospital stay, decreased blood loss, and quicker return to
work [1]. Also in this regard, the MIS tubular approach has been demonstrated to decrease
paraspinal muscle trauma as well as immediate post-operative VAS pain scores and narcotic
use when compared to traditional open dissection [2,3] Lastly, the MIS approach has been
shown to have a significantly lower risk of surgical site infection [4].
Surgical Procedure
Under general anesthesia, the patient is placed prone on a Jackson table with a Wilson
frame. The target disc is identified under AP and lateral fluoroscopic guidance. A stab
incision is made through the skin, subcutaneous tissue, and fascia in order to place dilators
onto the interlaminar space. Once appropriate positioning of the dilators is confirmed on AP
and lateral fluoroscopy, a 16mm tubular retractor is placed and held in place with an
articulating arm attached to the operating table. The microscope is now brought into the field
in order to help with illumination and visualization throughout the procedure.
Minimally Invasive Microdiscectomy 111
Figure 2A. Positioning of the intra-operative fluoroscopy. The C arm is angled slightly cranially to be
in the plane of the disc space.
Figure 2B. Intra-operative fluoroscopic image demonstrating the en face view of the L5-S1 disc space
in the AP plane.
Figure 3. Intra-operative fluoroscopic image demonstrating the docking of the tubular retractor to
access the disc space.
Any remaining soft tissue that was not swept off the lamina is coagulated with Bovie
electrocautery. An angled curette is then used to create a plane between the ligamentum
flavum and the cephalad lamina. A high-speed burr is used to thin the lamina in preparation
for the hemilaminotomy. Using Kerrison rongeurs, the laminotomy is extended from medial
to lateral to the level of the medial edge of the facet joint. The ligamentum flavum is then
carefully separated from the underlying dura and excised. The medial 3 mm of facet can then
be removed and a foraminotomy is performed.
Once the dura is visualized, a Penfield 4 is used to identify the lateral edge of the
traversing nerve root. The nerve root may be adherent to the underlying disc herniation, and
can be dissected with the use of a blunt nerve hook. Epidural bleeding may be encountered
with mobilization of the traversing nerve root and can be controlled with bipolar
electrocautery or surgifoam. Once adequately mobilized, the nerve root can be retracted
towards the midline. A nerve root retractor is the placed to hold the nerve root medial to the
disc herniation. Bipolar cautery is then used to coagulate epidural vessels overlying the disc
herniation.
A No. 15 blade is used to incise the annulus overlying the disc herniation. Once the
annulus is opened with either a slit or a box incision, a micropituitary rongeur is inserted into
the annulotomy and the herniated disc material is removed. Several passes with the
micropituitary rongeur may be required to ensure that no additional fragments remains.
Alternatively, a reverse-angled curette can be passed in the disc space to dislodge any
remaining fragments. The disc space is irrigated with saline and then inspected visually for
any fragments.
Figure 4. Tubular retractor image demonstrating the identification of the lamina and interlaminar space.
Figure 5. Tubular retractor image demonstrating retraction of the exposed nerve root towards the
midline utilizing a nerve root retractor and visualization of the disc space.
Figure 6. Tubular retractor image demonstrating the creation of an annulotomy and portion of the
herniated disc expressing through annulus.
Pearls and Pitfalls

 Fluoroscopic visualization is critical to have an en face view of the disc space in the
AP plane in order to appropriately plan the incision and place the dilators.
 In obese patients, it is important to understand the location of the midline, as it can be
easy to make the fascial incision on the contralateral side.
 It may be necessary to move the tubular retractor in a cephalad or caudal direction in
order to remove the entire herniated disc.
 Excellent hemostasis is critical as there is no dead space and any collection of
hematoma can create a mass effect on the thecal sac.
Figure 7. Tubular retractor image demonstrating the exposure of the nerve root and the dural sac
following decompression.
Literature Summary
Numerous studies have demonstrated the effectiveness and safety of a minimally invasive
discectomy (MID). Lau et al. retrospectively reviewed twenty patients who underwent MID
and twenty-five patients who underwent an open discectomy (OD). There were no differences
between the two groups in regards to operative time, length of hospitalization, or
complications. The MID group had significantly less blood loss (p=0.02) and a trend to
improvement in post-operative neurological improvement (p=0.06) [5].
In another study, German et al. demonstrated that patients who underwent MID
experienced half the length of hospitalization as compared to patients undergoing OD (0.84
days vs. 1.43 days, respectively). No statistically significant differences were identified in
operative time, rate of cerebrospinal fluid leak, or need for physical therapy consultation. The
MID group demonstrated significantly lower rates of blood loss, post-anesthesia care unit
narcotic use, and the need for admission to the hospital [1].
Park et al. reported on twenty-three MID and forty-three OD patients in a retrospective
review. The authors found that the creatine phosphokinase (CPK) serum levels were
significantly lower in the serum of the MID group as compared to the OD group on post-
operative days three and five. The clinical scales for back pain using VAS were significantly
lowed in the MID group [6].
Dasenbrock et al., in a recent meta-analysis of six randomized controlled trials, found
evidence that suggests both OD and MID lead to a substantial and equivalent long-term
improvement in leg pain. Incidental durotomies occurred significantly more frequently during
MID, but total complications did not differ between the techniques [7].
A recent Cochrane Database systematic review looking at outcomes between MID and
open microdiscectomy (OD) was conducted. The study noted that there was low-quality
evidence that MID was associated with worse low back pain than the OD group at six-month
follow-up; this was not significant at one year. There were no clear differences between MID
and OD group on other primary outcomes measures including Oswestry Disability index or
persistence of motor or sensory neurological deficits. However, MID was associated with a
lower incidence of surgical site infections as well as a shorter hospitalization [4].
References
[1] German, J. W., Adamo, M. A., Hoppenot, R. G., Blossom, J. H. & Nagle, H. A. (2008).
Perioperative results following lumbar discectomy: comparison of minimally invasive
discectomy and standard microdiscectomy. Neurosurg Focus, 25(2), E20.
[2] Shin, D. A., Kim, K. N., Shin, H. C. & Yoon, D. H. (2008). The efficacy of
microendoscopic discectomy in reducing iatrogenic muscle injury. J Neurosurg Spine,
8(1), 39-43.
[3] Harrington, J. F., & French, P. (2008). Open versus minimally invasive lumbar
microdiscectomy: comparison of operative times, length of hospital stay, narcotic use
and complications. Minim Invasive Neurosurg, 51(1), 30-35.
[4] Rasouli, M. R., Rahimi-Movaghar, V., Shokraneh, F., Moradi-Lakeh, M. & Chou, R.
(2014). Minimally invasive discectomy versus microdiscectomy/open discectomy for
symptomatic lumbar disc herniation. Cochrane Database Syst Rev, 9, Cd010328.
[5] Lau, D., Han, S. J., Lee, J. G., Lu, D. C. & Chou, D. (2011). Minimally invasive
compared to open microdiscectomy for lumbar disc herniation. J Clin Neurosci, 18(1),
81-84.
[6] Park, B. S., Kwon, Y. J., Won, Y. S. & Shin, H. C. (2010). Minimally Invasive Muscle
Sparing Transmuscular Microdiscectomy : Technique and Comparison with
Conventional Subperiosteal Microdiscectomy during the Early Postoperative Period. J
Korean Neurosurg Soc, 48(3), 225-229. d
[7] Dasenbrock, H. H., Juraschek, S. P., Schultz, L. R., Witham, T. F., Sciubba, D. M.,
Wolinsky, J. P., . . . Bydon, A. (2012). The efficacy of minimally invasive discectomy
compared with open discectomy: a meta-analysis of prospective randomized controlled
trials. J Neurosurg Spine, 16(5), 452-462.
Chapter 13
Full Endoscopic Discectomy for

Recurrent Lumbar Disc Herniation
Pablo J. Diaz-Collado, MD and James J. Yue, MD

Department of Orthopaedics and Rehabilitation, Yale-New Haven Hospital
New Haven, CT, US
Case Summary
55-year-old male who is six months status post open posterior L4 right hemilaminectomy
and L4-5 discectomy for an L4-5 herniated disc complicated by a post-operative infection
requiring irrigation and debridement in the operating room presents complaining of recurrent
back pain and right lower extremity radicular pain. The pain is sharp and radiates from the
posterior right buttock down to his toes. The patient also complains of right lower extremity
weakness and stumbling when he walks. No bowel or bladder dysfunction is noted.
On physical examination, he is afebrile and having weakness in his right lower extremity,
specifically in his extensor hallux longus and tibialis anterior muscles.
Pre-operative laboratory work-up demonstrates a normal white blood cell count,
erythrocyte sedimentation rate and C-reactive protein. Radiographs reveal multi-level
degenerative changes and loss of disc height at L4-5 (Figure 1). T2-weighted MRI
demonstrate recurrent L4-5 right paracentral disc herniation (Figure 2). Computed
tomographic (CT) imaging reveal post-operative changes in the L4-5 disc space and loss of
disc height following a right-sided L4 hemilaminectomy (Figure 3).
118 Pablo J. Diaz-Collado and James J. Yue
(A)
(B)
Figure 1. Pre-operative (A) AP and (B) lateral lumbar spine upright radiographs demonstrating
multilevel degenerative changes of the lumbar spine with osteophyte formation at the endplates and loss
of L4-5 disc height.
Full Endoscopic Discectomy for Recurrent Lumbar Disc Herniation 119
(A)
(B)
Figure 2. Pre-operative (A) sagittal STIR T2 and (B) axial T2-weighted MRI demonstrating a recurrent
L4-5 right paracentral disc herniation with severe right neuroforaminal and central spinal stenosis.
(A)
(B)
(C)
Figure 3. (A) Sagittal and (B, C) axial CT at L4-5 level demonstrating post-operative changes
including air in the L4-5 disc.
Surgical Approach
An intra-foraminal, endoscopic far lateral posterior approach was chosen to perform the
lumbar discectomy in this patient. By means of intra-operative fluoroscopic imaging and
guidewires, the endoscope was placed into the working portal to provide visualization of the
herniated disc for decompression while minimizing tissue disruption [1].
Minimally invasive techniques in lumbar discectomy have demonstrated significantly
decreased estimated blood loss, re-admisssion rates, post-operative narcotic utilization, and
length of hospitalization as compared to open techniques [2]. As such, an endoscopic
approach to lumbar discectomy was chosen for this patient due to the potential for decreased
tissue disruption and post-operative pain [1].
Surgical Procedure
An intra-foraminal far lateral posterior needle entry point was used to position the
working cannula and endoscope. The patient is first positioned prone on a Wilson frame.
Local anesthetic (1% lidocaine without epinephrine) with intra venous sedation is used for
anesthesia. Anterior-posterior (AP) fluoroscopic imaging is used to mark the midline using
the spinous process equally positioned between both pedicles. On the lateral view the
posterior facet line (PFL) is marked on the patient‟s skin. Needle placement is always started
posterior to the posterior facet line. The skin is anesthetized with a 25 gauge needle and then
an 18 gauge spinal needle is then positioned with the bevel pointed downward. (Figure 4, 5).
Under AP and lateral fluoroscopic imaging the needle is advanced anterior-medially until the
needle impinges on the facet complex. As the needle is advanced, additional lidocaine is
injected. The needle is then partially removed and the bevel is then advanced until it is
docked on the most posterior aspect of the disc space in the inferior half of the foramen.
(Figure 6). The needle should never pass medial to the medial border of the facet on the AP
view. (Figure 7A-C). On the lateral view, the needle should just enter into the posterior
annulus. Any report of leg pain by the patient should result in needle re-positioning.
Figure 4. Illustration demonstrating needle placement at the L4-5 disc space.

Figure 5. Intra-operative photograph demonstrating placement of needle.
Figure 6. Photograph of the end of scope with working portal, light and irrigation portal.
Figure 7a. Intra-operative AP radiograph demonstrating access into the L4-5 disc space with cannula
and flexible probe.
Figure 7b. Intra-operative AP radiograph demonstrating access into the L4-5 disc space with cannula
and flexible probe.
Figure 7c. Intra-operative AP radiograph demonstrating access into the L4-5 disc space utilizing
bipolar cautery.
Figure 8. Intra-operative endoscopic visualization of the thecal sac and posterior annulus.
The stylet of the needle is removed and a guidewire is placed through the needle. The
needle is then removed and a 2-hole obturator is then placed over the guidewire. Care should
be taken not to advance the guide wire until the obturator is placed. Once the obturator is
positioned into the foramen, the working cannula is placed over the obturator and the
endoscope is placed into the cannula (Figure 8). Under direct endoscopic visualization, the
disc material is identified, freed, and removed. Nerve probes and pituitaries are used through
the endoscope to manipulate the disc material and palpate the potential neurologic structures.
Bi-polar cauterization is used to obtain hemostasis as necessary as well as to facilitate tissue
removal. Decompression is verified when pulsation of the spinal contents is confirmed and
the patient reports pain relief. Additional intra-discal decompression can be performed by
directing the needle in a less horizontal trajectory and by placing the obturator and cannula
within the disc space.
Pearls and Pitfalls

 Intra-foraminal endoscopic approaches to the spine require appropriate knowledge of
the foraminal anatomy as well as an understanding of endoscopic optical principles.
 Careful assessment of the pelvic bony anatomy is required. Needle placement cannot
be performed if the most superior aspect of the pelvic brim is higher than the inferior
aspect of the superior pedicle.
 The herniated disc should also not extend below the middle of the inferior pedicle as
determined on MRI evaluation.
 Careful assessment of the retro-peritoneal contents relative to the planned needle
trajectory should also be carefully evaluated.
 Appropriate adjustments to needle trajectory should be made based upon positioning
of the retro-peritoneal position.
 Revision endoscopic approaches are the least complex at L2-5 levels. The L5-S1
level is more demanding and may require an open approach.
 Due to the alteration in foraminal anatomy in cases of spondylolisthesis, endoscopic
spine surgery should not be routinely performed for recurrent disc herniations in this
subset of patients.
 A potential complication of endoscopic spine surgery is unintentional durotomy. If a
durotomy is experienced, it is not recommended that any foreign material be
introduced near the defect to prevent intra-dural migration.
 At the conclusion of the case, the endoscope should be removed and patient placed
on bedrest for 24 hours and slowly mobilized.
Literature Summary
Over the last 25 years, endoscopic microdiscectomy has developed into a minimally
invasive technique that allows for decompression of lumbar disc herniations [1,3,4,5,6,7,8].
Decompression can be achieved under excellent direct video visualization using endoscopes,
tubular retractors with dilators, bipolar cautery, and pituitary rongeurs. Transforaminal and
interlaminar approaches have been described [9]. Endoscopic microdiscectomy can be used to
address paramedian, foraminal, and extraforminal disc herniations. Potential advantages of
endoscopic microdiscectomy include less blood loss, less post-operative pain, and shorter
hospitalizations.
Success is dependent on patient selection, familiarity with the spatial orientation and with
the anatomy at risk. Patients best suited for endoscopic microdiscectomy are those with
single-level herniations, who have not undergone prior surgery, and whose disc occupies <50
% of the spinal canal with limited migration or sequestration of the disc fragments.
Retrospective studies of patients with recurrent disc herniations have demonstrated
endoscopic microdiscectomy to be effective in selected cases [10].
Complication rates of endoscopic microdiscectomy have been reported to be around 5%
[7]. Potential complications are trauma to neurovascular structures, discitis, and cerebrospinal
fluid leak. However, no significant difference in pain, functional outcome scores, and re-
herniation rates have been found on retrospective studies and prospective randomized
controlled trials of patients with lumbar disc herniations undergoing standard
microdiscectomy compared to transforaminal and interlaminar endoscopic microdiscectomy
[10,11].
In conclusion, endoscopic microdiscectomy is a promising minimally invasive technique
that can be very helpful in treating certain lumbar disc pathologies including recurrent disc
herniations obviating the need for fusion and extensive scar mobilization experienced in
traditional posterior approaches. As with every new technique, there is a learning curve for
surgeons that must be overcome before mastering this technique.
References
[1] Ruetten, S., Komp, M., Merk, H. & Godolias, G. (2007). Use of newly developed
instruments and endoscopes: full-endoscopic resection of lumbar disc herniations via
the interlaminar and lateral transforaminal approach. Journal of neurosurgery Spine,
6(6), 521-530.
[2] German, J. W., Adamo, M. A., Hoppenot, R. G., Blossom, J. H. & Nagle, H. A. (2008).
Perioperative results following lumbar discectomy: comparison of minimally invasive
discectomy and standard microdiscectomy. Neurosurg Focus, 25(2), E20.
[3] Kambin, P. & Brager, M. D. (1987). Percutaneous posterolateral discectomy. Anatomy
and mechanism. Clinical orthopaedics and related research(223), 145-154.
[4] Kambin, P. (1989). Percutaneous lumbar diskectomy. JAMA: the journal of the
American Medical Association, 262(13), 1776.
[5] Kambin, P. & Schaffer, J. L. (1989). Percutaneous lumbar discectomy. Review of 100
patients and current practice. Clinical orthopaedics and related research, (238), 24-34.
[6] Yue, J. J., Han, S. D., Xiao, H. & Yacob, A. (2014). The Treatment of Single Level
Multi-Focal Subarticular and Paracentral and/or Far Lateral Lumbar Disc Herniations:
The Single Incision Multi Focal Endoscopic Surgery Solution. IJSS, 9, 1-24.
[7] Yeung, A. T. & Yeung, C. A. (2003). Advances in endoscopic disc and spine surgery:
foraminal approach. Surgical technology international, 11, 255-263.
[8] Yeung, A. T. & Yeung, C. A. (2007). Minimally invasive techniques for the
management of lumbar disc herniation. The Orthopedic clinics of North America, 38(3),
363-372, abstract vi.
[9] Ruetten, S., Komp, M., Merk, H. & Godolias, G. (2008). Full-endoscopic interlaminar
and transforaminal lumbar discectomy versus conventional microsurgical technique: a
prospective, randomized, controlled study. Spine (Phila Pa 1976), 33(9), 931-939.
[10] Ruetten, S., Komp, M., Merk, H. & Godolias, G. (2009). Recurrent lumbar disc
herniation after conventional discectomy: a prospective, randomized study comparing
full-endoscopic interlaminar and transforaminal versus microsurgical revision. Journal
of spinal disorders & techniques, 22(2), 122-129.
Case Vignette 6:
Lumbar Spinal Stenosis
Chapter 14
Open Laminectomy
Safdar N. Khan, MD1 , Jordan Kapke1,

Vincent J. Alentado2,3, Daniel Lubelski2,4
and Thomas E. Mroz, MD2,4
1
Department of Orthopaedics, The Ohio State University Wexner Medical Center
Columbus, OH, US
2
Cleveland Clinic Center for Spine Health, Cleveland Clinic, Cleveland, OH, US
3
Case Western Reserve University School of Medicine, Cleveland, OH, US
4
Cleveland Clinic Lerner College of Medicine, Cleveland, OH, US
Case Summary
A 73-year-old female presents with progressively worsening ability to walk distances due
to pain and weakness in her legs. She currently can walk less than one block before she needs
to sit down to relieve her symptoms. She finds that leaning on a shopping cart allows her to
walk for a longer period of time. MRI of the lumbar spine is significant for central and lateral
recess stenosis at the L4-5 level (Figures 1, 2, 3).
132 Safdar N. Khan, Jordan Kapke, Vincent J. Alentado et al.
Figure 1. Axial T2-weighted MRI demonstrating central and lateral recess stenosis at the L4-5 level.
Figure 2. Axial T2-weighted MRI demonstrating central and lateral recess stenosis at the L5-S1 level.
Open Laminectomy 133
Figure 3. Sagittal T2-weighted MRI demonstrating central stenosis at the L4-5 level.
Surgical Approach
This patient suffers from spinal stenosis, the most common reason for lumbar surgery in
patients older than 65 years. Open decompressive lumbar laminectomy is an effective
treatment option that predictably results in significant relief of neurogenic claudication
symptoms. [1,2,3] Surgery is indicated in patients who have failed non-operative treatment
(minimum 3 to 6 months) with NSAIDs, physical therapy and epidural corticosteroid
injections. Pre-operative imaging is mandatory to visualize the degree and location of the
spinal stenosis and to rule out instability requiring fusion. Imaging studies must correlate with
the patient‟s symptoms.
Surgical Procedure
The patient is typically placed in the prone position on a Jackson table with the abdomen
hanging free and decompressed. This position decreases the mean central venous pressure,
leading to decreased engorgement of the epidural veins and diminished intraoperative blood
loss.
An incision is made over the midline, most frequently over L4-L5 and extending the
length of the area to be decompressed. The dissection is carried down to the fascia, and self-
retaining retractors are positioned. Using a Cobb elevator and Bovie electrocautery, the fascia
is incised on either side of the midline and reflected laterally to the facet joints. Care must be
taken not to violate the facet joint capsule. A Kocher clamp is placed on a preselected spinous
process and a Woodson probe placed on the undersurface of the corresponding lamina. Once
this is done, an intraoperative lateral radiograph is taken to delineate the exact level (Figure
4). Once the level is confirmed, a more lateral dissection then ensues with stripping of the
posterior spinous musculature, including the multifidus muscles. The muscles are stripped
from medial to lateral using a Cobb to assist in retracting. The Bovie tip is visualized at all
times and care is taken to stay on bone to avoid plunging into the spinal canal. Steady,
sweeping motions are used to peel the musculofascial layers off the spine. The spinous
process, lamina, pars interarticularis and facet joints are exposed at each lumbar level
requiring a laminectomy. Once adequate exposure has been accomplished, the spinal canal
can be decompressed.
Figure 4. Intra-operative lateral fluoroscopic radiograph demonstrating verification of the appropriate

target level.
Figure 5. Post-operative MRI of patient treated with open laminectomy for lumbar spinal stenosis.
Decompression is initiated with the removal of the interspinous ligament using a Leksell
rongeur. A large Leksell can also be used to remove the superior spinous process and half of
the inferior spinous process for adequate exposure. The lamina is thinned on both sides with a
high-speed burr. A Kerrison rongeur is used to begin decompressing the central stenosis. The
ligamentum flavum is left as a temporary barrier over the dura. Decompression is done in a
caudal to cephalad manner. The surgeon must be mindful of the pars interarticularis on each
side to avoid fractures. A medial facetectomy aids in lateral recess decompression. Up to 50%
of the medial aspect of the inferior facet may be removed with a sharp ¼-inch osteotome. The
ligamentum flavum and bone is removed bilaterally out to the level of the pedicle and a
Woodson probe is used to palpate the pedicle from within the canal. Adequate decompression
should allow the tip of the probe to pass into the foramina without obstruction.
Decompression is deemed complete when the lateral margin of the thecal sac is
visualized and the lateral recesses are free of any stenosis as palpated by a Woodson elevator.
Pearls and Pitfalls

 Patients who respond to an epidural steroid injection preoperatively tend to have a
good prognosis in regards to surgical outcome.
 Routine plain lateral and flexion/ extension lateral lumbar spine films should be used
to check for dynamic instability that would be better treated with a lumbar fusion
rather than a laminectomy alone.
 Wrong level surgery or exposure can place the patient at risk of early adjacent level
disease. It also represents a significant risk for litigation against the surgeon.
 Staying sub-periosteal during the exposure will limit the amount of blood loss during
the case and vastly improve visualization.
 Any local bone that is removed during the procedure should be saved in the event
that bone graft is needed for conversion to a fusion.
 If more than 50% of both facets are removed or if one facet is entirely removed, the
patient may require a fusion due to potential spinal instability.
 Be mindful to preserve the facet joint capsules at the cephalad and caudal extent of
the exposure. Failure to due so may result in accelerated adjacent level disease.
 Preserving the ligamentum flavum as long as possible will provide the surgeon with
a barrier that can minimize an incidental durotomy. During the bony decompression,
attempt to stay sub-laminar but supra-flaval. At the conclusion of the bony
decompression; the flavum can be carefully removed with a pituitary or Kerrison
rongeur.
 Decompression of the lateral recess and foramen (if applicable) should be performed
from the opposite side of the patient in order to avoid incidental durotomy.
 To avoid an incidental durotomoy, a 0.5” x 0.5” gauze pad can be inserted between
the thecal sac and the ligamentum flavum in order to protect the thecal sac from the
bite of the Kerrison rongeur. Alternatively, depressing the dura with a Woodson tool
or similar instrument for each Kerrison bite is an effective technique to safely
decompress the neural elements.
 If an incidental durotomy occurs, a watertight seal should be obtained either
primarily with a 6-0 Prolene suture or with a fascial graft. Fibrin glue
(cryoprecipitate, thrombin, and calcium) can be placed over the defect. The patient
should be on bed rest for 24 hours follwing the procedure and monitored for a dural
leak. If there is a dural leak, the patient typically presents with a headache when
sitting up.
 Care must be taken when performing revision laminectomies because of epidural
adhesion and abnormal anatomical landmarks. A preoperative CT scan is helpful to
better define the bony anatomy for surgical planning. Carefully burring the bone
away in regions of scar is often safer than using a curette to develop planes between
the dura and surrounding lamina and facet joint.
 Surgery may not relieve low back pain, and patients should be informed that the
primary goal is to relieve symptoms of neurogenic claudication.
Literature Summary
For several decades, open laminectomy has been considered the surgical standard for
treating lumbar spinal stenosis because of the preponderance of evidence demonstrating
superior satisfaction scores, improvement in patient functional status, and relief of symptoms.
However, since spinal stenosis is more common in the elderly and often occurs in patients
with many comorbid conditions, this invasive approach is not always indicated. Therefore,
there has been an increasing number of less-invasive surgical techniques developed for this
patient population. However, studies examining these less invasive approaches (e.g.,
interspinous distraction or interlaminar fenestration) do not have sufficient long-term data. [4]
Therefore, open laminectomy remains the mainstay of treatment for many spine surgeons.
There have been few studies directly comparing open laminectomy versus minimally
invasive laminectomy for the treatment of lumbar spinal stenosis. In a retrospective study of
126 patients by Rahman et al., the 38 patients who underwent bilateral decompression via a
minimally invasive approach were found to have shorter operating times, less blood loss,
shorter length of stay and fewer complications than the 88 patients who underwent open
bilateral decompression to treat lumbar spinal stenosis. [5] A randomized trial of 54 patients
by Mobbs et al. demonstrated that for the 27 patients who underwent minimally invasive
unilateral laminectomy for bilateral decompression, the mean improvement in visual analog
scale score was significantly better than those patients treated with open laminectomy
(p=0.013). [6] However, Oswestry Disability Index (ODI) scores were statistically similar
between the two groups, although there was a trend towards significantly better
improvements in the minimally invasive group (p=0.055).
In a prospective study of 194 patients by Katz et al., patients who were treated with a
decompressive laminectomy for lumbar spinal stenosis were found to have a satisfaction rate
of 78% (based on patient questionnaire) at 6-month follow-up. [7] Using a linear regression
model to adjust for potential confounders, the authors found that a predominance of
preoperative back pain as opposed to leg pain was associated with lower postoperative patient
satisfaction. At 10-year follow-up, 23% had undergone reoperation for spinal instability or
recurrent stenosis, but 75% of patients remained satisfied with the results of the surgery. [8]
The randomized, multicenter Spine Patient Outcomes Research Trial (SPORT) evaluated
laminectomy versus conservative management for the treatment of lumbar stenosis in patients
who had failed at least 12 weeks of non-surgical management. [9] The as-treated analysis
demonstrated statistically significantly better 3-month postoperative outcomes for patients
who underwent open laminectomy compared to patients treated conservatively. Short Form-
36 (SF-36) outcomes were consistently better for the surgery group with scores of 19.8 vs.
9.8, and 17.8 vs. 8.7 for bodily pain and physical function SF-36 subsets, respectively.
Similarly, using the Oswestry Disability Index (ODI) scales, the improvement was 17.0 vs.
6.8 in favor of surgery when compared to conservative treatment. At 2-year follow-up, the as-
treated analysis demonstrated that 63% of patients treated surgically self-reported major
improvement in their symptoms versus only 29% of the non-surgical group. At this 2-year
follow-up interval, there were again statistically significantly better outcomes in the surgical
compared to the non-surgical group as measured by the SF-36 and ODI scale scores. This
difference remained statistically significant at annual intervals up to a 4-year follow-up
analysis. [10] While this study provided excellent evidence supporting surgery, there were
several limitations. The intention-to-treat analysis is confounded by the high crossover rate
observed within the study. Furthermore, the study failed to standardize conservative
management for patients, allowing some to argue that with more appropriate and standardized
conservative management, the non-surgically treated patients may have demonstrated greater
improvement in symptoms.
With appropriate patient selection and surgical technique, open laminectomy
demonstrates excellent results in the treatment of lumbar spinal stenosis. Patients who fail
conservative management and demonstrate neurogenic symptoms consistent with lumbar
spinal stenosis often improve significantly from laminectomy performed by an experienced
spine surgeon.
References
[1] Malmivaara, A., Slätis, P., Heliövaara, M., Sainio, P., Kinnunen, H., Kankare, J., Dalin-
Hirvonen, N., Seitsalo, S., Herno, A,Kortekangas, P., Niinimäki, T., Rönty,
H., Tallroth, K., Turunen, V., Knekt, P., Härkänen, T. & Hurri, H. (2007). Surgical or
nonoperative treatment for lumbar spinal stenosis? A randomized controlled trial.
Spine., 32(1), 1-8.
[2] Mariconda, M., Fava, R., Gatto, A., Longo, C. & Milano, C. (2002). Unilateral
laminectomy for bilateral decompression of lumbar spinal stenosis: a prospective
comparative study with conservatively treated patients. J. Spinal Disord. Tech., 15(1),
39-46.
[3] Weinstein, J. N., Lurie, J. D., Tosteson, T. D., Hanscom, B., Tosteson, A. N., Blood, E.
A., Birkmeyer, N. J., Hilibrand, A. S., Herkowitz, H., Cammisa, F. P., Albert, T.
J., Emery, S. E., Lenke, L. G., Abdu, W. A., Longley, M., Errico, T. J. & Hu, S. S.
(2007). Surgical versus nonsurgical treatment for lumbar degenerative
spondylolisthesis. N. Engl. J. Med., 22, 2257-2270.
[4] Katz, J. N. & Harris, M. B. (2008). Lumbar Spinal Stenosis. N. Engl. J. Med., 358(8),
818–825.
[5] Rahman, M., Summers, L. E., Richter, B., Mimran, R. I. & Jacob, R. P. (2008).
Comparison of techniques for decompressive lumbar laminectomy: the minimally
invasive versus the “classic” open approach. Minim. Invasive Neurosurg., 51(2), 100–
105.
[6] Mobbs, R. J., Li, J., Sivabalan, P., Raley, D. & Rao, P. J. (2014). Outcomes after
decompressive laminectomy for lumbar spinal stenosis: comparison between minimally
invasive unilateral laminectomy for bilateral decompression and open laminectomy:
clinical article. J. Neurosurg. Spine., 21(2), 179–186.
[7] Katz, J. N., Lipson, S. J., Brick, G. W., Grobler, L. J., Weinstein, J. N., Fossel, A.
H., Lew, R. A. & Liang, M. H. (1995). Clinical correlates of patient satisfaction after
laminectomy for degenerative lumbar spinal stenosis. Spine., 20(10), 1155–1160.
[8] Katz, J. N., Lipson, S. J., Chang, L. C., Levine, S. A., Fossel, A. H. & Liang, M. H.
(1996). Seven- to 10-year outcome of decompressive surgery for degenerative lumbar
spinal stenosis. Spine., 21(1), 92–98.
[9] Weinstein, J. N., Tosteson, T. D., Lurie, J. D., Tosteson, A. N., Blood, E., Hanscom,
B., Herkowitz, H., Cammisa, F., Albert, T., Boden, S. D., Hilibrand, A., Goldberg,
H., Berven, S. & An, H. (2008). Surgical versus nonsurgical therapy for lumbar spinal
stenosis. N. Engl. J. Med., 358(8), 794–810.
[10] Weinstein, J. N., Tosteson, T. D., Lurie, J. D., Tosteson, A., Blood, E., Herkowitz,
H., Cammisa, F., Albert, T., Boden, S. D., Hilibrand, A., Goldberg, H., Berven, S.
& An, H. (2010). Surgical versus nonoperative treatment for lumbar spinal stenosis
four-year results of the Spine Patient Outcomes Research Trial. Spine., 35(14), 1329–
1338.
Chapter 15
Minimally Invasive Tubular

Decompression
Xin Feng Li1,MD, Ji Hyun Lee2 and Larry T. Khoo2, MD

1
Department of Orthopaedics and Rehabilitation, Renji Hospital, Shanghai, China
2
The Spine Clinic of Los Angeles, University of Southern California
Los Angeles, CA, US
Case Summary
An 81 year-old male presents with progressively worsening ability to walk due to pain
and weakness in his legs. He currently can ambulate less than one block before he needs to sit
down to relieve his symptoms. He has no pain with sitting or lying down. The CT and MRI of
the lumbar spine is significant for severe central and lateral recess stenosis at the L2-3, L3-4,
and L4-5 levels (Figure 1A,B,C,D,E). He has undergone 4 epidural steroid injections, 2
courses of physical therapy and traction over the last 18 months with no improvement and
progressive worsening of his claudication.
142 Xin Feng Li, Ji Hyun Lee and Larry T. Khoo
(A) (B)
(C) (D)
Figure 1. Continued on next page.

