Prospective analysis of clinico-radiological efficacy of Trans-foraminal Lumbar Interbody Fusion (TLIF) in degenerative disc disease - Mid term follow up of 2 years
Background: Low back pain as a result of degenerative disc disease (DDD) imparts a large socioeconomic impact on the health care system. Correct diagnosis and treatment of DDD is difficult and controversial. Whether inter-body fusion is the treatment of choice in DDD is still a dilemma. The Transforaminal interbody fusion (TLIF) developed by Harms is a modification of posterior lumbar interbody fusion(PLIF). Advantage of the TLIF over PLIF with lesser complications avoidance of epidural scarring, less intra-operative bleeding, and lesser chance of dural injury.
Methods: We evaluated 30 patients operated for DDD with TLIF between 2014 to 2017. Patients > 35 years, both sexes, two level or less involvement, degenerative spondylolisthesis (grade I, II), with predominantly low-back pain, with or without radiculopathy or claudication, disability to perform daily activities and not relived by non-operative treatment for at least 6 months were included. All other cases were excluded. Thorough clinical and radiological examination was done. Patient was followed up at 1, 3, 6 and 9 months post-op for X-ray (to see for progress of union), VAS score and ODI index and complications. Bony fusion was assessed by a single radiologist on basis of X-ray only.
Results: 17 M 13 F patients with 19 patients having instability while 11 not, were evaluated. L4-5 was the most common level. Average pre-operative VAS score was 7.7667 (S.D 1.104) while at last follow-up was 2.133 (S.D 0.434). Average pre-operative ODI was 47.133 (S.D 8.215) while at last follow-up it was 25.533 (S.D 4.191) (Table-2). Mean operative time for one and two level was 97.3 minutes and 143.2 minutes respectively. Average blood loss was 465 ml (390- 580ml). 28 patients had bony fusion at last follow-up (93 %). Two patients who did not show bony fusion were asymptomatic. We encountered intra-operative violation of S1 pedicle in one case, dural puncture in three cases, contra-lateral radiculopathy in one case and asymptomatic adjacent segment disease in 4 cases at final follow-up.
Conclusion: We conclude from our study that TLIF is simpler, easier and safe procedure for Degenerative Disc Disease with good surgical, functional and radiological outcomes.
Harms J, Jeszenszky D (1998). The unilateral transforaminal approach for posterior lumbar interbody fusion. OrthopTraumatol 6:88-99.
Krock E, Rosenzweig DH, Chabot-Doré AJ, Jarzem P, Weber MH, Ouellet JA, Stone LS, Haglund LJ Cell Mol Med. Painful, degenerating intervertebral discs up-regulate neurite sprouting and CGRP through nociceptive factors. 2014 Jun; 18(6):1213-25.
Hancock MJ, Maher CG, Latimer J, Spindler MF, McAuley JH, Laslett M, Bogduk N. Systematic review of tests to identify the disc, SIJ or facet joint as the source of low back pain. Eur Spine J. 2007 Oct; 16(10):1539-50.)
Shemshaki H, Nourian SM, Fereidan-Esfahani M, Mokhtari M, Etemadifar MR J. What is the source of low back pain? Craniovertebr Junction Spine. 2013 Jan; 4(1):21-4.)
D'Orazio F, Gregori LM, Gallucci M Eur J Radiol. Spine epidural and sacroiliac joints injections--when and how to perform. 2015 May; 84(5):777-82.)
Tessitore E, Molliqaj G, Schatlo B, Schaller K. Clinical evaluation and surgical decision making for patients with lumbar discogenic pain and facet syndrome. Spine (Phila Pa 1976) 2014;39:1314–24.
Watters WC 3rd, Resnick DK, Eck JC, Ghogawala Z, Mummaneni PV, Dailey AT, Choudhri TF, Sharan A, Groff MW, Wang JC, Dhall SS, Kaiser MG J. Guideline update for the performance of fusion procedures for degenerative disease of the lumbar spine. Part 13: injection therapies, low-back pain, and lumbar fusion. Neurosurg Spine. 2014 Jul; 21(1):79-90.
Humphreys SC, Hodges SD, Patwardhan AG, Eck JC, Murphy RB, Covington LA. Comparison of posterior and transforaminal approaches to lumbar interbody fusion. Spine (Phila Pa 1976) 2001;26:567–71.
