2. We’re passionate about Putting patients first Quality, safety and patient experience Transforming services to meet the health needs of future generations

3. Missed Screw Technique for Lumbar Fusion Shoaib Khan Mr Bhatia Mr Krishna

4. Opening of the Stockton and Darlington Railway Painting in 1880’s, crowds are watching the inaugural train cross the Skerne Bridge in Darlington.

5. Congreve Matchbox (1827) First Friction match developed by John Walker

6. Lumbar Spine Disease Major public health concern Leading cause of disability Middle-age working population Multiple avenues of treatment

7. Lumbar Spine Disease Degenerative disc disorders Secondary changes: Stenosis, Spondylolisthesis, Facet joint OA

8. Conservative Measures Analgesia Exercise Education Physiotherapy

9. Lumbar Spine Disease Surgical treatment stabilization/fusion The primary goal of treatment is pain relief and improve function

10. History of Procedure Lumbar Fusion: 7 decades Symptomatic Lumbar Spine disease

11. History of PLIF 1944, Briggs and Milligan : Laminectomy 1946, Jaslow: Spinous Process 1953, Cloward: Iliac Crest Autograft 1961, Humphreys: Ant lumbar plate

12. History of PLIF 1990’s Interbody Implants and Instruments Presently: Synthetic Cages/ Premilled Allograft

13. Evolution of Technique Augmentation with Pedicle Screws Stability of Construct Increased Fusion rate

14. History of TLIF 1982, Harms and Rolinger Transforaminal route Less retraction on thecal sac and nerves Spares contralateral lamina, facet and pars Safe for revision cases b/c of its PL trajectory

15. Indications Spinal Instability Spinal Stenosis Spondylolisthesis Degenerative scoliosis Discogenic low back pain Recurrent Lumbar Disc Herniation Postdiscectomy collapse with neuroforaminal stenosis Pseudoarthrosis

16. Techniques ALIF PLIF TLIF PLF Circumferential fusion

17. Biomechanics High fusion potential : Grafts are placed under compression Interbody fusions place the bone graft in the load-bearing position spinal columns

18. Spinal Loads and Articular Surface in Lumbar Spine

19. Pedicle screw-rod constructs increase biomechanical rigidity and decrease pseudoarthrosis rates Interbody fusion devices: Restore intervertebral height and segmental lordosis

20. Interbody fusionPL fusion Interbody Grafts Compression 80%20% Intervertebral surface area 90%10% VascularityMoreLess Sagittal BalanceBetterLess Better Interbody vs PL fusion

21. Relative Contraindications Three Level DDD Single level disc disease causing radiculopathy without back pain/instability Severe osteporosis

22. Interbody Grafts Autologous Illiac crest graft Structural Allograft Metallic cages with bone chips Titanium Mesh Cages Carbon Fiber Cages PEEK cages

23. Interbody Cages Provide stability, fills the disc space, require less structural bone graft Maintain spinal alignment, neuroforaminal height, prevent graft dislodgement and collapse, enhance fusion rates Carriers for osteoinductive or osteoconductive materials

24. PLIF Technique Laminectomy and Facetectomy Reveals rostral exiting and caudal traversing nerve roots and disk spaces Thecal sac and nerve roots retracted medially

25. PLIF Technique Discectomy Interbody graft placement Pedicle screw-rod compression: restore lumbar lordosis and maintain disk height

26. PLIF Technique Risks of incidental durotomy/nerve injury Cages : Postoperative Radiculopathy Bilateral facetectomy to achieve adequate graft placement Postoperative Instability and failure if pedicle screw instrumentation is not added

27. TLIF Technique Unilateral laminotomy and complete facetectomy on the symptomatic side or bilaterally Full laminectomy and contralateral foraminotomy Discectomy

28. TLIF Technique Posterior bony lips of the end plates may be removed Interbody graft placement Pedicle screw-rod compression: restore lumbar lordosis and maintain disk height