Minimally Invasive Tubular Decompression 143
(E)
Figure 1. A, B, C, D, E. Pre-operative MRI and CT imaging of the lumbar spine demonstrate severe
central, lateral recess and foraminal stenosis at L2/3,L3/4, and L4/5. There is no evidence of significant
scoliosis, spondylolisthesis or motion on dynamic radiographs.
Surgical Approach
The direct posterior MIS decompression method is a widely employed and successful
technique. This approach seeks to take advantage of the time proven efficacy of direct spinal
decompression, while applying a new paradigm for handling soft tissues. MIS direct lumbar
decompression/discectomy favors a “muscle splitting” rather than a sub-periosteal dissection
technique. [1] This „„muscle splitting‟‟ method is thought to result in less injury to the soft
tissues thereby reducing post-operative discomfort. The introduction of various retractors
including tubular corridors (Figure 2A, B) combined with the operative microscope have
allowed for a decrease in the size of the skin incision and extent of soft tissue trauma. [1,2,3]
In the case of a lumbar disc herniation or unilateral lateral recess stenosis, the paraspinal
skin incision (usually 1.5 cm off the midline for lateral recess stenosis/paracentral disc
herniation; >3 cm off midline for far lateral disc herniation) is made ipsilateral to the
pathology to allow for a more direct path. For treatment of central stenosis, a lateral incision
is made on either side of midline but still allows for bilateral decompression, while preserving
the spinous processes and midline tension band (Figure 2B).
Figure 2A. Illustration of introduction of minimally invasive tubular retractors to spread the
musculature to create an atraumatic pathway down to the target level of pathology.
Figure 2B. Schematic demonstrating the tubular retractor locked in 2 different positions: A. Lateral
position over the lamina-facet junction ideal for ipsilateral decompression of lateral recess stenosis or
microdiscectomy. B. Medial position over the lamina-spinous process junction ideal for decompression
of central canal and partial contralateral lateral recess.
Figure 2C. Lateral fluoroscopic imaging demonstrating confirmation of the positioning over the target
level.
Surgical Procedure
Under fluoroscopic guidance, the left paramedian L2-L3, L3-L4, and L4-L5 incisions
were marked and pre-anesthetized with 0.25% Marcaine with 1:200,000 epinephrine both at
the skin, muscle, and sub-periosteal level. Using a #11 scalpel blade, the previously marked
paramedian incision was opened down to the level of lumbodorsal fascia. The lumbar fascia
was then incised and a series of dilators were used to atraumatically split the lumbar fascia
and musculature while docking on the left L4-L5 lamina facet junction. (Figure 2A) The final
working portal measuring 18mm diameter by 60 mm length was then secured to the bed-
mounted retractor (Figure 2B). The operative microscope was then brought to the field of
view after the level was confirmed under AP and lateral fluoroscopic imaging. (Figure 2C) A
high-speed 3 mm matchstick burr was then used to drill a left L4-L5 hemilaminotomy down
to the level of the thickly calcified ligamentum flavum (Figure 3A). The ipsilateral medial
facet was also drilled in this fashion. The working portal was then angled to the contralateral
right L4-L5 side (Figure 3B). The matchstick burr was then used to resect the inner table of
the densely hypertrophied facet on the contralateral side (Figure 3B). This decompression
was carried out to the contralateral foramen and superior articulating process. The right L4
exiting nerve root could clearly be seen and was inspected with a Woodson elevator (Figure
3c). Then, using 2 and 3 mm Kerrison rongeurs, the ligamentum flavum was fully resected in
the contralateral right L4-L5 recess, central L4-L5 interlaminar space, and the ipsilateral left
L4-L5 recess. Next, the additional drilling of the ipsilateral medial facet was completed such
that the axilla and the exiting and traversing nerve were clearly visualized. In this fashion, a
full bilateral decompression was completed at L4-L5.
Figure 3A. Visualization through the working portal demonstrating the position of the spinous process,
the dura and the ligamentum flavum. The angle of the oblique contralateral tubular position is also
demonstrated.
Figure 3B. Intra-operative image demonstrating the angling of the working portal to the contralateral
right L4-5 side.
Figure 3C. Intra-operative image demonstrating the visualization of the right L4 exiting nerve root.
The working portal was then withdrawn and the tubular dilators were then used to access
the L3-4 level in a similar fashion. The same decompression as detailed above for L4-5 was
then completed at L3-4 and subsequently at L2-3 through separate fascial entries. Subsequent
post-operative MRI imaging at 6 weeks demonstrated good decompression at the operative
levels with the patient reporting near complete resolution of his pre-operative claudication
(Figure 4).
Figure 4. Post-operative sagittal MRI demonstrating decompression at the operative levels.

Pearls and Pitfalls

 The initial incision should be placed paramedian to the spine approximately at the
level of the medial pedicle on the AP fluoroscopic image. This will allow for room to
angle the tube (Figure 3B) and achieve a contralateral decompression.
 After the initial ipsilateral hemilaminotomy, it is important to keep the ligamentum
flavum on the dura to protect it during the contralateral decompression. Drilling
underneath the spinous process and the inner table of the contralateral lamina is best
accomplished with the flavum still present to protect the dura and to minimize
epidural bleeding.
 Bilateral decompression can be achieved by removing the base of the spinous process
allowing access to the contralateral side while simultaneously medializing the
trajectory of the tubular dilator.
 It is important to first drill the medial-ventral aspect of the contralateral inferior
articulating facet prior to drilling the superior-medial aspect of the superor
articulating facet. A Kerrison rongeur can then be placed into the contralateral
foramen to achieve a foraminal decompression and foraminoplasty along the axis of
the exiting nerve root.
 During the initial part of the learning curve with this technique, it is helpful to use
AP and lateral fluoroscopy to ensure that the tube is angled in the proper trajectory in
both the rostrocaudal and mediolateral direction.
Literature Summary
Lumbar discectomy and decompression for stenosis are arguably two of the most
common and long-standing operations in spine surgery. Vascular ischemia of the nerve roots
is thought to be involved in the pathogenesis of neurogenic claudication in lumbar stenosis.
[2] The compressive elements include disc herniations ventrally, and/or ligamentum flavum
and facet hypertrophy dorsally. Despite decades of advances in spine surgery, the gold
standard for the treatment of both pathologies still remains a direct decompression of the
neural structures. [1,4]
MIS techniques when used for direct bilateral decompression of lumbar stenosis via a
unilateral approach have been demonstrated to offer a similar short-term clinical outcome
when compared to traditional techniques while decreasing operative blood loss, length of
hospitalization, and narcotic utilization. [5] The microendoscopic decompressive laminotomy
technique was also validated in a series of cadaveric studies in which equivalent
decompression was achieved by way of either the traditional or endoscopic technique. [6]
Although small non-randomized studies as mentioned above do suggest marginally
smaller post-operative oral analgesic requirement and decreased length of hospital stay in the
MIS direct decompression group, the actual efficacy and suspected superiority of the MIS
technique compared to the traditional technique is still not well characterized. Future studies
are still needed to determine the role of MIS techniques in the treatment of lumbar stenosis
and disc herniation.
References
[1] Riesenburger, R. I. & David, C. A. (2006) Lumbar microdiscectomy and
microendoscopic discectomy. Minim Invasive Ther Allied Technol., 15(5), 267-270
[2] Asgarzadie, F. & Khoo, L. T. (2007) Minimally invasive operative management for
lumbar spinal stenosis: overview of early and long-term outcomes. Orthop Clin North
Am., 38(3), 387-399.
[3] Maroon, J. C. (2002) Current concepts in minimally invasive discectomy.
Neurosurgery, 51(5), S137-S145.
[4] Deen, H. G., Fenton, D. S. & Lamer, T. J. (2003). Minimally invasive procedures for
disorders of the lumbar spine. Mayo Clin Proc., 78(10), 1249-1256.
[5] Khoo, L. T. & Fessler, R. G. (2002) Microendoscopic decompressive laminotomy for
the treatment of lumbar stenosis. Neurosurgery., 51(5), S146-S154.
[6] Guiot, B. H., Khoo, L. T. & Fessler, R. G. (2002). A minimally invasive technique for
decompression of the lumbar spine. Spine., 27(4), 432-438.
Chapter 16
Interspinous Process Distraction
Ehsan Saadat, MD and Thomas D. Cha, MD

Department of Orthopaedic Surgery, Massachusetts General Hospital
Boston, MA, US
Case Summary
The patient is a 78 year-old retired anesthesiologist with aortic valve stenosis and severe
gastroesophageal reflux who presented with two years of worsening neurogenic claudication
with bilateral buttock and thigh heaviness. He reported marked difficulty with standing and
walking with prompt relief upon sitting. Examination revealed no sensory or motor
disturbance in the bilateral lower extremities and exacerbation of his bilateral buttock/thigh
symptoms upon spinal extension beyond neutral. A lumbosacral MRI revealed severe central
stenosis at L4-5 (Figure 1).
152 Ehsan Saadat and Thomas D. Cha
(A) (B)
Figure 1. Pre-operative mid-sagittal (A) and L4-L5 axial (B) T2-weighted magnetic resonance images
demonstrating mild anterolisthesis of L4 on L5, with marked facet arthrosis and hypertrophy and severe
central stenosis.
Surgical Approach
A minimally invasive implantation of a spinous process distractor was chosen to address
this patient‟s pathology. The interspinous process decompression system provides an
alternative option to conservative treatment and formal decompressive surgery for patients
suffering from neurogenic claudication. The device is implanted between the spinous
processes and reduces pathologic extension at the symptomatic level(s), while allowing
flexion and un-restricted axial rotation and lateral bending. Interspinous distraction reduces
intradiscal pressure, facet loading and prevents narrowing of the spinal canal and neural
foramina, thereby relieving claudicatory symptoms.
Interspinous device (ID) implantation is a minimally invasive operative option requiring
limited operative time. These devices should be considered for patients with neurogenic
claudication that is promptly relieved by bending or sitting, in whom medical comorbidities
prohibit formal decompressive surgery.
Interspinous Process Distraction 153
Surgical Procedure
The patient is placed on a radiolucent table in the right lateral decubitus position and
asked to flex his or her spine. After the operative level is confirmed fluoroscopically, the
patient is given an injection of local analgesic; general anesthesia is not typically required. A
midline incision centered over the appropriate level is made over the stenotic level and carried
down through the skin and subcutaneous tissue to the fascia. The fascia is opened on both
sides of the supraspinous ligament with great care being taken to protect the supraspinous and
interspinous ligaments. The spinous processes are stripped sub-periosteally to their base. At
this point, hypertrophied facet joints can be partially resected to ensure that anterior
placement of the implant is feasible. A curved dilator is inserted into the anterior margin of
the interspinous space to pierce the interspinous ligament, and a sizing distractor is then
inserted to determine the appropriate implant size. The interspinous device is then secured to
the insertion instrument and placed in the interspinous space. An adjustable wing is fastened
to the implant and then positioned as close to the spinous process as possible.
(A) (B)
Figure 2. Post-operative AP (A) and lateral (B) radiographs demonstrating an interspinous device
implanted at the L4-5 level.
Figure 3. Post-operative lateral and AP radiographs demonstrating an interspinous device implanted at

the L4-5 level.
Figure 4. Illustration demonstrating the placement of an interspinous device.
Pearls and Pitfalls

 While the standard described technique for interspinous device implantation involves
the patient in a lateral decubitus position, prone positioning on an Andrews frame can
also be an option based on patient tolerance.
 The hips should be flexed at least 90 degrees, mimicking a sitting position in which
patients are free of claudication. Having a patient in this position obviates the need to
apply any distractive force to the spinous process spreader and may avoid spinous
process fracture.
 Utilizing an interspinous device one size smaller than indicated on the spreader
avoids the need to apply significant force to position the device in the interspace,
lowering the risk of spinous process fracture.
 The L5-S1 level is a relative contraindication to interspinous device implantation due
to the difficulty of fixation to the small S1 spinous process.
Literature Summary
When compared to non-operative treatment for lumbar spinal stenosis, interspinous
devices offer a significant advantage. In a study of 200 patients with neurogenic intermittent
claudication comparing outcomes following treatment with an interspinous device to non-
operative management of lumbar spinal stenosis, Zucherman et al. found a success rate of
59% versus 12% in the non-operative management cohort at 1 year. [1] At 2-year follow up
of the same cohort of patients, the interspinous device group reported improved symptom
severity by 45% from baseline, as compared to 7.4% improvement in the control group. [1] A
separate study of the same cohort of patients focusing on quality of life measures, found that
the interspinous device produces a general health benefit in patients with LSS that is
significantly better than conservative treatment. In this study, physical function improved by
44% in the interspinous device group compared with a 0.4% decrease in function in the
control group (p< 0.001). Additionally, Medical Outcomes Study Short Form-36 (SF-36)
scores at 2 years follow-up demonstrated significantly higher scores in the interspinous device
group in the domains of quality of life, physical functioning, bodily pain, mental health, the
physical component summary, and social functioning. [2]
While interspinous device implantation seems to offer a distinct benefit over non-
operative care for patients with neurogenic intermittent claudication, this benefit diminishes
when such devices are compared to traditional decompressive surgery for lumbar stenosis. A
2010 prospective study by Sobottke et al. [3] compared clinical outcomes in 8 patients who
underwent interspinous device placement with 21 patients who had microsurgical bilateral
operative decompression and found no significant difference between groups in terms of
improvement in back/leg pain or Oswestry Disability Index, Short Form Health Survey (SF-
36) physical, and SF-36 mental component summaries.
In 2011, Chou et al. [4] conducted a systematic review of RCTs separately comparing
laminectomy and interspinous device with non-operative management using a modified
network analysis approach. This analysis concluded there was low-level evidence supporting
improved disability and pain outcomes at 12 months with an ID as compared to a
laminectomy.
A randomized control trial comparing clinical outcomes between treatment with an
interspinous device to lumbar decompression for 1- or 2- level stenosis found significant
improvement in both groups through two years postoperatively in both the intent to treat and
as treated analysis. The interspinous device group experienced a significantly higher
reoperation rate. However, the results of the subsequent interspinous device removal and
decompression were similar to the results of initial decompression. [5]
In a recent large retrospective comparative effectiveness study, Patil et al. [6] found
significantly higher index hospitalization (7.5% vs. 3.5%, p = 0.099) and 90-day (9.2% vs.
3.5%, p= 0.028) complication rate in the laminectomy group compared with the interspinous
device cohort. The interspinous device patients had significantly greater reoperation rates than
the laminectomy patients at 12 months follow-up (12.6% vs. 5.8%, p= 0.026) and incurred
higher cumulative costs than laminectomy patients at 12 months follow-up ($39,173 vs.
$34,324, p= 0.289).
Complications related to the interspinous devices have consisted primarily of spinous
process fractures. Other complications noted with implantation of these devices include new
radicular deficits, device dislocations, and bilateral foot drop. [7, 8, 9] Re-operation rates after
interspinous device implantation have ranged from 4.6% to as high as 85% in various studies.
[5, 9, 10, 11] The reason for most re-operations appear to be inadequate control of symptoms,
and the secondary operations involve device removal and formal decompression and/or
fusion. In a series by Kutcha et al.11, 8 (4.6%) of 175 patients receiving the interspinous
device later required device removal with microsurgical decompressions. In a series of 12
patients with spinal stenosis and grade 1 spondylolisthesis who underwent interspinous device
implantation, second operations consisting of decompressions with posterolateral fusions
were required in 7 (58%) patients within two postoperative years. [11]
Interspinous device placement is a minimally invasive and simple operative option that
appears to offer an advantage in the management of neurogenic claudication versus non-
operative management. However, this benefit may not be sustained when such devices are
compared to formal decompressive surgery. Interspinous devices should be considered as a
therapeutic option for patients with neurogenic claudication that is promptly relieved by
bending or sitting and whose medical comorbidities may prohibit a formal decompression.
Avoiding general anesthesia as well as the ability to continue a patient‟s anticoagulation for
cardiovascular comorbidities are the primary benefits for an interspinous device implantation.
References
[1] Zucherman, J. F., Hsu, K. Y., Hartjen, C. A., Mehalic, T. F., Implicito, D. A., Martin,
M. J., …, Ozuna, R. M. (2005). A multicenter, prospective, randomized trial evaluating
the X STOP interspinous process decompression system for the treatment of neurogenic
intermittent claudication: two-year follow-up results. Spine. 30(12), 1351-1358.
[2] Hsu, K. Y., Zucherman, J. F., Hartjen, C. A., Mehalic, T. F., Implicit,o D. A., Martin,
M. J., …, Ozuna, R. M. (2006). Quality of life of lumbar stenosis-treated patients in
whom the X STOP interspinous device was implanted. J Neurosurg. Spine. 5(6), 500-
507.
[3] Sobottke, R., Rollinghoff, M., Siewe, J., Schlegel, U., Yagdiran, A., Spangenberg, M.,
…, Koy, T. (2010). Clinical outcomes and quality of life 1 year after open
microsurgical decompression or implantation of an interspinous stand-alone spacer.
Minimally invasive neurosurgery. 53(4), 179-183.
[4] Chou, D., Lau, D., Hermsmeyer, J. & Norvell, D. (2011). Efficacy of interspinous
device versus surgical decompression in the treatment of lumbar spinal stenosis: a
modified network analysis. Evidence-based spine-care journal. 2(1), 45-56.
[5] Verhoof, O. J., Bron, J. L., Wapstra, F. H. & van Royen, B. J. (2008). High failure rate
of the interspinous distraction device (X-Stop) for the treatment of lumbar spinal
stenosis caused by degenerative spondylolisthesis. Eur Spine J. 17(2), 188-192.
[6] Patil, C. G., Sarmiento, J. M., Ugiliweneza, B., Mukherjee, D., Nuño, M., Liu, J. C., …,
Boakye, M. (2014). Interspinous device versus laminectomy for lumbar spinal stenosis:
a comparative effectiveness study. Spine J. 14(8), 1484-1492.
[7] Barbagallo, G. M., Corbino, L. A., Olindo, G., Foti, P., Albanese, V. & Signorelli, F.
(2010). The "sandwich phenomenon": a rare complication in adjacent, double-level X-
stop surgery: report of three cases and review of the literature. Spine. 35(3), E96-100.
[8] Chung, K. J., Hwang, Y. S. & Koh, S. H. (2009) Stress fracture of bilateral posterior
facet after insertion of interspinous implant. Spine. 34(10), E380-383.
[9] Kim, D. H., Tantorski, M., Shaw, J., Martha, J., Li, L., Shanti, N., …, Kwon, B. (2011).
Occult spinous process fractures associated with interspinous process spacers. Spine.
36(16), E1080-1085.
[10] Bowers, C., Amin, A., Dailey, A. T. & Schmidt, M. H. (2010). Dynamic interspinous
process stabilization: review of complications associated with the X-Stop device.
Neurosurgical focus. 28(6), E8.
[11] Kuchta, J., Sobottke, R., Eysel, P. & Simons, P. (2009). Two-year results of
interspinous spacer (X-Stop) implantation in 175 patients with neurologic intermittent
claudication due to lumbar spinal stenosis. Eur Spine J. 18(6), 823-829.
Case Vignette 7: Degenerative Lumbar
Stenosis with Spondylolisthesis
Chapter 17
Open Posterior Decompression

and Fusion
Christopher C. Gillis, MD1, Paul A. Anderson, MD3,

Jason W. Savage, MD2 and John E. O’Toole, MD1
1
Department of Neurosurgery, Rush University Medical Center, Chicago, IL, US
2
Department of Orthopaedic Surgery, Northwestern Feinberg School of Medicine
Chicago, IL, US
3
Department of Orthopedics and Rehabiliation, University of Wisconsin – Madison
Madison, WI, US
Case Summary
66-year-old male presents with new onset lower back pain radiating to the right lower
extremity with numbness and tingling into the right foot. The pain is constant, stabbing and
burning in nature, located just above the right buttock and radiating into the posterior thigh
and the dorsum of the foot.
Physical examination reveals right lower extremity weakness, specifically in the tibialis
anterior and extensor hallucis longus muscles. His symptoms were refractory to conservative
treatment, including non-steroidal anti-inflammatories (NSAIDs), physical therapy, and
several epidural steroid injections. Evaluation of plain radiographs and MRI reveal grade 1
degenerative spondylolisthesis. (Figure 1, 2)
162 Christopher C. Gillis, Paul A. Anderson, Jason W. Savage et al.
(A) (B)
(C) (D)
Figure 1. (A) On anteroposterior and (B) lateral and (C) flexion- (D) extension radiograph of the
lumbar spine reveals spondylotic changes throughout, with a grade 1 L4-L5 degenerative
spondylolisthesis.
Open Posterior Decompression and Fusion 163
(A)
(B)
Figure 2. (A) On Sagittal and (B) Coronal MRI of the lumbar spine reveals central spinal stenosis and a
grade 1 degenerative spondylolisthesis at L4-5.
Surgical Approach
The patient‟s symptoms were refractory to conservative treatment (NSAIDs, PT, and
ESIs). Therefore, we discussed the operative treatment options. The approach chosen for this
case was an open posterior decompression and fusion. The reasons for selecting an open
decompression include the need for a wider decompression due to the extent of compression
(as detailed below) as well as in cases of significant osteoporosis. The open exposure and
traditional wide laminectomy in the presence of a spondylolisthesis typically necessitate a
fusion with posterior instrumentation. Two main options are available for the instrumentation:
traditional pedicle screws and cortical trajectory screws. For our approach, we selected
cortical trajectory screws. This allows for a smaller midline opening without the requirement
for lateral exposure out to the level of the transverse processes, as would be required for a
traditional pedicle screw trajectory. The reduced exposure leads to a more rapid patient
postoperative recovery, decreased postoperative pain, and reduced need for post-operative
narcotics.
Through this relatively tissue sparing midline approach, we also perform a posterior
interbody fusion. The screw insertion for a cortical bone trajectory also may reduce the
incidence of adjacent segment disease due to the ability to avoid violation of the supra-
adjacent facet joint and capsule.
In osteoporotic patients, instrumentation can be inserted with significantly better screw
purchase through a cortical bone trajectory. The choice of interbody cage placement must be
carefully weighed in the case of osteoporosis due to the increased possibility of endplate
violation with subsequent subsidence and possibly worsened stenosis, particularly in the
neuroforamina. In the setting of poor bone quality, the screw purchase can be enhanced
through the use of polymethylmethacrylate.
Surgical Procedure
Cortical Screw Instrumentation with Posterior Interbody Fusion
The patient is positioned prone on a radiolucent operating table with a Jackson frame.
The level is marked with intraoperative fluoroscopy and a midline incision is made based on
the spinous process bony landmarks. The incision is taken down to the level of the fascia,
then sparing the interspinous ligament the fascia is opened paramedian and the muscle
dissected off the lamina in a subperiosteal fashion. The bony dissection is taken laterally to
expose the facet joint, just lateral to the pars interarticularis.
Using the exposed boney landmarks and fluoroscopy, the entrance for the screw is
marked out approximately 3 – 5mm medial to the pars interarticularis at the inferior edge of
the transverse process (Figure 3). This starting point is approximately the midpoint of the
inferior facet of the level above. For the most superior level to be instrumented, it is
recommended to place the entry point 2 mm inferior to the usual entry point in order to avoid
injury to the supra-adjacent facet. The trajectory of screw insertion is 20⁰ medial to lateral and
30 - 45⁰ caudal to cephalad (Figure 4). This trajectory has a similar feel in orientation to that
used for lateral mass screws in the cervical spine.
Figure 3. Illustration of the entrance for the screw marked out approximately 3 – 5mm medial to the
pars interarticularis at the inferior edge of the transverse process. Images provided by Medtronic, Inc.
Figure 4. Illustration of the trajectory of screw insertion is 20⁰ medial to lateral and 30 - 45⁰ caudal to
cephalad. Images provided by Medtronic, Inc.
With the entry points defined, the drill is used to create the pilot trajectory for the screws.
Given that the trajectory is pure cortical bone, copious irrigation and a two handed slow
tapping and advancing technique should be used. The pilot trajectory should be
approximately 2 to 3 mm in width through the pars interarticularis. Fluoroscopy or intra-
operative neuronavigation is used throughout this part of the procedure to ensure the
appropriate trajectory to a depth of 10 – 15mm. The appropriate trajectory travels just over
the dorsal and anterior portion of the neural foramen, which makes intraoperative imaging
key to avoid injury to neural structures. The trajectory is confirmed with a ball tipped probe.
The drilling is done prior to the decompression and discectomy.
For the decompression, the inferior articular process of the superior level and medial
portion of the superior articulating process of the inferior level are removed. The superior
articulating process should be removed to the level of the inferior pedicle thereby exposing
the underlying lateral thecal sac, venous plexus and disc space. At least 3 mm of bone must
be left between the tapped trajectory and the bony resection. If desired, this exposure is
carried out on both sides for bilateral decompression and/or bilateral interbody insertion.
Carefully cutting away from the thecal sac, an annulotomy is created. A combination of
curettes, rasps and shavers are used to prepare the disc space and endplate for interbody
insertion. The disc space preparation and the interbody technique is similar to other posterior
interbody techniques. After the endplate preparation, the disc space is packed with morcelized
local autograft and a bone graft extender.
Once the decompression is complete and the interbody cages are placed, the cortical
pedicle screws can be inserted. The trajectories are probed again and confirmed prior to screw
placement. The typical screw lengths used are 25-35mm, and the polyaxial head should be
placed high enough above the pars that the tulip does not impinge into the facet capsule
(Figure 5). Fluoroscopy in both an anterior – posterior and lateral views is used to confirm
hardware placement after the rods and set screws are placed.
Figure 5. Illustration of the typical screw lengths used are 25-35mm, and the polyaxial head should be
placed high enough above the pars that the tulip does not impinge into the facet capsule. Images
provided by Medtronic, Inc.
(A) (B)
Figure 6. Post-operative (A) Anterioposterior and (B) lateral radiographs demonstrating posterior
instrumentation placement.
Pearls and Pitfalls

 Patient positioning is very important. Always extend the hips and knees, which will
maximize lumbar lordosis. This will help restore regional alignment, and prevent
iatrogenic flatback.
 Cortical bone drilling can be difficult and burning the bone may result in subsequent
instrumentation failure with screw loosening and pullout.
 Leaving enough bone near the entry hole and trajectory as well as on the pars
interarticularis is critical in order to avoid a bone fracture with screw insertion.
 Avoid damaging the supra-adjacent facet capsule as this can lead to adjacent segment
degeneration.
 An adequate lateral recess decompression must be performed by removing the
hypertrophic ligamentum and superior articular facet joints out to the medial aspect
of the corresponding pedicle. This step can be performed with a high-speed burr,
osteotome, or Kerrison rongeurs.
o A Woodson elevator should pass easily underneath the lamina, along the
medial aspect of the pedicles, and into the foramen above and below.
 Pedicle screws can be easily placed using anatomic landmarks. Pre-operative
imaging studies (MRI or CT) and an intra-operative lateral radiograph help plan
screw size and trajectory.
o If any difficulty is encountered placing screws, intra-operative fluoroscopy
should be used to guide placement.
o Performing the decompression first in cases using a traditional pedicle

trajectory often aids in screw placement as it gives the surgeon direct
visualization of the anatomy and allows for palpation of the pedicle (medial
wall and foramen).
 Decorticate the facet joints/transverse processes and pack the posterolateral gutters
with bone graft prior to placing the pedicle screws.
o This allows for easier access to this space and provides a better fusion bed.
Literature Summary
Degenerative spondylolisthesis is relatively common, and occurs in up to 10-15% of the
general population. The associated hypertrophic ligamentum flavum and facet joint
arthropathy often produce spinal stenosis, and patients typically present with either
neurogenic claudication, radiculopathy, or a combination of both. Patients who have
symptoms that are refractory to conservative treatment are good candidates for surgical
intervention. Patients treated with surgery have significantly improved SF-36 bodily pain and
function scores, as well as ODI scores compared to non-operative controls. [1] Several
landmark studies have demonstrated that decompression and fusion results in better clinical
outcomes than decompression alone. [2,3] Patients with lumbar stenosis and spondylolisthesis
have an improved outcome in measures of bodily pain, physical function and Oswestry
Disability Index with surgical decompression and fusion compared to non-operative
management with a durable improvement out to 4 years. [1] Subsequent studies have clearly
shown that the use of instrumentation improves fusion rates[4], and that achieving a solid
fusion leads to better long-term results [5]. It is recognized that in certain selected patient
groups, decompression alone may be possible but the specifics of which patient groups and
the evidence to support this is an ongoing area of investigation. [6, 7]
Adjacent segment stenosis is relatively common, but in the absence of adjacent level
instability, a decompression alone at that level suffices. Pedicle screw fixation has become the
gold standard when performing a posterolateral fusion for degenerative spondylolisthesis. The
placement of lumbar cortical screws is gaining popularity as a less invasive technique to
achieve fusion. In comparing instrumentation techniques, we focus on the differences
between traditional trajectory pedicle screws and cortical bone trajectory screws. Perez-
Orribo et al., examined the biomechanical characteristics of differing posterior screw fixation
with and without interbody support in 28 cadaveric lumbar spines. The spine samples were
tested after hardware placement using a standard servohydraulic system. Although a number
of differing combinations of constructs were tested, the overall comparison was primarily
between pedicle and cortical screws. The results demonstrated superiority of cortical screw
stability with the presence of a TLIF interbody cage. [1] This technique can be useful in
osteoporotic patients, as screw purchase may be better in cortical bone. No clinical studies to
date compare the fusion rates or clinical outcomes of cortical bone screws compared to
pedicle screws in the treatment of degenerative spondylolisthesis.
Further analysis of the strength of the cortical bone trajectory was illustrated by
Matsukawa et al. [8] The cortical bone screws maximize thread contact with the cortical bone
surface which leads to enhanced screw purchase via this thread contact. The authors reviewed
previous lab studies demonstrating a 30% increase in the uniaxial yield pull-out load of a
cortical screw rod construct compared to the traditional approach. The authors also reviewed
previous studies noting the inverse relationship between bone mineral density and the stability
of pedicle screws.
Another benefit of the cortical trajectory screw is the preservation of the supra-adjacent
facet. He et al., [9] performed a nine-year prospective study of 178 patients examining the
incidence in superior adjacent segment pathology between two different techniques of pedicle
screw insertion (though they did not specifically include cortical bone trajectory). This study
also measured the general outcomes of the patients via the Oswestry Disability Index, and
visual analogue scale of both the back and leg; the authors found no significant difference in
overall outcome.
Based on the literature, we find that the use of a cortical bone trajectory has superior
instrumentation qualities to that of a traditional pedicle screw approach, particularly for
patients with low bone density who are at significant risk for hardware loosening and failure.
There are benefits on screw thread – bone contact, torque, and pull out strength. The approach
requires a smaller overall tissue dissection and exposure to achieve decompression and
fusion, and with both less tissue dissection and less anatomic disruption in the area of the
adjacent facet, this technique may potentially result in decreased rates of ASD.
Other fusion techniques include transpsoas interbody fusion with supplemental posterior
percutaneous fixation and transforaminal lumbar interbody fusion with instrumentation
(TLIF). The former relies upon indirect decompression, has a high rate of neuropraxia at the
L4-L5 level and is less advantageous in older patients due to risk of graft subsidence. The
TLIF is commonly performed but results have not been shown to be better than standard
instrumented fusion for degenerative lumbar spondylolisthesis. We do utilize this technique
under some conditions such as severe foraminal stenosis due to loss of distance between
pedicles (often termed “up-down stenosis”), lateral listhesis, degenerative scoliosis, and in
patients at risk for non union such as the obese or those with immune suppression.
References
[1] Perez-Orribo, L., Kalb, S., Reyes, P. M., Chang, S. W., & Crawford, N. R. (2013).
Biomechanics of lumbar cortical screw-rod fixation versus pedicle screw-rod fixation
with and without interbody support. Spine. 38(8), 635-641.
[2] Herkowitz, H. N., & Kurz, L. T. (1991). Degenerative lumbar spondylolisthesis with
spinal stenosis. A prospective study comparing decompression with decompression and
intertransverse process arthrodesis. Journal of Bone and Joint Surgery. 73(6), 802-808.
[3] Ghogawala, Z., Benzel, E. C., Amin-Hanjani, S., Barker, F. G., 2nd, Harrington, J. F.,
Magge, S. N., Borges, L. F. (2004). Prospective outcomes evaluation after
decompression with or without instrumented fusion for lumbar stenosis and
degenerative Grade I spondylolisthesis. Journal of Neurosurgery: Spine. 1(3), 267-272.
[4] Fischgrund, J. S., Mackay, M., Herkowitz, H. N., Brower, R., Montgomery, D. M., &
Kurz, L. T. (1997). 1997 Volvo Award winner in clinical studies. Degenerative lumbar
spondylolisthesis with spinal stenosis: a prospective, randomized study comparing
decompressive laminectomy and arthrodesis with and without spinal instrumentation.