Zhang Kai, Sun Wei,Zaho Chang-qing, Li Hua, Ding Wei, Xei You-zhuan, Sun Xiao-jiang & Zaho Jie: International orthopaedics (SICOT)38:111-116.(2014).
Deng-Lu Yan, Fu-Xing Pei, Jian LI, Cheng-long Soo (2008) Comparative study of PILF and TLIF treatment in adult degenerative spondylolisthesis. Eur spine J 17(10):1311-1316.
Sloboda T, Rusnak R: Minimally invasive transforaminal fusion (mitlif) for the treatment of the degenerative lumbar spine (Single centre study). Int Health Journal. 2016 March;1:17-20
MJD Jacobsohn; RN Dunn. Transforaminal lumbar interbody fusion (TLIF): Assessment of clinical and radiological outcome, SA orthop. j. vol.8 n.1 Pretoria Jan. 2009
Seng-Yew Poh, Wai-Mun Yue, Li-Tat John Chen, Chang-Ming Guo, William Yeo, Seang-Beng Tan. Two-year outcomes of transforaminal lumbar interbody fusion, Journal of Orthopaedic Surgery 2011;19(2):135-40)
Pier Paolo Mura, Mauro Costaglioli, Maurizio Piredda, Silvia Caboni , Silvia Casula, TLIF for symptomatic disc degeneration: a retrospective study of 100 patients. Eur Spine J (2011) 20 (Suppl 1):S57–S60)
Lowe T, Tahernia A (2002) Unilateral transforaminal posterior lumbar interbody fusion procedure. Orthopaedics 25: 1179-1183.
Khan NR1, Clark AJ, Lee SL, Venable GT, Rossi NB, Foley KT. Surgical Outcomes for Minimally Invasive vs Open Transforaminal Lumbar Interbody Fusion: An Updated Systematic Review and Meta-analysis. Neurosurgery. 2015 Dec;77(6):847-74)
Lauber S, SchulteTL, Liljenqvist U, Halm H, Hackenberg L. Clinical and radiologic 2-4-year results of transforaminal lumbar interbody fusion in degenerative and isthmic spondylolisthesis grades 1 and 2. Spine (Phila Pa 1976) 2006;31:1693–8)
Alsebaey AA, Seleem NA (2017) Transforaminal Lumber Interbody Fusion in Management of Degenerative Lumber Disc Disease. Research Article 8(3): 00316. DOI: 10.15406/mojor.2017.08.00316
France JC, Norman TL, Santrock RD, McGrath B, Simon BJ. Randomised prospective study of posterolateral fusion: Outcome with and without pedicle screw instrumentation. Spine 1999 March 15;24(6):553-60.)
Kanyana M, Cunningham BW, Sefter JC, Goldstein JA, Stewart G, Kaneda K. Does spinal instrumentation influence healing process of posterolateral fusion? An in vivo animal model. Spine 1999 June 1;24(11):1058-65.)
Rosenberg WS, MummaneniPV.Transforaminal lumbar interbody fusion: technique, complications, and early results, Neurosurgery.75-48:569;2001
McAfee PC, DeVine JG, Chaput CD, Prybis BG, Fedder IL, Cunningham BW, Farrell DJ, Hess SJ, Vigna FE. The indications for interbody fusion cages in the treatment of spondylolisthesis: analysis of 120 cases. Spine (Phila Pa 1976). 2005 Mar 15;30(6 Suppl): S60-5.
Hunt, T., Shen, F.H., Shaffrey, C.I. et al. Eur Spine J (2007) 16(Suppl 3): 311.
Ghiselli G, Wang JC, Bhatia NN, Hsu WK, Dawson EG. Adjacent segment degeneration in the lumbar spine. J Bone Joint Surg Am 2004; 86:1497–503.
Park P, Garton HJ, GalaVC, Hoff JT, McGillicuddy JE. Adjacent segment disease after lumbar or lumbosacral fusion: review of the literature. Spine (Phila Pa 1976) 2004; 29:1938–44.
Adjacent level disease following lumbar spine surgery: A review. Nancy E. Epstein. SurgNeurol Int. 2015; 6(Suppl 24): S591–S599.