Posterior lumbar fusion vs Lumbar interbody fusion Evidence based.pptx

 Lumbar degenerative disc diseases (LDDD):
irreversible process in lumbar disk architecture.
 Addressing the pathology with or without fusion
surgery.
 A clear benefit of lumbar fusion surgery: lowered
pain and disability scores.
INTRODUCTION
LDDD
Disc herniation
Spondylosis
Spondylolysis
Spondylolisthesis
Spinal stenosis
Facet joint arthropathy
Combination

FUSION SURGERY
POSTERIOR
LUMBAR FUSION
INTERBODY
FUSION
PLIF
Posterior structure;
Complication, Longer
OTT, Bleeding
TLIF
Facetectomy, Lordosis,
Less morbid, Shorter
OTT
ALIF
Avoids spinal canal,
Achieve better
lordosis: Fusion
similar, Major
complication
LLIF
MIS Learning Curve

1. Degenerative disc disease (generally associated with Modic changes)
2. Lumbar segmental instability (iatrogenic, degenerative, or other causes),
3. Spinal stenosis
4. Spondylolisthesis
5. Degenerative scoliosis
6. Deformity
7. Pseudarthrosis after previous fusion surgery
8. Recurrent disc herniations
Common Indications of Fusion surgery

 Degenerative disk disease with a significant back pain component
 Associated with MODIC changes
 Lumbar Segmental instability requiring fusion for stabilization
 Iatrogenic “Douglas Orr Statement” , degenerative
 Symptomatic spinal stenosis with a significant back pain component that
would benefit from fusion
 15% to 20% short-term failure and 50% long-term failure of Posterior
Decompression surgery alone (Cloward)
Surgical Indication

 Progressive Spondylolisthesis (symptomatic), or requires decompression with
a need to fuse spondylolisthesis level
 10 degrees of angulation on lumbar flex/ex
 Spondylolisthesis of 4 mm or more / Gr II or more
 Intra-op: Rocking of Adjacent vertebral bodies one on another ( Kocher clamps
on adjacent spinous processes)
 Degenerative scoliosis requiring fusion segments
 Salvage for pseudoarthrosis of a previous inter-transverse fusion or
arthroplasty
 Recurrent disk herniation
SURGICAL INDICATION

1. Arachnoiditis
2. Active Infection
3. Short life expectancy <3 months
4. Severe Osteoporosis
5. Significant Epidural Fibrosis
CONTRAINDICATIONS

EVIDENCE OF
SURGERY IN
LUMBAR DISC HERNIATION

 Design
 Multicenter RCT with ITT Analysis
 Patients:
 Early surgery vs Non Operative management: 141 vs 142
 Results
 Early surgery resulted in faster recovery
 No difference in outcomes in 1 year.
 Limitations
 High cross-over rates: 11% of surgery to conservative; 39% of conservative to
surgery
 Blinding not possible.
 Follow-up only 1 year
Herniated Nucleus Pulposus
Multicenter RCT with ITT Analysis
Peul WC et al NEJM 2007
EBM-Spine: Lumbar Herniated Nucleus Pulposus

 Design
 2 Combined Trials (Due to protocol non-adherence)
 RCT- 501 Patient
 Observational Cohort- 743
 Patients: 1244
 Results
 Surgery resulted in greater improvement compared with non-operative treatment
at 4 years.
 Limitations
 Cross over (40% of surgery group, 45% of non- operative).
 This precluded meaningful analysis of the data on an ITT basis because the 2
groups were very similar in treatment received at 2 years.
EBM: Spine Patient Outcomes Trial
(SPORT)
Weinstein JN , et.al. JAMA 2006, Spine 2008
Spine: Lumbar HNP

 Takeshima et al. 2000:
 95 patients:
 51: fusion surgery,
 44: decompression alone.
 Favors fusion surgery: Lower : Rates of revision and low-back pain scores.
 Fu et al. 2005: 41 patients:
 Discectomy: 21 patients
 Discectomy and fusion 18 patients
 No significant difference
FUSION FOR HERNIATED DISC

 Design: systematic literature review of Level I & II studies
 Patients: Two RCTs and 5 OSs of 630 patients were included
 325 were in the TLIF and 305 were in the PLF group
 Result:
 Evidence is not sufficient to support that TLIF provides higher fusion rate than PLF, and this poor
evidence indicates that TLIF might improve only clinical outcomes.
 Strengths
 Large number of patients
 RCT and observational patients
 Validated outcome measure used
 Limitations
 Inclusion of both level I and Level II studies.
 Heterogenicity in multiple studies.
Transforaminal lumbar interbody fusion versus
posterolateral fusion in degenerative lumbar
spondylosis
A meta-analysis
Bin-Fei Zhang et 2016
EBM-spine: Lumbar spondylosis