Spine. 22(24), 2807-2812.
[5] Kornblum, M. B., Fischgrund, J. S., Herkowitz, H. N., Abraham, D. A., Berkower, D.
L., & Ditkoff, J. S. (2004). Degenerative lumbar spondylolisthesis with spinal stenosis:
a prospective long-term study comparing fusion and pseudarthrosis. Spine. 29(7), 726-
733; discussion 733-724.
[6] Eismont, F. J., Norton, R. P., & Hirsch, B. P. (2014). Surgical management of lumbar
degenerative spondylolisthesis. Journal of the American Academy of Orthopaedic
Surgeons. 22(4), 203-213.
[7] Resnick, D. K., Watters, W. C., 3rd, Sharan, A., Mummaneni, P. V., Dailey, A. T.,
Wang, J. C., Kaiser, M. G. (2014). Guideline update for the performance of fusion
procedures for degenerative disease of the lumbar spine. Part 9: lumbar fusion for
stenosis with spondylolisthesis. Journal of Neurosurgery: Spine. 21(1), 54-61.
[8] Matsukawa, K., Yato, Y., Kato, T., Imabayashi, H., Asazuma, T., & Nemoto, K.
(2014). In vivo analysis of insertional torque during pedicle screwing using cortical
bone trajectory technique. Spine. 39(4), E240-245.
[9] He, B., Yan, L., Guo, H., Liu, T., Wang, X., & Hao, D. (2014). The difference in
superior adjacent segment pathology after lumbar posterolateral fusion by using 2
different pedicle screw insertion techniques in 9-year minimum follow-up. Spine.
39(14), 1093-1098.
Chapter 18
Minimally Invasive Transforaminal

Lumbar Interbody Fusion
Islam M. Elboghdady, Junyoung Ahn,

Khaled Aboushaala, MD, Vincent J. Rossi,
and Kern Singh, MD
Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, US
Case Summary
A 66-year-old male presents with new onset lower back pain radiating to the right lower
extremity with numbness and tingling into the right foot. The pain is constant, stabbing and
burning in nature, located just above the right buttock and radiating into the posterior thigh
and the dorsum of the foot. Physical examination reveals right lower extremity weakness,
specifically in the tibialis anterior and extensor hallucis longus muscles. Plain radiographs
demonstrate anterolisthesis of the L4 vertebral body. (Figure 1) MRI of the lumbar spine
reveals central spinal stenosis and a grade 1 degenerative spondylolisthesis at L4-5.
(Figure 2).
172 Islam M. Elboghdady, Junyoung Ahn, Khaled Aboushaala et al.
(A) (B)
(C)
Figure 1. Pre-operative radiograph in the (A) neutral, (B) flexion, and (C) extension positions
demonstrating anterolisthesis of the L4 vertebral body.
Minimally Invasive Transforaminal Lumbar Interbody Fusion 173
(A)
(B)
Figure 2. Pre-operative (A) sagittal and (B) axial T2-weighted MRI demonstrating severe spinal
stenosis accompanied by a grade I spondylolisthesis.
Surgical Approach
A minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) was chosen as
the approach that best addressed this patient‟s pathology. Such an approach allows for a direct
decompression of the stenosis as well as stabilization of the spondylolisthesis in the least
traumatic manner. When compared to alternatives such as open decompression with or
without fusion an MIS-TLIF offers the advantage of the least disruptive approach to the
pathology, sparing the paraspinal muscles from the traditional open dissection. The
visualization of the neural elements after decompression is direct and uncompromised.
The minimally invasive approach offers less disruption to the paraspinal musculature via
gaining access to the spine through a series of tubular dilators. Additionally, an MIS-TLIF
has been demonstrated to have decreased operative time, blood loss, length of stay, and total
hospital costs when compared to an open approach. [1] Furthermore, the MIS approach has a
significantly lower rate of surgical site infections while offering arthrodesis rates similar to its
open counterpart. [2]
Surgical Procedure
The patient is placed prone on a Jackson table and the target level is identified under
fluoroscopic guidance. A 2-3 cm incision is made on the side of the pathology, lateral to the
pedicle line (visualized radiographically), and a Jamshidi needle is advanced through the
paraspinal musculature into the targeted pedicle. The Jamshidi is advanced 15-20 mm into the
pedicle in 5 mm increments, after which a guidewire is placed through the cannula. The
guidewire is advanced to the medial wall of the pedicle on the AP fluoroscopic image and
placement is confirmed under lateral fluoroscopic guidance ensuring that the tip of the
guidewire is beyond the posterior edge of the vertebral body wall (Figure 3).
Figure 3. Intra-operative AP fluoroscopic image demonstrating proper advancement of the guidewires

to the medial wall of the pedicle.
The pedicles above and below the level of interest are cannulated and sequential dilators
are placed between the guidewires until the tubular retractor can be docked over the pars
interarticularis. Utilizing a high speed burr, a laminectomy is performed on the cephalad
vertebrae. The burr is then used to pass through the pars interarticularis laterally and the
inferior articular process of the cephalad vertebrae is then removed bilaterally. The removed
bone is saved for the graft. The ligamentum flavum is removed using a Kerrison rongeur to
expose the nerve roots bilaterally.
The venous complex overlying the disc space is coagulated via electrocautery and an
annulotomy is performed (Figure 4). A subtotal discectomy is achieved via disc shavers,
pituitary rongeurs, and curved curettes. The disc space is adequately prepared and a trial
interbody device is placed to restore appropriate lumbar lordosis (Figure 5). The trial is
removed and bone graft saved from the earlier procedure is packed into the disc space with a
goal being 20-30 cc of bone graft per level of fusion. Once half of the graft is placed, an
articulating interbody spacer is placed such that the position of the cage is in the anterior third
of the disc space allowing for restoration of segmental lordosis through compression of the
posterior pedicle screws.
Figure 4. Tubular retractor image demonstrating removal of the ligamentum flavum and coagulation of
the venous complex overlying the disc space.
Figure 5. Intra-operative lateral fluoroscopic image demonstrating preparation of the disc space
utilizing an endplate shaver curette.
With the device properly placed, pedicle taps can be advanced over the guidewires and
stimulated with EMG evoked potentials to further identify any potential breach of the medial
pedicle wall. The taps are then removed and appropriately sized pedicle screws are placed.
Screw positioning is verified under fluoroscopic guidance (Figure 6,7). A properly sized rod
is then inserted sub-muscularly and compression is applied across the disc space re-
establishing segmental lordosis. Reduction can be performed at this time if deemed
appropriate by the treating surgeon.
Figure 6. Intra-operative fluoroscopic “bulls-eye” view demonstrating guidewires for pedicle screw
placement.
Figure 7. Intra-operative lateral fluoroscopic image demonstrating confirmation of pedicle screw

placement. The interbody device is properly positioned in the anterior third of the disc space.
(A)

(B)
Figure 8. Post-operative (A) AP and (B) lateral radiographs demonstrating proper instrumentation and
interbody cage placement. Disc height and lordosis has been restored.
(A) (B)

(C)
Figure 9. Post-operative (A) sagittal, (B) coronal, and (C) axial CT images demonstrating no loosening
of instrumentation or cage migration. Bone growth across the fusion graft can be visualized.
Pearls and Pitfalls

• The tubular retractor should be placed with a parallel trajectory with respect to the
disc space angling medially. Achieving this trajectory can be particularly difficult in
obese patients and those with a higher grade spondylolisthesis.
• Performing a complete facetectomy is critical to ensure proper visualization of the
disc space. Inadequate visualization can compromise disc space preparation and the
placement of a properly size interbody device resulting in subsequent device
migration and pseudarthrosis.
• Resect the entire superior articular process of the inferior level flush to the pedicle
exposing the disc space in its entirety.
• Bilateral decompression can be achieved by removing the base of the spinous process
allowing access to the contralateral side while simultaneously medializing the
trajectory of the tubular dilator.
• Postural/Passive reduction can be achieved via this approach with a thorough
facetectomy and end plate preparation. An active reduction also can be performed,
however, it carries the same risk as the open surgery with the potential for nerve root
palsy and screw loosening.
Literature Summary
Numerous studies have demonstrated the advantages of a minimally invasive TLIF over
other approaches for the treatment of degenerative lumbar stenosis with spondylolisthesis. In
comparison to open approaches, MIS-TLIF significantly reduces operative and anesthesia
time, as well as hospitalization. [1] Minimally invasive TLIF is also associated with
significantly lower rates of transfusion compared to an open TLIF. [3]
In addition to improved intra-operative parameters, MIS-TLIF demonstrates high fusion
rates comparable to open TLIF exceeding 90%. [3,4] MIS-TLIF patients can expect
arthrodesis rates up to 94.8% at final follow up. [4] Improvements in Visual Analogue Scale
(VAS) scores for back pain, leg pain, and Oswestry disability index (ODI) are similar
between MIS and Open TLIF patients with a tendency for more rapid improvement in post-
operative pain in MIS cases. [3,5] Moreover, MIS-TLIF patients require significantly lower
post-operative narcotic pain medication and demonstrate shorter time to narcotic
independence. [6,7]
In comparison to an open approach, the risk of surgical site infection (SSI) is
significantly lower following a minimally invasive TLIF with a reported cumulative
incidence of 0.6% for MIS cases. [2] Moreover, the rate of symptomatic adjacent segment
disease requiring re-intervention is significantly lower following minimally invasive TLIF
compared to an open approach. [8] Lastly, total hospital costs are significantly reduced in
MIS-TLIF cases compared to open TLIF and provides an opportunity for cost-saving and
reduction of hospital resource utilization. [1,9]
References
[1] Pelton, M., Singh, K. (2012). A comparison of perioperative costs and outcomes in
patients with and without workers' compensation claims treated with minimally
invasive or open transforaminal lumbar interbody fusion. Spine. 37(22), 1914-1919.
[2] Parker, S.L., Adogwa, O., Witham, T.F., Aaronson, O.S., Cheng, J., McGirt, M.J.
(2011). Post-operative infection after minimally invasive versus open transforaminal
lumbar interbody fusion (TLIF): literature review and cost analysis. Minimally invasive
neurosurgery. 54(1), 33-37.
[3] Archavlis, E., Carvi y Nievas, M. (2013). Comparison of minimally invasive fusion and
instrumentation versus open surgery for severe stenotic spondylolisthesis with high-
grade facet joint osteoarthritis. Eur Spine J. 22(8), 1731-1740.
[4] Wu, R.H., Fraser, J.F., Hartl, R. (2010). Minimal access versus open transforaminal
lumbar interbody fusion: meta-analysis of fusion rates. Spine. 35(26), 2273-2281.
[5] Seng, C., Siddiqui, M.A., Wong, K.P., Zhang, K., Yeo, W., Tan, S.B., Yue, W.M.
(2013). Five-year outcomes of minimally invasive versus open transforaminal lumbar
interbody fusion: a matched-pair comparison study. Spine. 38(23), 2049-2055.
[6] Adogwa, O., Parker, S.L., Bydon, A., Cheng, J., McGirt, M.J. (2011). Comparative
effectiveness of minimally invasive versus open transforaminal lumbar interbody
fusion: 2-year assessment of narcotic use, return to work, disability, and quality of life.
J Spinal Disord. Tech. 24(8), 479-484.
[7] Parker, S.L., Lerner, J., McGirt, M.J. (2012). Effect of minimally invasive technique on
return to work and narcotic use following transforaminal lumbar inter-body fusion: a
review. Professional case management. 17(5), 229-235.
[8] Parker, S.L., Adamson, T.E., McGirt, M.J., Deshmukh, V.R. (2014). 152 Rate of
Symptomatic Adjacent Segment Disease After Minimally Invasive vs Open
Transforaminal Lumbar Interbody Fusion. Neurosurgery. 61,(1), 210.
[9] Parker, S.L., Mendenhall, S.K., Shau, D.N., Zuckerman, S.L., Godil, S.S., Cheng, J.S.,
McGirt, M.J. (2013). Minimally Invasive versus Open Transforaminal Lumbar
Interbody Fusion for Degenerative Spondylolisthesis: Comparative Effectiveness and
Cost-Utility Analysis. World neurosurgery. 82(1-2), 230-8.
Chapter 19
Lateral Interbody Fusion
Ehsan Tabaraee, MD, Junyoung Ahn

and Frank M. Phillips, MD
Chicago, IL, US
Case Summary
66-year-old male presents with new onset lower back pain radiating to the right
lower extremity with numbness and tingling into the right foot. The pain is constant,
stabbing and burning in nature, located just above the right buttock and radiating into the
posterior thigh and the dorsum of the foot. Physical examination reveals right lower
extremity weakness, specifically in the tibialis anterior and extensor hallucis longus
muscles. Plain radiographs demonstrate degenerative L4-5 spondylolisthesis. (Figure 1)
MRI of the lumbar spine reveals central spinal stenosis and a grade 1 degenerative
spondylolisthesis at L4-5. (Figure 2)
184 Ehsan Tabaraee, Junyoung Ahn and Frank M. Phillips
(A) (B)
(C) (D)
Figure 1. Pre-operative (A) AP and (B) lateral (C) flexion and (D) extension radiographs demonstrating
a degenerative L4-5 spondylolisthesis.
Lateral Interbody Fusion 185
(A)
(B)
Figure 2. Pre-operative (A) sagittal and (B) axial MRI images of the lumbar spine demonstrating a loss
of height with lateral recess and foraminal narrowing at L4-5.
Surgical Approach
Lateral lumbar interbody can be used when anterior column support is required in the
lumbar spine above the L5-S1 level, as either a part of a circumferential fusion or as a stand-
alone alternative to posterolateral or transforaminal interbody techniques. Symptomatic
degenerative spondylolisthesis, degenerative disc disease, recurrent disk herniation,
pseudoarthrosis, adjacent segment stenosis/instability and degenerative scoliosis, are some of
the diagnoses that have been addressed with lateral interbody arthrodesis.
The fundamental benefits of interbody arthrodesis lie in the biomechanical advantage of
anterior column fusion. Anterior arthrodesis is subject to biomechanically advantageous
compressive forces rather than cantilever bending associated with a posteriolateral fusion.
The location of the interbody allows for load-sharing properties and a broader fusion bed with
reported high fusion rates. Fogel et al. investigated the biomechanics of lateral interbody
cages with and without supplemental fixation in a cadaveric degenerative spondylolisthesis
model. The destabilization model increased segment range of motion by 181% of the intact
segment while stand alone lateral cages reduced the excess motion back to 77% of normal. [1]
Advocates have pointed out correction of segmental alignment and indirect neural
decompression as a consequence of motion segment distraction with lateral interbody cage
placement. Marulanda et al. measured changes in disc height, foraminal, central canal areas at
L3-4 and L4-5 before and after lateral interbody cage placement with and without posterior
instrumentation in cadavers. These areas were increased by 60%, 59%, and 33.3%
respectively. [2] Other reported benefits of lateral interbody fusion include a smaller incision,
less postoperative pain, and shorter hospital stays.
Surgical Procedure
After endotracheal intubation, the patient is placed in the lateral decubitus position with
the knees and hips flexed to decrease tension on the ipsilateral iliopsoas. The patient is placed
such that the iliac crest is just distal to the break in the bed. The patient is thoroughly secured
to the table prior to the manipulation of the bed. The operating room table is manipulated in
the coronal plane to provide unobstructed lateral access to the lumbar spine (Figure 3). The
table is adjusted to obtain proper anteroposterior and lateral fluoroscopic images. The
operative disc space is localized on lateral imaging. This projection is marked out on the skin
using a radio-opaque object. The original technique described involved two relatively small
incisions. The first is a transverse incision made at the lateral edge of the erector spinae. This
incision is used to develop the retroperitoneal space. An antero-medial trajectory is taken
through the thoracolumbar fascia toward the psoas muscle into the retroperitoneal space.
Once the retroperitoneum is entered, the fat and viscera are bluntly mobilized from the
posterior abdominal wall. This space is created to help guide the initial dilator through an
expanded retroperitoneal space. The second incision is made on the lateral aspect of the body
in line with the disc space of interest. This allows the introduction of the serial dilators and
final retractor.
Figure 3. Intra-operative positioning of the patient in the lateral decubitus position with the iliac crest
distal to the incision site.
The initial cannulated dilator is docked on the center of the disc as seen on the lateral x-
ray and parallel to the endplate on AP imaging. A thin guide-wire is placed through the initial
dilator to secure its location. During the placement of each sequential dilator, real time and
directional EMG neuromonitoring is used to assess for stimulation of the lumbar plexus or
nerve roots. Once the largest dilator is safely placed under neuromonitoring guidance, a
specialized multi-blade illuminated retractor is placed over the last dilator prior to removal
(Figure 4). The retractor is expanded to visualize the disc. An EMG probe is used to survey
the surgical field for proximity of the lumbar nerves.
Figure 4. The retractor is secured to the table with an extension that provides a secure but adjustable
portal to the operative disc space.
Once the disc space is isolated and deemed safe, the annulus is cleared of muscle and is
incised. The discectomy and endplate preparation follows with the use of pituitary rongeurs,
elevators, and curettes. The contralateral annulus is disrupted to mobilize the treated segment
and to allow for better alignment, correction and distraction. Care should be taken to avoid
inadvertent disruption of the ALL. The interbody cages are filled with bone graft material
prior to implantation. Final fluoroscopic images are obtained to verify proper cage placement
(Figure 5). It is important that the broadest cage that spans the ring-apophyses of the adjacent
vertebra is selected. Supplemental fixation with either a lateral plate, or pedicle screws may
be considered.
(A) (B)
Figure 5. Intra-operative (A) AP and (B) lateral fluoroscopy images of L4-5 lateral interbody cage
prior to percutaneous posterior instrumentation.
(A) (B)
Figure 6. Post-operative (A) AP and (B) lateral radiograph at 1 year demonstrating anterior column
arthrodesis with posterior instrumentation.
Pearls and Pitfalls

 Proper positioning will minimize poor visualization and access difficulties. Perfect
AP and lateral fluoroscopic images are critical for the safety of the procedure.
 The accessory posterior incision will allow a guided approach to the retroperitoneal
space.
 Real time neuromonitoring is advised during sequential dilation through the psoas
muscle or with manipulation of the retractor to avoid iatrogenic injury to the lumbar
plexus.
 Accurate fluoroscopic visualization is crucial to safe disc space preparation and
proper sizing of the interbody.
 Supplemental fixation with either lateral plate, pedicle screws, or facet screws should
be considered to increase biomechanical stability.
Literature Summary
Since its original description, lateral interbody fusions have become a versatile option for
multiple pathologies of the thoracic and lumbar spine. [3,4] Numerous studies have argued
that the advantages of minimally invasive lateral interbody fusion include minimizing
posterior muscle disruption and indirect decompression provided by the distracted disc space.
The lateral interbody fusion has resulted in less blood loss and decreased hospitalization.
Oliveira et al. prospectively studied 21 patients with degenerative disc disease and spinal
stenosis at 43 lumbar levels (8 with spondylolisthesis) who underwent stand-alone lateral
interbody fusions and assessed the indirect decompressive effect. Mean operative time,
estimated blood loss, and length of stay were 47 minutes, 23 ml, and 29.5 hours, respectively.
The foraminal height, foraminal area, and central canal area dimensions were increased by
13.5% (20.9 to 24 mm), 25% (243 to 303 mm2), and 33% (7 to 9.5 mm2) respectively. [5]
Elowitz et al. described short-term results of 25 patients undergoing 31 levels of lateral
interbody fusion for multiple pathologies including mild spondylolisthesis and spinal stenosis.
Visual Analogue Scale (VAS) score for back and leg pain intensity as well as the Oswestry
Disability Index (ODI) improved significantly following surgery. [6] In addition, the canal
dimensions improved by 50% in the AP and medial/lateral direction while the canal area
increased by 143%.
Kepler et al. investigated the clinical outcomes and imaging of 29 patients who
underwent 67 lateral interbody fusions. The authors found that the average foraminal area
increased by 35% while ODI and Short Form Health Survey (SF-12) PCS scores improved
significantly. [7] In addition, Rodgers et al. demonstrated in 63 patients with grade 2
spondylolisthesis and stenosis were treated with lateral interbody and percutaneous pedicle
screw fixation. At a minimum of 12 months, average pain level and degree of listhesis was
decreased by 80% (8.7 to 2.2) and 73%, respectively. Disc height was doubled without any
major complications or non-unions. [8]
There is a learning curve associated with this approach with complications reported from
1-60% in a variety of patient populations. [9] The most common of which are numbness or
weakness in the ipsilateral hip and thigh although most are transient in nature. In a report of
600 patients, Rodgers et al. noted an overall incidence of perioperative complications to be

6.2% with a 1.8% reoperation rate. [10] Potentially devastating injuries such as direct
vascular insult, bowel perforation, or vertebral fractures are rare but have been reported. [11,
12, 13]
References
[1] Fogel, G.R., Turner, A.W., Dooley, Z.A., Cornwell, G.B. (2014). Biomechanical
Stability of Lateral Interbody Implants and Supplemental Fixation in a Cadaveric
Degenerative Spondylolisthesis Model. Spine. 39(19), E1138-46.
[2] Marulanda, G.A., Nayak, A., Murtagh, R., Santoni, B.G., Billys, J.B., Castellvi, A.E.
(2014). A Cadaveric Radiographic Analysis on the Effect of Extreme Lateral Interbody
Fusion Cage Placement with Supplementary Internal Fixation on Indirect Spine
Decompression. J Spinal Disord Tech. 27(5), 263-70.
[3] Ozgur, B.M., Aryan, H.E., Pimenta, L., Taylor, W.R. (2006). Extreme Lateral
Interbody Fusion (XLIF): A Novel Surgical Technique for Anterior Lumbar Interbody
Fusion. Spine J. 6(4), 435-443.
[4] Phillips, F.M., Isaacs, R.E., Rodgers, W.B., Khajavi, K., Tohmeh, A.G, Deviren, V., …,
Kurd, M. (2013). Adult Degenerative Scoliosis Treated with XLIF: Clinical and
Radiographic results of a Prospective multicenter Study with 24-Month Follow-Up.
Spine. 38(21), 1853-61.
[5] Oliveira, L., Marchi, L., Coutinho, E., Pimenta, L. (2010). A radiographic assessment
of the ability of the extreme lateral interbody fusion procedure to indirectly decompress
the neural elements. Spine. 35(26), SS331–S337.
[6] Elowitz, E.H., Yanni, D.S., Chwajol, M., Starke, R.M., Perin, N.I. (2011). Evaluation of
indirect decompression of the lumbar spinal canal following minimally invasive lateral
transpsoas interbody fusion: radiographic and outcome analysis. Minimally Invasive
Neurosurgery. 54(5-6), 201–206.
[7] Kepler, C.K., Sharma, A.K., Huang, R.C., Meredith, D.S., Girardi, F.P. Jr, Sama, A.A.
(2012). Indirect foraminal decompression after lateral transpsoas interbody fusion.
Journal of Neurosurgery: Spine. 16(4), 329–333.
[8] Rodgers, W.B., Lehmen, J.A., Gerber, E.J., Rodgers, J.A. (2012). Grade 2
spondylolisthesis at L4-5 Treated by XLIF: Safety and Midterm Results in the “Worse
Case Schenario”. ScientificWorldJournal.
[9] Sclafani, J.A., Kim, C.W. (2014). Complications Associated with the Initial Learning
Curve of Minimally Invasive Spine Surgery: a Systematic Review. Clin Orthop Relat
Res. 472(6), 1711-7.
[10] Rodgers, W.B., Gerber, E.J., Patterson, J. (2011). Intraoperative and Early
Postoperative Complications in Extreme Lateral Interbody Fusion: An Analysis of 600
Cases. Spine. 36(1), 26-32.
[11] Assiana, R., Majmundar, N.J., Herschman, Y., Heary, R.F. (2014). First Report of
Major Vascular Injury Due to Lateral Transpsoas Approach Leading to Fatality. J
Neurosurg Spine. 21(5), 1-5.
[12] Tormenti, M.J., Maserati, M.B., Bonfield, C.M., Okonkwo, D.O., Kanter, A.S. (2010).
Complications and Radiographic Correction in Adult Scoliosis Following Combined
Transpsoas Extreme Lateral Interbody Fusion and Posterior Pedicle Screw
Instrumentation. Neurosurg Focus. 28(3), E7.
[13] Dua, K., Kepler, C.K., Huang, R.C., Marchenko, A. (2010). Vertebral Body Fracture
after anterolateral Instrumentation and Interbody Fusion in Two Osteoporotic Patients.
Spine J. 10(9), e11-5.
Case Vignette 8:
L5-S1 Isthmic Spondylolisthesis
Chapter 20
Open Posterior Approach
Isaac L. Moss, MD, MASc, FRCSC

Department of Orthopaedic Surgery and Neurosurgery,
University of Connecticut Health Center,
Farmington, CT, US
Case Summary
36 year-old female presents with 4 years of worsening back and bilateral lower extremity
pain despite years of conservative management. She is unable to work due to her symptoms.
Physical exam is significant for pain in the low back and bilateral lower extremities with
straight leg raise testing. There is mild numbness in the feet bilaterally but no weakness.
Range of motion is limited secondary to back pain. Imaging evaluation of the lumbar
spine reveals bilateral spondylolysis of L5 resulting in a mobile L5/S1 spondylolisthesis and
severe bilateral L5 foraminal stenosis. (Figure 1, 2)
196 Isaac L. Moss
(A)
(B)
Figure 1. Pre-operative (A) AP neutral and (B) lateral neutral radiographs demonstrating L5-S1
spondylosis with a grade II spondylolisthesis .
Open Posterior Approach 197
(A) (B)
(C)
Figure 2. Pre-operative (A, B) Flexion and (C) extension radiograph demonstrating L5-S1 spondylosis
with a grade II spondylolisthesis.
198 Isaac L. Moss
(A)
(B)
Figure 3. Intra-operative fluoroscopic images (A) prior to interbody cage insertion and (B) following
interbody cage placement demonstrating restoration of disc height and partial reduction of the
spondylolisthesis.
(A) (B)
Figure 4. Post-operative (A) AP and (B) lateral radiographs demonstrating L5-S1 instrumented fusion
with pedicle screws and an interbody device resulting in restoration of disc height and partial slip
reduction.
Surgical Approach
An open posterior approach is chosen as the ideal procedure to treat this patient‟s
pathology. The open approach allows for a traditional Gill laminectomy, removing the L5
lamina through the defect in the pars interarticularis, achieving complete decompression of
the bilateral foramina. A transforaminal interbody fusion (TLIF) allows for further distraction
of the foramen as well as slip reduction. Stabilization is achieved with an interbody device
and bone graft as well as pedicle screw fixation. This combination of complete
200 Isaac L. Moss
decompression and circumferential fusion will reliably relieve the patient‟s radiculopathy and
improve back pain via a single approach.
Surgical Procedure
The patient is placed prone on a Jackson table with chest, thigh and hip pads to relieve
abdominal pressure and to re-create lumbar lordosis. Surface anatomy can be used to localize
the level of pathology, generally one interspinous space below the highest point of the iliac
crests. The step off between the L4 and L5 spinous processes can often be palpated if the
spondylolisthesis does not reduce with positioning. A spinal needle and fluoroscopy are
useful to confirm that the planned incision is centered over the pathology.
A midline incision is made from the L4 spinous process to the sacrum. Paraspinal
musculature is then dissected off the L5 and S1 spinous processes and laminae. The L4-5 and
L5-S1 facet joints are exposed and dissection is continued laterally to expose the L5
transverse processes and sacral ala. Care should be taken not to disrupt the capsule of the L4-
5 facet joint, as this level will not be included in the fusion.
The L5 lamina is generally found to be hypermobile due to the pars defect, however it is
advised to place a radio-opaque marker on the spine and confirm fluoroscopically that the
appropriate level is exposed.
Once the level of pathology is confirmed, self-retaining retractors are used to maintain
exposure. The L5 lamina can be removed in one large fragment. In either case, the L4-5 and
L5-S1 interspinous ligaments are resected. The L5-S1 facet capsule is removed and a curette
is then used to separate the L5 lamina from its soft-tissue attachments, the ligamentum flavum
being the most substantial. The fibrous tissue in the area of the pars defect can be divided
with a curette or resected with a Kerrison rongeur. Caution is necessary to avoid injury to the
exiting nerve root. It may be helpful to divide the lamina in to two halves in order to be able
to work on releasing the bone from both within and outside the spinal canal.
After the L5 lamina is removed, the ligamentum flavum should be resected for improved
visualization and decompression. The remaining L5 pars and accompanying fibrous tissue
should be carefully resected in order to adequately decompress the foramen and exiting nerve
root. Osteophytes from the inferior endplate of L5 should be resected to fully decompress the
exiting nerve, especially after reduction.
Attention is then turned to placing pedicle screw instrumentation. The starting point for
pedicle screws at L5 is determined using bony landmarks to identify the intersection of the
lateral border of the pars and the middle of the transverse process. The location and trajectory
of the pedicle can be confirmed by palpation from within the spinal canal. Fluoroscopic
guidance is suggested, as the L5 pedicle can be at a significant lordotic angle. The starting
point for the S1 pedicle screw is just lateral and inferior to the base of the S1 superior
articular process. Screws should be angled medially and toward the sacral promontory with a
goal of achieving bicortical fixation. A larger screw is suggested for the S1 pedicle as
compared to lumbar pedicle screws. Position of the screws should be checked with
fluoroscopy and electromyographic stimulation can be used to identify medial or inferior
pedicle breaches.
With secure pedicle fixation achieved, interbody fusion can be addressed to provide
foraminal distraction, spondylolisthesis reduction and increase the surface area for fusion. A
distractor can be placed in the L5 and S1 pedicle screws to increase the safe working area and
ease of access to the disc space. Care should be taken not to over-distract in an effort to avoid
weakening the screw-bone interface. If not done already, the cranial aspect of the S1 pedicle
should be skeletonized by removing any remaining superior articular process with a Kerrison
rongeur. The dura and nerve roots are identified, mobilized and protected to expose the disc
space. The overlying venous complex should be coagulated with electrocautery. An
annulotomy is then performed and a blunt paddle should be should used to establish a
working path within the disc space. A subtotal discectomy is then achieved with a
combination of shavers, curettes and pituitary rongeurs. Blunt paddles can be used to distract
within the disc space and offload the pedicle screws as well as to establish the appropriate
size of the interbody device. The cartilaginous endplate should be carefully removed with a
curette. A trial interbody device is then inserted at an oblique angle with the appropriate size
and position confirmed with fluoroscopy. The trial interbody device is removed and the disc
space is packed with morcelized bone graft from the laminectomy, along with bone graft
extenders, if necessary, to achieve approximately 20 cc of graft within the disc. The
appropriately sized interbody cage is then packed with bone graft and impacted into the disc
space using fluoroscopic guidance. The final position of the cage should be ventral to the
posterior aspect of both the L5 and S1 vertebral bodies on the lateral x-ray and the tip should
be past the midline on the AP view. Pedicle screw distraction is then removed to confirm a
firm press fit of the cage within the disc space. Placement of an appropriately sized interbody
cage will result in significant reduction of the spondylolisthesis and correction of the slip
angle.
The L5 transverse process and the sacral ala are then decorticated with a burr and the
lateral gutters are packed with bone graft accomplishing a posterolateral fusion. An
appropriately sized rod is then selected, placed within the tulips of the pedicles screws and
secured with set screws. Compression can be applied through the construct if desired to
restore lordosis and further secure the interbody device.
Pearls and Pitfalls