29. PLIF and TLIF Approach Bottom :TLIF PL Appraoch for TLIF Posterior Approach for PLIF

30. Graft Placement PL for TLIF Posterior for PLIF

31. PLIF Outcome Good outcome in properly selected pt Fusion rates: 85% Comparison of low back fusion techniques: TLIF and PLIF approaches Chad D. Cole Todd D. McCall Meic H. Schmidt.Andrew T. Dailey

32. TLIF Fusion Rate Single-level TLIF: More than 90% Multilevel procedure: Less than 90% Villavicencio AT, Burneikiene S, Bulsara KR, et al: Perioperative complications in transforaminal lumbar interbody fusion versus anterior-posterior reconstruction for lumbar disc degeneration and instability. J Spinal Disord Tech 2006

33. TLIF vs PLIF STUDIES HAVE SHOWN THAT THE THERE IS NO STATISTICAL DIFFERENCE IN THE FUSION RATES OF TLIF Vs PLIF

34. Zhang, Qunhu et al. “A Comparison of Posterior Lumbar Interbody Fusion and Transforaminal Lumbar Interbody Fusion: A Literature Review and Meta- Analysis.”BMC Musculoskeletal Disorders 15 (2014): 367. PMC. Web. 22 Oct. 2015 Park JS, Kim YB, Hong HJ, Hwang SN. Comparison between posterior and transforaminal approaches for lumbar interbody fusion. J Korean Neurosurg Soc.2005;37:340–344. Yan DL, Li J, Gao LB, Soo CL. Comparative study on two different methods of lumbar interbody fusion with pedicle screw fixation for the treatment of spondylolisthesis. Zhonghua Wai Ke Za Zhi. 2008;467:497–500. Zhuo X, Hu J, Li B, Sun H, Chen Y, Hu Z. Comparative study of treating recurrent lumbar disc protrusion by three different surgical procedures. Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi. 2009;23:1422–1426.

35. PLIF Complications Transient/ Permanent Nerve Injury Graft Displacement Intervertebral space collapse with neuroforaminal stenosis Loosening Subsidence Pseudoarthrosis

36. TLIF Complications Pedicle screw misplacement Transient Neurological deficit Dural/Neural injury Graft extrusion

37. Other Complications Blood loss Durotomy Arachnoiditis Wound infection Delayed wound healing Haematoma Screw misplacement

38. Other Complications Intraoperative pedicle fracture Urinary retention Pulmonary embolism Seroma Epidural fibrosis/scar

39. Our Study Rate of interbody fusion using PLIF/TLIF with a missed screw technique. Fusion was performed at two levels with no intervening screw at the middle pedicle

40. Methods Retrospective radiological analysis Fusion at 2 levels with missed screw technique Radiographs were assessed independently by Radiologist and Spinal Surgeon

41. Assessment Criteria Brantigan-Steffee fusion: -Denser and more mature bone fusion area than originally achieved at surgery -No interspace between the cage and the vertebral body -Mature bony trabeculae bridging the fusion area.

42. Demographics Total No: 40 Males: 24 Females: 16 Avg Age: 44.7 years Time period: 3 years & 6 months Mean Follow up: 19.8 months

43. Cages Used CARBON FIBER CAGESPEEK CAGES

44. Results Fusion achieved (assessed by Independent Observer) 29 patients (76%) at both levels 3 patients (7%) at one level No definite fusion was observed in the remaining 6 patients (15%) 2 excluded from study- inadequate follow up.

45. 57 yr old female Back pain & radiculopathy L3/4 Spondy Spondy L3/4 Disc Degeneration Reduced Disc Height

46. MRI L Spine Disc Degeneration L3/4,4/5,L5/S1 Minor Disc bulge L4/5

47. 2 level fusion Spondy reduced

48. 44 yr old male Chronic Back Pain

49. MRI L Spine Modic changes L4/5, L5/S1 Disc bulges L4/5, L5/S1

50. 2 level fusion Disc heights maintained Lordosis restored

51. 64 yr old female Chronic Back Pain

52. 2 level fusion

53. Conclusion Fusion can be achieved without middle pedicle screw while performing PLIF/TLIF at two levels

54. THANKS VERY MUCH

55. UNIVERSITY HOSPITAL OF NORTH TEES