 Design: A Prospective, Randomized, Multicenter (19 Centers in Sweden)
 Patients: 294 patients
 Nonsurgical group (n =72).
 Surgical groups (n= 222):
 Group 1 = 75 : posterolateral fusion
 Group 2 = 74 : posterolateral fusion + screw placement
 Group 3 = 75 : posterolateral fusion + variable screw placement + interbody fusion
 Results
 All surgical techniques were found to reduce pain and decrease disability substantially, but no
significant differences were found among the groups.
 There was no obvious disadvantage in using the least demanding surgical technique of
posterolateral fusion without internal fixation.
 Limitations
 Cross over
 Short follow up (2 Years)
Chronic Low Back Pain and Fusion: A Comparison
of Three Surgical Techniques
A Prospective Multicenter Randomized Study From the Swedish Lumbar Spine Study
Group
Fritzell et al. in (2001): 294 patients

 Design: Single blind randomized study
 Patients: 64 patients
 Either lumbar fusion with posterior transpedicular screws (37) and post-operative
physiotherapy, or cognitive intervention and exercises (27).
 Result:
 Equal improvement in patients with chronic low back pain
 Strengths
 Level I evidence: CONSORT reporting.
 Limitations
 Limited number of patients
 Short follow up: 1-year.
Randomized Clinical Trial of Lumbar Instrumented Fusion
and Cognitive Intervention and Exercises in Patients with
Chronic Low Back Pain and
Disc Degeneration
Brox et al. Spine; 2003;28(17)

 Design: Literature review: Pubmed MeSH, Cochrane
 Scientific foundation: 36 reference article including RCT, II, III studies
 Result:
 The etiology of the stenosis, however, may play a role in benefit for fusion over
decompression. ( Spondylolisthesis)
 Uncomplicated stenosis is not considered indication for fusion.
 Strengths
 Extensive literature search
 Limitations
 Heterogenicity of references: RCT, Retrospective studies.
 The majority of studies are compromised by a heterogeneous cohort of patients with
respect to presenting diagnosis and a lack of standardized surgical approaches.
Guideline update for the performance of fusion procedures
for degenerative disease of the lumbar spine
Resnick DK et al. J Neurosurg Spine. 2014
EBM-Spine: Lumbar Canal Stenosis

 Design: Systemic Review
 Scientific foundation: Ovid MEDLINE and the Cochrane databases
 84 RCTs and 24 Systemic reviews
 Results:
 Fusion is no more effective than intensive rehabilitation (cognitive behavioral
emphasis)
 Strengths
 Extensive literature search
 Limitations
 Heterogenicity
Surgery for Low Back Pain
A Review of the Evidence for an American Pain Society
Clinical Practice Guideline
Chou R et al. Spine. 2009

 Design
 RCT with ITT Analysis
 Patients
 94 Patients, (50 Surgical, 44 Non-surgical)
 Results
 Surgery better in ODI, leg and back pain.
 Greater difference at 1 year than at 2 years
 Crossover rate 10% (low) in either direction.
 Level I evidence favoring surgery
 Limitations
 Small number of patients
 20% of surgery group had instrumented fusion (variation in surgical management)
The Finnish Spinal Stenosis Study
Simotas AC et al. 2001.Clin. Orthopedic Relat Res

 Design
 Prospective observational Cohort 10 year follow-up
 Patients
 148 Patients- (81 Surgical, 67 Nonsurgical)
 Results
 Level 2 evidence that decompression may provide better outcomes over nonsurgical
treatment.
 Limitations
 Cross over to surgery 39%
 Non-randomized: more severe patients to surgery
 Few patients with mild symptoms were treated with surgery
Maine Lumbar Study
Atlas SJ et al, Spine 2005

 Design
 RCT with prospective observational Cohort
 Patients
 654 Patients (289 RCT, 365 Observational)
 Results
 Level 2 evidence to suggest that surgery results in better outcome at 2 years and
maintained at 4 years.
 Limitations
 High cross over
 33% of surgery group to non-surgery group
 43% from non-surgery group had surgery
 Surgical treatment variable (11% had a fusion)
 Non-surgical treatment not specified
Sport Trial for Lumbar Spinal Stenosis
Weinstein J, et. al., NEJM 2008, Spine 2010

 Design
 RCT
 Patients
 247 patients with lumbar spinal stenosis at one or two adjacent vertebral levels
 Fusion group : 111 patients : Decompression surgery plus fusion
surgery
 Decompression-alone group : 117 patients: decompression surgery alone
 Results
 Bleeding and Operative time significantly higher in fusion group.
 ODI, VAS: insignificant difference
 Conclusion:
 Among patients with lumbar spinal stenosis, with or without degenerative
spondylolisthesis, decompression surgery plus fusion surgery did not result in better
clinical outcomes at 2 years and 5 years than did decompression surgery alone.