• Spina bifida occulta is often found in association with isthmic spondylolisthesis and
should be identified on pre-operative imaging to reduce the risk of inadvertent
durotomy during exposure.
• Gentle traction applied to the lamina through the spinous process by an assistant will
while dissecting soft tissue off the bone will make the Gill laminectomy more
efficient and improve safety.
• Aggressive reduction of spondylolisthesis has been associated with exiting nerve root
palsy, thus complete foraminal decompression including inferior endplate
osteophytes should be achieved prior to attempting any reduction maneuvers. In
some cases, only partial slip reduction should be attempted.
• Working within the disc space at an angle not parallel to the endplate can lead to
breach and fracture of the subchondral bone. This can be avoided by using lateral
202 Isaac L. Moss
fluoroscopic guidance as well as a blunt instrument to establish an initial working

path within the disc space.
• Resection of a small portion of the posterior aspect of the superior S1 endplate can
also help to establish a safe and reproducible working corridor.
• Maximizing the footprint of the interbody cage selected will decrease the stress on
the endplate within the disc space and reduce the chance of failure.
• An insert and rotate interbody cage design maybe useful in regaining interbody
height in collapsed disc spaces by inserting the cage in its shorter dimension and then
rotating it to its full height once it is securely in the disc space.
• If high-grade spondylolisthesis (>50%) and dysplastic features are present, consider
extension of the fusion to L4.
Literature Summary
A lytic defect of the pars interarticularis is estimated to be present in 6% of the
population. [1] Many are asymptomatic and only a small minority of patients will require
surgical intervention. Progressive spondylolisthesis, often associated with worsening
symptoms, occurs as a result of intervertebral disc degeneration leading to neuroforaminal
stenosis both in adolescence and adulthood. [2] Patients most often present with back pain
and lumbar radiculopathy due to compression of the exiting nerve root at the effected level.
When non-operative measures fail, decompression alone is not considered a viable option as
it is likely to exacerbate the underlying segmental instability present. Thus, fusion is
recommended in these cases and has been shown to provide significant improvement in
function and quality of life measures. [3, 4, 5]
The pathoanatomy of this condition presents several challenges to achieving solid
arthrodesis, including small and often dysplastic posterior elements, a large gap between the
fusion bases in the slipped position, and incompetent anterior stabilizing structures. [6]
Instrumentation is recommended as it provides immediate stabilization and higher rates of
fusion in this unstable environment. [7,8]
Interbody fusion was introduced to aid in listhesis reduction to restore spinal alignment
while providing an additional fusion surface. [6] Several studies have demonstrated improved
solid arthrodesis rates approaching 95% when interbody fusion is performed as compared to
posterolateral fusion alone. [5] Whether or not this improved fusion rate results in improved
functional outcomes, measures remains controversial. Interbody fusion at L5-S1 can be
achieved via an anterior or posterior approach. While the anterior approach has some
advantages, it has been associated with higher complications rates [4] and requires a second
approach if combined with posterior screw fixation.
There has been debate as to whether or not complete reduction of the spondylolisthesis is
necessary to achieve satisfactory clinical outcomes. Studies to address this question have
demonstrated improved radiographic parameters with reduction, but no difference in
functional and quality of life outcome measures as compared to patients with unreduced slips.
[9,10] There is some evidence to suggest that restoration of normal spinopelvic sagittal
alignment is associated with improved outcomes. [11] Thus, in this case, an open
laminectomy with posterolateral and interbody fusion were selected to provide decompression
of the neural elements, restoration of disc and foraminal height, partial slip reduction and
solid fixation with a high rate of fusion.
References
[1] Vaccaro, A.R., Ring, D., Scuderi, G., Cohen, D.S., Garfin, S.R. (1997). Predictors of
outcome in patients with chronic back pain and low-grade spondylolisthesis. Spine
22(17), 2030-2034.
[2] Floman, Y. (2000). Progression of lumbosacral isthmic spondylolisthesis in adults.
Spine. 25(3), 342-347.
[3] Molinari, R.W., Sloboda, J.F., Arrington, E.C. (2005). Low-grade isthmic
spondylolisthesis treated with instrumented posterior lumbar interbody fusion in U.S.
servicemen. J Spinal Disord. Tech. 18, S24-29.
[4] Wang, S-J., Han, Y-C., Liu, X-M., Ma, B., Zhao, W.D., Wu, D.S., Tan, J. (2014).
Fusion techniques for adult isthmic spondylolisthesis: a systematic review. Arch Orthop
Trauma Surg. 134(6), 777-784.
[5] Ye, Y-P, Xu, H, Chen, D. (2013). Comparison between posterior lumbar interbody
fusion and posterolateral fusion with transpedicular screw fixation for isthmic
spondylolithesis: a meta-analysis. Arch Orthop Trauma Surg. 133(12), 1649-1655.
[6] Suk, S.I., Lee, C.K., Kim, W.J., Lee, J.H., Cho, K.J., Kim, H.G. (1997). Adding
posterior lumbar interbody fusion to pedicle screw fixation and posterolateral fusion
after decompression in spondylolytic spondylolisthesis. Spine. 22(2), 219-220.
[7] Bernhardt, M., Swartz, D.E., Clothiaux, P.L., Crowell, R.R., White, A.A. 3rd. (1992).
Posterolateral lumbar and lumbosacral fusion with and without pedicle screw internal
fixation. Clin Orthop Relat Res. (284), 109-115.
[8] Boos, N., Marchesi, D., Zuber, K., Aebi, M. (1993). Treatment of severe
spondylolisthesis by reduction and pedicular fixation. A 4-6-year follow-up study.
Spine. 18(12), 1655-1661.
[9] Audat, Z.M., Darwish, F.T., Al Barbarawi M.M., Obaidat, M.M., Haddad, W.H.,
Bashaireh, K.M., Al-Aboosy, I.A. (2011). Surgical management of low grade isthmic
spondylolisthesis; a randomized controlled study of the surgical fixation with and
without reduction. Scoliosis. 6(1), 14.
[10] Lian, X-F., Hou, T-S., Xu, J-G., Zeng, B.F., Zhao, J., Liu, X.K., Yang, E.Z., Zhao, C.
(2014). Single segment of posterior lumbar interbody fusion for adult isthmic
spondylolisthesis: reduction or fusion in situ. Eur Spine J. 23(1), 172-179.
[11] Bourghli, A., Aunoble, S., Reebye, O., Le Huec, J.C. (2011). Correlation of clinical
outcome and spinopelvic sagittal alignment after surgical treatment of low-grade
isthmic spondylolisthesis. Eur Spine J. 20(Suppl 5), 663-668.
Chapter 21
Minimally Invasive Posterior Approach
Saad B. Chaudhary, MD
Department of Orthopaedic Surgery, Rutgers University – New Jersey Medical School
Newark, NJ, US
Case Summary
A 36 year-old female presents with 4 years of worsening back and bilateral lower
extremity pain despite years of conservative management. She is unable to work due to
her symptoms. Physical exam is significant for pain in the low back and bilateral lower
extremities with straight leg raise testing. There is mild numbness in the feet bilaterally
but no weakness. Range of motion is limited secondary to back pain. Imaging evaluation
of the lumbar spine reveals bilateral spondylolysis of L5 resulting in a mobile L5/S1
spondylolisthesis and severe bilateral L5 foraminal stenosis (Figure 1,2,3).
206 Saad B. Chaudhary
(A) (B)
Figure 1. (A) AP, (B) lateral and (C) cone-down view demonstrating Grade II isthmic spondylolisthesis
at L5-S1.
(A) (B)
Figure 2. Pre-operative (A) Right and (B) left parasagittal CT scan images confirm the bilateral pars
defects and associated foraminal narrowing.
Minimally Invasive Posterior Approach 207
(A) (B)
Figure 3. Pre-operative (A) Midsagittal and (B) right parasagittal T2-weighted MRI demonstrating the
low-grade spondylolisthesis with severe foraminal stenosis.
Surgical Approach
Isthmic Spondylolisthesis can be surgically addressed with an anterior approach, a
posterior approach, or a combined anterior-posterior (AP) approach to facilitate spinal
realignment, decompression and stabilization. Traditionally, an open posterior approach has
been employed to accomplish the preceding surgical goals. However, this pathology can be
effectively addressed with a decreased morbidity via a minimally invasive
posterior/transforaminal decompression and arthrodesis procedure.
A minimal access procedure minimizes muscle damage by respecting inter-muscular
planes and results in reduced post-operative pain and discomfort for the patient.
For the vast majority of low-grade spondylolistheses, this approach provides direct access
to the neural elements bilaterally, for a thorough decompression, utilizing a unilateral working
corridor. In certain circumstances, specifically in managing high-grade spondylolisthesis
(Grades III and IV), a bilateral approach may be warranted. A bilateral minimally invasive
approach allows complete access to the facet complex in order to obtain a wide bilateral
facetectomy along with a sub-articular and foraminal decompression, thereby aiding in
spondylolisthesis reduction and spinal re-alignment.
The many benefits of the Minimally Invasive Transforaminal Interbody Fusion (MIS-
TLIF) approach include decreased operative time, lower blood loss, and minimal muscle
damage when compared to the open technique. Clinically, this results in reduced post-
operative pain, narcotic requirements, and an earlier discharge. [1] Most of the available
literature also establishes a lower infection rate and a high rate of arthrodesis utilizing this
minimal access technique. [2, 3]
Surgical Procedure
The patient is placed prone on a rotating Jackson spine table. The operative level must be
targeted and confirmed using fluoroscopy. After anesthetizing the skin at the lateral margin of
the pedicles, a 2-3 cm skin incision is made. This approach should be performed on the most
symptomatic side for the patient.
The lumbodorsal fascia is identified and incised and through this fascial opening a
Jamshidi needle is docked on the transverse process / facet junction. Once the starting point
and trajectory is confirmed on a perfectly centered and positioned AP view, the Jamshidi
needle is advanced approximately 15 to 20 mm until the tip of the tip of the needle is at the
medial pedicle wall. This placement is confirmed using an AP fluoroscopic image, followed
by a lateral shot to confirm entry into the posterior vertebral body (Figure 4). Once this
positioning is confirmed, the Jamshidi needle is further advanced into the vertebral body. This
is subsequently followed by the placement of guidewires through the Jamshidi needles
halfway into the vertebral bodies.
All four pedicles of the interested motion segment are cannulated and guidewires are
inserted simultaneously; one level at a time above and below the disc space of interest.
Pedicle entry is followed by accessing the facet complex using either a static or an
expandable tubular retractor system (Figure 5).
Initially, dilators are passed through the lumbodorsal fascia onto the facet complex. The
dilator orientation should be parallel to the intervertebral disc space. Subsequently, the
appropriately sized (diameter and depth) retractor is positioned over the facet and attached to
the operating table. Illumination and magnification can be obtained using an operative
microscope, an endoscope, or surgical loupes. The inferior articulating process and the
ipsilateral hemi-lamina are resected and removed using a combination of an osteotome, high-
speed burr, and / or kerrison rongeurs. The superior articulating process is also identified and
removed using the above tools. The ligamentum flavum is removed and the traversing nerve
root and thecal sac are identified. This technique allows for a complete bilateral
decompression (Figure 6). All the removed bone is saved and prepared for use as autograft to
facilitate the interbody arthrodesis.
(A) (B)
Figure 4. Intra-operative (A) AP and (B) lateral fluoroscopic images demonstrating techniques for safe
simultaneous cannulation of pedicles.
Figure 5. Intra-operative fluoroscopic image confirming appropriate retractor placement and trajectory
for access into the intervertebral disc space.
Figure 6. Intra-operative photograph visualization of bilateral decompression via a unilateral approach.

The cottonoid pledget with string is placed over the ipsilateral disc space and the curette is at the
contralateral lateral recess.
At this point, the disc space is isolated, the overlying epidural vessels are coagulated and
an annulotomy is performed. A subtotal discectomy can be performed using various tools
including pituitary rongeurs, curettes and disc space shavers. The interbody space is
meticulously prepared without compromising the integrity of the bony endplates. Once the
disc space is prepared and sized, it should be packed with autograft bone along with bone
graft extenders as needed for a total volume of 20 to 30 cc of bone graft per level. After
placement of half of the bone graft in the anterior and contra-lateral disc space, a lordotic
interbody cage is inserted. The optimal (boomerang) cage placement is in the anterior 1/3 of
the disc space to facilitate reduction and restore segmental lordosis. The implant placement is
confirmed fluoroscopically (Figure 7). The remainder of the graft is packed within and
behind the cage.
(A) (B)
Figure 7. Intra-operative (A) AP and (B) lateral fluoroscopic images demonstrating the placement of a
lordotic boomerang shaped trial in the anterior disc space for optimal establishment of lordosis and
maintenance of segmental alignment.
The previously placed guide-wires in the vertebral bodies are then utilized to tap the
screw trajectories. Stimulated EMG evoked potentials are performed to further confirm the
absence of a pedicle breach. The taps are removed and the percutaneous pedicle screws are
placed over the guide wires. The wires are removed and final screw-construct position is
confirmed using bi-planar fluoroscopy. Rods are sized and deployed bilaterally. Further
active reduction with specialized instrumentation can be performed as needed at this time,
based on patient factors and surgeon experience to achieve the desired spinal alignment
(Figures 8, 9).
(A) (B)
Figure 8. Post-operative (A) AP and (B) lateral radiograph demonstrating appropriate placement of a
lordotic bullet-shaped implant into the disc space with achievement of optimal reduction and lordosis
with restoration of disc and foraminal height.
(A) (B)
Figure 9. Post-operative (A) AP and (B) lateral fluoroscopic films reveal the placement of a lordotic
boomerang implant into the disc space with achievement of reduction and lordosis with restoration of
disc and foraminal height for another patient with a prior L4-5 ALIF and bilateral pars fractures with a
Grade I spondylolisthesis.
Pearls and Pitfalls

 Approach the TLIF on the most symptomatic side. However, for high-grade (Grade
III, IV) slips, consider a bilateral approach for complete facetectomies and foraminal
decompression. A bilateral approach will facilitate safe(r) reduction and minimize
new onset radiculopathy or neurologic injury.
 Place the retractor in a medially directed orientation centered on the facet in the AP /
frontal plane. Keep the retractor trajectory parallel to the intervertebral disc in the
sagittal plane. This alignment is critical for optimum surgical outcomes, especially in
the morbidly obese. Plan skin incisions appropriately; lateral to the pedicle / facet
margin, based on the patient‟s body habitus.
 Complete facetectomy and bilateral lateral recess decompression is crucial in
obtaining a safe reduction and for gaining access to the disc space for restoration of
disc/foraminal height. It is essential to skeletonize the superior and medial pedicle
borders of the caudal level by removing the entire superior articulating process. This
optimizes unobstructed access to the intervertebral disc space.
 For low-grade slips, bilateral decompression can be obtained through a unilateral
approach by angling the retractor medially and utilizing a rotating Jackson table. This
technique facilitates resection of the base of the spinous process and the undersurface
of the contra-lateral lamina for optimal lateral recess decompression. Maintain the
integrity of the ligamentum flavum until the desired bony resection is complete.
 Spondylolisthesis reduction and maintenance of disc and foraminal height can be
accomplished through intra-discal distraction or by placing a rod contra-lateral to the
planned TLIF with temporary distraction. Further active reduction can be achieved
after the intervertebral space has been prepared and a lordotic cage has been
implanted. Aggressive reduction does carry a risk of hardware loosening / failure or

nerve root palsy.
Literature Summary
Various surgical procedures have been established in the literature for the treatment of an
isthmic spondylolisthesis. These techniques include decompression, decompression and
posterolateral fusion with or without instrumentation, and decompression with instrumented
interbody fusion. A comprehensive debate on the controversies surrounding optimal surgical
approach for low-grade spondylolisthesis is beyond the scope of this chapter. While each
surgical approach possesses distinct advantages and disadvantages, little doubt exists on the
benefits and improved outcomes of circumferential fusion with anterior column support in
this patient population. [4] Anterior column support and interbody access along with posterior
instrumentation can all be achieved through a single posterior transforaminal lumbar
interbody approach (TLIF).
This approach as popularized by Harms et al. provides access to all three columns and
can facilitate slip reduction, restoration of foraminal height, improve global alignment and
optimize arthrodesis. [5] All of the aforementioned surgical goals can be elegantly
accomplished utilizing a minimally invasive approach. [6] Several publications have
delineated short and mid-term advantages of the minimally invasive TLIF (MIS-TLIF) over
traditional open surgeries. Admittedly, the available data includes patients with both
degenerative and isthmic spondylolisthesis. However, the data for each subgroup appears to
be favorable.
Wang et al. prospectively report their results on 85 patients with degenerative or isthmic
spondylolisthesis treated by a minimally invasive TLIF (MIS-TLIF) or an open TLIF (O-
TLIF). The MIS-TLIF group had significantly reduced blood loss, post-operative transfusion,
and shorter hospital stay. [7] Additional peri-operative parameters that favor the minimally
invasive approach over the traditional open approach include decreased narcotic dependence
and earlier return to work. [1,2] Objective clinical improvement with reduction in Visual
Analogue Scale (VAS) scores and decrease in Oswestry Disability Index (ODI) scores have
also been well documented in the MIS-TLIF group, with a trend towards a more rapid
improvement post-operatively. [8, 9]
Arthrodesis rates for the MIS-TLIF procedure is at least equivalent to, and based on Wu‟s
meta-analysis, superior to the traditional open surgery. The rate of solid arthrodesis has been
reported to approach 95%. [3] This is combined with an overall similar complication rate and
a markedly reduced infection rate of 0.6% vs. 4% in the MIS vs. open approach, respectively.
[10, 11] Lastly, in our value-based health care system, cost-savings cannot be over-looked.
Available data suggests that MIS spine procedures result in cost savings and improved patient
outcomes. [12]
References
[1] Isaacs R.E., Podichetty V.K., Santiago P., Sandhu F.A., Spears J., Kelly K., Rice L.,
Fessler R.G. (2005). Minimally invasive microendoscopy-assisted transforaminal
lumbar interbody fusion with instrumentation. J. Neurosurg. Spine. 3, 98-105.
[2] Parker S.L., Lerner J., McGirt M.J. (2012). Effect of minimally invasive technique on
return to work and narcotic use following transoframinal lumbar inter-body fusio: a
review. Prof. Case Manag. 17(5), 229-35.
[3] Wu R.H., Fraser J.F., Hartl R. (2010). Minimal access versus open transforaminal
lumbar interbody fusion: meta-analysis of fusion rates. Spine. 15;35(26), 2273-81.
[4] Kwon B.K., Hilibrand A.S., Malloy K., Savas P.E., Silva M.T., Albert T.J., Vaccaro
A.R. (2005). A critical analysis of the literature regarding surgical approach and
outcome for adult low-grade isthmic spondylolisthes. J. Spinal Disord. Tech. 18 Suppl,
S30-40.
[5] Harms J.G., Jeszensky D. (1998). The unilateral transforaminal approach for posterior
interbody fusion. J. Orthop. Traumatol. 6, 88-89.
[6] Schwender J.D., Holly L.T., Rouben D.P., Foley K.T. (2005). Minimally invasive
transforaminal lumbar interbody fusion (TLIF): technical feasibility and initial results.
J. Spinal Disord. Tech. 18 Suppl, S1-6.
[7] Wang J., Zhou Y., Zhang Z.F., Li C.Q., Zheng W.J., Liu J. (2010). Comparison of one-
level minimally invasive and open transforaminal lumbar interbody fusion in
degenerative and isthmic spondylolisthesis grades 1 and 2. Eur. Spine J. 19(10), 1780-
4.
[8] Seng C., Siddiqui M.A., Wong K.P., Zhang K., Yeo W., Tan S.B., Yue W.M. (2013).
Five-year outcomes of minimally invasive versus open transforaminal lumbar interbody
fusion: a matched-pair comparison study. Spine. 38(23), 2049-2055.
[9] Kim J.S., Jung B., Lee S.H. (2012). Instrumented Minimally Invasive spinal-
Transforaminal Lumbar Interbody Fusion (MIS-TLIF); Minimum 5-years follow-up
with Clinical and Radiologic Outcomes. J. Spinal Disord. Tech.
[10] Parker S.L., Adogwa O., Witham T.F., Aaronson O.S., Cheng J., McGirt M.J. (2011).
Post-operative infection after minimally invasive versus open transforaminal lumbar
interbody fusion (TLIF): literature review and cost analysis. Minim. Invasive
Neurosurg. 54(1), 33-7.
[11] McGirt M.J., Parker S.L., Lerner J., Engelhart L., Knight T., Wang M.Y. (2011).
Comparative analysis of perioperative surgical site infection after minimally invasive
versus open posterior/transforaminal lumbar interbody fusion: analysis of hospital
billing and discharge data from 5170 patients. J. Neurosurg. Spine. 14(6), 771-778.
[12] Al-Khouja L.T., Baron E.M., Johnson J.P., Kim T.T., Drazin D. (2014). Cost-
effectiveness analysis in minimally invasive spine surgery. Neurosurg. Focus. 36(6),
E4.
Chapter 22
Anterior Lumbar Interbody Fusion
Cliff Tribus, MD
Department of Orthopedic and Rehabilitative Medicine,
University of Wisconsin-Madison, WI, US
Case Summary
36 year-old female presents with 4 years of worsening back and bilateral lower extremity
pain despite years of conservative management. She is unable to work due to her symptoms.
Physical exam is significant for pain in the low back and bilateral lower extremities with
straight leg raise testing.
There is mild numbness in the feet bilaterally but no weakness. Range of motion is
limited secondary to back pain. Imaging evaluation of the lumbar spine reveals bilateral
spondylolysis of L5 resulting in a mobile L5/S1 spondylolisthesis and severe bilateral L5
foraminal stenosis (Figures 1, 2, 3)
216 Cliff Tribus
Figure 1. Pre-operative radiograph taken in the flexion position demonstrating a stable Grade 2 isthmic
spondylolisthesis.
Figure 2. Pre-operative radiograph taken in the extension position demonstrating a stable Grade 2
isthmic spondylolisthesis.
Anterior Lumbar Interbody Fusion 217
Figure 3. Sagittal T2-weighted MRI demonstrating Grade 2 spondylolisthesis and degenerative disc
disease at L5-S1.
Surgical Approach
An anterior lumbar interbody approach was chosen for this patient to best address the
pain generators in a patient with a grade 2 isthmic spondylolisthesis at the L5-S1 level. The
merits of adding posterior stabilization will also be presented. Pain in the case of an isthmic
spondylolisthesis may emanate from the instability, the degenerative disc disease, the
foraminal stenosis, the pars defect itself or the unstable Gill lamina. An interbody fusion,
when compared to stand alone posterior based approaches may be effective in addressing
these pain generators and restoring anatomy. [1,2]
When the patient is in the supine position, under general anesthesia, the effect of gravity
on the deformity can serve to allow a passive reduction. Distraction within the disc space will
often complete the reduction in a safe, non-challenging way which can then be stabilized by
the interbody fusion. The stand-alone anterior technique affords stabilization with minimal
muscle destruction, a shortened hospital stay and avoidance of a posterior approach. [3] The
addition of posterior hardware provides more rigid fixation and a more validated approach.
[4]
Surgical Procedure
The patient is placed supine on a standard operating table with an extension bump to
allow for fluoroscopic view of the lumbosacral spine. The arms are abducted 90 degrees and
all other areas of potential pressure are adequately padded.
218 Cliff Tribus
An oblique incision is created in the lower abdomen. The incision should begin just right
of midline above the pubic symphysis and extend proximally and to the left. The rectus sheath
is incised in line with the incision and the left lateral rectus muscle is retracted towards
midline. Alternatively, the surgeon may choose to work in the midline between the right and
left rectus muscle. Typically, the approach is below the arcuate line of the posterior rectus
sheath; if not, the posterior rectus sheath is incised at its lateral insertion to allow entry into
the retroperitoneum. Blunt dissection ensues, mobilizing the peritoneum and attached ureter
from left to right to expose the great vessel bifurcation and the sacral promontory. The middle
sacral artery and vein are ligated and the L5-S1 disc is exposed. Self-retaining retractors are
positioned to protect the local vasculature and after radiographically confirming the
appropriate level the disc is incised and resected (Figure 4). A complete discectomy is
performed back to the posterior annulus. The posterior longitudinal ligament (PLL) is
retained to provide a tether for the reduction. Inter-vertebral spreaders are then sequentially
placed progressively distracting the disc space. The distraction, with a retained PLL, often
provides a passive reduction of the spondylolisthesis (Figures 5,6,7).
Figure 4. Intra-operative view of the L5-S1 disc. The middle sacral artery and vein have been ligated
and the disc incised.
Figure 5. Pre-operative lateral x-ray demonstrating a grade 1 isthmic spondylolisthesis

Figure 6. Intra-operative distraction obtains anatomic reduction of spondylolisthesis.
Figure 7. The anatomically reduced spondylolisthesis being stabilized by the Translation Plate
(Spineology).
The interbody device of choice should provide structure and adequate stability. Femoral
allograft, PEEK or metallic implants are all viable choices. Autograft or a bone growth
product should be utilized to augment the fusion.
The challenge for a stand-alone anterior interbody device in the setting of an isthmic
spondylolisthesis is two-fold. First, the pars defects remove the posterior column stability and
thus create a less biomechanically stable construct. Secondly, most anterior devices do not
allow for active reduction of the spondylolisthesis. There are currently two devices approved
by the FDA that attempt to address these two problems; the Monument device from Globus
(Audubon, PA), and the Translation plate (Figure 8) from Spineology (St. Paul, MN). Both
220 Cliff Tribus
devices allow reduction of low-grade spondylolisthesis utilizing implant-implant translation

while also attempting to provide inherent stability with vertebral body screws.
Figure 8. Translation Plate by Spineology.
The Monument device has the advantage of being zero profile with the relative
disadvantage being only unicortical endplate fixation. The Translation plate has the advantage
of the reduction maneuver pulling against four cortices of two divergent screws while
avoiding penetrating the endplate with the relative disadvantage being a 4 mm profile. Both
products are new and have no reported clinical results.
Augmenting the interbody construct with an anterior plate is another viable option.
Further active reduction of the spondylolisthesis is not feasible but augmenting the strength of
the anterior interbody construct and avoiding the posterior approach is the goal (Figure 9,
10).
Figure 9. Lateral radiograph of a grade 2 isthmic spondylolisthesis.

