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Interbody Fusion
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Posterior Lumbar Interbody Fusion (PLIF) Surgery

As with all spinal fusion surgery, a posterior lumbar interbody fusion (PLIF) surgery involves adding bone graft to an area of the spine to set up a biological response that causes the bone to grow between the two vertebral elements and thereby stop the motion at that segment. If you are considering posterior lumbar fusion surgery as a treatment for your spine condition, please contact us to determine what option is best for you, what your insurance will cover and any additional surgery costs.

Unlike the posterolateral gutter fusion, the PLIF achieves spinal fusion in the low back by inserting a bone graft and/or spinal implant (e.g. cage) directly into the disc space. When the surgical approach for this type of procedure is from the back it is called a posterior lumbar interbody fusion (PLIF). A PLIF fusion is often supplemented by a simultaneous posterolateral spine fusion surgery.

First, the spine is approached through a three-inch to six-inch long incision in the midline of the back and the left and right lower back muscles (erector spinae) are stripped off the lamina on both sides and at multiple levels.

After the spine is approached, the lamina is removed (laminectomy) which allows visualization of the nerve roots. The facet joints, which are directly over the nerve roots, may then be undercut (trimmed) to give the nerve roots more room. The nerve roots are then retracted to one side and the disc space is cleaned of the disc material. A bone graft, or anterior interbody cages with bone, is then inserted into the disc space and the bone grows from vertebral body to vertebral body.

Doing a pure PLIF spine surgery has the advantage that it can provide anterior fusion of the disc space without having a second incision as would be necessary with an anterior/posterior spine fusion surgery. However, it has some disadvantages:

  • Not as much of the disc space can be removed with a posterior approach (from the back).
     
  • An anterior approach (from the front) provides for a much more comprehensive evacuation of the disc space and this leads to increase surface area available for a fusion.
     
  • A much larger bone graft and/or spinal implant can be inserted from an anterior approach
     
  • In cases of spinal deformity (e.g. isthmic spondylolisthesis) a posterior approach alone is more difficult to reduce the deformity
     
  • There is a small but finite risk that inserting a bone graft or cage posteriorly will allow it to retropulse back into the canal and create neural compression.

PLIF surgery rates are higher than posterolateral fusion rates because the bone is inserted into the anterior portion (front) of the spine. Bone in the anterior portion fuses better because there is more surface area than in the posterolateral gutter, and also because the bone is under compression. Bone in compression heals better because bone responds to stress (Wolff's law), whereas bone under tension (posterolateral fusions) does not see as much stress.

PLIF Spine Surgery Risks and Complications

The principal risk of this type of low back surgery is that a solid fusion will not be obtained (nonunion) and further back surgery to re-fuse the spine may be necessary. Fusion rates for a PLIF should be as high as 90-95%.

Nonunion rates are higher for patients who have had prior spine surgery, patients who smoke or are obese, patients who have multiple level fusion surgery, and for patients who have been treated with radiation for cancer. Not all patients who have a nonunion will need to have another spine fusion procedure. As long as the joint is stable, and the patient's symptoms are better, more back surgery is not necessary.

Other than nonunion, the risks of a spinal fusion surgery include infection or bleeding. These complications are fairly uncommon (approximately 1% to 3% occurrence). In addition, there is a risk of achieving a successful spine fusion, but the patient's pain does not subside.

Minimally-Invasive PLIF Surgery

The success rate for posterior fusion in the treatment of refractory discogenic back pain is only 60-70%. The selection of the appropriate patient for this surgery has been blamed for the relatively poor results. Other possible causes of poor results are that the actual pain-causer, the disc, is not addressed. Studies have shown continued significant movement of the disc despite solid posterior fusion. One study showed that patients with continued back pain after solid posterior fusion were improved after anterior fusion of the disc space.

In an attempt to improve the results of fusion surgery, fusion of the disc has been performed to directly address the most common source of pain. Unlike the posterolateral gutter fusion, the PLIF achieves spinal fusion by inserting bone graft and possibly instrumentation directly into the disc space. The disc excision and fusion can be performed anteriorly, or through a posterior approach. When the posterior approach is used to remove and fuse the disc, this is called a PLIF, Posterior Lumbar Interbody Fusion.

An alternative approach is used to minimize retraction of the dura. By resecting the facet joint, a farther lateral approach can be used to remove the disc. This approach, with removal of the facet, is called a TLIF - Transforaminal Lumbar Interbody Fusion.

THE GENERAL PROCEDURE:

1. First, the spine is approached through a three-inch to six-inch long incision in the midline of the back and the left and right back muscles (erector spinae) are stripped off the lamina on both sides and at multiple levels.

2. After the spine is approached, to perform the PLIF procedure, the lamina is removed (laminectomy) which allows visualization of the nerve roots. The facet joints, which are directly over the nerve roots, are usually undercut to give the nerve roots more room and more room for performing the fusion and/or instrumentation. For the TLIF procedure the entire facet joint is removed.

3. The nerve roots are then retracted to one side and the disc space is cleaned of the disc material. Bone graft is then inserted into the disc space with or without interbody cages. For a standard PLIF procedure, the bone graft and/or instrumentation is performed on both sides. For the TLIF procedure, the disc space is accessed from one side, reaching over to remove and replace the disc on the other side.

AFTER SURGERY

Possible Risks or Complications with Surgery

  • Nerve Injury
  • Adjacent disc disease
  • Infection
  • Bleeding
  • Non-union
  • Advantages of PLIF and TLIF

    The PLIF and TLIF approach has an advantage over the posterolateral gutter fusion in that the large spinal muscles do not need to be dissected off the transverse processes, so there is less scarring of the muscle and associated pain for the patient. The major advantage of PLIF and TLIF is that there is significantly more surface area for fusion in the disc space as compared to the posterolateral gutter.

    Potential Disadvantages of PLIF

    However, the PLIF requires substantial retraction of the nerve roots to gain access to the disc space. Significant traction can injure the nerve root and has the potential to result in chronic leg pain and back pain. The pain associated with this type of nerve root injury can be severe, and there are no effective options for treatment. The TLIF requires less retraction of the dural sac, but nerve injury can occur at the level of the nerve cell bodies (dorsal root ganglion). Pain associated with manipulation of the DRG can also be very severe and debilitating. Fortunately, these complications are rare with meticulous care of the nerves.

    There are numerous veins (epidural veins) over the disc space, and surgery in this area creates the potential for excessive blood loss during the surgery.

    Recurrent pain after a successful spinal fusion procedure is more likely due to a “transfer” lesion at the motion segment above or below the fusion, because stress is transferred to the next level and may cause that vertebral segment to degenerate and breakdown.

    Nonunion rates of between 0% and 20% have been quoted in the medical literature. Nonunion rates are higher for patients who have had prior surgery, patients who smoke or are obese, patients who have multiple level fusion surgery, and for patients who have been treated with radiation for cancer.

    Other than nonunion, the risks of a spinal fusion surgery include infection or bleeding. These complications are fairly uncommon (approximately 1% to 3% occurrence).

     

     
     

     

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