A Randomized, Controlled Trial of Fusion Surgery for
Lumbar Spinal Stenosis
Försth et al. NEJM. 2016

 Design
 RCT with prospective observational cohort
 304 RCT, 303 Observational Cohort
 Patients
 521 Patients Follow-up, (372 Surgery, 149 No-surgery)
 Results
 Surgery patients (laminectomy with 1 level fusion) had substantially greater pain relief
and improvement in function at 4 years.
 Limitations
 High level of cross over, difficult to interpret ITT analysis
 36% of surgery group, 49% of non-operative group
 Non-operative treatment not standardized
 Surgical treatment not standardized
 (fusion posteriorly or circumferentially with or without instrumentation)
Surgical vs. Nonsurgical Treatment for
Lumbar Degenerative Spondylolisthesis
Weinstein J. et. al. NEJM 2007, JBJS 2009
EBM-Spine: Degenerative spondylolisthesis

 Design
 Literature Review: RCT and comparative observational studies in English, German and
French (1966-2005)
 Patients
 13 Studies of 578 patients
 Results
 Fusion is more effective than laminectomy in achieving a satisfactory outcome
 Instrumentation increased fusion rate
 Decompression only had the least satisfactory outcome
 Limitations
 Some studies included non-consecutive patients
 Some had undefined follow-up
 No standardized outcome measure was used consistently
 Strengths
 Comprehensive review on degenerative spondylolisthesis
Spondylolisthesis: A Systemic Review
Martin CR et.al. Spine 2007

 Design: Level III
 Patients:
 96 patients with spondylolisthesis (isthmic or degenerative) were analyzed
 Result:
 TLIF procedures were associated with significantly shorter surgical time.
 Overall complication rate was 25%.
 There was no difference in blood loss, hospital duration or occurrence or postoperative pain.
 Strengths
 Limitations
 Standard shortcoming of retrospective studies.
Transforaminal versus Posterior Lumbar Interbody Fusion
as operative treatment of lumbar spondylolisthesis:
A retrospective case series
SL de Kunder et al. 2017

 Design
 Systematic literature review and meta-analysis
 Nine studies were included (one randomized controlled trial and eight case series),
including 990 patients (450 TLIF and 540 PLIF)
 Results
 TLIF has advantages over PLIF in the complication rate, blood loss, and operation
duration. The clinical outcome is similar, with a slightly lower postoperative ODI
score for TLIF.
 Strengths
 Extensive review of literature
 Large number of patient in either group analyzed.
 Limitations
 level of evidence is limited, mostly because of the retrospective nature of the
included articles
Transforaminal lumbar interbody fusion (TLIF) versus
posterior lumbar interbody fusion (PLIF) in lumbar
spondylolisthesis
A systematic review and meta-analysis
SL de Kunder et. Spine. 2017

SPONDYLOLISTHESIS
WITH
STENOSIS

 Design
 A Prospective Long Term Study “Comparing Fusion and Pseudoarthrosis”
 Patients
 58 Patients with laminectomy and non-instrumented fusion
 Results
 Clinical outcome was excellent to good in 86% of patients with a solid arthrodesis and
in 56% of patients with a pseudarthrosis (P =0.01).
 Strengths
 Follow-up was long (5-14 years)
 Limitations
 Small number
 Non-standardized outcome measure 19% (11 patients) lost to follow-up Single center,
secondary analysis
Degenerative Lumbar Spondylolisthesis with
Spinal Stenosis
Kornblum, et al. Spine 2008
EBM-Spine: Degenerative spondylolisthesis with Stenosis

 Design: Prospective Cohort Study
 Patients
 601 Patients (randomized and observational cohort)
 368 Surgery (fusion in 93% / 78% instrumentation)
 233 Non-surgery
 Result:
 A trend toward improved cost effectiveness with circumferential instrumented fusion
 Surgery results in better improvement of health
 Strengths
 Multicenter study
 Limitations
 Non-operative care not specified
Costs relied upon self-reported utilization data Follow-up limited to 2 years
Surgical Treatment of Spinal Stenosis with
Spondylolisthesis
Tosteson AN et al, Ann Internal Medicine 2008
EBM-Spine: Degenerative spondylolisthesis with Stenosis