Figure 10. Lateral x-rays of a grade 2 isthmic spondylolisthesis partially reduced and stabilized by
interbody cages and an anterior plate.
The anterior incision is closed in layers and the patient is placed in the prone position
under anesthesia. Posterior transpedicular stabilization can be accomplished in a number of
ways with advantages and disadvantages of each. Fluoroscopy assisted percutaneous
placement of screws and rods for stabilization is the least invasive. This technique relies on
the interbody construct to provide the biology for healing and the passive distraction for
neural decompression. At the other end of the spectrum is an open midline approach, Gill
type laminectomy, posterior fusion with local bone autogenous graft and pedicle screw
fixation (Figure 11, 12).
Figure 11. Lateral radiographs demonstrating a grade 2 isthmic spondylolisthesis with disc space
collapse.
222 Cliff Tribus
Figure 12. Lateral radiographs demonstrating a grade 2 isthmic spondylolisthesis with disc space
collapse treated by anterior distraction with near complete reduction of the spondylolisthesis and
posterior stabilization with transpedicular fixation.
Pearls and Pitfalls

• Not all low-grade isthmic spondylolistheses are equal. Be aware that many will have
dysplastic features that must be recognized, as they will complicate traditional
surgical approaches.
• The anatomy of the slip should be scrutinized. Occasionally, the angle of the disc
space is too steep to access anteriorly. The angle of the disc should be extrapolated
on preoperative radiographs to be certain that it does not extend below the pubic
symphysis. This orientation should be confirmed intra-operatively with fluoroscopy
prior to making the incision.
• Remaining oriented to the alignment of the disc space is critical. Typical
disorientation leads to violating the endplate of S1.
• Once the alignment of the disc space is established, a narrow distractor should be
placed. This will “pop” the disc space open and greatly facilitate the discectomy.
• Delivering the anterior interbody device can be challenging in the absence of a
dedicated system. The difficulty is in maintaining disc distraction while placing the
implant or graft. The disc space will have the propensity to collapse and for the
deformity recur.
• In using a femoral ring allograft anteriorly, the surgeon should consider an S1
anterior screw with a washer buttressing the graft in place.
Literature Summary
Posterior stand-alone approaches for the treatment of isthmic spondylolisthesis without
addressing the disc space are falling out of favor. There is little surface area for fusion, the
fusion heals under tension and the degenerative disc is not addressed. Adding interbody
ablation of the disc and fusion is now gaining wide spread acceptance. [1,2,5,6]
There is still justifiable debate as to whether the interbody technique is best accomplished
through an anterior or TLIF (PLIF) approach. Suk provides the strongest argument for
Anterior and posterior approach but the argument is still not clear. 56 patients were studied
(35 posterior interbody fusions and 21 combined anterior-posterior fusions). The combined
anterior-posterior cohort experienced a greater operative time and longer duration to
radiographic fusion yet had significantly less loss of reduction. [7]
Stand-alone anterior approaches for isthmic spondylolisthesis do not have significant
support in the literature. Kuslich et al. demonstrated a high failure rate with stand alone
interbody cages in spondylolisthesis but most of these were placed through a PLIF
approach.[3] Cunningham et al. discussed the biomechanical disadvantages of stand-alone
ALIF cages for isthmic spondylolisthesis and recommended against its utilization. [4]
In summary, a grade 2 isthmic spondylolisthesis that has failed non-operative care allows
the treating physician several surgical options. The surgeon must identify the pain generator
and include this source of pain in the treatment. Ablating the disc is a priority. An anterior
interbody fusion with posterior stabilization is the slightly preferred approach in the literature
while posterior fusion and TLIF (or PLIF) are acceptable alternatives. Stand-alone anterior
approaches have appeal but the surgeon must be cognizant of the high failure rates in the
historical techniques and virtually no surgical literature to support its efficacy.
References
[1] Ekman P., Moller H., Tullberg T., Neumann P., Hedlund R. (2007). Posterior lumbar
interbody fusion versus posterolateral fusion in adult isthmic spondylolisthesis. Spine.
32(20), 2178–2183.
[2] Suk S.I., Lee C.K., Kim W.J., Lee J.H., Cho K.J., Kim H.G. (1997). Adding posterior
lumbar interbody fusion to pedicle screw fixation and posterolateral fusion after
decompression in spondylolytic spondylolisthesis. Spine. 22(2), 210-9; discussion 219-
20.
[3] Kuslich S.D., Ulstrom C.L., Griffith S.L., Ahern J.W., Dowdle J.D. (1998). The Bagby
and Kuslich method of lumbar interbody fusion. History, techniques, and 2-year follow-
up results of a United States prospective, multicenter trial. Spine. 23(11), 1267-78
[4] Cunningham B., Polly D. (2002). The Use of Interbody Cage Devices for Spinal
Deformity: A Biomechanical Perspective. Clin Orthop Relat Res. 394, 73–83.
[5] Deguchi M., Rapoff A., Zdeblick T. (1998). Posterolateral fusion for isthmic
spondylolisthesis in adults: analysis of fusion rate and clinical results. J Spinal Disord
Tech. 11(6), 459 -464.
224 Cliff Tribus
[6] Cunningham E., Elling E.M., Milton A.H., Robertson P.A. (2013) What is the optimum
fusion technique for adult isthmic spondylolisthesis–PLIF or PLF? A long-term
prospective cohort comparison study. J Spinal Disord Tech. 26(5), 260–267.
[7] Suk K.S., Jeon C.H., Park M.S., Moon S.H., Kim N.H., Lee H.M. (2001). Comparison
between posterolateral fusion with pedicle screw fixation and anterior interbody fusion
with pedicle screw fixation in adult spondylolytic spondylolisthesis. Yonsei Med. J.
42(3), 316-23.
Case Vignette 9:
Lumbar Degenerative Disc Disease
Chapter 23
Minimally Invasive Lumbar

Interbody Fusion
Branko Skovrlj, MD1

and Sheeraz A. Qureshi, MD, MBA2
1
Department of Neurosurgery, Mount Sinai Medical Center, New York, NY, US
2
Department of Orthopaedic Surgery, Mount Sinai Medical Center, New York, NY, US
Case Summary
A 39-year-old non-smoking male who works as an accountant and spends the
majority of his working day sitting, presents with several years of progressively
worsening low back pain (LBP). The pain has gotten so severe that he has difficulty
sitting or standing for extended periods and is unable to engage in activities of daily
living without significant pain. He denies any radiating symptoms into his lower
extremities. He has tried multiple conservative treatment modalities including physical
therapy and epidural steroid injections with no success. Physical examination is positive
only for reproduction of low back pain with lumbar extension. Imaging evaluation
reveals a degenerative L5-S1 disc without lumbar stenosis or spondylosis (Figure 1).
228 Branko Skovrlj and Sheeraz A. Qureshi
(A) (B)
Figure 1. Pre-operative (A) Sagittal and (B) Axial T2-weighted magnetic resonance imaging (MRI)
axial and sagittal images demonstrated a desiccated L5-S1 disc (“black disc”) without evidence of disc
bulging or herniation and no evidence of stenosis or spondylosis.
Surgical Approach
A minimally invasive transforaminal lumbar interbody fusion (MIS TLIF) was chosen as
the approach of choice to address this patient‟s pathology. The MIS TLIF allows for a
midline-sparing, minimally destructive approach to the L5-S1 disc while allowing for
complete removal of the diseased disc followed by stabilization of the affected level by way
of an interbody fusion.
When compared to traditional open TLIF, the MIS TLIF offers several advantages. The
MIS approach offers significantly less disruption to the paraspinal musculature by gaining
access to the spine through a series of unilaterally placed serial dilators. This allows for
preservation of the midline supraspinous and interspinous ligaments, which stabilize the spine
and decreases paraspinal muscle damage created by muscle ischemia from prolonged
retraction. MIS TLIF has been shown to have decreased operative times, estimated blood loss
(EBL), length of stay (LOS) and hospital costs when compared to open TLIF. [1, 2] In
addition, the MIS TLIF has significantly lower rate of postoperative surgical site infection
(SSI). [3]
Surgical Procedure
The patient is placed prone on a four-post Jackson table and the L5-S1 level is identified
using fluoroscopic guidance. On AP fluoroscopic imaging, the lateral aspect of the L5 and S1
pedicles is marked and an incision approximately 2.5 cm in length is made in the middle of
Minimally Invasive Lumbar Interbody Fusion 229
that line. A Jamshidi needle is placed on the lateral aspect of the pedicle and advanced 15-20
mm into the pedicle under fluoroscopic guidance (Figure 2, 3). A guidewire is then placed
through the Jamshidi cannula and advanced to the medial wall of the pedicle as seen on the
AP fluoroscopic imaging (Figure 4). A lateral fluoroscopic image is then obtained ensuring
that the tip of the guidewire is beyond the posterior edge of the vertebral body wall. The same
procedure is then repeated on the opposite side, however only 1cm stab incisions are used at
the level of the pedicles of interest.
Figure 2. Intra-operative AP fluoroscopic image demonstrating appropriate positioning of the Jamshidi

needle.
Figure 3. Intra-operative AP fluoroscopic image demonstrating advancement of the Jamshidi needle

toward the medial edge of the pedicle.
Figure 4. Intra-operative AP radiograph demonstrating the advancement of a guidewire through the

Jamshidi cannula to the medial wall of the pedicle.
Once the L5 and S1 pedicles on both sides are cannulated, serial dilators are used to
allow placement of a tubular retractor directly on top of the L5-S1 facet joint. Utilizing a
high-speed burr, the inferior articulating facet of L5 is removed followed by partial removal
of the superior articulating facet of S1 to the level of the superior edge of the S1 pedicle. The
remaining of the inferior articulating process of L5 is removed using a Kerrison rongeur to
expose the inferior edge of the pedicle of L5.
The ligamentum flavum overlying the thecal sac is identified and left intact and the
exiting L5 nerve root is visualized to prevent it from injury. The venous complex overlying
the disc space is coagulated using bipolar electrocautery. A bayonetted 11-blade knife is used
to perform an annulotomy. A discectomy is then performed utilizing a combination of disc
shavers, angled curettes and pituitary rongeurs. It is critical to perform an aggressive
discectomy while assuring that the anterior annulus remains intact. Once the disc space is
adequately prepared, a trial interbody device is placed in the disc space until satisfactory disc
height and lumbar lordosis are restored and the trial is then removed. An extra small sponge
of INFUSE (Sofamor Danek, Memphis, TN, USA) together with 30cc of allograft cancellous
chips and bone putty are injected into the anterior aspect of the disc space by way of a bone
funnel. An articulating lordotic cage is then placed into the anterior thirds of the disc space
under fluoroscopic guidance.
With the interbody device in place, pedicle taps are advanced over the previously placed
guidewires. The taps are then removed and appropriately sized pedicle screws are placed with
aid of fluoroscopy to assure safe and accurate screw placement. A fitted rod is then inserted
underneath the paraspinal musculature and compression is applied across the disc space to
establish segmental lordosis of the L5-S1 level.
Minimally Invasive Lumbar Interbody Fusion 231
Pearls and Pitfalls

 Initial placement of the tubular retractor system with a medially angled trajectory
parallel to the level of the disc space is critical first step.
 Achieving a complete facetectomy is paramount to ensure proper visualization of
disc space of interest. Resecting the entire superior articulating facet of S1 (caudal
vertebral level) flush against the superior edge of the pedicle of S1 will allow for the
adequate visualization of the L5-S1 disc. Failure to obtain adequate visualization of
the disc space may result in incomplete preparation of the disc space and the inability
to correctly place the appropriately sized interbody device resulting in subsequent
device migration and potential nonunion at that level.
 Aggressive resection of the disc material and endplates from the L5-S1 disc space is
of utmost importance to achieve a successful interbody fusion. Care must be taken
not to violate the anterior annulus and anterior longitudinal ligament complex as this
may result in cage migration anteriorly.
 Placement of the biggest lordotic cage with best fit in the disc space assures
restoration of the disc height as well as segmental lumbar lordosis. Articulating
lordotic cages allow for easier placement of the interbody cage in the middle of the
anterior third of the disc space. Expandable cages allow easier placement of the cage
at the desired location with the added benefit of expansion while at the desired
location and under fluoroscopic visualization.
 Achieving bicortical purchase on the S1 screws is critical to assure adequate
biomechanical stabilization of the screw and rod construct during the time of bony
healing and fusion, decreasing the chance for fusion failure and subsequent
pseudoarthrosis.
Literature Summary
Numerous studies exist comparing perioperative and long-term outcomes of MIS-TLIF
versus open TLIF. In comparison to the open approach, MIS TLIF has been shown to have
short- and long-term clinical outcomes comparable to open TLIF with the additional benefits
of decreased postoperative pain, decreased EBL, faster recovery times, reduced postoperative
narcotic use, faster postoperative ambulation and shorter LOS. [4, 5, 6, 7]
Fusion rates following MIS TLIF exceed 90% and are comparable to those of open TLIF.
[8] A meta-analysis of fusion rates of MIS TLIF found a mean fusion rate of 94.8%. [9] In
addition, MIS TLIF has been associated with a reduction in mean hospital costs while
maintaining similar 2-year direct health care costs and gain of quality-adjusted life years. [10]
References
[1] Adogwa O., Parker S.L., Bydon A., Cheng J., McGirt M.J. (2011). Comparative
J Spinal Disord Tech. 24(8), 479-484.
[2] Pelton M.A., Phillips F.M., Singh K. (2012). A comparison of perioperative costs and
outcomes in patients with and without workers' compensation claims treated with
minimally invasive or open transforaminal lumbar interbody fusion. Spine. 37, 1914-
1919.
[3] Parker S.L., Adogwa O., Witham T.F., Aaronson O.S., Cheng J., McGirt M.J. (2011).
Post-operative infection after minimally invasive versus open transforaminal lumbar
interbody fusion (TLIF): literature review and cost analysis. Minim Invasive Neurosurg
54(1), 33-37.
[4] Seng C., Siddiqui M.A., Wong K.P., Zhang K., Yeo W., Tan S.B., Yue W.M. (2013).
Five-year outceoms of minimally invasive versus open transforaminal lumbar interbody
fusion: a matched-pair comparison study. Spine. 38(23), 2049-2055.
[5] Lee K.H., Yue W.M., Yeo W., Soeharno H., Tan S.B. (2012). Clinical and radiological
outcomes of open versus minimally invasive transforaminal lumbar interbody fusion.
Eur Spine J. 21, 2265–2270.
[6] Peng C.W., Yue W.M., Poh S.Y., Yeo W., Tan S.B. (2009). Clinical and radiological
outcomes of minimally invasive versus open transforaminal lumbar interbody fusion.
Spine. 34, 1385-1389.
[7] Adogwa O., Parker S.L., Bydon A., Cheng J., McGirt M.J. (2011). Comparative
J Spinal Disord Tech. 24(8), 479-484.
[8] Archavlis E., Carvi y Nievas M. (2013). Comparison of minimally invasive fusion and
instrumentation versus open surgery for severe stenotic spondylolisthesis with high-
grade facet joint osteoarthritis. Eur Spine J. 22(8), 1731-1740.
[9] Wu R.H., Fraser J.F., Hartl R. (2010). Minimal access versus open transforaminal
lumbar interbody fusion: meta-analysis of fusion rates. Spine. 35(26), 2273-2281.
[10] Parker S.L., Mendenhall S.K., Shau D.N., Zuckerman S.L., Godil S.S., Cheng J.S.,
McGirt M.J. (2014). Minimally invasive versus open transforaminal lumbar interbody
fusion for degenerative spondylolisthesis: comparative effectiveness and cost-utility
analysis. World Neurosurg. 82(1-2), 230-238.
Chapter 24
Anterior Lumbar Interbody Fusion

Jim Youssef, MD, Douglas Orndorff, MD, Sue Lynn Myhre, PhD,
Rachel Ebner and Emily Barney
Durango Orthopedic Associates and Spine
Durango, CO, US
Case Summary
A 55 year-old female presents with persistent low back pain and right and left
sacroiliac (SI) joint pain. She complains of a stabbing pain at her right SI joint as well as
a constant aching pain across her lower lumbar region that sometimes migrates up her
back.
Physical examination demonstrates that her straight leg raise is positive on the left
and negative on the right. The patient is positive for sciatic notch tenderness on the right
side, though complains of pain bilaterally. She is also tender to palpation at the L5-S1
level central to the midline.
The patient‟s AP, lateral and flexion and extension x-rays reveal 4mm of
retrolisthesis at L5-S1, and severe disc collapse at L5 (Figure 1). Additionally, there is
moderate facet arthropathy at the L5-S1 level. MRI examination confirms the presence of
facet joint arthritis along with disc degeneration and neural foraminal narrowing at L5-S1
(Figure 2).
234 Jim Youssef, Douglas Orndorff, Sue Lynn Myhre et al.
(A) (B)
(C) (D)
Figure 1. Pre-operative (A) lateral, (B) AP, (C) extension, and (D) flexion radiographs demonstrating
retrolisthesis of L5 on S1and disc collapse at L5-S1.
(A)
(B)
Figure 2. Pre-operative (A) sagittal and (B) axial views demonstrating facet joint arthritis, disc
degeneration, and neural foraminal narrowing at L5-S1.
Surgical Approach
The Anterior Lumbar Interbody Fusion (ALIF) with application of a femoral ring
allograft and anterior titanium plating at L5-S1 was selected for the treatment of this patient‟s
disc space collapse and neuroforaminal narrowing. The anterior approach was chosen as it has
many advantages over a traditional posterior approach. The ALIF maintains the patient‟s
posterior paraspinal muscles as well as the integrity of the posterior longitudinal ligament
unlike the Posterior Lumbar Interbody Fusion (PLIF) and Transforaminal Lumbar Interbody
Fusion (TLIF) procedures. [1,2] Additionally, the ALIF technique allows for direct
visualization of the disc space while providing a larger and safer footprint area for bone graft
placement. Furthermore, the ALIF approach may be associated with a reduced risk of
epidural scarring while permitting a more adequate disc removal and disc height restoration to
restore lordosis. [1,3] The reestablishment of sagittal alignment through the improvement of
lumbar lordosis is another advantage of an ALIF. Normal lumbar lordosis is 61 degrees. [4]
The ALIF technique has been demonstrated to be superior in restoring lordosis when
compared to the TLIF approach. In a 32-patient study, ALIF restored 6.2 degrees of lordosis
whereas TLIF restored lordosis by 2.1 degrees.[5] These factors contribute to the stabilization
and alignment of the patient‟s spine and success of fusion, and result in a lower risk of
adjacent level disease. [6] However, the literature remains conflicted on which surgical
approach offers the shortest operation time, shortest hospital stay, and the lowest cost. [10-12]
The ALIF technique is a viable option for patients who are female, younger than 60
years-old, and patients whose body mass index (BMI) is within the healthy range. [2,7,8] The
integrity of the adjacent levels is especially pertinent for younger individuals as these patients
will require stability for a longer period of time. In addition, the combined posterior
retroperitoneal arthrodesis with anterior instrumentation remains a stable construct. [9]
Collectively, these factors increase the likelihood of achieving fusion.
An individual with a higher BMI is at an increased risk for infection, a more difficult
approach, and an increased probability of vascular injury. Kalb et al. demonstrated that BMI
values were a negative predicator for a female patients‟ Prolo total score, and a positive
predicator for male patients‟ Prolo score. [8] The Prolo score is based on a scale of 2-10 that
combines the clinical success of surgery, measured by a patient‟s description of pain, with
their functional abilities. For females, obesity or higher BMI values was associated with a less
favorable post-operative Prolo score. As such, BMI is an indicator or at least a method of
assessment for determining which patients may be the best candidates for an ALIF procedure.
Surgical Procedure
Under general endotracheal anesthesia, the patient is positioned supine on a modular
radiolucent table with a lumbar roll placed in the lumbosacral junction to restore lumbar
lordosis. The hips are flexed to 30 degrees to decrease psoas tension thus aiding in the
anterior retroperitoneal access. Exposure occurs through a left lower quadrant paramedian
incision, where the rectus sheath and underlying rectus muscles are divided longitudinally.
The retroperitoneum is entered laterally retracting the peritoneum and its contents from left to
right. The importance of the left to right movement is that it protects the parasympathetic and
sympathetic nerve chains lying directly anterior to the disc space and reduces risk of
retrograde ejaculation in males. This technique exposes the L5-S1 disc space after division of
the middle sacral vessels using hemoclips. Electrocautery is not suggested here, as it increases
the risk of damage to the aforementioned parasympathetic and sympathetic nerve chains, and
increases the risk of retrograde ejaculation. Intra-operative x-rays are obtained to confirm
correct location of the intended disc space, using a needle as a marker. Once confirmation of
the L5-S1 disc space has been confirmed radiographically, an annulotomy is performed using
a number 10 blade in the L5-S1 disc space, and then a Cobb elevator is used to elevate the
cartilaginous endplates of the vertebral bodies of L5 and S1 respectively. After completing a
discectomy, the endplates are taken down to punctate bleeding. Next, using paddle distractors,
sequential distraction across the disc space is performed, which allows for the restoration of
disc space height. Sequential trial sizing for an implant is then performed to a size consistent
with the normal adjacent disc height or the size of best fit for the patient. The corresponding
implant, a femoral ring allograft, is prepared by packing the implant with cortical cancellous
allograft bone or bone morphogenic protein (BMP). The implant is placed using fluoroscopic
guidance in the L5-S1 disc space and correct positioning is confirmed with AP and lateral x-
rays.
Next, attention is drawn to the anterior instrumentation. A titanium anterior locking plate
is sized and placed in the anterior lumbar spine at L5-S1. Holes are perforated using a
perforating awl to a depth consistent with the patient‟s anatomy and appropriate length screws
are placed and secured within the locking plate at L5 and S1. The wound is irrigated and
inspected for any obvious source of bleeding. Once adequate hemostasis is achieved, final AP
and lateral x-rays are taken for confirmation of positioning, hardware and restored disc height
(Figure 3).
(A)

(B)
Figure 3. Intra-operative (A) AP and (B) lateral fluoroscopic images with visible hardware at L5-S1
and restored disc space height and alignment.
Pearls and Pitfalls

 Proper training and understanding of the anatomy, relevant techniques, implant
sizing and implant alignment for this approach are required. The presence of an
access surgeon is strongly recommended.
 Correct supine (dorsal side on the table, ventral side facing up) positioning of the
patient intra-operatively allows for successful and safe surgical access.
 Knowledgeable patient selection is vital. Specifically, age, BMI and relevant patient
health history should be examined. The anterior approach does not necessarily
produce a higher risk of complication in patients over 60 years old. However, a
higher incidence of repair for intra-operative vascular injuries has been demonstrated
in older patients. [2]
 Complete and successful discectomy and endplate preparation is crucial for proper
implant placement and fusion. Degenerated discs are the prime generator of pain, as
they cause the sensitization of local nerves upon mechanical loading. [1]
 Females have a higher rate of ALIF procedures than males. This may be due to the
risk of retrograde ejaculation in the male population, which is caused by damage to
the presacral plexus that is made vulnerable in the anterior approach especially at the
L5 – S1 level. [2,13]
 Typically, there is a higher rate of retrograde ejaculation with a transperitoneal
approach compared to a traditional retroperitoneal approach. Though women are not
as at risk of this complication, the same level of caution should be maintained with
the counterpart vessels and nerves in the female body.
 Special caution should be exercised, especially at levels L4-L5, when operating
around the superior hypogastric sympathetic nerve plexus, due to the anatomy of the
iliac vessels and iliolumbar vein. [1] The vascular anatomy at the L4-5 level and
higher requires special attention in order to identify and gain control of the
iliolumbar vein prior to retraction of the vessels over the disc space.
 To promote fusion and ensure long-term relief, Posterior Lumbar Fusion (PLF) can
be added to the approach. The addition of a PLF can create more stability and
longevity of the hardware. [9] This approach is more often used when the patient has
instability from a spondylolisthesis or is at higher risk of pseudoarthrosis. By adding
the posterior approach there is increased operative time, muscle dissection, pain,
bleeding, and increased risk of adjacent segment disease.
Literature Summary
Since the introduction of the ALIF technique in 1932, the procedure has been recognized
as an effective method of treatment for chronic low back pain, disc degeneration and
retrolisthesis. Today, ALIF is one of the most popular and fastest growing spine approaches.
[7] Compared to TLIF and PLIF surgeries, the ALIF technique allows for direct intra-
operative visualization and greater access to the interbody space. [12] As a result, the ALIF
approach may be associated with a safer access for instrumentation, more effective disc
removal, a lower risk of nerve damage, and a lower risk of requiring a larger implant or
structural allograft than in a posterior approach. [1, 2] Together, these characteristics of the
ALIF approach create an excellent and stable environment for hardware placement, disc
height restoration, and arthrodesis. Additionally, the ALIF technique has the capability of
maintaining the integrity of the posterior paraspinal muscles. The literature has demonstrated
an association between long-term post-operative pain and damage of the paraspinal muscles.
[14] Additionally, any damage to the nerves around these muscles also correlates with poor
patient outcomes that may last as long as 2-5 years. [14]
Studies have reported a reduced occurrence of adjacent level disease in ALIF patients
with additional posterior fixation when compared to TLIF patients. [6] Hueng et. al.
conducted a three-dimensional simulation of two-levels of the spine. [9] The authors
demonstrated decreased motion following fusion in the ALIF sample as compared to the
TLIF sample suggesting TLIF patients may be at a higher risk of adjacent level disease.
Based on the success of fusion and associated stability, the intradiscal pressure of loading
direction causes less movement in these patients, protecting the adjacent levels from
degeneration and lowering the chances of future surgery. [6]
To date, the literature does not demonstrate a clear consensus as to which approach may
be associated with the lowest cost, shortest length of stay, lowest blood loss, or the highest
operative efficiency. [1, 10, 11, 15] However, studies have demonstrated that the ALIF
technique may be the most successful at restorating lumbar lordosis as compared to both PLIF
and TLIF. [1, 2, 10, 12]
(A) (B)
(C) (D)
Figure 4. Post-operative 6-month images of (A) lateral, (B) AP, (C) extention, and (D) flexion
radiographs demonstrating visualization of hardware at L5-S1 and evidence of bony fusion across the
level.
In addition, the ALIF approach compared favorably to the TLIF in regards to the
improvements in the Visual Analog Score (VAS), Oswestry Disability Index (ODI), fusion
rate, infection rate, and post-operative narcotic requirements. [10-12]
As with all surgeries, there are risks of infection and blood vessel disruption with the
ALIF procedure. However, the benefits of maintaining the paraspinal muscles, promoting
hardware stability, lowering the risk of adjacent level disc disease, and minimizing blood loss
may outweigh the risks involved with the procedure.
References
[1] Mobbs, R.J. Logantham, A. Yeung, V. Prashanth, JR. (2013). Indications for Anterior
Lumbar Interbody Fusion. Orthopaedic Surgery. 5, 153-63.
[2] Rothenfluh, D.A., Koenig, M., Stokes, O.M., Behrbalk, E., Boszczyk, B.M. (2014).
Access-related complications in anterior lumbar surgery in patients over 60 years of
age. Eur Spine J. 23 (Suppl 1), S86-S92.
[3] Jiang, S.D., Chen, J.W., Jiang, L.S. (2012). Which procedure is better for lumbar
interbody fusion: anterior lumbar interbody fusion or transforaminal lumbar interbody
fusion? Archives of orthopaedic and trauma surgery. 9,1259-1266.
[4] Benglis, D, Prado, L, Haid, R. Anterior Interbody Techniques for Restoration of Spinal
Alignment.Global Spinal Alignment: Principles, Pathologies, and Procedures.Ahead of
print.
[5] Hsieh, P. (2007). Anterior Lumbar Interbody Fusion in Comparison with
Transforaminal Lumbar Interbody Fusion: Implications for the Restoration of
Foraminal Height, Local Disc Angle, Lumbar Lordosis, and Sagittal Balance. J Neuro
Spine. 7(4), 379-386.
[6] Tang, S. (2012). Does TLIF Aggravate Adjacent Segmental Degeneration More
Adversely than ALIF? A Finite Element Study. Turkish Neurosurgery. 22m 324-28.
[7] Du Bois M., Szpalski M., Donceel P., (2012). A decade‟s experience in lumbar spine
surgery in Belgium: sickness fund beneficiaries, 2000–2009. Eur. Spine J. 21, 2693-
2703.
[8] Kalb, S., Perez-Orribo, L., Kalani, M.Y., Snyder, L.A., Martirosyan, N.L., Burns, K.,
Standerfer, R.J., Kakarla, U.K., Dickman, C.A., Theodore, N. (2013). The influence of
common medical conditions on the outcome of anterior lumbar interbody fusion. J.
Spinal Disord. Tech. ahead of print.
[9] Hueng, D.Y., Chung, T.T., Chuang, W.H., Hsu, C.P., Chou, K.N., Lin, S.C. (2014).
Biomechanical Effects of Cage Positions and Facet Fixation on Initial Stability of the
Anterior Lumbar Interbody Fusion Motion Segment. Spine. 39, E770-E776.
[10] Dorward, I.G., Lenke, L.G., Bridwell, K.H., Oʼleary, P.T., Stoker, G.E., Pahys, J.M.,
Kang, M.M., Sides, B.A., Koester, L.A., (2013). Transforaminal Versus Anterior
Lumbar Interbody Fusion in Long Deformity Constructs. Spine. 38, E755-E762.
[11] Ghogawala, Z., Whitmore, R.G., Watters, W.C. 3rd, Sharan, A., Mummaneni, P.V.,
Dailey, A.T., Choudhri, T.F., Eck, J.C., Groff ,M.W., Wang, J.C., Resnick, D.K., Dhall,
S.S., Kaiser M.G. (2014). Guideline update for the performance of fusion procedures
for degenerative disease of the spine, Part 3: Assessment of economic outcome. J.

