Unilateral transforaminal lumbar interbody fusion and bilateral anterior-column fixation with two Brantigan I/F cages per level: clinical outcomes during a minimum 2-year follow-up period

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Object

There are no published reports of unilateral transforaminal lumbar interbody fusion (TLIF) in which two Brantigan I/F cages were placed per level through a single portal to achieve bilateral anterior-column support. The authors describe such a surgical technique and evaluate the clinical outcomes of this procedure.

Methods

Data obtained in 86 (93.5%) of the first 92 consecutive patients who underwent the procedure were retrospectively reviewed; the minimum follow-up duration was 2 years. The clinical outcomes were evaluated using the Japanese Orthopaedic Association (JOA) scoring system. Disc height, disc angle, cage positioning in the axial plane, and fusion status were radiographically evaluated.

The mean follow-up period was 33.8 months. The mean improvement in the JOA score was 77.2%. Fusion was successful in 93% of the cases. According to the Farfan method, the mean anterior and posterior disc heights increased from 20.2 and 16.9% preoperatively to 35.9 and 22.7% at follow up, respectively (p < 0.01). The mean disc angle increased from 4.8° preoperatively to 7.5° at last follow-up examination (p < 0.01). Two cages were correctly placed to achieve bilateral anterior-column support in greater than 85% of the cases. The following complications occurred: hardware migration in two patients and deep infection cured by intravenous antibiotic therapy in one patient.

Conclusions

Unilateral TLIF involving the placement of two Brantigan cages per level led to good clinical results. Two Brantigan cages were adequately placed via a single portal, and reliable bilateral anterior-column support was achieved. Although the less invasive unilateral approach was used, the outcomes were as good as those in many reported series of posterior lumbar interbody fusion in which the Brantigan cages were placed via the bilateral approach.

Abbreviations used in this paper: CT = computerized tomography; DSH = disc space height; JOA = Japanese Orthopaedic Association; MR = magnetic resonance; PLF = posterolateral fusion; PLIF = posterior lumbar interbody fusion; PS = pedicle screw; TLIF = transforaminal lumbar interbody fusion.

Article Information

Address reprint requests to: Hiroshi Taneichi, M.D., Center for Spinal Disorder and Injury, Bibai Rosai Hospital, Higashi-4, Mi-nami-1, 3-1, Bibai, 072-0015, Japan. email: tane@bibaih.rofuku.go.jp.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Artist’s illustrations of the unilateral TLIF that involves the placement of two Brantigan I/F cages per level. Access to the disc and preparation of the disc space is shown. A: Unilateral facetectomy is conducted to create access to the disc space for interbody fusion. Midline neural decompression is combined with unilateral facetectomy, if necessary. B: A portal for interbody fusion is created between the exiting nerve root and the thecal sac with the traversing root. These neural tissues are covered with cotton sheets to prevent injury during the intradiscal procedures. C: Aggressive discectomy is performed using straight and curved-ring curettes via a unilateral single portal. Not only the anterior portion but also the posterior portion and contralateral side of the disc space need to be almost completely excised. D: Disc height elevation maneuver. Following rough excision of the disc, a disc height expander is inserted for release of the disc space contracture. The increased DSH should be maintained using an interspinous spreader.

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    Artist’s illustrations of cage placement and bone graft insertion into the disc space. A muscle splitting paraspinal approach could also be used in this instance. A: Following the placement of morcellized cancellous bone graft material into the far anterior portion of the disc space, the first cage is obliquely inserted into the contralateral side of the disc space via the portal which is made on the surgeon’s side. B: After the cage holder has been detached, the posterior part of the cage is pushed toward the opposite side to be raised up by a cage positioner. C: The second cage is placed on the surgeon’s side after implanting the bone graft beside the first cage. D: Bilateral anterior-column support is attained using two Brantigan I/F cages placed via the unilateral approach

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    Artist’s illustrations of additional PLF and instrumentation placement. Left: Supplemental PLF is conducted. Center: Compressive force is applied to create physiological lumbar lordosis and to apply compressive force to the graft bone. Right: The unilateral TLIF procedures are completed.

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    Preoperative and postoperative radiological and neuroimaging studies obtained in a 60-year-old woman suffering from rheumatoid arthritis, a 3-year history of disabling low back pain, and an 11-month history of severe bilateral leg pain. A and B: Plain radiographs revealing spondylolisthesis with marked L4–5 disc collapse and mild T12–L5 scoliosis (16°). C: Sagittal MR imaging demonstrating L4–5 stenosis and L5–S1 intervertebral degenerative changes. The patient underwent unilateral L4–S1 TLIF. The portals were made in the concave side (left) of the scoliosis, allowing easy transposition of the cage from the portal side to the contralateral side.D and E: Axial MR images depicting wide two-column (L4–5 [D]) and narrow two-column (L5–S1 [E]) settings with good positioning of the contralateral cages; these provide reliable bilateral anterior-column support. F and G: Anteroposterior and lateral radiographs demonstrating solid union with physiological alignment in both the coronal and sagittal planes at 32 months after surgery.

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