ANTERIOR
VS
POSTERIOR
APPROACH

 Lordosis: ALIF >>> LLIF >>>TLIF >>>PLIF
 Instability:
 Anterior: ALL
 With ALL release, robust concomitant posterior pedicle fixation is recommended.
 ALL: Anterior Insufficient
 Posterior
 Posterior tension band ( TLIF vs PLIF)
 At risk
 Posterior approach
 Paraspinal muscles, spinal nerves: epidural scarring and perineurial fibrosis
 and does not involve removal of posterior bony structures
 Anterior approach
 Great blood vessels, peritoneal contents, ureter and sympathetic plexus.
ANTERIOR VS POSTERIOR APPROACH

Procedure Mean degree of
correction (in mm)
Median (in mm)
TLIF 3.89 3.5
PLIF 3.81 3.4
LLIF 4.47 4.0
ALIF 4.67 5.2
LORDOSIS CORRECTION
Rothrock RJ et al. 2018. Lumbar Lordosis Correction with Interbody Fusion: Systematic Literature
Review and Analysis. World Neurosurgery.
ALIF >>> LLIF >>>TLIF >>>PLIF

Effect of TLIF and PLIF
on Sagittal Spinopelvic Balance
Uysal et al. 2018: Effect of PLIF and TLIF on sagittal spinopelvic balance of patients with
degenerative spondylolisthesis. Acta Orthopaedica et Traumatologica Turcica
Variables Change PLIF TLIF P value
Sacral slope (SS) Pre Op 29.33 ± 11.17 31.05 ± 10.21 0.643
Post OP 27.27 ± 10.82 31.79 ± 9.64 0.207
Lumbar lordosis
(LL)
Pre Op 45.47 ± 14.89 44.05 ± 10.62 0.749
Post OP 43.87 ± 15.73 47.68 ± 10.55 0.404
Pelvic tilt (PT) Pre Op 16.13 ± 9,74 16.32 ± 7.35 0.951
Post OP 18.53 ± 10.47 15.58 ± 6.94 0.331
Pelvic incidence
(PI)
Change 45.8 ± 10.75 47.37 ± 7.3 0.616

 Design: Meta analysis
 Scientific foundation: 29 article sorted from 6114 articles
 Result:
 All four approaches had similar fusion rates (p = 0.320 & 0.703).
 ALIF has superior radiological outcome, achieving better postoperative disc height (p =
0.002 & 0.005) and postoperative segmental lordosis (p = 0.013 & 0.000).
 TLIF had better Oswestry Disability Index scores (p = 0.025 & 0.000) while PLIF had the
greatest blood loss (p = 0.032 & 0.006).
 Complication rates were similar between approaches.
 Strengths
 Extensive literature review
Large number of patients
Validated outcome measure
 Limitations
 Heterogenicity of studies
A meta-analysis comparing
ALIF, PLIF, TLIF and LLIF
Teng et al. J Clin Neurosci. 2017

Posterior lumbar Fusion
vs
Posterior lumbar interbody fusion
techniques

 Design
 Network meta-analysis using contrast-based method.
 Patients
 992 patients from Fifteen RCTs were included.
 Result
 Circumferential fusion might be worth to be recommended because it exhibits the best
balance between fusion rate and overall adverse event.
 PLF is still an inferior procedure and requires shorter operative time.
Effects and Safety of Lumbar Fusion Techniques in Lumbar
Spondylolisthesis: A Network Meta-Analysis of Randomized
Controlled Trials
Kang YN et al. Global spine Journal. 2021

 Design
 Systemic review and meta analysis
 Patients
 8 studies meeting our inclusion criteria, with a total of 616 patients (308 PLF, 308
PLIF)
 Result
 Patients who underwent PLIF had significantly higher fusion rates.
 No statistically significant difference was identified in terms of clinical outcomes,
complication rates, revision rates, operation time or blood loss.
Posterolateral Fusion Versus Posterior Lumbar Interbody
Fusion: A Systematic Review and Meta-Analysis of
Randomized Controlled Trials
Elsayed Said et al. Global Spine Journal. 2021

PLIF VS TLIF
COMPARISON PLIF TLIF
INTRODUCED BY
Jaslow 1946
Cloward 1953
Harms 1990s
Trajectory Posterior approach
More lateral trajectory; unilateral
exposure of the neural foramen
Facet Preserved Entire facetectomy
Posterior tension bands Destroyed Maintained
Scope of operation L3-S1 Thoracolumbar
Concern
Epidural adhesion, root damage, and
extent of neural retraction, blood loss
Pedicle damage
Advantage Facet preserved, bilateral access
Greater lordosis and foraminal
width, posterior tension band,
contralateral posterior column
integrity
Complications Higher, Bleeding 50% Lower than PLIF
Fusion rate 80-90% 85-92%
Lordosis (+), 3.81degree (++), 3.89 degree