Neurosurg. Spine. 21, 14-22.
[12] Goz, V., Weinreb, J.H., Schwab, F., Lafage, V., Errico, T.J. (2014). Comparison of
complications, costs, and length of stay of three different lumbar interbody fusion
techniques: an analysis of the Nationwide Inpatient Sample database. Spine J. 14(9),
2019-27.
[13] McCarthy, M.J., Ng, L., Vermeersch, G., Chan, D. (2012). A Radiological Comparison
of Anterior Fusion Rates in Anterior Lumbar Interbody Fusion. Global Spine J. 2, 195-
206.
[14] Phillips, F.M., Lieberman, I., Polly, D.W. (2014). Minimally Invasive Spine Surgery:
Surgical Techniques and Disease Management. New York: Springer. Google Books.
Web. 27 Aug. 2014.
[15] Jiang, S.D., Chen, J.W., Jiang, L.S. (2012). Which procedure is better for lumbar
interbody fusion: anterior lumbar interbody fusion or transforaminal lumbar interbody
fusion? Arch. Orthop. Trauma Surg. 9, 1259-1266.
Chapter 25
Lumbar Disc Replacement
Jack E. Zigler, MD, FACS, FAAOS

Texas Back Institute, Plano, TX, US
Case Summary
The patient is a 42 year-old male who has had an L4-5 microdiscectomy in 2007.
Following that surgery, he was completely relieved of right-sided sciatica. The patient was
asymptomatic for 3 years, but began to develop left-sided leg and low back pain.
On physical examination, he has difficulty sitting and standing for longer than 5-10
minutes. He states that his left leg and low back pain were 50/50 as to which bothered him the
most. He has a positive seated straight leg raising sign on the left at 60 degrees, worsened by
ankle dorsiflexion. His SLR on the right was negative at 90 degrees.
Plain x-rays demonstrated no gross instability, with only mild collapse of disc height at
L4-5 (Figure 1). MRI demonstrated evidence of a prior right-sided L4-5 laminotomy with
residual mild mass effect on the right, as well as an eccentric left posterolateral L5-S1
protrusion that indented the left S1 root. There is a decrease in disc space hydration noted at
both L4-5 as well as L5-S1 on T2 weighted images (Figures 2, 3). Facet morphology was
normal at both L4-5 and L5-S1.
244 Jack E. Zigler
Figure 1. AP, extension, and flexion radiographs demonstrating minimal disc collapse at L4-5.
Figure 2.A. Pre-operative axial T2-weighted MRI demonstrating a prior right-sided L4-5 laminotomy
with residual mild mass effect. Note the normal facets at this level.
Lumbar Disc Replacement 245
Figure 2.B. Pre-operative axial T2-weighted MRI demonstrating an eccentric left posterolateral
L5-S1 protrusion indenting the left S1 root. Note the normal facets at this level.
Figure 3. Pre-operative sagittal T2-weighted MRI demonstrating decreased in disc space

hydration at L4-5 and L5-S1.
246 Jack E. Zigler
Surgical Approach
Clinically, this is a healthy and previously active man with equal components of
mechanical back pain as well as left-sided sciatica, both contributing to cause significant
functional disability despite 2-3 years of conservative therapy (medications, injections,
chiropractic treatment, physical therapy).
Although the post-laminectomy disc space collapse at L4-5 is immediately at suspicion
for causing the low back pain, the equally troublesome left leg pain does not appear to be
emanating from L4-5. The only mass effect at that level is right-sided, and there does not
appear to be enough disc space collapse to implicate foraminal stenosis as causing left-sided
symptoms.
Imaging demonstrates two-level anatomic disc disease, but the disc(s) responsible for his
mechanical and neuro-irritative symptoms may involve one or more levels. Committing this
patient to a two-level intervention, particularly a two-level fusion, based on anatomic
radiographic evidence alone, is not appropriate. Further evaluation was necessary and the
patient was deemed a candidate for lumbar discography.
An experienced technician performed the discography. In a case as this one, the
discography may potentially save this patient from an unnecessary surgical level.
Alternatively, if both levels were clearly anatomically disrupted and positive for significant
pain reproduction, reconstruction of both levels would be much more likely to be
recommended.
As a direct result of recent studies demonstrating that discography may contribute to
breakdown of otherwise normal discs (something we have not seen in our clinical practice), a
control injection at the L3-4 level was not performed. Discography was performed at L4-5
and L5-S1 only. At the L4-5 level, a degenerated pattern of dye distribution was demonstrated
(Figure 4). However, with pressurization, the patient reported only a pressure sensation, but
no provocation of back or leg pain. Following injection and pressurization of the L5-S1 disc,
with abnormal dye distribution, the patient reported significant concordant reproduction of his
back and leg pain (Figure 5). The discography technician noted that L4-5 did not reproduce
pain. A repeat pressurization was performed at the L4-5 level which did not produce pain.
Figure 4. CT/discogram of L4-5 demonstrating disc degeneration. Note: There was no provocation of
back or leg pain.
Figure 5. CT/discogram of L5-S1 demonstrating internal disc derangement with a left-sided protrusion.
Note: The injection resulted in concordant provocation of back and leg pain.
The results of the discography demonstrated that although the L4-5 disc was abnormal
structurally, it was not the etiology of this patient‟s disabling back and leg pain. The L5-S1
level, with a left sided protrusion causing a positive tension sign and internal derangement
causing mechanical back pain with pressurization, was clearly the pain generator.
Several new questions arose once this information was available. Would an arthroplasty
at L5-S1 help protect the structurally abnormal L4-L5 disc more effectively than a fusion? In
accordance to the findings of a study comparing single-level disc replacement and fusion
cohorts in the ProDisc IDE trial, a lumbar disc replacement was performed. [1] If arthroplasty
was not an available surgical option (e.g. insurance denial), surgeons may consider a two-
level fusion rather than load the abnormal L4-5 level with an arthrodesis segment below.
Lastly, when anteriorly reconstructing the L5-S1 level through a retroperitoneal approach
in the face of an abnormal (but not surgically indicated) L4-5 disc, a right-sided approach will
leave a virgin left retroperitoneum should an anterior approach to L4-5 be needed in the
future. This is referred to as “strategic” planning as the L5-S1 disc can be approached
anteriorly from either right or left, but the more proximal levels require a left-sided approach
to protect the vena cava from injury.
With the available data, the final decision-making for this patient was informed by the
following:
1. The patient is a surgical candidate because he has significant functional disability,

has failed conservative care, and we have identified the L5-S1 disc as the pain
generator.
2. If the patient required fusion, performing a 2-level fusion may have been
reconsidered due to concerns that the L4-5 disc would become symptomatic above a
fusion and subsequently require another procedure.
3. The decision to perform an arthroplasty at L5-S1 was made as disc replacement may
lower the risk of adjacent level disease.
248 Jack E. Zigler
4. A right-sided retroperitoneal approach for the disc replacement was performed,

maintaining the integrity of the left retroperitoneum for any future anterior spinal
approaches.
Surgical Procedure
The patient is brought into the operating room, transferred supine onto a radiolucent
table, and intubated. Neuromonitoring is used on our patients routinely. The arms are padded
and taped across the chest wall. The table is positioned such that the spine is parallel to the
floor. Often, a pre-operative bolus of corticosteroid is administered, particularly if the disc
space is collapsed and there are concerns about nerve stretching during the disc space
distraction and mobilization.
Our access surgeon makes a midline infra-umbilical skin incision and then a right-sided
retroperitoneal approach to the L5-S1 disc space. If making a transverse skin incision, the
trajectory of the L5-S1 disc space and where it intersects the anterior abdomen must be
considered so the surgeon has a direct line-of-sight into the disc space. A vertical skin
incision is more extensile and allows the incision to be modified if the line-of-sight or
retraction needs to be adjusted.
With exposure of the disc space and safe retraction of the iliac vessels, a marker is placed
on the anterior annulus in the presumed midline. C-arm fluoroscopy is utilized in the AP
projection to ensure that a satisfactory AP image is obtained and that the midline is correctly
identified. A Bovie mark is usually made on the adjacent endplate for reference throughout
the case. The C-arm is moved into lateral projection to verify the level, and to be used as the
disc space is evacuated.
Figure 6. Intra-operative image demonstrating an annulotomy made symmetrically, centered on the

midline as determined by intraoperative fluoroscopy.
A rectangular annulotomy is made, centered on the midline mark (Figure 6). A Cobb
elevator is used between the boney endplate and disc, freeing the disc from the inferior
endplate of L5 and the superior endplate of S1. Extreme care is taken not to perforate the
boney endplate in order to minimize the risk of subsidence. All visible disc material is
removed back to the posterior longitudinal ligament, paying careful attention to the
posterolateral corners.
The PLL is released transversely behind the endplate of L5 or S1, using lateral
fluoroscopy to demonstrate the cup of a small angle curette behind the vertebral body.
Occasionally, the PLL is transversely resected with a Kerrison rongeur. Intradiscal distractors
are useful in mobilizing the segment, a critical step in the procedure.
Once mobilized, trial interbody devices are utilized within the disc space for maximum
endplate coverage, as well as to determine appropriate height and lordosis. Optimal position
of the implant trial is demonstrated on both AP and lateral images. A chisel is placed down
the trial‟s stem, and osteotomy cuts are made in the endplates of the vertebral bodies. The
appropriate sized ProDisc-L implant (currently the only FDA-approved lumbar disc
replacement available in the US) is assembled on the back table. As the chisel and trial are
removed, the collapsed metal endplates are placed into the disc space, and under lateral
fluoroscopic image, are malleted into optimal position to the back edge of the disc space.
An appropriate-sized polyethylene component is placed into the inserter, and a distractor
is used to progressively distract the disc space (through the metal endplates) while the
polyethylene component is advanced into the inferior metal component. With maximal
intradiscal distraction verified on lateral image (looking posteriorly for “daylight”), a manual
poly pusher is used to lock the poly component into its receiver tray in the inferior metal
component. Satisfactory locking of the poly component is verified both visually and tactilely
before the inserter is removed (Figure 7). Intra-operative radiographs are obtained to verify
appropriate positioning of the implant in the AP and lateral plains (Figure 8).
Figure 7. Intra-operative image demonstrating appropriate positioning of the implant.

250 Jack E. Zigler
(A)
(B)
Figure 8. Intra-operative (A) AP and (B) lateral fluoroscopic imaging confirming appropriate
positioning of device.
The anterior keel cuts are addressed with bone wax or Floseal, a vessel protector may be
used (at the surgeon‟s option) and once the retroperitoneum is inspected (checking the ureter
and the iliac vessels), the peritoneum is allowed to fall back into place, and the wound closed.
Intra-operative and post-operative mechanical sequential compression devices are used,
but the patients are mobilized out of bed later that day, with ambulation encouraged. Two-
thirds of single-level arthroplasty patients at our practice are discharged on the first post-
operative day while the remaining patients are typically discharged 24 hours later.
Pearls and Pitfalls

• The first pearl relates to patient selection. The IDE study‟s inclusion and exclusion
criteria and the 5-year follow-up outcomes data on these patients demonstrate the
value of appropriate patient selection. We feel strongly that patients who satisfy the
inclusion criteria of the IDE study demonstrate excellent outcomes.
• Be absolute about ruling out osteoporosis. We have seen healthy, active 30 year-old
men who have negative T-scores on DEXA scan. There is no good recovery from an
acute post-operative endplate fracture with subsidence following lumbar arthroplasty.
• A good access surgeon is a necessary part of your team. Some spine surgeons elect to
perform their own access, but the majority of U.S. surgeons have an access partner.
Good teamwork leads to better surgery and outcomes for patients.
• Gain adequate exposure of the anterior lumbar spine. One must see all the way across
to the right and left sides of the disc space, and the sight line must allow for good
visualization back to the Posterior Longitudinal Ligament. Take adequate time to
establish a good AP view of the spine, and mark the midline on the adjacent endplate
of the vertebra above or below (or both) so that you can use it as a point of reference
throughout the case.
• Always release the PLL. This will improve the patient‟s flexion range. Remove the
PLL if parallel distraction is still difficult to achieve, or if looking for an extruded
disc fragment. If distraction continues to be difficult, look at the anterolateral corners
of the annulus, which may need to be incised and released.
• Consent every arthroplasty candidate for a fusion. If despite best efforts, the segment
cannot be mobilized or if an endplate defect or fracture is encountered, fusion is the
best intraoperative solution.
Conclusion
In the United States, the patients enrolled in the ProDisc-L lumbar artificial disc IDE
study have been followed, and their clinical and radiographic outcomes reported in peer-
reviewed literature. [2, 3] These patients were carefully selected, after failure of (on average)
9 months of conservative care for functionally disabling mechanical discogenic low back pain
(pre-operative mean ODI score greater than 60%). The patients were screened by strict
inclusion/exclusion criteria, externally randomized (outside the control of the operating
surgeons) to receive either a single-level artificial disc or a 360° spinal fusion. The patients
252 Jack E. Zigler
were then evaluated with very high follow-up rates at both 2-years (98% follow-up) and 5-
years (83% follow-up). Additionally, 5-year post-operative radiographs were compared to
pre-operative radiographs by independent radiologists using digitized films and comparison
software algorithms to analyze adjacent level degenerative changes between the two
treatment groups.
From this robust database, patients randomized to ProDisc-L disc replacements maintain
their segmental motion while only one-third of the patients demonstrate adjacent level
degenerative changes at 5 years post-operative. [1] The patients randomized to arthroplasty
required fewer re-operations, enjoyed a higher rate of return to recreational activities, and
were more satisfied than patients randomized to a fusion.
This data is compelling and lends strength to the recommendation of arthroplasty instead
of fusion for patients who are candidates for either procedure. Other investigations have
shown that cost (both direct and indirect) is lower with arthroplasty and that outcomes
demonstrate trends or statistical superiority for TDR in almost every category.
References
[1] Zigler, J.E., Glenn, J., Delamarter, R.B. (2012). Five-year adjacent-level degenerative
changes in patients with single-level disease treated using lumbar total disc
replacement with ProDisc-l versus circumferential fusion. J Neurosurg Spine.17, 504-
11.
[2] Zigler, J.E., Delamarter, R.B. (2012). Five-year results of the prospective, randomized,
multicenter, Food and Drug Administration investigational device exemption study of
the ProDisc-l total disc replacement versus circumferential arthrodesis for the treatment
of single-level degenerative disc disease. J Neurosurg Spine. 17, 493-501.
[3] Zigler, J., Delamarter, R., Spivak, J.M., Linovitz, R.J., Danielson, G.O. 3rd, Haider,
T.T., Cammisa, F., Zuchermann, J., Balderston, R., Kitchel, S., Foley, K., Watkins,
R., Bradford, D., Yue, J., Yuan, H., Herkowitz, H., Geiger, D., Bendo, J., Peppers,
T., Sachs, B., Girardi, F., Kropf, M., Goldstein, J. (2007). Results of the prospective,
randomized, multicenter Food and Drug Administration investigational device
exemption study of the ProDisc-l total disc replacement versus circumferential fusion
for the treatment of 1-level degenerative disc disease. Spine. 32, 1155-62.
Other Related Publications

Blumenthal, S., McAfee, P.C., Guyer, R.D., Hochschuler, S.H., Geisler, F.H., Holt,
R.T., Garcia, R. Jr., Regan, J.J., Ohnmeiss, D.D. (2005). A prospective, randomized,
multicenter Food and Drug Administration Investigational Device Exemption study of
lumbar total disc replacement with the CHARITE artificial disc versus lumbar fusion:
Part I: Evaluation of clinical outcomes. Spine. 30, 1565-75.
Buttner-Janz, K., Schellnack, K., Zippel, H., (1987). [An alternative treatment strategy in
lumbar intervertebral disk damage using an SB Charité modular type intervertebral disk
endoprosthesis]. Z. Orthop. Ihre Grenzgeb. 125, 1-6.
David, T., (2007). Long-term results of one-level lumbar arthroplasty: Minimum 10-year
follow-up of the CHARITE artificial disc in 106 patients. Spine. 32, 661-6.
Fritzell, P., Berg, S., Borgström, F., Tullberg, T., Tropp, H. (2011). Cost effectiveness of disc
prosthesis versus lumbar fusion in patients with chronic low back pain: Randomized
controlled trial with 2-year follow-up. Eur Spine J. 20, 1001-11.
Gornet, M.F., Burkus, J.K., Dryer, R.F., Peloza, J.H. (2011). Lumbar disc arthroplasty with
Maverick disc versus stand-alone interbody fusion: A prospective, randomized,
controlled, multicenter Investigational Device Exemption trial. Spine. 36, E1600-E11.
Guyer, R.D., McAfee, P.C., Banco, R.J., Bitan, F.D., Cappuccino, A., Geisler,
F.H., Hochschuler, S.H., Holt, R.T., Jenis, L.G., Majd, M.E.,Regan, J.J., Tromanhauser,
S.G., Wong, D.C., Blumenthal, S.L. (2009). Prospective, randomized, multicenter Food
and Drug Administration Investigational Device Exemption study of lumbar total disc
replacement with the CHARITE artificial disc versus lumbar fusion: Five-year follow-up.
Spine J. 9, 374-386.
Park, C.K., Ryu, K.S., Lee, K.Y., Lee, H.J., (2012). Clinical outcome of lumbar total disc
replacement using ProDisc-L(r) in degenerative disc disease: Minimum 5-year follow-up
results at a single institute. Spine. 37, 672-7.
Chapter 26
Pre-Sacral Lumbar Interbody Fusion
Ehsan Tabaraee, MD, Vincent J. Rossi

and Kern Singh, MD
Chicago, IL, US
Case Summary
A 39-year-old male complains of several years of progressively worsening low back pain.
He has tried multiple non-operative modalities including physical therapy and injections
without success. The pain in his back has become so severe that he has difficulty sitting or
standing for extended periods and is unable to engage in activities of daily living without
pain. He has no radiating symptoms. His physical examination is positive only for
reproduction of low back pain with lumbar extension. Imaging evaluation is significant for a
degenerative L5-S1 disc without significant facet arthrosis (Figures 1, 2).
256 Ehsan Tabaraee, Vincent J. Rossi and Kern Singh
Figure 1. Pre-operative sagittal T2-weighted MRI demonstrating degenerative disc disease at L5-S1.
Figure 2. Pre-operative axial T2-weighted MRI demonstrating degenerative disc disease at L5-S1.
Surgical Approach
The foundation of minimally invasive spine (MIS) surgery has centered on minimizing
paraspinal tissue damage by utilizing tubular retractor systems and the paramedian muscle
splitting approach. Despite the increasing popularity of MIS fusion techniques, the surgical
plane still requires passage through important spinal stabilizers and possible damage of
segmental stabilizers as well as critical vascular and neurologic structures. [1]
The biomechanical demands and unique anatomy of the lumbosacral junction have led to
the advent of pre-sacral axial lumbar interbody fusion (PALIF). This procedure is a true
percutaneous approach that can be utilized for pathology from L4 to the sacrum through an
atraumatic pre-sacral space. This plane avoids direct damage to potential pain generators and
important spine stabilizers such as the multifidus muscle, facets, neural structures, and pars
Pre-Sacral Lumbar Interbody Fusion 257
interarticularis. Additionally, the biomechanical advantage of the PALIF over conventional

anterolateral or posterolateral implants is based on the perpendicular force distribution of the
interbody device across the lower lumbar disc space undergoing arthrodesis. [2]
Relative indications include primary fusion for degenerative disc disease at either L4-5 or
L5-S1, adjunct lumbosacral fusion during deformity surgery, and revision arthrodesis after
previous posterior lumbar surgery. This fixation may be utilized as a stand-alone construct or
in conjunction with facet or pedicle screw systems. Radiographic workup includes an MRI
that extends to the tip of the coccyx with contrast or CT with and without gastrointestinal
contrast for pre-operative evaluation of the pre-sacral vascular anatomy as well as bowel wall
integrity. Patients with previous pelvic visceral surgery should not be considered for this
procedure. Other contraindications include the surgeon‟s lack of familiarity or comfort with
the pre-sacral anatomy, high-grade spondylolisthesis, severe scoliosis, trauma, or tumor cases.
Surgical Procedure
Following successful induction and intubation of general anesthesia, the patient is
positioned prone on a Jackson table. Neuromonitoring is optional. The gluteal fold and the
anus are prepped and draped in standard sterile fashion. The anus can be covered and should
be distal to the paracoccygeal entry site.
Figure 3. Illustration demonstrating positioning of the paracoccygeal incision.

Figure 4. Illustration demonstrating blunt dissection of the pre-sacral space.
Figure 5. Illustration demonstrating the stylet centered on the anterior sacrum.
A 1-2 cm incision is placed 2 cm caudal to the paracoccygeal notch (Figure 3).

Following the skin incision, the subcutaneous tissue and fascia are incised. Blunt finger
dissection is utilized to create a potential space in the pre-sacral fat (Figure 4). A guide pin-
stylet assembly is inserted and gently advanced along the midline aspect of the anterior
sacrum (Figure 5). Gentle short sweeping motions can be performed with the stylet on the
anterior sacrum to mobilize the pre-sacral contents anterior toward the osseous floor. Under
fluoroscopy, the guide pin is docked at the midpoint of the S1-2 junction. The desired
trajectory is verified via intra-operative fluoroscopy prior to the tapping the guide pin through
the sacrum with a cannulated slap hammer (Figure 6). The guide pin is then advanced across
the desired interspace(s).
Figure 6. Intra-operative lateral fluoroscopic image demonstrating the guide pin trajectory toward the
center of the L5-S1 disc space.
Figure 7. Intra-operative lateral fluoroscopic image demonstrating drilling and expansion of the
working channel into the L5-S1 disc space.
Figure 8. Intra-operative lateral fluoroscopic image demonstrating resection of the L5-S1 intervertebral
disc.
A series of beveled dilators are placed over the guide pin to displace the pre-sacral tissue
anteriorly and to create the osseous working channel in the sacrum. The diameters of the
dilators typically begin at approximately 6 mm and increase until a final 10 mm dilator is
inserted. The working tubular retractor is placed over the dilators. Fluoroscopy is utilized to
verify the trajectory of the corridor prior to final placement into the sacrum. Once secure, the
guide pin and dilators are removed. A 9 mm threaded reamer is utilized to create a channel
through the sacrum and L5-S1 disc up to but not through the L5 inferior endplate (Figure 7).
The discectomy is then performed with the use of special custom-made angled cutting
and capturing devices (Figure 8). Most of these devices are made of Nitinol metal that allows
the tool to adjust from straight form to an angled form after passage through the working
portal. This structural alteration is performed under fluoroscopy to create a radially shaped
volumetric discectomy while the outer annulus is maintained.
The bone graft material of choice is introduced through a funnel shaped cannula into the
disc space. A bevel at the rostral end of the cannula is rotated to distribute the bone graft
evenly in the interbody space. The cannula is removed and a 7.5 mm drill is inserted through
the working corridor and into the vertebral body above under fluoroscopy. This reamer is
advanced until 1 cm of the superior endplate remains. Once the second reamer is removed,
the bone is retained for either the disc space above or the cannulated device.
The guide pin is inserted through the working corridor and a larger cannula is exchanged
over the guide pin to allow for the final placement of the titanium axial interbody device. The
final size of the device will be determined by measuring the buried guide pin and the amount
of desired distraction. The axial interbody device is designed with a differential diameter and
thread pitch allowing for distraction of the interspace. The proximal aspect of the screw is of
a smaller diameter but with wider thread pitches then the distal half. Once the device is
seated, the guide pin and cannula are removed. A specialized cannula called an “injector” is
attached to the distal end of the device. The remaining graft material is passed along this
injector and into the disc space through small channels in the device. After the injector is
removed, a threaded plug is placed to prevent extrusion of graft material into the pre-sacral
space.
Figure 9. Post-operative AP radiograph of final construct following pre-sacral lumbar interbody fusion
utilizing posterior pedicle screws, rods, and AxiaLIF 1L+ rod.
Figure 10. Post-operative lateral radiograph of final construct following pre-sacral lumbar interbody
fusion utilizing posterior pedicle screws, rods, and AxiaLIF 1L+ rod.
The surgical site is thoroughly irrigated and hemostasis is maintained prior to a layered
closure. At this point the posterior instrumentation with cannulated percutaneous screw
fixation can be undertaken to augment the rigidity of the construct prior to fusion
(Figures 9, 10).
Pearls and Pitfalls

• Optional setup modifications include catheter insufflation in the rectum for better
visualization on intra-operative fluoroscopy and tactile feedback during the approach.
• Use fluoroscopy judiciously during the advancement of the initial guide pin assembly
along the middle of the anterior sacrum to avoid lateral displacement into the sacral
foramen.
• Initiate the dilator into the pre-sacral space with the bevel facing ventrally for easier
displacement of the viscera. Once in contact with the sacrum, the bevel can be
rotated 180 degrees to match the inclination of the sacrum.
• At each step of reaming, retain the bone for autologous graft material.
• Fluoroscopy must be used at every step to verify the appropriate trajectory of the
tools and devices.
• Given that there are different sized reamers used, great care must be taken to avoid
penetration of the proximal vertebral body with the initial larger diameter reamer.
• The size of the interbody device is determined by combining the desired amount of
distraction to the measurements obtained using the guide pin.
Conclusion
The pre-sacral axial interbody device offers a true minimally invasive approach to
lumbosacral fusion with an interbody that provides in-line fixation and distraction while
avoiding retraction of vascular or neural elements and preserving the paraspinal musculature.
[1] Additional posterior instrumentation may be implemented without the need for
repositioning the patient.
Supportive evidence has been limited to heterogeneous case series with short-term
follow-up. Tobler et al. reviewed 156 patients who underwent L5-S1 pre-sacral axial
interbody fusion for primarily degenerative disc disease. At the final 2-year follow-up, pain
scores were decreased by 63% (7.7 to 2.7) and ODI decreased by 54% (36.6 to 19.0).
Clinically significant improvements (as defined by a 30% improvement in scores) were seen
in 86% and 74% of patients with back pain and functional impairment. Fusion was
demonstrated in 94% of patients. [3]
Zeilstra et al. reported results for 131 single level axial interbody fusions. At a mean 21-
month follow-up back pain, leg pain, and ODI decreased by 51%, 42% and 50%,
respectively. In addition, the employment rate increased by 20% while the patient satisfaction
was 83% at final follow-up. However, 13% (n=17) underwent re-operation either at the index
(n=8) or adjacent levels. [4]
The pre-sacral axial interbody has been compared to traditional anterior interbody fusions
at L5-S1. Wang et al. retrospectively reviewed 96 patients who underwent either fusion
method in conjunction with supplemental posterior fixation. Arthrodesis rate and
complications at final follow-up for the axial and anterior lumbar interbody fusion (ALIF)
techniques were similar (85% vs. 79% fusion). However, one patient in the ALIF group
suffered an iliac artery laceration.
Despite evidence demonstrating comparable clinical and radiographic outcomes to
traditional fusion techniques, undesirable radiographic findings and rare but devastating
complications have been reported. Lindley et al. reported the complications in 68 patients
who underwent axial interbody fusion. The overall complication rate was 26.5%. The rates of
pseudarthosis, infection, fracture, and rectal perforation rates were 8.8%, 5.9%, 2.9%, and
2.9% respectively. [6] Marchi et al. prospectively observed 27 patients who underwent a L4-
S1 axial interbody fusion. Surgical time and length of stay were 172 minutes and 1.4 days,
respectively. Back VAS score and ODI scores were reduced by 50 % (8 to 4) and 40% (51.7
to 31.4), respectively. There was an 18.5% reoperation rate (n=5) with one revision due to a
perforated rectum from device migration 14 months following surgery. Additionally, 84% of
patients demonstrated undesirable radiographic findings such as halo lucency, device
migration, or endplate degeneration. [7]
An anatomic study by Li et al. has provided insight regarding this uncommon and
unfamiliar approach. Details regarding the fascia propria of the rectum, rectosacral space, and
parietal pre-sacral fascia were analyzed in cadavers. The proximity of the pelvic splanchnic
nerves to the pre-sacral space, sacral midline, and paracoccygeal notch were 2.2, 1.9, and 4
cm respectively. In addition, during a surgical simulation, it was demonstrated that the
equipment came within 8 mm of the pelvic splanchnic nerves. Other features that may
account for the variability in the complication rates include multi-laminar fascial structures,
extensive pre-sacral venous plexus, and the distal intersection of the fascia propria of the
rectum to the parietal pre-sacral fascia. [8] Thus, refinements in technique and technology
will be necessary for greater acceptance of this approach.
References
[1] Marotta, N., Cosa,r M., Pimenta, L., Khoo, L. (2006). A Novel Minimally Invasive
Presacral Approach and Instrumentation Technique for Anterior L5-S1 Intervertebral
Discectomy and Fusion. Neurosurg Focus. 20 (1), E9.
[2] Ledet, E.H., Tymeson, M.P., Salerno, S., Carl, A.L., Cragg, A. (2005). Biomechanical
Evaluation of a Novel Lumbosacral Axial Fixation Device. J Biomech Eng. 127 (6),
929-33.
[3] Tobler, W.D., Gerszten, P.C., Bradley, W.D., Raley, T.J., Nasca, R.J., Block, J.E.,
(2011). Minimally Invasive Axial Presacral L5-S1 Interbody Fusion: Two-Year
Clinical and Radiographic Outcomes. Spine. 36 (20), 1296-301.
[4] Zeilstra, D.J., Miller, L.E., Block, J.E. (2013). Axial Lumbar Interbody Fusion: a 6-
Year Single-Center Experience. Clin Interv Aging. 8, 1063-9.
[5] Whang, P.G., Sasso, R.C., Patel, V.V., Ali, R.M., Fischgrund, J.S. (2013). Comparison
of Axial and Anterior Interbody Fusions of the L5-S1 Segment: A Retrospective
Cohort Analysis. J. Spinal Disord Tech. 8, 437-43.
[6] Lindley, E.M., McCullough, M.A., Burger, E.L., Brown, C.W., Patel, V.V. (2011).
Complications of Axial Lumbar Interbody Fusion. J Neurosurg Spine. 3, 273-9.
[7] Marchi, L., Oliveira, L., Coutinho, E., Pimenta, L. (2012). Results and Complications
after 2-Level Axial Lumbar Interbody Fusion with Minimum 2-year Follow-up. J
Neurosurg Spine. 3, 187-92.
[8] Li, X., Zhang, Y., Hou, Z., Wu, T., Ding, Z. (2012). The Relevant Anatomy of the
Approach for Axial Lumbar Interbody Fusion. Spine. 37(4), 266-71.
Case Vignette 10:
Degenerative Lumbar Scoliosis
Chapter 27
Open Posterior Approach
Blaine T. Manning1, Khaled M. Kebaish, MD2

and Hamid Hassanzadeh, MD1
1
Department of Orthopaedic Surgery, University of Virginia, Charlottesville, VA, US
2
Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD, US
Case Summary
A 66-year-old male presents with long-standing worsening low back pain and difficulty
walking distances. The pain is located primarily in the lower back but occasionally radiates
into the lower extremities. Physical examination reveals a kyphotic posture with an antalgic
gait. Motor and sensory testing is normal. Radiographic evaluation is notable for a
degenerative lumbar scoliosis with a loss of lumbar lordosis and multi-level spondylosis
(Figure 1). MRI evaluation reveals multi-level disc space collapse with central and foraminal
stenosis (Figure 2).
268 Blaine T. Manning, Khaled M. Kebaish and Hamid Hassanzadeh
Figure 1. Long standing radiographs, anteroposterior view depicting a degenerative lumbar 39

degrees left convex curve extending from L1-L4. Lateral view demonstrates positive sagittal
balance with a grade II spondylolisthesis at L4-L5 and a grade II retrolisthesis at L2- L3.
(A)

(B)
(C)
(D)
Figure 2. Pre-operative (A-C) axial and (D) sagittal T2-weighted MRI demonstrating multi-level
disc space collapse with central and foraminal stenosis.
Surgical Approach
Decompression and posterolateral fusion with instrumentation via an open posterior
approach was selected to address this patient‟s condition. This technique is one of the most
commonly utilized procedures in treating degenerative lumbar scoliosis and achieves both
decompression and stabilization simultaneously. While correction of the deformity is
desirable, the main goals of surgery in this case are pain relief and improvement in quality of
life. [1] In this regard, patient satisfaction following instrumented posterior fusion remains
high. [2]
Compared to other techniques such as lateral interbody fusion or anterior/posterior
fusion, this approach requires only one incision. This procedure avoids repositioning or
entrance into the thorax, which can negatively impact lung function. The posterior approach
is also useful in achieving distal exposure past the fifth lumbar vertebrae and correcting
coronal and sagittal imbalances such as those observed in this patient.
Surgical Procedure
The patient is positioned on the Jackson frame in the prone position. A midline skin
incision is carried out from T10 to S1. After local analgesic infiltration, sub-periosteal
dissection is performed bilaterally with a dissection extending laterally to the transverse
processes and the ala of the sacrum distally. (Figure 3) Following decompression of the
foramen and lateral recesses, sublaminar decompression and facetectomy are performed using
osteotomes and Kerrison rongeurs. Smith-Petersen/Ponte osteotomies are then performed at
T12-L1, L1-2, and L2-3. Sublaminar decompression is performed to maintain the posterior
bony elements in order to increase the surface area available for the fusion.
Figure 3. Intra-operative photograph demonstrating dissection and exposure of the spinous processes.
Prior to the placement of instrumentation, vertebroplasty at the upper most instrumented

vertebra and supra-adjacent level is performed. Following pedicle preparation, cement filler is
placed into the pedicle and lateral radiographs are obtained to confirm positioning. Attention
is then directed towards obtaining pelvic fixation using bilateral S2 alar iliac screws. After
identifying the entry point between the S1-S2 foramen, the drill is directed into the ala and
ilium. A guidewire is advanced and screws are placed. Attention is next directed towards
placing the rods and obtaining deformity correction. Starting on the concave side, the rod is
contoured with adequate lordosis. The rod is first attached distally to the S1 and S2 alar iliac
screw. Using the reduction instruments, gentle manipulation of the coronal curve is performed
with the screws. The spine is gradually reduced to the rod. On the contralateral side, a second
rod is contoured and attached to all screws. Additional correction of both the corronal and
sagittal plane is obtained by de-rotating the rod with segmental distraction and compression.
(Figure 4)
Attention is now directed towards harvesting iliac crest bone graft, which is performed
through a separate fascial incision after exposing the posterior aspect of the crest. Cortico-
cancellous strips are harvested. The wound is then closed in layers. Careful decortication of
all posterior elements is conducted. Local autograft bone is mixed with demineralized bone
matrix and the harvested iliac crest bone graft. The mixture is then placed over the
decorticated surface, both posteriorly and posterolaterally. Lateral radiographs are obtained to
confirm adequate correction.
Figure 4. Intra-operative photograph demonstrating the placement of posterior spinal instrumentation.
Pearls and Pitfalls

