Paraspinal-approach transforaminal lumbar interbody fusion for the treatment of lumbar foraminal stenosis

Clinical article

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Object

Foraminal stenosis is a common cause of lumbar radicular symptoms. Recognition of the dynamic pathology, as well as the static anatomical changes, is important to achieving successful surgical outcomes. Excessive facet and anulus removal leads to subsequent disc space narrowing and/or segmental instability, which can cause poor results after decompressive surgery. The objective of this study was to evaluate the efficacy of the paraspinalapproach transforaminal lumbar interbody fusion (TLIF) in the treatment of lumbar foraminal stenosis.

Methods

Twenty levels of lumbar foraminal stenosis in 16 patients were treated using an instrumented paraspinal-approach TLIF. There were 12 single-level and 4 two-level cases. Pathologies included foraminal stenosis at 13 levels and lateral disc herniation with disc space narrowing at 7.

Results

In all patients, preoperative radicular symptoms and mechanical low-back pain were resolved immediately after the operation and leg weakness improved gradually. The recovery rate using the Japanese Orthopaedic Association score was 89.1%. Bony union was achieved within 6 months after the operation in all cases. Postoperative MR imaging showed minimal changes in the paraspinal muscles in the single-level cases.

Conclusions

The paraspinal-approach TLIF is a minimally invasive, safe, and secure procedure for treating lumbar foraminal lesions. Direct visualization and decompression for the foraminal lesion, distraction of the collapsed disc space, and stabilization of the unstable segments can be achieved simultaneously through the paraspinal approach, which produces successful clinical and radiological results.

Abbreviations used in this paper: DRG = dorsal root ganglion; JOA = Japanese Orthopaedic Association; PS = pedicle screw; TLIF = transforaminal lumbar interbody fusion.

Article Information

Address correspondence to: Shunsuke Fujibayashi, M.D., Ph.D., Department of Orthopaedic Surgery, Graduate School of Medicine, Kyoto University, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto 606-8507, Japan. email: shfuji@kuhp.kyoto-u.ac.jp.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Disc height and foraminal height (FH) were measured using lateral radiographs obtained in the neutral position. Disc height was calculated as the average of the anterior disc height (A) and posterior disc height (B). Foraminal height was measured as the distance between the pedicles.

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    Magnetic resonance imaging grades of paravertebral muscle injury. Preoperative images are shown on the left and postoperative images on the right. A: Typical case of Grade 0 with no signal change in the multifidus muscle. B: Typical case of Grade 1 with signal change in less than 50% of the cross-sectional area of the multifidus. The arrow indicates muscle degenerative changes in the deep layer of the muscle. C: Typical case of Grade 2 with signal change in more than 50% of the multifidus area. The arrow indicates muscle degenerative changes in the multifidus muscle.

  • View in gallery

    Artist's illustration of the paraspinal-approach TLIF. Left: Bilateral paraspinal approach, placement of the PSs, and exposure of the neural foramen after excision of the unilateral facet joint. Right: Interbody placement of the titanium cage combined with porous hydroxyapatite spacer and grafting of autologous local bone chips around the cage and contralateral facet joint.

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    Case 6. Preoperative and postoperative radiological studies obtained in a 58-year-old man with foraminal stenosis combined with lateral disc herniation at L5–S1. A: Parasagittal MR image demonstrating foraminal stenosis with a Modic change of the vertebral endplate. B: Axial MR image demonstrating foraminal stenosis with lateral disc herniation (arrow) on the right side at the L5–S1 level. C and D: Anteroposterior and lateral radiographs demonstrating good positioning of the interbody cage and PSs. E: Sagittal reconstruction CT image demonstrating solid bony union into and around the cage 6 months after surgery. F: Axial MR images demonstrating minimal changes in the paraspinal muscles before surgery (upper) and 6 months after surgery (lower).

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