 Prone on a Jackson's table
 Middle block placed beyond a hinge to allow proper LORDOSIS across the
instrumented segments
 Abdomen Free: prevent epidural venous bleed
 Intra-operative C-arm (fluoroscopy) localization
POSITIONING

Pedicle Screws Inserted after Subperiosteal Dissection
Pars Interarticularis and Transverse process of Cephalad and Caudad level exposed
Cephalad Facet Joint
shouldn’t be violated
For T4-5 TLIF, the T3-
T4 Facet joint shouldn’t
be violated

SIDE?
Where the patient has more Radicular Symptoms
Rod applied in the contralateral side and mildly distracted before Facetectomy

Inferior articular process of cranial vertebra is drilled
OR chiseled as cranial as possible to maximize exposure taking care not to violate the cranial pedicle

Using Leksell, the Superior facet of the caudal level is resected as flush with
the pedicle as possible. Neural Foramen is completely decompressed
Removal of Ligamentum
Flavum
LF is freed from the lamina
with curette esp Redo
To prevent accidental durotomy

The Neural Foramen is opened completely to expose
the EXITING nerve root, the lateral part of the Inter-vertebral
Disc and Theca medially.

Exposure of the Neural foramen Proper tactile Identification of the structures
Epidural Vessels Coagulated
Exiting Nerve and Theca Protected
Discectomy done form one Side
Shavers/Roungers

Using Curettes, Box curette, Shavers , Rongeurs
Disc and cartilaginous end plate removed
In the Anterior 3rd Osseous end plate curetted to enable bony fusion “RISKY?”
ALL and rest of the Osseous End plate preserved to support structural graft

Disc Height measured with Sizers (under fluoroscopy)
If disc space narrow- Distraction on C/L Rod
Place Larger Sized cage

Cancellous bone introduced in to the disc space, close to the ALL
prevents the cage position too anteriorly

When Iliac Crest Grafts used instead of Cages

Final position of the structural graft checked visually and radiologically
Disc space Distraction released
Leg end (beyond hinge) raised to induce Lumbar Lordosis
Rods contoured to maintain Lordosis
Construct compressed to establish optimum graft-bone interface

Final Tightening
Transverse Processes drilled and covered with Only graft
Posterolateral Fusion

IMPLANT
MATERIALS
Metal mesh cage
Titanium
Cobalt
Chromium
Stainless steel
Polymeric
rectangular cages
Brantigan carbon
cage
Polyetheretherke
tone-PEEK
Bioabsorbable
cages
Threaded cage
BAK cage
Ray cage
Carbon fiber
Hydrosorb cage
Ceramic cages Silicon Nitride
hydroxyapatite
IMPLANTS
All solid metal implants have an elastic modulus that is more than 13 times as strong as cancellous bone.
PEEK is closest to cancellous bone, and CFRP is closest to cortical bone.

1. Lumbar surgery rates have increased steadily over time, and hence related complications.
2. Evidence of the superiority of one technique over the other is sparse.
3. Surgery offers greater improvement compared with non-operative treatment in LDDD.
4. Surgery in disc herniation resulted in faster recovery, However no added benefit of fusion
surgery.
5. There was no obvious disadvantage of posterolateral fusion without internal fixation in
patient with spondylosis.
6. Among patients with lumbar spinal stenosis without spondylolisthesis, decompression plus
fusion surgery may not result in better clinical outcomes.
7. In patient with spondylolisthesis with or without stenosis, fusion is more effective than
laminectomy in achieving a satisfactory outcome. Decompression only had the least
satisfactory outcome.
8. Patients who underwent interbody fusion may have significantly higher fusion rates
compared to posterior lumbar fusion only.
9. TLIF has advantages over PLIF in the complication rate, blood loss, and operation duration.
The clinical outcome is similar, with a slightly lower postoperative ODI score for TLIF.
10. In the end, The choice of technique is still greatly based on the surgeons’ preference and
experience.
TAKE HOME MESSAGE

EVIDENCE: POSTERIOR LUMBAR FUSION V/S ANTERIOR INTERBODY FUSION
SURESH BISHOKARMA, MCH
CONSULTANT NEUROSURGEON
Upendra Devkota Memorial National Institute of Neurological and Allied Sciences

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