• Restoring sagittal alignment is the most important goal in treating degenerative
scoliosis.
• Recreating the relationship between pelvic incidence and lumbar lordosis is
paramount to restoration of neutral sagittal balance.
• Ponte-type osteotomies and multi-level facetectomies facilitate mobilization of the

spine and help to recreate sagittal plane realignment.
• Careful selection of levels is key to prevent future adjacent segment disease
(Figure 3).
• Pelvic fixation creates a stable base for maintaining the proximal construct and
overall balance.
• Preservation of midline bony structures will increase fusion rates via increasing the
area of the fusion bed.
• Consider anterior support for increased stability and decreased rates of pseudarthrosis
at the lumbosacral junction.
• Adjusting for poor bone quality and considering the use of cement augmentation will
help decrease the likelihood of fixation failure and fracture.
• Identifying and correcting the fractional curve is crucial for restoring coronal
alignment.
Figure 5. Standing lateral radiograph demonstrating poor proximal level selection resulting in proximal
junctional failure.
Conclusion
Posterior fusion with instrumentation offers patients with degenerative lumbar scoliosis
significant deformity reduction while improving function and quality of life. [4] One series of
adult lumbar scoliosis patients reported an 86% satisfaction rate in terms of pain relief and
walking ability. [2] In another series of degenerative scoliosis patients, 83% reported severe
pain pre-operatively with 93% reporting mild or no pain at follow-up. [3]
(A) (B)
Figure 6. Post-operative AP and lateral radiographs demonstrating deformity correction via posterior
segmental instrumentation from T10 to pelvis utilizing S2AI screws.
Despite high rates of patient satisfaction, published complication rates for posterior
fusion and instrumentation remain elevated and vary widely from 20% to 68%. [5,6]
Reported complications include surgical infection, urinary tract infection, hardware failure,
compression fracture, radiculopathy, and pseudarthrosis. Excessive intra-operative blood loss
is among the most significant risk factors for development of early post-operative
complications and typically relates to the number of levels fused. [5] Risk factors for adjacent
segment disease include pre-operative disc degeneration and older age. [7] Late operative site
pain can be relieved by implant removal in most patients. [8]
No consensus exists regarding the surgical management of degenerative lumbar scoliosis.
A posterior-only approach offers similar deformity correction as a combined
anterior/posterior approach while decreasing blood loss, operative time, length of stay, and
avoiding additional anesthesia. [9] Compared to a minimally invasive approach, traditional
open approaches for posterior lumbar interbody fusion require significantly shorter surgical
times while minimizing the risk of technical complications. [10] In any case of lumbar
scoliosis, careful consideration of benefits and risks is warranted before proceeding with
operative management.
References
[1] Di Silvestre, M., Lolli, F., Bakaloudis, G. (2014). Degenerative lumbar scoliosis in
elderly patients: dynamic stabilization without fusion versus posterior instrumented
fusion. Spine J. 14(1), 1-10.
[2] Marchesi, D.G,. Aebi, M. (1992). Pedicle fixation devices in the treatment of adult
lumbar scoliosis. Spine. 17(8), S304-9.
[3] Simmons, E.D., Jr., Simmons, E.H. (1992) Spinal stenosis with scoliosis. Spine. 17(6
Suppl), S117-20.
[4] Wu, C.H., Wong, C.B., Chen, L.H., Niu, C.C., Tsai, T.T., Chen, W.J. (2008).
Instrumented posterior lumbar interbody fusion for patients with degenerative lumbar
scoliosis. J Spinal Disord. Tech. 21(5), 310-5.
[5] Cho, K.J., Suk, S.I., Park, S.R., Kim, J.H., Kim, S.S., Choi, W.K., …, Lee SR. (2007).
Complications in posterior fusion and instrumentation for degenerative lumbar
scoliosis. Spine. 32(20), 2232-7.
[6] Raffo, C.S., Lauerman, W.C. (2006). Predicting morbidity and mortality of lumbar
spine arthrodesis in patients in their ninth decade. Spine. 31(1), 99-103.
[7] Ha, K.Y., Son, J.M., Im, J.H., Oh, I.S. (2013). Risk factors for adjacent segment
degeneration after surgical correction of degenerative lumbar scoliosis. Indian J
Orthop. 47(4), 346-51.
[8] Cook, S., Asher, M., Lai, S.M., Shobe, J. (2000). Reoperation after primary posterior
instrumentation and fusion for idiopathic scoliosis. Toward defining late operative site
pain of unknown cause. Spine. 25(4), 463-8.
[9] Good, C.R., Lenke, L.G., Bridwell, K.H., O'Leary, P.T., Pichelmann, M.A., Keeler,
K.A., …, Koester, L.A. (2010). Can posterior-only surgery provide similar
radiographic and clinical results as combined anterior (thoracotomy
/thoracoabdominal)/posterior approaches for adult scoliosis? Spine. 35(2), 210-8.
[10] Park, Y., Ha, J.W. (2007). Comparison of one-level posterior lumbar interbody fusion
performed with a minimally invasive approach or a traditional open approach. Spine.
32(5), 537-43.
Chapter 28
Minimally Invasive Posterior Approach
Jordan Glaser, MD and Nomaan Ashraf, MD

Department of Orthopaedic Surgery, Mount Sinai Medical Center, New York, NY, US
Case Summary
A 66 year-old male presents with long-standing worsening low back pain and difficulty
walking. The pain is primarily in the lower back but occasionally radiates into the lower
extremities. Physical examination reveals a forward flexed posture with abnormal gait
pattern. Motor and sensory testing is normal. Radiographic evaluation demonstrates a
degenerative lumbar scoliosis with loss of lumbar lordosis and multi-level disc space collapse
(Figures 1, 2, 3)
278 Jordan Glaser and Nomaan Ashraf
(A) (B)
Figure 1. Pre-operative (A) AP and (B) lateral radiograph demonstrating degenerative scoliosis. The
apex of the midlumbar major curve is at L3-4, L4-5. There is a lateral listhesis presented at L4-5. There
is a fractional lumbosacral curve appreciated as well.
(A)
(B)
(C)
Figure 2. Pre-operative axial T2-weighted MRI demonstrating degenerative lumbar scoliosis at (A) L2-
3, (B) L3-4, and (C) L4-5.
Figure 3. Pre-operative sagittal T2-weighted MRI demonstrating degenerative lumbar scoliosis from
L2-4.
Surgical Approach
A number of minimally invasive surgical techniques effectively treat degenerative spinal
deformity. A multi-level, minimally invasive transforaminal lumbar interbody fusion is an
excellent option in those patients in whom lateral surgery is contraindicated due to previous
retroperitoneal surgery, anomalous vascular/neural plexus anatomy, or pathology involving
the L5-S1 level.
Multi-level transforaminal lumbar interbody fusion with percutaneous pedicle screw
stabilization was chosen as the best method for correcting this patient‟s deformity while
simultaneously permitting direct decompression. Employment of minimally invasive
techniques allows for less soft tissue disruption, smaller exposure, decreased blood loss and
reduced operative time when compared with open techniques. [1] Additionally, a full direct
decompression can be performed of the bilateral foramen, lateral recess, and central canal if
there is an inadequate indirect decompression via placement of an interbody device. Anterior
placement of the cage within the disc space also allows for application of cantilever forces
necessary to improve lumbar lordosis. Distraction of the concavity via placement of the
interbody device also assists in correction of the scoliotic deformity in the coronal plane.
Applying these principles allows for significant curvature correction and improvement in both
coronal and sagittal planes.
The side of approach for the TLIF must be determined based on goals of surgery for the
individual patient. Correction of a fractional lumbosacral curve is crucial in creating a stable
base for the entire spine. Elevation of the concave side of the fractional curve is most easily
achieved by approaching the disc space from the ipsilateral side. Regarding the major
midlumbar curvature, it is easier to access the disc space and place cages across the midline to
the contralateral side for cage placement if approached from the convex side, given that the
vertebrae are rotated toward the convexity (which lies ipsilateral to the concavity of the
fractional lumbosacral curve). [2] This standard approach towards curvature correction
utilizing the MIS TLIF technique may be adjusted level-by-level if the surgeon determines
that the patient may benefit from direct decompression of a given nerve root via facetectomy
on the concave side of the midlumbar curve. (Rotation may add difficulty to the approach.)
Surgical Procedure
The patient is placed on a radiolucent Jackson four-post frame utilizing standard arm
positioning with shoulders abducted, slightly flexed and elbows flexed to 90 degrees. The
abdomen should be allowed to hang free, which aids in restoring lumbar lordosis. Bony
prominences should be well-padded and patient position should be assessed from the foot of
bed to ensure appropriate rotation and symmetry.
We prefer to utilize multiple vertical bilateral incisions for placement of pedicle screws
and for decompression and graft placement. As with all minimally invasive procedures
meticulous fluoroscopic imaging is critical. The C-arm must be tilted to appropriately align
the endplate, indicated by radiographic representation of the superior endplate as a single
dense line to ensure appropriate visualization of the pedicle. In the patient with significant
deformity, the machine will need to be adjusted significantly at every vertebral level. An 18
mm longitudinal mark is then made just lateral to the lateral edge of the pedicle bilaterally.
The skin incision is then carried down through the fascia, and under fluoroscopy, Jamshidi
needles are utilized to cannulate the pedicles. Nitinol guidewires are advanced utilizing
standard percutaneous pedicle screw placement techniques. We prefer to place all of the
nitinol guidewires at the start of the case before beginning the decompression and interbody
arthrodesis. The guidewires are secured to the drapes with a non-penetrating towel clamp so
that they do not interfere with the procedure. The x-ray machine is then placed in the lateral
viewing position.
To begin the facetectomy and decompression, the facet joint of interest is identified and a
series of tubular dilators are docked onto its ventral surface. It may be necessary to extend the
incision 2-3 mm to accommodate a larger retractor; however, we typically utilize an 18 mm
tubular retractor. The operating microscope is brought into the field and using a high-speed
burr a facetectomy is performed. If further decompression is necessary, the tube can be angled
and the bed airplaned away from the surgeon to allow for decompression to the contralateral
lateral recess and foramen. Complete facetectomy must now be performed at the exposed
level with resection of the superior facet to the level of the pedicle inferiorly. The cranial
extent of bone resection can be limited to aligning the residual bone of the pars with the
inferior endplate of the cranial vertebra. The superior facet is drilled to allow enough space
for graft by alignment with the superior edge of the pedicle. [3] However, if approaching from
the convex side of the major lumbar curve, a more laterally angulated approach to the disc
space may allow for improved access and ease of placement of a graft on the contralateral
side of the disc space. [4] This angulated approach may allow access without the need for a
full facetectomy; however, a complete facetectomy will provide the added benefit of adding
flexibility to the curvature improving correction.
Following removal of the ligamentum flavum, Kambin‟s triangle is exposed and care is
taken to identify the locations of the traversing and exiting nerve roots. [3] Bipolar
electrocautery is utilized to coagulate the epidural veins. An annulotomy is created with a 15
blade and opened with rotating shavers. Disc material is removed with a pituitary rongeur.
Endplate preparation is carried out with a combination of curettes and rasps. [5, 6]
Trial spacers are sequentially localized within disc space and assessed for good purchase,
suggesting the required size. Expandable cages may be useful in providing increased height
on the concavity of the curvature due to ease of insertion into a smaller space followed by
expansion once localized appropriately. Whether the disc space is approached from the
concave or convex side of the lumbar curvature, a standard TLIF cage should be placed on
the concave side of the disc space in order to promote correction of the coronal deformity by
promoting increased disc space height. However, if the cantilever technique is necessary at a
given spinal level in order to increase lumbar lordosis for correction of sagittal imbalance,
then a banana-shaped cage placed anteriorly may provide benefit given that they are less
likely to migrate posteriorly and more biomechanically sound. [6,7,8] Bone graft (autograft,
allograft, or a preferred combination) may be packed anteriorly within the disc space and the
annulotomy may be sealed with fibrin glue after placement of the final implant.
Cannulae are placed over the guide-wire to dilate the soft tissue and allow a path for the
tap, followed by the screw. It is our preference to under-tap by 1mm. The screw is advanced
along the guide-wire until its tip lies 5 mm ventral to the posterior wall of the vertebral body.
At this point, the guidewire may be removed and the screw is advanced to the desired point.(5)
The appropriate rod length is then determined utilizing calipers. Rods can then be placed
through the rod sleeves under the fascia using a combination of direct visualization and
radiographic imaging to ensure appropriate placement and alignment. Set-screws are placed
directly or with the assistance of a rod reducer. Compression on the convexity of the
deformity or distraction on the concavity can then be performed as necessary, level-by-level,
to assist in curvature correction in both the coronal and sagittal planes (Figure 4).
Pearls and Pitfalls

• For appropriate orientation of endplates and pedicles under the C-arm, it may be
easier to rotate the bed or add reverse Trendelenburg for ease of visualization instead
of adjusting the rotation and tilt of the C-arm in patients with very large curves.
• Prior to surgery, review imaging to develop an understanding of parameters that may
limit successful correction including the presence of bridging osteophytes or fused
segments between vertebrae. Pre-operative planning allows the determination of the
laterality in regards to the facetectomy.
• Ensure that the fractional lumbosacral curve is corrected in order to create a stable,
well-aligned base for the entire spine.
Figure 4. Intra-operative AP fluoroscopic radiograph demonstrating posterior pedicle screw

instrumentation.
 Frequent imaging should be taken to ensure that there is no inadvertent guidewire

advancement while tapping or placing the pedicle screws.
 Overly aggressive endplate preparation may compromise construct stability and lead to
implant subsidence and suboptimal deformity correction.
Literature Summary
Harms and Rolinger introduced the TLIF technique in 1982 for the treatment of
degenerative spinal disorders that necessitate interbody fusions. [9] In 2002, Foley et al., went
on to introduce the minimally invasive TLIF in order to reduce approach related paraspinal
muscle damage. [4] Since its introduction, investigators have gone on to report significant
advantages to the minimally invasive technique including less blood loss, less postoperative
pain, early ambulation, decreased narcotic usage, and decreased length of inpatient hospital
stay. [1, 3, 7, 10]
Jagannathan et al., published a report in 2009 demonstrating success of multi-level TLIF
for correction of adult spinal deformity in 80 patients who had undergone short-segment (1, 2,
or 3 level) transforaminal lumbar interbody fusion (TLIF) procedures for lumbar degenerative
disorders. [11] Jagannathan went on to report that an average of 22.2° of segmental lordosis
improvement was achieved with an L5–S1 TLIF, while an L4–5 TLIF produced an average of
11.3° improvement. Multi-level TLIF was more effective in correcting overall lumbar
lordosis than single-level surgery (27.3° +/− 3.4° vs. 17.4° +/4.4°). Based on these results it
was concluded that for the majority of patients with a preoperative sagittal imbalance of less
than 10 cm, short-segment TLIF procedures were able to improve sagittal alignment. Only 30
% of the patients with a sagittal imbalance of more than 10 cm, however, achieved acceptable
correction, indicating the need for a more extensive surgery. [11] Yson et al., published a
similar study on the results of spinal deformity correction utilizing open bilateral
facetectomies and TLIF, demonstrating significant lordosis restoration within the cohort. [12]
These mentioned studies support the conclusion that open TLIF technique is a viable option
for curvature correction in patients with limited sagittal imbalance and flexibility through the
disc spaces. Based on the success of the minimally invasive TLIF technique as compared to
open technique for degenerative conditions of the lumbar spine, it is reasonable to extrapolate
that MIS techniques may be utilized efficiently towards treating adult spinal deformity fitting
the parameters described in literature supporting the use of open TLIF techniques. Wang
published his results regarding a case series of 25 patients treated with multi-level MIS TLIF
with expandable cages. The mean preoperative Cobb angle was 29.2° which improved to
9.0°; the mean preoperative global lumbar lordosis of 27.8 degrees improved to 42.6°degrees;
and the mean preoperative SVA improved from 7.4 cm to 4.3 cm post-operatively. [8]
(A) (B)
Figure 5. Post-operative (A) AP and (B) lateral fluoroscopic radiograph demonstrating posterior
pedicle screw instrumentation.
As described in Jaganathan‟s article based on the results of correction, there are

limitations to the power of this procedure, particularly when SVA preoperative value is
greater than 10 cm. [11] Additionally, particularly rigid curvatures or those with bridging
osteophytes or fusion masses between segments will be difficult to correct with this
technique. Multi-level MIS TLIF correction of adult spinal deformity is an attractive
alternative when treating flexible, moderate degenerative curvatures of the lumbar spine. The
operative surgeon must know the limitations of the applied technique. Pre-operative imaging
studies must be reviewed carefully to ensure that there are no bridging bony structure which
would inhibit correction of curvature by significantly limiting flexibility at the disc space
level.
The benefits of employing this technique include the fact that this is an all-posterior
surgery with significant muscle sparing and decreased blood loss. The posterior approach also
allows access to both the L5-S1 and L4-L5 levels, which typically provide the most
significant contribution of lordosis to the lumbar spine. Therefore, intervention at these disc
levels is crucial in restoration of sagittal balance. Additionally, the facetectomy also provides
direct decompression of potentially aggravated nerve roots in addition to the indirect
decompression afforded by the restoration of disc height, improved lumbar lordosis, and
curvature correction.
The main drawback to the TLIF procedure is that the size of cage introduced into the disc
space is limited and does not typically bridge across the cortical rim of the vertebral body.
The limited cage footprint increases the risk of subsidence. Nevertheless, given the
appropriate patient and deformity, a multi-level MIS TLIF for the correction of degenerative
scoliosis can be an effective, efficient, and safe method of surgical treatment based upon
reported outcomes.
References
[1] Park, P., Foley, K.T. (2008). Minimally invasive transforaminal lumbar interbody
fusion with reduction of spondylolisthesis: technique and outcomes after a minimum of
2 years‟ follow-up. Neurosurg Focus. 25, E16.
[2] Schwab, F.J., Hawkinson, N., Lafage, V., Smith, J.S., Hart, R., Mundis, G., ...
Mummaneni, P.V. (2012). Risk factors for major perioperative complications in adult
spinal deformity surgery: a multi-center review of 953 consecutive patients. Eur Spine
J. 21(12), 2603–10.
[3] Karikari, I., Isaacs, R. (2010). Minimally Invasive Transforaminal Lumbar Interbody
Fusion – A Review of Techniques and Outcomes. Spine. 35(26S), S294-S301.
[4] Umehara, S., Zindrick, M.R., Patwardhan, A.G., Havey, R.M., Vrbos, L.A., Knight
GW,…, Lorenz, M.A. (2000). The biomechanical effect of postoperative hypolordosis
in instrumented lumbar fusion on instrumented and adjacent spinal segments. Spine.
25(13), 1617–24.
[5] Fayssoux, R., Kim, C. (2013). Minimally Invasive Transforaminal Interbody Fusion –
Chapter 19, Operative Techniques in Spine Surgery (Edited by Rhee J, Boden S, Flynn
J), Philadelphia, PA: Lippincott, Williams, & Wilkin.
[6] Foley, K.T., Lefkowitz, M.A. (2002). Advances in minimally invasive spine surgery.
Clin Neurosurg. 49, 499–517.
[7] Anand, N., Hamilton, J.F., Perri, B., Miraliakbar, H., Goldstein, T. (2006). Cantilever
TLIF with structural allograft and RhBMP2 for correction and maintenance of
segmental sagittal lordosis: long-term clinical, radiographic, and functional outcome.

Spine. 31(20), E748–53.
[8] Wang, M.Y. (2013) Improvement of sagittal balance and lumbar lordosis following less
invasive adult spinal deformity surgery with expandable cages and percutaneous
instrumentation. J Neurosurg Spine. 18(1), 4–12.
[9] Harms, J., Rolinger, H. (1982). A one-stage procedure in operative treatment of
spondylolisthesis: dorsal traction-reposition and anterior fusion [in German]. Z Orthop
Ihre Grenzge. 120(3), 343–7.
[10] Scheufler, K.M., Cyron, D., Dohmen, H., Eckardt, A. (2010). Less Invasive Surgical
Correction of Adult Degenerative Scoliosis. Part II: Complications and Clinical
Outcome. Neurosurgery. 67(6), 1609-1621.
[11] Jagannathan, J., Sansur, C.A., Oskouian, R.J. Jr., Fu, K.M., Shaffrey, C.I. (2009).
Radiographic restoration of lumbar alignment after transforaminal lumbar interbody
fusion. Neurosurgery. 64(5), 955 – 63.
[12] Yson, S.C., Santos, E.R., Sembrano, J.N., Polly Jr, D.W. (2012). Segmental lumbar
sagittal correction after bilateral transforaminal lumbar interbody fusion. J Neurosurg
Spine. 17(1), 37–42.
Chapter 29
Lateral Approach
Yu-Po Lee, MD and Jessica Lee

Department of Orthopaedic Surgery, University of California, San Diego, CA, US
Case Summary
A 68-year-old female presents with progressive lower back pain radiating posteriorly
down both legs greater on the right than the left. The patient‟s past medical history is
significant for diabetes mellitus not requiring insulin. The pain is intermittent and worse with
walking and bending. The pain began two years prior and has progressed over time despite
conservative treatment that included physical therapy and epidural injections. Physical
examination reveals right lower extremity weakness, specifically in the tibialis anterior and
extensor hallucis longus muscles. Radiographs reveal a lumbar degenerative scoliosis (Figure
1) and MRI of the lumbar spine reveals lateral recess and neuroforaminal stenosis most severe
at L4-5 (Figure 2).
288 Yu-Po Lee and Jessica Lee
Figure 1. Pre-operative (A) AP and (B) lateral radiograph demonstrating degenerative scoliosis. The
apex of the midlumbar major curve is at L3-4, L4-5. There is a lateral listhesis presented at L4-5.
(A) (B)
Lateral Approach 289
(C)
Figure 2. Pre-operative axial T2-weighted MRI demonstrating degenerative scoliosis at (A) L2-3, (B)
L3-4, and (C) L4-5.
The patient‟s past medical history is significant for diabetes mellitus not requiring
insulin. The pain is intermittent and worse with walking and bending. The pain began two
years prior and has progressed over time despite conservative treatment that included physical
therapy and epidural injections. Physical examination reveals right lower extremity weakness,
specifically in the tibialis anterior and extensor hallucis longus muscles. Radiographs reveal a
lumbar degenerative scoliosis (Figure 1) and MRI of the lumbar spine reveals lateral recess
and neuroforaminal stenosis most severe at L4-5 (Figure 2).
Surgical Approach
Multi-level lateral lumbar interbody fusion with percutaneous pedicle screws was chosen
as the approach that would best address the pathology while minimizing risk. A long posterior
decompression and instrumented fusion would expose her to increased post-operative
morbidity given her diabetic history. Multi-level lateral interbody fusion with percutaneous
pedicle screws allows for correction of the scoliosis and indirect decompression of the
stenosis as well as stabilization of the spondylolisthesis in the least traumatic fashion.
Correction of the scoliosis is obtained at the disc space level with insertion of the interbody
grafts via a lateral approach. Pedicle screws are necessary to prevent subsidence of the
interbody cages into the vertebral bodies. Placement of the pedicle screws percutaneously
offers a method to improve stability with less disruption to the paraspinal musculature. Multi-
level lateral lumbar interbody fusion with percutaneous pedicle screws has been demonstrated
to decrease operative time, blood loss, and length of stay when compared to an open
approach. [1,2,3] Furthermore, the MIS approach has a significantly lower rate of surgical site
infections while offering arthrodesis rates similar to its open counterpart.
Surgical Procedure
Once the patient has been intubated and prophylactic antibiotics given, the patient is
placed in the lateral decubitus position. An axillary roll and appropriate padding are helpful in
decreasing pressure sores and neuropraxias. When correcting a scoliosis, it is easier to
perform the lateral approach on the side of the concavity as it allows for easier access to a
larger number of levels through a smaller incision. Taping over the greater trochanter and the
chest helps secure the patient to the bed. The table should be flexed to increase the distance
between the iliac crest and the rib cage. The leg on top should also be flexed, abducted, and
externally rotated to relax the psoas. Radiographs should be obtained prior to prepping and
draping to ensure that there is appropriate visualization. A cross-table AP radiograph should
be obtained and the table should be rotated to place the patient in a true AP position.
Once the patient has been prepped and draped, begin with a lateral fluoroscopic image. A
radio-opaque marker is placed over the center of the disc space (Figure 3). A 2 cm line is
drawn to mark the incision once the center of the disc has been identified. Both transverse and
longitudinal incisions have been described and each has its own pros and cons. A transverse
incision may offer better cosmetic results, but can result in the need for more than one
incision to be made when performing multiple levels. Longitudinal incisions may stretch and
can be extended to accommodate multiple levels. A second mark is made posterior to this first
mark at the border between the erector spinae muscles and the abdominal obliques at the
same levels of the intended fusion. At this second mark, a transverse incision of about 2 cm
long is made to accommodate the surgeon‟s index finger (Figure 4).
Figure 3. Lateral radiograph centering the marker over the middle of the disc space. This is the
midpoint of the lateral incision.
Figure 4. This image demonstrates the two-incision approach. One incision is centered directly over the
disc space. The other incision is placed postero-lateral to allow access to the retroperitoneal space.
Dissection is carried down to the lumbodorsal fascia. A clamp can be used to puncture
through the fascia and muscle fibers to provide entry into the retroperitoneal space. Once an
opening has been created, the index finger is used to push the peritoneum anteriorly and to
palpate the psoas muscle. Sweep the index finger inferiorly to feel the inner table of the iliac
crest and the transverse process to verify that you are in the abdominal cavity. Once the psoas
is identified, the index finger is swept up to the previously made direct lateral mark. A 2 cm
incision is made and the external and internal oblique muscles are identified and dissected.
The transverses abdominis muscles are split and dilators are placed through this opening. The
index finger, which is already in the retroperitoneal space, guides the initial dilator onto the
psoas. The fibers of the psoas are then split with the dilator utilizing neuromonitoring.
Increasingly, more surgeons are placing the dilator through the psoas under direct
visualization to decrease the risk of potential bowel or vessel injury. A lateral radiograph
should be taken to verify central position of the dilator at the desired disc space (Figure 5).
Once the position of the initial dilator is secured by placing a K-wire through the dilator and
into the disc space, larger dilators are used to spread the psoas under neuromonitoring. Once
the retractor is secured to the table, the dilators are removed to provide lateral access to the
disc. Care must be taken not to distract the retractor too much as this may increase the risk of
nerve injury. It is recommended that the discectomy be performed with the least amount of
retractor opening in order to decrease the risk of nerve injury. A neuromonitoring probe can
be used to check for any nerves that may be crossing the working window of the retractor. If a
nerve is detected, the K-wire should be repositioned away from the nerve and the psoas re-
dilated.
Figure 5. Lateral fluoroscopic image demonstrating appropriate positioning of the initial dilator and
guide pin in the disc space.
AP and lateral radiographs (Figure 6A and 6B) should be obtained at this point to verify
that the retractor is docked over the center of the target disc space. Once the appropriate
positioning has been confirmed, the retractor should be secured in place. A lateral discectomy
is then performed in standard fashion with shavers, curettes, and rasps (Figure 7). The
discectomy should be performed prior to releasing the contralateral side with a Cobb elevator
because this decreases the risk of pushing disc material into the contralateral psoas. A Cobb
elevator should be utilized to release the contralateral annulus. Releasing the contralateral
annulus increases the flexibility of the spine in the coronal plane and aids in the correction of
coronal plane deformities (Figure 8A and 8B). Sizers and trials are then used to determine
the optimal implant size. The implant is then filled with the surgeon‟s graft or fusion enhancer
of choice and impacted across the disc space (Figure 9A and 9B).
(A) (B)
Figure 6. Intra-operative (A) AP and (B) lateral radiograph verifying good position of the dilator.
Notice that the retractor is centered over the midpoint of the disc and that the anterior blades do not
open past the anterior border of the vertebral body.
Figure 7. Intra-operative fluoroscopic radiograph demonstrating a shaver used to remove the

cartilaginous endplates.
(A) (B)
Figure 8. Intra-operative fluoroscopic radiograph demonstrating (A) a Cobb elevator is used to release
the contralateral annulus. (B) When correcting a degenerative scoliosis, rotating the Cobb elevator is
helpful in further releasing the annulus.
(A) (B)
Figure 9. Final (A) AP and (B) lateral fluoroscopic radiographs demonstrating appropriate positioning
of the graft.
Pearls and Pitfalls

 For lateral interbody fusion, it is often easier to adjust the table to get the
perfect AP and lateral and just have the c-arm rotate between 0 and 90 degrees.
 It is crucial to review the MRI preoperatively to understand the location of the
lumbar plexus.
 It is often easier to address a degenerative scoliosis from the side of the
concavity.
 For lateral interbody fusion, aggressive deployment of the retractor or repeated
passes through the psoas with the initial dilator may injure the lumbar the
plexus.
 Be careful not to allow the retractor to drift anteriorly as injuries to the bowel
and vasculature have been described.
(A) (B)
Figure 10. Post-operative (A) AP and (B) lateral radiographs at 3 months demonstrating improvement
of the scoliosis and the lateral listhesis with maintenance of lumbar lordosis.
Literature Summary
The LIF (lateral interbody fusion) approach is a modification of the anterior approach to
the lumbar spine. The technique was first described in 2001 by Pimenta [4], and has since
been reported on by several authors with excellent short-term outcomes. [1,2,3] In a study by
Rodgers et al., the authors reported on their experience on over 600 patients. [2] The overall
incidence of peri-operative complications was 6.2% and the average hospital stay was 1.21
days. There were no wound infections, vascular injuries, or intraoperative visceral injuries.
The authors reported 4 (0.7%) transient postoperative neurologic deficits. Alimi et al.,
reported their results of 90 patients. [5] ODI scores improved 21% and VAS scores for back,
buttock, and leg pain decreased 3.7, 3.6, and 3.7 points respectively. LIF is effective in
treating selective spinal disorders while minimizing risks and complications for degenerative
conditions. This finding compares favorably with open scoliosis surgery in which
complication rates approach 30-40%. [6,7,8]
Limitations do exist with this far lateral approach. First, the iliac crest limits the potential
exposure to levels above L5-S1 and oftentimes prevents access to the L4-5 disc space Also,
dissecting the psoas major, though technically straightforward, must be done carefully so as
not to injure the nerves of the lumbar plexus. The cause of nerve injury during the transpsoas
approach still remains unknown. [1,5,10] Factors that increase the risk of nerve injury include
performing a LIF at the L4-5 level, excessive opening of the retractor, and prolonged
deployment of the retractor.
Lateral interbody fusion is a technically demanding surgery. However, there are many
benefits of the LIF that make it an attractive alternative to traditional open surgery. Prior to
deciding on a LIF, it is important that the surgeon weigh the pros and cons of the procedure
relative to other fusion techniques for treating degenerative scoliosis. The primary benefits of
the procedure are that a large graft is implanted potentially resulting in significant deformity
correction. Also, when dealing with lumbar stenosis, a considerable amount of indirect
decompression may be achieved with insertion of the device. The main drawback is the
potential risk of nerve injury to the lumbar plexus, particularly when treating the L4-5 level.
Furthermore, the L5-S1 level cannot be treated with this technique. However, the LIF is an
excellent procedure for correcting lumbar degenerative diseases and is a worthwhile
procedure to master.
References
[1] Ozgur, B.M., Aryan, H.E., Pimenta, L, Taylor, W.R. (2006). Extreme Lateral Interbody
Fusion (XLIF): a novel surgical technique for anterior lumbar interbody fusion. Spine J.
6(4), 435-443.
[2] Rodgers, W.B., Gerber, E.J., Patterson, J.R. (2011). Intraoperative and early
postoperative complications in extreme lateral interbody fusion (XLIF): An analysis of
600 cases. Spine. 36(1), 26-32.
[3] Isaacs, R.E., Hyde, J., Goodrich, J.A., Rodgers, W.B., Phillips, F.M. (2010). A
prospective, nonrandomized, multicenter evaluation of extreme lateral interbody fusion
for the treatment of adult degenerative scoliosis: perioperative outcomes and

complications. Spine. 35(26 Suppl), S322-30.
[4] Pimenta L. (2001). Lateral endoscopic transpsoas retroperitoneal approach for lumbar
spine surgery. Presented at the VIII Brazilian Spine Society Meeting, Belo Horizonte,
Minas Gerais, Brazil.
[5] Alimi, M., Hofstetter, C.P., Cong, G.T., Tsiouris, A.J., James, A.R., Paulo, D., …,
Härtl, R. (2014). Radiological and clinical outcomes following extreme lateral
interbody fusion. J. Neurosurg. Spine. 20(6),623-35.
[6] Charosky, S., Guigui, P., Blamoutier, A., Roussouly, P., Chopin, D., Study Group on
Scoliosis. Complications and risk factors of primary adult scoliosis surgery: a
multicenter study of 306 patients. Spine. 37(8), 693-700.
[7] Cho, S.K., Bridwell, K.H., Lenke, L.G., Yi, J.S., Pahys, J.M., Zebala, L.P., …, Baldus,
C.R. (2012). Major complications in revision adult deformity surgery: risk actors and
clinical outcomes with 2- to 7-year follow-up. Spine. 37(6), 489-500.
[8] Sansur, C.A., Reames, D.L., Smith, J.S., Hamilton, D.K., Berven, S.H., Broadstone,
P.A., …, Shaffrey, C.I. (2010). Morbidity and mortality in the surgical treatment of
10,242 adults with spondylolisthesis. J. Neurosurg. Spine. 13(5), 589-93.
[9] Lykissas, M.G., Aichmair, A., Hughes, A.P., Sama, A.A., Lebl, D.R., Taher, F., ...,
Girardi, F.P. (2014). Nerve injury after lateral lumbar interbody fusion: a review of 919
treated levels with identification of risk factors. Spine J. 14(5), 749-58.
[10] Pumberger, M., Hughes, A.P., Huang, R.R., Sama, A.A., Cammisa, F.P., Girardi, F.P.
(2012). Neurologic deficit following lateral lumbar interbody fusion. Eur. Spine J.
21(6), 1192-9.
[11] Houten, J.K., Alexandre, L.C., Nasser, R., Wollowick, A.L. (2011). Nerve injury during
the transpsoas approach for lumbar fusion. J. Neurosurg. Spine. 15(3), 280-4.
Editors’ Contact Information
Dr. Kern Singh, MD

