Percutaneous Transforaminal Lumbar Interbody Stabilization

Published on 10/03/2015 by admin

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Last modified 10/03/2015

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Chapter 29 Percutaneous Transforaminal Lumbar Interbody Stabilization

Sang-Ho. Lee, MD, PhD, Won-Chul. Choi, MD

Percutaneous endoscopic transforaminal discectomy has been an effective alternative to microdiscectomy for patients with soft lumbar disc herniations [1–5]. However, it is ineffective in the presence of lumbar segmental instability due to degenerative disc disease. Percutaneous transforaminal lumbar interbody stabilization (PTLIS) is a new surgical method for treating lumbar segmental instability due to degenerative disc disease and low-grade degenerative spondylolisthesis.

The specially designed B-Twin expandable holder (Disc-O-Tech Medical Technologies Ltd., Herzliya, Israel), which is made of titanium, is used as an interbody spacer to achieve stability without open discectomy and fusion [6–11]. In cases of failure, this minimally invasive procedure does not impede conventional surgical approaches.

Advantages

The major advantages of PTLIS are as follows:

image It requires a small insertion diameter.
image There is no soft tissue and bone damage.
image The facet joints are not destroyed.
image Stability is not compromised.
image There is no dural sac or root manipulation.
image There is less risk of cerebrospinal fluid fistula and neurologic compromise.
image The amount of bleeding is negligible.
image There is a lower risk of infection.
image The procedure can be done alone or supplemented with pedicle screw fixation.

Indications

PTLIS is performed for the following conditions:

image Degenerative disc disease (DDD)
image Internal disc derangement syndrome (IDD)
image Herniated lumbar discs with segmental instability
image Degenerative spondylolisthesis
image Spinal stenosis with segmental instability
image Recurrent disc herniation

Contraindications

The contraindications to PTLIS include the following:

image Infectious conditions such as tuberculosis
image Severe osteoporosis
image More than grade II spondylolisthesis
image Spine infection, tumor, metabolic bone disease

Complications

The following complications have occurred with PTLIS:

image Deterioration of the spinal curvature
image Implant migration or malpositioning
image Device deformity or breakage
image Infection
image Bone fracture at the level of surgery
image Discitis, arachnoiditis, or other inflammation
image Subsidence

Preoperative preparation

Patient Symptoms

The patient in whom PTLIS is performed suffers from low back pain with or without leg pain due to instability.

Imaging Diagnosis

PTLIS is performed in patients in whom imaging detects the following:

image Magnetic resonance imaging findings correspond with physical findings.
image Computed tomography depicts a soft disc herniation.

Plain films are used preoperatively for intervertebral space measurement.

Instrumentation

The implant is supplied preloaded on its delivery system. It is inserted into the intervertebral space in a narrowed tube configuration and is expanded once in place.

Prior to surgery, the required implant diameter is determined through the use of lateral and anteroposterior radiographs and computed tomography or magnetic resonance imaging. The intervertebral space is measured, and 10% to 20% is added to determine the appropriate expanded diameter of the device (Table 29.1). This diameter determines the implant to be selected.

Table 29.1 Selection of Size of B-Twin Implant*

image

The length of the intervertebral space (the anteroposterior borders of the vertebral body) should be at least 28 mm for the use of the trapezoid implants. Verification of implant diameter and length is also performed during surgery, as detailed in the later Figures 29-1 to 29-8

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