Posterior Lumbal Interbody Fusion

1. Posterior Lumbar
Interbody Fusion
Present by : dr Syahreza Manefo
Spine Division Neurosurgery Departement
Faculty of Medicine – Universitas Padjajaran
Bandung - 2022

2. Introduction
Posterior lumbar interbody fusion (PLIF) :
● Widely used, safe, and effective technique used for the treatment of spinal instability
● PLIF was initially introduced by Dr. Robert Cloward in 1953  it was originally performed
using structural iliac crest bone graft and no supplemental internal fixation
Wolfla E Christopher Neurosurgical Operative Atlas – Spine and Peripheral Nerves.3rd ed. 2017. Thieme Publishing
showed low complication rates and near perfect fusion rates
PLIF :

3. indicated for the treatment of patients requiring surgical arthrodesis of the lumbar spine
Patient Selection
a candidate for PLIF will have an underlying condition that requires both a dorsal decompression
(particularly if this involves a diskectomy) and a surgical arthrodesis, including :
Wolfla E Christopher Neurosurgical Operative Atlas – Spine and Peripheral Nerves.3rd ed. 2017. Thieme Publishing
PLIF Indication :
Disk herniation with
concomitant instability or
deformity
Disabling low back pain
Lateral or foraminal disk
herniations requiring
facetectomy for treatment
Massive disk herniations
requiring bilateral complete
facetectomy for adequate
decompression
Certain recurrent disk
herniations
Contraindication :
• A standard PLIF should not be performed at or above the level of the conus medullaris
• Tethered cords and similar congenital anomalies

4. Preoperative Preparation
Informed
consent
regarding risk
and benefit
Ask patient to
stop smoking
Stop NSAID 1
week before
and 1 month
after
procedure
Routine
Blood Test
Anesthesia
Foley
cathether
Perioperative
antibiotics
Wolfla E Christopher Neurosurgical Operative Atlas – Spine and Peripheral Nerves.3rd ed. 2017. Thieme Publishing

5. Preoperative Preparation : Positioning
Pressure on the abdomen should be minimized
by using transverse rolls at the levels of the
shoulders and waist or with any of a variety of
frames designed specifically for this purpose.
Wolfla E Christopher Neurosurgical Operative Atlas – Spine and Peripheral Nerves.3rd ed. 2017. Thieme Publishing
Patients are positioned prone with the
lumbar spine in lordosis.

6. Preoperative Preparation : Positioning
Abduction of the arms alleviates
interference with lateral radiography,
although they should not be abducted
more than 90 degrees.
All pressure points should be generously
padded, and the genitalia and breasts
should be free of compression.
Wolfla E Christopher Neurosurgical Operative Atlas – Spine and Peripheral Nerves.3rd ed. 2017. Thieme Publishing

7. Operative Procedure
A midline incision incorporating
three spinous processes is
designed, centered on the spinous
process of the upper vertebrae of
the segment to be fused (i.e., L4, in
the case of an L4–5 fusion)
The incision is infiltrated with 0.5%
lidocaine/1:200,000 epinephrine
After the patient is prepared and
draped, and the surgical “timeout”
is performed, the skin incision is
made down to the thoracolumbar
fascia with minimal use of the
electrocautery.
The fascia is then opened, and a
bilateral subperiosteal dissection is
performed of the spinous
processes, lamina, and facets of
the levels to be fused.
bilateral transpedicular screws are
placed in the rostral and caudal
vertebrae.
After appropriate connectors and
rods have been placed, the
hardware is provisionally tightened
Wolfla E Christopher Neurosurgical Operative Atlas – Spine and Peripheral Nerves.3rd ed. 2017. Thieme Publishing
Dorsal view of segment to be fused, after placement of posterior
nonsegmental instrumentation. Cranial is right, caudal is left.
Ordinarily, transverse processes would not be exposed. Note
that heads of screws are directed laterally so as not to impinge
on the cranial facet joint.

8. Operative Procedure
The decompression is performed at this time.
The author prefer an extensive decompression
with bilateral laminectomy of the uppermost
vertebrae, complete bilateral facetectomy, and,
at a minimum , removal of the rostral half of the
lamina below.
Thus, at L4–5, the thecal sac will be exposed in
its entirety, both L4 nerve roots will be exposed
from a point just medial to the L4 pedicles all
the way out the foramina, and both L5 nerve
roots will be exposed from their axillae to a
point just medial to the L5 pedicles bilaterally
Wolfla E Christopher Neurosurgical Operative Atlas – Spine and Peripheral Nerves.3rd ed. 2017. Thieme Publishing
Dorsal view of the segment to be fused, after bone removal. Note
that laminectomy and facetectomy allow an excellent view of the
thecal sac, as well as the cranial nerve roots (sweeping below
cranial pedicles and exiting through the foramen) and caudal
nerve roots (sweeping medial to the caudal pedicles). Note also
that disk space lies primarily ventral to the cranial lamina.