Associate Professor
Department of Orthopaedic Surgery
Rush University Medical Center
Email: Kern.singh@rushortho.com
Dr. Sheeraz Qureshi, MD, MBA

Associate Professor, Orthopaedic Surgery
Mount Sinai Hosptial
Icahn School of Medicine
Email: SheerazQureshiMD@gmail.com
Index
A B
access, 53, 87, 88, 96, 110, 112, 123, 124, 147, 148, back pain, 83, 84, 91, 101, 106, 115, 117, 136, 137,
168, 174, 179, 180, 186, 189, 201, 207, 209, 211, 161, 171, 180, 183, 195, 200, 202, 203, 205, 215,
212, 213, 222, 228, 232, 236, 238, 239, 248, 251, 227, 233, 239, 243, 246, 247, 251, 253, 255, 262,
281, 282, 285, 290, 291, 295 267, 277, 287
acupuncture, 71 base, 148, 153, 179, 200, 211, 272, 281, 282
adhesion(s), 35, 62, 105, 136 Belgium, 241
adults, 15, 203, 223, 296 bending, 59, 152, 156, 185, 287, 289
advancement, 174, 229, 230, 262, 283 beneficiaries, 241
afebrile, 117 benefits, 25, 69, 106, 156, 169, 185, 207, 212, 231,
age, 36, 46, 69, 78, 238, 241, 274 241, 274, 285, 295
An technique, 35, 36 bias, 7
analgesic, 148, 153, 270 bilateral, 13, 74, 148, 179
anatomy, 54, 87, 125, 136, 168, 200, 217, 222, 237, biomechanics, 185
238, 239, 256, 257, 280 bleeding, 112, 148, 237, 239
anesthesiologist, 151 blood, 24, 25, 53, 61, 68, 78, 88, 96, 97, 106, 110,
ankylosis, 46 114, 121, 125, 133, 136, 137, 148, 174, 189, 207,
Anterior, v, vi, vii, 3, 16, 47, 49, 53, 54, 55, 56, 59, 212, 228, 239, 241, 274, 280, 283, 285, 289
69, 71, 79, 83, 89, 97, 121, 185, 190, 212, 215, blood pressure, 24
223, 233, 236, 241, 242, 263, 264, 280 body mass index (BMI), 236, 238
anticoagulation, 156 bone, 14, 15, 23, 33, 43, 46, 47, 54, 62, 63, 74, 78,
anti-inflammatories, 161 86, 87, 134, 135, 136, 164, 166, 167, 168, 169,
anus, 257 175, 187, 199, 200, 201, 208, 209, 219, 221, 230,
anxiety, 106 236, 237, 251, 260, 262, 271, 272, 281
aorta, 85, 87 bone growth, 219
aortic valve, 151 bowel, 83, 88, 117, 190, 257, 291, 294
apex, 84, 278, 288 bowel perforation, 190
artery(s), 7, 54, 74, 79, 85, 87, 96, 218, 263 brachial plexus, 7, 62
arthritis, 233, 235 Brazil, 296
arthrodesis, 8, 17, 47, 56, 60, 69, 78, 87, 169, 170, breakdown, 36, 246
174, 180, 185, 188, 202, 207, 208, 212, 236, 239,
247, 252, 257, 274, 281, 289
arthroplasty, 8, 10, 11, 13, 14, 15, 16, 247, 251, 252, C
253
calcification(s), 84, 87
assessment, 125, 180, 190, 232, 236
calcium, 136
asymptomatic, 202, 243
candidates, 168, 236, 252
axilla, 145
300 Index
capsule, 33, 134, 164, 166, 167, 200 controversial, 202

cartilage, 5 controversies, 212
cartilaginous, 14, 62, 201, 237, 293 cortex, 35, 43, 85
catheter, 262 cortical bone, 15, 164, 165, 168, 169, 170
cauterization, 74, 125 cosmetic, 290
cerebrospinal fluid, 68, 114, 126 cost, 7, 36, 37, 106, 180, 212, 213, 232, 236, 239,
Cervical Fusion, 79 252
cervical laminectomy, 37 cost saving, 212
cervical radiculopathy, 8, 17 covering, 25
Cervical Spine, 16, 78, 79 creatine, 114
anterior, v, vi, vii, 3, 16, 47, 49, 53, 54, 55, 56, 59, creatine phosphokinase, 114
69, 71, 79, 83, 89, 97, 121, 185, 190, 212, 215, critical analysis, 213
223, 233, 236, 241, 242, 263, 264, 280 CT, 31, 36, 41, 45, 51, 59, 61, 68, 72, 87, 94, 95,
instrumentation, 90, 164, 191, 202, 263 117, 120, 136, 141, 143, 167, 179, 195, 206, 246,
laminectomy, v, vi, 29, 131 247, 257
laminoforaminotomy, v, 19, 25 CT scan, 36, 72, 87, 136, 206
laminoplasty, v, 39, 46, 47, 48
posterior, v, vi, vii, 19, 25, 29, 37, 53, 55, 56, 71,
78, 79, 161, 164, 191, 195, 221, 223, 236, 239, D
251, 267, 273, 277
daily living, 227, 255
screws, 62, 200
database, 242, 252
surgical approach, 5, 10, 21, 33, 43, 53, 61, 74,
debridement, 117
85, 93, 104, 110, 121, 133, 143, 152, 164, 173,
decompression, v, vi, 16, 49, 54, 125, 135, 136, 141,
185, 199, 207, 217, 228, 236, 246, 256, 270,
161, 190, 270
280, 289
decortication, 74, 271
cervical spondylosis, 15, 29, 31, 39, 41, 46, 47, 49,
defects, 206, 219
51
deficit, 296
challenges, 74, 202
deformation, 91
Chicago, 49, 59, 71, 91, 161, 171
degenerate, 46
China, 141
degenerative conditions, 284, 295
claudication, 133, 136, 141, 147, 148, 151, 152, 154,
deltoid, 71
155, 156, 157, 168
denial, 247
clinical diagnosis, 55
deposition, 87
clinical symptoms, 10, 68
depression, 106
clinical syndrome, 47
depth, 166, 208, 237
closure, 75
destruction, 217
coccyx, 257
diabetes, 69, 287, 289
compensation, 180, 232
dilation, 93, 189
compilation, ix
disability, 15, 36, 115, 137, 155, 168, 169, 180, 189,
compliance, 78
212, 232, 241, 246, 247
complications, 5, 7, 15, 25, 26, 35, 36, 37, 46, 47, 53,
disc herniation, v, vi, 1, 3, 9, 81, 83, 89, 91, 99, 101,
54, 55, 61, 62, 71, 78, 85, 87, 88, 96, 97, 106,
109, 117, 126
107, 114, 115, 126, 137, 156, 157, 189, 202, 241,
discitis, 126
242, 263, 274, 285, 295, 296
discography, 246
compression, 4, 10, 13, 20, 25, 29, 35, 36, 39, 43, 46,
discomfort, 83, 143, 207
49, 50, 53, 55, 62, 79, 83, 84, 88, 91, 110, 164,
discs, 7, 46, 87, 88, 90, 96, 106, 238, 246
175, 176, 201, 202, 230, 251, 271, 274, 282
disease progression, 55
compression fracture, 274
diseases, 295
confounders, 137
displacement, 262
consensus, 36, 239, 274
distraction, vi, 151, 217, 280
consumption, 106
distribution, 246, 257
control group, 155
dysphagia, 7, 21, 46, 53, 54, 78
controlled trials, 115, 126
Index 301
force, 24, 105, 155, 257

E formation, 50, 63, 118
fracture(s), 135, 156, 157, 190, 191, 211
edema, 43, 78
fragments, 5, 112, 126
ejaculation, 237
funding, 7
elbows, 281
electrocautery, 12, 21, 33, 53, 112, 134, 175, 201,
230, 282 G
embolus, 24
EMG, 176, 187, 210 gait, 29, 39, 47, 49, 84, 267, 277
employment, 262 gastroesophageal reflux, 151
endoscope, 121, 124, 125, 208 general anesthesia, 21, 74, 110, 153, 156, 217, 257
endotracheal intubation, 74, 186 glue, 136, 282
environment, 202, 239 grades, 213
epinephrine, 121, 145 gravity, 217
equipment, 21, 263 growth, 68, 179
erythrocyte sedimentation rate, 117 guidance, 11, 14, 74, 93, 110, 145, 174, 176, 187,
esophagus, 7, 12, 15, 54, 63, 74, 78 200, 201, 202, 228, 230, 237
etiology, 247
evidence, 7, 16, 25, 43, 46, 59, 60, 72, 74, 89, 97,
115, 137, 143, 155, 168, 202, 228, 240, 243, 246, H
262, 263
evoked potential, 53, 176, 210 harvesting, 271
evolution, 97 headache, 136
excision, 87 healing, 221, 231
exclusion, 251 health, 88, 155, 212, 231, 238
expertise, 89 health care, 212, 231
exposure, 15, 23, 24, 33, 36, 43, 46, 53, 54, 85, 88, health care costs, 231
105, 114, 134, 135, 136, 164, 166, 169, 200, 201, health care system, 212
248, 251, 270, 280, 295 health condition, 88
extensor, 43, 117, 161, 171, 183, 287, 289 height, 3, 4, 9, 19, 20, 46, 55, 67, 101, 102, 117, 118,
extrusion, 105, 260 178, 185, 186, 189, 198, 199, 202, 203, 210, 211,
212, 230, 231, 236, 237, 238, 239, 243, 249, 282,
285
F hematoma(s), 25, 114
hemostasis, 21, 33, 35, 114, 125, 237, 262
facial nerve, 78 herniated, 5, 7, 21, 24, 85, 87, 88, 90, 93, 94, 95, 96,
fascia, 5, 12, 21, 33, 53, 62, 93, 104, 105, 110, 133, 101, 103, 104, 105, 106, 109, 112, 113, 114, 117,
145, 153, 164, 186, 208, 258, 263, 281, 282, 291 121, 125
fat, 105, 186, 258 herniated nucleus pulposus, 104
fibers, 85, 105, 291 heterogeneity, 89
fibrin, 282 hospitalization, 25, 96, 106, 114, 115, 121, 148, 156,
fibrous tissue, 200 180, 189
films, 30, 136, 211, 252 hypertrophy, 148, 152
fixation, 33, 34, 36, 37, 54, 55, 74, 76, 77, 78, 155, hypotension, 24
168, 169, 185, 187, 189, 199, 200, 201, 202, 203,
217, 220, 221, 222, 223, 224, 239, 257, 262, 263,
271, 272, 274 I
flex, 153
flexibility, 282, 284, 285, 292 iatrogenic, 53, 87, 115, 167, 189
Food and Drug Administration (FDA), 219, 249, identification, 35, 77, 85, 113, 296
252, 253 idiopathic, 274
foramen, 5, 36, 74, 77, 121, 124, 136, 145, 148, 166, iliac crest, 54, 62, 63, 86, 186, 200, 271, 290, 291,
167, 168, 199, 200, 262, 270, 271, 280, 281 295
iliopsoas, 186
302 Index
ilium, 271
illumination, 110
L
image(s), 5, 14, 22, 23, 24, 34, 43, 45, 51, 63, 64, 65,
laceration, 263
66, 76, 85, 93, 111, 112, 113, 114, 146, 147, 148,
laminar, 136, 263
174, 175, 176, 177, 179, 185, 186, 187, 188, 189,
laminectomy, v, vi, 29, 33, 34, 35, 36, 37, 43, 46, 47,
198, 206, 208, 209, 210, 228, 229, 238, 240, 243,
48, 55, 74, 87, 88, 95, 131, 134, 135, 136, 137,
248, 249, 259, 260, 290, 291, 292
138, 155, 156, 157, 164, 170, 175, 199, 201, 202,
imbalances, 270
221, 246
implant placement, 209, 238
laminoforaminotomy, v, 19, 25
implants, 62, 219, 257
laminoplasty, v, 39, 46, 47, 48
improvements, 25, 36, 46, 47, 105, 137, 241, 262
laterality, 53, 56, 282
in vitro, 16
layered closure, 36, 262
incidence, 11, 15, 36, 56, 69, 78, 97, 115, 164, 169,
learning, 88, 126, 148, 189
180, 190, 238, 271, 295
legs, 29, 39, 49, 91, 131, 141, 287
infection, 21, 47, 53, 55, 75, 106, 110, 117, 180, 207,
ligament, 5, 14, 46, 53, 54, 55, 85, 96, 135, 153, 164,
212, 213, 228, 232, 236, 241, 263, 274
218, 231, 236, 249
inflation, 35
light, 22, 71, 101, 122
injections, 71, 83, 133, 141, 161, 227, 246, 255, 287,
litigation, 136
289
liver, 85
injure, 294, 295
localization, 25, 96
injury(s), 7, 12, 15, 34, 36, 53, 54, 56, 61, 74, 78, 79,
longevity, 7, 36, 239
85, 87, 106, 115, 143, 164, 166, 189, 190, 200,
lordosis, 10, 15, 30, 31, 35, 36, 40, 46, 50, 54, 55,
211, 230, 236, 238, 247, 291, 294, 295, 296
67, 167, 175, 176, 178, 200, 201, 209, 210, 211,
insertion, 153, 157, 164, 165, 166, 167, 169, 170,
230, 231, 236, 239, 241, 249, 267, 271, 277, 280,
198, 218, 282, 289, 295
281, 282, 283, 284, 285, 286, 294
instrumentation, 90, 164, 191, 202, 263
lumbar laminectomy, 133, 138
insulin, 287, 289
lumbar radiculopathy, 202
integrity, 34, 35, 43, 93, 96, 209, 211, 236, 239, 248,
lumbar spine, 97, 101, 107, 109, 118, 131, 136, 141,
257
143, 149, 162, 163, 168, 170, 171, 183, 185, 186,
interface, 201
189, 195, 205, 215, 237, 241, 251, 274, 284, 285,
internal fixation, 203
287, 289, 295, 296
internal oblique, 291
lung function, 270
interspinous device, 152, 156, 157
intervention, 55, 79, 180, 246, 285
ipsilateral, 143, 144, 145, 148, 186, 189, 208, 209, M
281
irrigation, 14, 117, 122, 165 magnetic resonance image, 152
ischemia, 148, 228 magnetic resonance imaging, 228
Islam, 101, 171 majority, 25, 83, 207, 227, 251, 283
management, ix, 8, 37, 46, 47, 69, 87, 90, 93, 96,
126, 137, 138, 149, 155, 156, 168, 170, 181, 195,
J
203, 205, 215, 274
manipulation, 88, 186, 189, 271
Jefferson, Thomas, 3, 83
mass, 33, 34, 35, 36, 37, 43, 46, 62, 74, 76, 77, 78,
joint pain, 233
114, 164, 236, 243, 244, 246
joints, 5, 13, 15, 35, 43, 53, 134, 153, 167, 168, 200
matrix, 86, 271
Jordan, vi, vii, 131, 277
measurements, 262
mediastinum, 86
K medical, 78, 152, 156, 241, 287, 289
medical history, 287, 289
knees, 167, 186 medication, 180
Kurd, v, 3, 190 mellitus, 287, 289
kyphosis, 25, 35, 36, 37, 46, 47, 83, 84, 86 mental health, 155
Index 303
meta-analysis, 8, 115, 180, 203, 212, 213, 231, 232 pathogenesis, 47, 148
microscope, 64, 65, 74, 105, 110, 143, 145, 208, 281 pathology, ix, 5, 10, 15, 47, 53, 55, 69, 74, 85, 87,
migration, 68, 125, 126, 179, 231, 263 88, 93, 104, 110, 143, 144, 152, 169, 170, 173,
modifications, 88, 96, 262 174, 199, 200, 207, 228, 256, 280, 289
Moon, 224 pelvis, 273
morbidity, 11, 68, 69, 87, 88, 90, 96, 97, 207, 274, perforation, 263
289 perfusion, 43
morphology, 243 peritoneum, 218, 236, 251, 291
mortality, 88, 90, 96, 97, 274, 296 pharynx, 78
mortality rate, 90, 97 Philadelphia, 89, 285
motor control, 29, 39, 49 physical therapy, 71, 114, 133, 141, 161, 227, 246,
multiple factors, 53, 79 255, 287, 289
muscles, 5, 43, 53, 54, 85, 86, 110, 117, 134, 161, pitch, 260
171, 174, 183, 236, 239, 241, 287, 289, 290, 291 plantar flexion, 101
Myelopathy, v, 27, 29, 39, 49 platysma, 5, 12, 53, 62
pleura, 85, 86, 89, 93, 96
pleural effusion, 96
N plexus, 166, 187, 189, 238, 239, 263, 280, 294, 295
pneumonia, 96
narcotic(s), 25, 106, 107, 110, 114, 115, 121, 148,
pneumothorax, 96
164, 180, 181, 207, 212, 213, 231, 232, 241, 283
polar, 125
nerve, 4, 5, 7, 10, 12, 13, 14, 15, 20, 21, 23, 24, 25,
polymethylmethacrylate, 164
35, 47, 53, 54, 56, 61, 62, 65, 68, 74, 85, 96, 104,
population, 16, 89, 137, 168, 202, 212, 238
105, 110, 112, 113, 114, 145, 147, 148, 175, 179,
posterior, v, vi, vii, 19, 25, 29, 37, 53, 55, 56, 71, 78,
187, 200, 201, 202, 208, 212, 230, 237, 239, 248,
79, 161, 164, 191, 195, 221, 223, 236, 239, 251,
281, 282, 285, 291, 295
267, 273, 277
neuralgia, 87, 88, 96
posterior cortex, 85
neuropraxia, 169
postoperative outcome, 137
neurosurgery, 126, 156, 180, 181
preparation, 14, 63, 112, 166, 176, 179, 187, 189,
neutral, 10, 11, 29, 30, 31, 36, 39, 49, 50, 53, 102,
231, 238, 271, 282, 283
151, 172, 196, 271
preservation, 10, 15, 21, 74, 169, 228
North America, 56, 69, 126
pressure sore, 290
NSAIDs, 14, 133, 161, 164
probe, 34, 35, 62, 65, 123, 134, 135, 166, 187, 291
nucleus, 21
prognosis, 136
prophylactic, 290
O prosthesis, 14, 15, 16, 17, 253
protection, 43
obesity, 69, 78, 236
obstruction, 85, 135
Q
operations, 97, 148, 156, 252
ossification, 14, 16, 21, 46, 53, 55
quality of life, 79, 155, 156, 180, 202, 232, 270, 273
osteoarthritis, 180, 232
osteoporosis, 89, 164, 251
osteotomy, 85, 249 R
radiculopathy, 15, 21, 25, 36, 37, 56, 79, 109, 168,
P 200, 211, 274
radio, 186, 200, 290
pacing, 36
rate of return, 252
palpation, 54, 168, 200
real time, 187
parallel, 11, 12, 13, 85, 93, 179, 187, 201, 208, 211,
reconstruction, 37, 246
231, 248, 251
recovery, 15, 46, 61, 68, 78, 89, 164, 231, 251
paralysis, 88
recreational, 252
paresis, 78
304 Index
rectum, 262, 263 spinal, vi, ix, 37, 56, 90, 129, 131, 138, 141, 151,
recurrence, 46, 104, 106 180, 190, 203, 213, 223, 224, 232, 241, 264, 274
redundancy, 46 spinal cord, 10, 24, 25, 29, 35, 39, 42, 43, 46, 47, 49,
reflexes, 83 53, 55, 56, 65, 84, 86, 87, 88, 91, 96
regression model, 137 compression, 201, 282
relief, 46, 47, 79, 104, 106, 125, 133, 137, 151, 239, spinal cord injury, 25, 46, 88
270, 273 spinal deformity, 223
repair, 78, 238 spinal fusion, 251
reproduction, 227, 246, 255 spinal stenosis, vi, 43, 119, 129, 131, 133, 135, 137,
requirements, 25, 207, 241 138, 139, 141, 149, 151, 155, 156, 157, 163, 168,
resection, 24, 64, 77, 85, 87, 88, 126, 166, 211, 231, 169, 170, 171, 173, 183, 189
260, 281 spondylolysis, 195, 205, 215
resolution, 71, 147 sponge, 93, 230
resource utilization, 106, 180 SSI, 180, 228
restoration, 95, 175, 198, 199, 202, 210, 211, 212, stability, 43, 74, 78, 86, 87, 168, 169, 189, 219, 236,
231, 236, 237, 239, 271, 283, 285, 286 239, 241, 272, 283, 289
restrictions, 71 stabilization, 36, 78, 157, 173, 202, 207, 217, 221,
retrograde ejaculation, 237, 238 222, 223, 228, 231, 236, 270, 274, 280, 289
risk(s), 14, 15, 21, 34, 53, 56, 61, 69, 74, 78, 88, 106, stabilizers, 21, 256
110, 125, 136, 155, 169, 179, 180, 201, 212, 236, states, 243
237, 238, 239, 241, 247, 249, 274, 285, 289, 291, sterile, 257
292, 295, 296 sternocleidomastoid, 5, 12, 53
risk factors, 69, 274, 296 stimulation, 187, 200
rods, 35, 166, 221, 261, 271 structure, 219, 285
root(s), 10, 13, 20, 21, 23, 24, 25, 35, 47, 53, 74, 85, subcutaneous tissue, 5, 104, 110, 153, 258
96, 104, 105, 106, 110, 112, 113, 114, 145, 147, success rate, 16, 36, 155
148, 175, 179, 187, 200, 201, 202, 208, 212, 230, suppression, 169
243, 245, 281, 282, 285 surface area, 74, 201, 223, 270
surgical approach, 5, 10, 21, 33, 43, 53, 61, 74, 85,
93, 104, 110, 121, 133, 143, 152, 164, 173, 185,
S 199, 207, 217, 228, 236, 246, 256, 270, 280, 289
surgical intervention, 168, 202
sacrum, 105, 200, 256, 258, 260, 262, 270
surgical technique, ix, 55, 137, 138, 280, 295
safety, 88, 114, 189, 201
suture, 136
savings, 212
symmetry, 281
scar tissue, 63, 74, 78, 105
symptoms, 13, 36, 46, 53, 55, 59, 71, 74, 78, 79, 83,
sciatica, 243, 246
131, 133, 136, 137, 138, 141, 151, 152, 156, 161,
scoliosis, vii, 8, 143, 169, 185, 190, 191, 203, 257,
164, 168, 195, 202, 205, 215, 227, 246, 255
265, 267, 270, 271, 273, 274, 277, 278, 279, 280,
syndrome, 8, 12, 88
285, 286, 287, 288, 289, 290, 293, 294, 295, 296
scope, 122, 212
screws, 62, 200 T
sensation, 47, 71, 91, 101, 109, 246
sensitization, 238 target, 11, 12, 22, 85, 87, 93, 110, 134, 144, 145,
serum, 114 174, 292
signs, 83, 84 technician, 246
simulation, 239, 263 techniques, ix, 46, 56, 88, 89, 104, 106, 110, 115,
Sinai, 9, 109, 227, 277 121, 126, 127, 138, 148, 166, 168, 169, 170, 185,
skin, 5, 12, 24, 33, 62, 85, 86, 93, 104, 110, 121, 203, 208, 212, 223, 238, 242, 256, 263, 270, 280,
143, 145, 153, 186, 208, 211, 248, 258, 270, 281 281, 284, 295
smoking, 69, 78, 227 technology, 126, 263
software, 252 tender to palpation, 233
soleus, 109 tension, 143, 186, 223, 236, 247
spina bifida, 201 testing, 195, 205, 215, 267, 277
Index 305
therapy, 14, 139, 246 vein, 218, 239

Thoracic Disc Herniation, vi, 81, 89, 91 ventilation, 88
thoracoscopy, 88 vertebrae, 74, 175, 270, 281, 282
thoracotomy, 85, 88, 89, 274 vertebral artery, 33, 35, 54, 78
thorax, 270 vessels, 112, 209, 237, 239, 248, 251
thrombin, 136 viscera, 93, 186, 262
tibialis anterior, 117, 161, 171, 183, 287, 289 visual field, 22
tin, 71, 161, 171, 183 visualization, 5, 11, 21, 33, 35, 43, 44, 61, 62, 68, 77,
tissue, 5, 22, 62, 74, 88, 93, 96, 104, 105, 112, 121, 86, 87, 88, 96, 104, 110, 113, 114, 121, 124, 125,
125, 143, 164, 169, 200, 201, 256, 260, 280, 282 136, 147, 168, 174, 179, 189, 200, 209, 231, 236,
titanium, 74, 236, 237, 260 239, 240, 251, 262, 281, 282, 290, 291
trachea, 5, 12, 15, 74, 78
training, ix, 89, 238
trajectory, 34, 35, 74, 125, 148, 164, 165, 166, 167, W
168, 169, 170, 179, 186, 200, 208, 209, 211, 231,
walking, 91, 151, 267, 273, 277, 287, 289
248, 259, 260, 262
weakness, 3, 9, 19, 25, 71, 83, 84, 88, 91, 101, 109,
transfusion, 180, 212
117, 131, 141, 161, 171, 183, 189, 195, 205, 215,
trauma, 5, 24, 88, 110, 126, 143, 241, 257
287, 289
trial, 6, 14, 54, 137, 138, 155, 156, 175, 201, 210,
weight loss, 83
223, 230, 237, 247, 249, 253
white blood cell count, 117
triceps, 3, 9, 19
Wisconsin, 161, 215
trochanter, 290
workers, 180, 232
tumor, 257
wound dehiscence, 75
wound infection, 295
U
unions, 189 X
United States (USA), 16, 77, 131, 223, 230, 251
x-rays, 15, 221, 233, 237, 243
ureter, 218, 251
urinary tract infection, 274
Y
V
yield, 169
vancomycin, 75
vasculature, 218, 294

Decision Making in Degenerative Spinal Surgery A Case Based Appr

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NEUROSCIENCE RESEARCH PROGRESS

DECISION MAKING IN DEGENERATIVE

Additional books in this series can be found on Nova‟s website

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DECISION MAKING IN DEGENERATIVE

SHEERAZ A. QURESHI, MD, MBA

NOTICE TO THE READER

Library of Congress Cataloging-in-Publication Data

ISBN:  (eBook)

Library of Congress Control Number: 2015931174

Published by Nova Science Publishers, Inc. † New York

Case Vignette 4: Thoracic Disc Herniation 81

Case Vignette 8: L5-S1 Isthmic Spondylolisthesis 193

Decision Making in Degenerative Spinal Surgery: A Case Based Approach brings

Anterior Cervical Discectomy

Figure 4. Intra-operative photograph demonstrating placement of the anterior plate.

Pearls and Pitfalls

Cervical Disc Replacement

Jonathan Rasouli, MD, Branko Skovrlj, MD

Figure 4. Horizontal incision made for approach to anterior cervical spine.

Figure 7. Lateral intra-operative radiograph of arthroplasty placed at C6-7.

Pearls and Pitfalls

Minimally Invasive Posterior

Ehsan Tabaraee, MD, Junyoung Ahn, Andrew J. Park

Figure 3. Photograph demonstrating prone positioning with Mayfield head-holder in place.

Pearls and Pitfalls

Posterior Cervical Laminectomy

Samuel C. Overley, MD, Steven J. McAnany, MD

Pearls and Pitfalls

 When decompression and fusion to the level of C7 is indicated, crossing the

Figure 4. Mayfield Tongs utilization in prone positioning.

Pearls and Pitfalls

following surgery [7]. In addition, despite its description as “motion preserving”,

treatment of cervical spondylotic myelopathy. Spine (Phila Pa 1976), 36(23), 1940-

Anterior Cervical Decompression

Shah-Nawaz M. Dodwad, MD and Alpesh A. Patel, MD

Pearls and Pitfalls

Krzysztof B. Siemionow, MD and Piotr Janusz, MD

Pearls and Pitfalls

Figure 4. Intra-operative image demonstrating the standard Smith-Robinson approach.

 Have a backup plan for removing the plate and screws.

Figure 8. Intra-operative microscope image demonstrating interbody screw placement.

Posterior Approach for an Anterior

Abhishek Kannan and Wellington K. Hsu, MD

Figure 6. Intra-operative image demonstrating bilateral placement of 3.5 mm x 14 mm screws at the C5

Pearls and Pitfalls

When planning a posterior revision for cervical pseudoarthrosis, a surgeon should

Sleiman Haddad, MD1, Paul W. Millhouse, MD2,

Pearls and Pitfalls

Minimally Invasive Retropleural

Junyoung Ahn, Ehsan Tabaraee, MD

Figure 2. Photograph demonstrating patient in the lateral decubitus position.

Pearls and Pitfalls

Islam M. Elboghdady1, Hamid Hassanzadeh, MD2

Pearls and Pitfalls

Minimally Invasive Microdiscectomy

Steven McAnany, MD, Jun Kim, MD

Pearls and Pitfalls

Full Endoscopic Discectomy for

Pablo J. Diaz-Collado, MD and James J. Yue, MD

Figure 4. Illustration demonstrating needle placement at the L4-5 disc space.

Figure 5. Intra-operative photograph demonstrating placement of needle.

Pearls and Pitfalls

ISBN: (eBook)