Review
Comparison of the different surgical approaches for lumbar interbody fusion

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Abstract

This review will outline the history of spinal fusion. It will compare the different approaches currently in use for interbody fusion. A comparison of the techniques, including minimally invasive surgery and graft options will be included. Lumbar interbody fusion is a commonly performed surgical procedure for a variety of spinal disorders, especially degenerative disease. Currently this procedure is performed using anterior, lateral, transforaminal and posterior approaches. Minimally invasive techniques have been increasing in popularity in recent years. A posterior approach is frequently used and has good fusion rates and low complication rates but is limited by the thecal and nerve root retraction. The transforaminal interbody fusion avoids some of these complications and is therefore preferable in some situations, especially revision surgery. An anterior approach avoids the spinal cord and cauda equina all together, but has issues with visceral exposure complications. Lateral lumbar interbody fusion has a risk of lumbar plexus injury with dissection through the psoas muscle. Studies show less intraoperative blood loss for minimally invasive techniques, but there is no long-term data. Iliac crest is the gold standard for bone graft, although adjuncts such as bone morphogenetic proteins are being used more frequently, despite their controversial history. More high-level studies are needed to make generalisations regarding the outcomes of one technique compared with another.

Introduction

Lumbar interbody fusion is an accepted treatment for a variety of spinal disorders, including trauma, infections and neoplastic conditions [1]. It involves placement of an implant (spacer, graft or cage) within the intervertebral space after discectomy. Currently lumbar interbody fusion is performed using four main approaches, posterior lumbar interbody fusion (PLIF), transforaminal lumbar interbody fusion (TLIF), anterior lumbar interbody fusion (ALIF) and lateral lumbar interbody fusion (LLIF) (Fig. 1). There is no evidence that one of these approaches is superior. These operations can also be performed using mini-open or minimally invasive (MIS) approaches [2]. Interbody fusion is preferable to other spinal fusion techniques because of lower rates of postoperative complications and pseudoarthrosis [3], [4].

Section snippets

Historical perspective

In 1891 Hadra first described spinal instrumentation with insertion of a silver spinous process wire [5]. In 1910 Lange developed a system of steel rods for attachment to the spine (Fig. 2) [6]. Fusion of the spine was first described in the medical literature by Albee in 1911 as an operation for Pott’s disease, using a tibial graft for stabilisation in tuberculous spondylitis [7], and also by Hibbs who described the technique for stabilising spinal deformities such as scoliosis [8]. Chandler

Surgical technique

PLIF utilises a direct posterior approach to the spine. A midline incision allows access to the disc space of interest via an open incision or sequential tubular dilators. Exposure, laminotomy, ligamentum flavum removal and discectomy and end plate preparation are then performed. PLIF utilises dual ovoid shaped spacers placed in the interspace, which is then supplemented by packed bone graft. The position of the implant is confirmed with fluoroscopy and the graft filled space is then stabilised

Surgical technique

Exposure is achieved through a midline or paramedian incision. The dissection is carried to the base of the transverse process or facet joint. A transforaminal window is then created on one side by resecting the ascending articular process of the lower vertebra to the medial wall of the pedicle (Fig. 1). This is followed by aggressive discectomy and end plate preparation. Bone graft is placed anteriorly and to the contralateral side of the disc space. The single kidney shaped implant is then

Surgical technique

The exposure of the anterior spine is classically through a left paramedian incision over the disc space to be fused. A retroperitoneal approach is taken to expose the anterior spine. At this point vascular structures and ureter are carefully identified and retracted to avoid injury. The aorta and vena cava only need to be retracted if accessing the L3–4 or L4–5 disc spaces; if operating on L5/S1, the space below the bifurcations of these vessels can be used. The anterior longitudinal ligament

Surgical technique

An LLIF operation begins with the patient in either the left or right lateral decubitus position. A lateral incision is made and access is gained to the retroperitoneal space, the peritoneum swept anteriorly and dissection carried out to the psoas muscle (Fig. 8). Electromyography monitoring is placed within psoas to identify the lumbosacral plexus. A transpsoas approach is taken and the muscle fibres are carefully separated [26]. Some authors have recommended dissection within the anterior

MIS versus open lumbar fusion

MIS is being used more frequently as surgeons become more familiar with the techniques and as newer technology becomes available. MIS interbody fusion has consistently been shown to reduce intraoperative blood loss [91]. There are no long-term data for these techniques and the benefit compared to open techniques is questionable as the decompression that can be achieved is greater with open approaches.

ALIF and LLIF are MIS techniques by their nature. Laparoscopic ALIF has been used in recent

Graft options

For achieving spinal fusion, the traditional graft material used is taken from the iliac crest of the patient [36], [101]. It provides the osteogenic factors and scaffold necessary for adequate bone fusion. Donor site problems include pain, paraesthesias, haematoma and infection [102], [103], [104]. Persistent pain is a common complaint in up to 60% of patients [105], [106]. This has led to the development of alternatives including demineralized bone matrices, tricalcium phosphate and BMP.

Conclusions

Spinal fusion has been performed for over a century, and interbody fusion procedures have been performed for over 50 years. The last two decades have seen a rapid expansion in stabilisation techniques and graft materials. Each option has its own advantages and disadvantages, and the approach taken ideally depends on the pathology present and the anatomy of the individual patient. There is an increasing trend toward MIS approaches due to less intraoperative blood loss, however long-term data is

Conflicts of Interest/Disclosures

The authors declare that they have no financial or other conflicts of interest in relation to this research and its publication.

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