9. Operative Procedure
The diskectomy begins with bipolar
coagulation of the epidural veins
and mobilization of the thecal sac
and lower nerve roots bilaterally.
Troublesome venous bleeding,
when it occurs, usually emanates
from one of three locations: the
axilla of the upper nerve root, the
region between the lower nerve root
and its associated pedicle, or the
midline epidural space.
Beginning preferentially on the left
side (the most difficult side for a
righthanded surgeon), the thecal
sac and lower nerve root are
retracted to expose the disk space.
The disk space is entered, and the
anulus is generously excised. All
accessible disk material is then
removed.
After repeating this procedure on
the contralateral side, a thorough
search is made for any remaining
free disk fragments or residual
midline subligamentous herniations
Wolfla E Christopher Neurosurgical Operative Atlas – Spine and Peripheral Nerves.3rd ed. 2017. Thieme Publishing
Dorsal view of the segment to be fused, during diskectomy.
The retractor protects the thecal sac and caudal nerve root.
Retraction is not performed past the midline. Thorough bone
removal gives excellent access to the midline epidural space,
lateral recess, and neural foramen.

10. Operative Procedure
The fusion begins with careful
preparation of the end plates using
curets
The objectives of this maneuver are
to remove any remaining disk
material, remove the cartilaginous
end plates, expose bleeding bone
while removing a minim um of cortex,
and, in some instances, to shape the
disk space to accept the bone graft
or implant or both
The anterior portion of the disk space
is then packed tightly with
morcellized local bone graft from the
decompression, usually using an
offset impactor.
The bone graft packed around a
structural allograft or implant is at
least as important in promoting
fusion as the bone contained within
either
Returning to the left side, the thecal
sac and lower nerve root are
retracted to expose the disk space.
This retraction is usually facilitated
by thorough diskectomy, although
under no circumstances should
structures be retracted across the
midline
Wolfla E Christopher Neurosurgical Operative Atlas – Spine and Peripheral Nerves.3rd ed. 2017. Thieme Publishing

11. Operative Procedure
A second retractor protects the upper nerve
root, taking care not to compress the nerve
root against the inferior surface of the pedicle
Wolfla E Christopher Neurosurgical Operative Atlas – Spine and Peripheral Nerves.3rd ed. 2017. Thieme Publishing
Dorsal view of the segment to be fused, after
diskectomy. The first retractor exposes the disk space
by retracting the thecal sac and caudal nerve root. The
second retractor protects the cranial nerve root but does
not compress the nerve root against the pedicle.
Dissection of the axilla of the cranial nerve root, as well
as disk removal, facilitates retraction and thorough
exploration of the epidural space.

12. Operative Procedure
The graft or implant is then
impacted into the disk space
and countersunk
The author prefer to place the
graft or implant as far ventrally
as possible, without violating
the ventral anulus, to lessen
the incidence of retropulsion
and promote lordosis after
compression
After the second graft or
implant has been placed, the
hardware is loosened,
compression is applied across
the segment, and the
hardware is given a final
tightening.
Appropriate placement of graft
and hardware is confirmed
with a lateral radiograph.
For a single-level fusion, a
crosslink is not used.
The wound is thoroughly
debrided and irrigated.
It is closed, in a standard
fashion, in layers.
A wound drain is used for 24
hours.
A standard, absorbent
dressing is used
Wolfla E Christopher Neurosurgical Operative Atlas – Spine and Peripheral Nerves.3rd ed. 2017. Thieme Publishing

13. Operative Procedure
Dorsal view of the segment to be fused
during placement of the bone graft and/or
implant. Complete facetectomy facilitates
placement of the graft and/or implant with a
minimum of retraction. Protection of the
cranial nerve root is especially important in
cases of spondylolisthesis, where the cranial
nerve root is otherwise easily displaced into
the trajectory of the graft and/or implant.
Laterally placed hardware does not interfere
with placement.
Wolfla E Christopher Neurosurgical Operative Atlas – Spine and Peripheral Nerves.3rd ed. 2017. Thieme Publishing

14. Postoperative Management
● Patients are allowed to mobilize as soon as their sensorium and level of discomfort w ill
allow but no later than 24 hours postoperatively.
● The use of a brace is at the discretion of the surgeon
Wolfla E Christopher Neurosurgical Operative Atlas – Spine and Peripheral Nerves.3rd ed. 2017. Thieme Publishing
Wounds are
clean and dry
Pain are
controlled with
oral medications
Patients are
ambulatory
Afebrile Eating Voiding
Post-op treatment
Patient’s Discharge Criteria

15. Postoperative Management
These are things
that need prompt
reevaluation
Bone graft
resorption
lucent lines
evidence of
hardware
loosening or
failure
persistent or
recurrent
complaints
Wolfla E Christopher Neurosurgical Operative Atlas – Spine and Peripheral Nerves.3rd ed. 2017. Thieme Publishing
Folllow
up :
Patients follow up at regular intervals with physical examination and
static and dynamic radiographs until radiographic evidence of
fusion is seen

16. Conclusion
PLIF has become a mature and
useful procedure for performing
surgical arthrodesis of the lumbar
spine
PLIF continues to
offer high fusion rates
and, in its current
standardized and
refined form,
excellent and
reproducible patient
outcomes
Wolfla E Christopher Neurosurgical Operative Atlas – Spine and Peripheral Nerves.3rd ed. 2017. Thieme Publishing

17. THANK YOU