A prospective randomized controlled study comparing transforaminal lumbar interbody fusion techniques for degenerative spondylolisthesis: unilateral pedicle screw and 1 cage versus bilateral pedicle screws and 2 cages

Clinical article

Yasuchika Aoki Department of Orthopaedic Surgery, Chiba Rosai Hospital;
Department of Orthopaedic Surgery, Toho University Sakura Medical Center;

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Masatsune Yamagata Department of Orthopaedic Surgery, Chiba Rosai Hospital;

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Yoshikazu Ikeda Department of Orthopaedic Surgery, Chiba Rosai Hospital;

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Fumitake Nakajima Department of Orthopaedic Surgery, Chiba Rosai Hospital;

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Seiji Ohtori Department of Orthopedic Surgery, Graduate School of Medicine, Chiba University; and

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Koichi Nakagawa Department of Orthopaedic Surgery, Toho University Sakura Medical Center;

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Arata Nakajima Department of Orthopaedic Surgery, Toho University Sakura Medical Center;

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Tomoaki Toyone Department of Orthopaedic Surgery, Teikyo University Chiba Medical Center, Chiba, Japan

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Sumihisa Orita Department of Orthopaedic Surgery, Chiba Rosai Hospital;

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Kazuhisa Takahashi Department of Orthopedic Surgery, Graduate School of Medicine, Chiba University; and

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Object

Many surgeons currently prefer to use transforaminal lumbar interbody fusion (TLIF), placing 1 unilateral pedicle screw (PS) and 1 cage. However, no study has examined whether unilateral fixation improves surgical outcome. The authors conducted a prospective randomized controlled trial with a minimum 2-year follow-up to analyze TLIF outcomes for 2 techniques: placement of a unilateral PS and a cage compared with placement of bilateral PSs and 2 cages.

Methods

Fifty patients with degenerative spondylolisthesis undergoing single-level TLIF were randomly assigned to receive either unilateral or bilateral fixation. Parameters compared between the groups were surgical invasiveness, severity of intermittent claudication, pre- and postoperative visual analog scale (VAS) scores (from 0 to 10 for back pain, lower-extremity pain, and lower-extremity numbness), postoperative disability scores for lumbar spinal disorders (Japanese Orthopaedic Association Back Pain Evaluation Questionnaire [JOABPEQ]), and fusion rates.

Results

The mean operative time for TLIF was significantly (p = 0.05) shorter and mean estimated blood loss was significantly lower in the unilateral than in the bilateral group. Intermittent claudication improved in response to each technique, but there was no significant intergroup difference. The unilateral group had a nonsignificant tendency toward less improvement in VAS score for back pain (1.5 vs 3.7 for the bilateral group) and exhibited significantly less improvement in VAS score for lower-extremity pain (2.1 vs 5.1, respectively) and numbness (1.7 vs 4.4). There were no significant differences between the groups in postsurgical scores for all 5 items of the JOABPEQ. The fusion rates were 87.5% (21 of 24 patients) in the unilateral group and 95.7% (22 of 23) in the bilateral group.

Conclusions

Transforaminal lumbar interbody fusion involving unilateral PS fixation and a single-cage technique is less invasive than a 2-cage technique and bilateral fixation, and it improved patients' symptoms. However, it resulted in less improvement in back pain, lower-extremity pain, and lower-extremity numbness. When considering unilateral PS fixation and a single cage, the surgeon should be aware of the potential limitations of this technique. Clinical trial registration no.: UMIN000007833 (UMIN).

Abbreviations used in this paper:

EBL = estimated blood loss; JOA = Japanese Orthopaedic Association; JOABPEQ = JOA Back Pain Evaluation Questionnaire; PLIF = posterior lumbar interbody fusion; PS = pedicle screw; TLIF = transforaminal lumbar interbody fusion.
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