J Korean Neurosurg Soc.  2019 Jul;62(4):422-431. 10.3340/jkns.2018.0143.

Correction of Spondylolisthesis by Lateral Lumbar Interbody Fusion Compared with Transforaminal Lumbar Interbody Fusion at L4–5

• Ko MJ
• Park SW
• Kim YB

• KMID: 2463673
• DOI: http://doi.org/10.3340/jkns.2018.0143

Abstract

OBJECTIVE
In an aging society, the number of patients with symptomatic degenerative spondylolisthesis (DS) is increasing and there is an emerging need for fusion surgery. However, few studies have compared transforaminal lumbar interbody fusion (TLIF) and lateral lumbar interbody fusion (LLIF) for the treatment of patients with DS. The purpose of this study was to investigate the clinical and radiological outcomes between TLIF and LLIF in DS.
METHODS
We enrolled patients with symptomatic DS at L4-5 who underwent TLIF with open pedicle screw fixation (TLIF group, n=41) or minimally invasive LLIF with percutaneous pedicle screw fixation (LLIF group, n=39) and were followed-up for more than one year. Clinical (visual analog scale and Oswestry disability index) and radiological outcomes (spondylolisthesis rate, segmental sagittal angle [SSA], mean disc height [MDH], intervertebral foramen height [FH], cage subsidence, and fusion rate) were assessed. And we assessed the changes in radiological parameters between the postoperative and the last follow-up periods.
RESULTS
Preoperative radiological parameters were not significantly different between the two groups. LLIF was significantly superior to TLIF in immediate postoperative radiological results, including reduction of spondylolisthesis rate (3.8% and 7.2%), increase in MDH (13.9 mm and 10.3 mm) and FH (21.9 mm and 19.4 mm), and correction of SSA (18.9° and 15.6°) (p<0.01), and the changes were more stable from the postoperative period to the last follow-up (p<0.01). Cage subsidence was observed significantly less in LLIF (n=6) than TLIF (n=21). Fusion rate was not different between the two groups. The clinical outcomes did not differ significantly at any time point between the two groups. Complications were not statistically significant. However, TLIF showed chronic mechanical problems with screw loosening in four patients and LLIF showed temporary symptoms associated with the surgical approach, such as psoas and ileus muscle symptoms in three and two cases, respectively.
CONCLUSION
LLIF was more effective than TLIF for spondylolisthesis reduction, likely due to the higher profile cage and ligamentotactic effect. In addition, LLIF showed mechanical stability of the reduction level by using a cage with a larger footprint. Therefore, LLIF should be considered a surgical option before TLIF for patients with unstable DS.

Keyword

Spinal fusion; Minimally invasive surgical procedures; Spondylolisthesis

MeSH Terms

Aging
Follow-Up Studies
Humans
Ileus
Minimally Invasive Surgical Procedures
Pedicle Screws
Postoperative Period
Spinal Fusion
Spondylolisthesis*

Figure

• 

  Fig. 1. Spondylolisthesis reduction in TLIF and LLIF. In preoperative state of DS, disc bulging and bucking of posterior longitudinal ligament and ligamentum flavum cause stenosis (A). TLIF improves stenosis through direct decompression of posterior elements, but it is difficult to insert of a cage with sufficient height, which is disadvantageous in terms of the spondylolisthesis reduction (B). LLIF can maximize the ligamentotaxic effect through insertion of cage with sufficient height, which indirectly decompresses the foraminal stenosis as well as corrects the DS effectively (C). TLIF : transforaminal lumbar interbody fusion, LLIF : lateral lumbar interbody fusion, DS : degenerative spondylolisthesis.

• 

  Fig. 2. Cases showing the largest change of reduced spondylolisthesis from immediate postoperative to last follow-up X-ray. In TLIF case, spondylolisthesis rate was 23.6% at preoperative (A), and reduced to 7.5% at immediately postoperative (B). It was slipped to 21.2% at 23 months after surgery (C). In LLIF case, spondylolisthesis rate was 28.7% at preoperative (D), and reduced to 6.7% at immediately postoperative (E). Then, it was 10.4% at 45 months after surgery (F). TLIF : transforaminal lumbar interbody fusion, LLIF : lateral lumbar interbody fusion.

Reference

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