We ’ re passionate about

2. We’re passionate about • Putting patients first • Quality, safety and patient experience • Transforming services to meet the health needs of future generations

3. Missed Screw Technique for Lumbar Fusion Shoaib Khan Mr Bhatia Mr Krishna

4. Opening of the Stockton and Darlington Railway Painting in 1880’s, crowds are watching the inaugural train cross the Skerne Bridge in Darlington.

5. Congreve Matchbox (1827) First Friction match developed by John Walker

6. Lumbar Spine Disease • Major public health concern • Leading cause of disability • Middle-age working population • Multiple avenues of treatment

7. Lumbar Spine Disease • Degenerative disc disorders • Secondary changes: Stenosis, Spondylolisthesis, Facet joint OA

8. Conservative Measures • Analgesia • Exercise • Education • Physiotherapy

9. Lumbar Spine Disease • Surgical treatment stabilization/fusion • The primary goal of treatment is pain relief and improve function

10. History of Procedure • Lumbar Fusion: 7 decades • Symptomatic Lumbar Spine disease

11. History of PLIF • 1944, Briggs and Milligan : Laminectomy • 1946, Jaslow: Spinous Process • 1953, Cloward: Iliac Crest Autograft • 1961, Humphreys: Ant lumbar plate

12. History of PLIF • 1990’s Interbody Implants and Instruments • Presently: Synthetic Cages/ Premilled Allograft

13. Evolution of Technique • Augmentation with Pedicle Screws • Stability of Construct • Increased Fusion rate

14. History of TLIF • 1982, Harms and Rolinger • Transforaminal route • Less retraction on thecal sac and nerves • Spares contralateral lamina, facet and pars • Safe for revision cases b/c of its PL trajectory

15. Indications • Spinal Instability • Spinal Stenosis • Spondylolisthesis • Degenerative scoliosis • Discogenic low back pain • Recurrent Lumbar Disc Herniation • Postdiscectomy collapse with neuroforaminal stenosis • Pseudoarthrosis

16. Techniques • ALIF • PLIF • TLIF • PLF • Circumferential fusion

17. Biomechanics • High fusion potential : Grafts are placed under compression • Interbody fusions place the bone graft in the load-bearing position spinal columns

18. Spinal Loads and Articular Surface in Lumbar Spine

19. Pedicle screw-rod constructs increase biomechanical rigidity and decrease pseudoarthrosis rates • Interbodyfusion devices: Restore intervertebral height and segmental lordosis

20. Interbody vs PL fusion

21. Relative Contraindications • Three Level DDD • Single level disc disease causing radiculopathy without back pain/instability • Severe osteporosis

22. Interbody Grafts • Autologous Illiac crest graft • Structural Allograft • Metallic cages with bone chips • Titanium Mesh Cages • Carbon Fiber Cages • PEEK cages

23. Interbody Cages • Provide stability, fills the disc space, require less structural bone graft • Maintain spinal alignment, neuroforaminal height, prevent graft dislodgement and collapse, enhance fusion rates • Carriers for osteoinductive or osteoconductive materials

24. PLIF Technique • Laminectomy and Facetectomy • Reveals rostral exiting and caudal traversing nerve roots and disk spaces • Thecal sac and nerve roots retracted medially

25. PLIF Technique • Discectomy  • Interbody graft placement • Pedicle screw-rod compression: restore lumbar lordosis and maintain disk height

26. PLIF Technique • Risks of incidental durotomy/nerve injury • Cages : Postoperative Radiculopathy • Bilateral facetectomy to achieve adequate graft placement • Postoperative Instability and failure if pedicle screw instrumentation is not added

27. TLIF Technique • Unilateral laminotomy and complete facetectomy on the symptomatic side or bilaterally • Full laminectomy and contralateral foraminotomy • Discectomy

28. TLIF Technique • Posterior bony lips of the end plates may be removed  • Interbody graft placement • Pedicle screw-rod compression: restore lumbar lordosis and maintain disk height

29. PLIF and TLIF ApproachBottom :TLIF Posterior Approach for PLIF PL Appraoch for TLIF

30. Graft Placement Posterior for PLIF PL for TLIF

31. PLIF Outcome • Good outcome in properly selected pt • Fusion rates: 85% • Comparison of low back fusion techniques: TLIF and PLIF approaches • Chad D. Cole Todd D. McCall Meic H. Schmidt .Andrew T. Dailey

32. TLIF Fusion Rate • Single-level TLIF: More than 90% • Multilevel procedure: Less than 90% • Villavicencio AT, Burneikiene S, Bulsara KR, et al: Perioperative complications in transforaminal lumbar interbody fusion versus anterior-posterior reconstruction for lumbar disc degeneration and instability. J Spinal Disord Tech 2006

33. TLIF vs PLIF STUDIES HAVE SHOWN THAT THE THERE IS NO STATISTICAL DIFFERENCE IN THE FUSION RATES OF TLIF Vs PLIF

34. Zhang, Qunhu et al. “A Comparison of Posterior Lumbar Interbody Fusion and Transforaminal Lumbar Interbody Fusion: A Literature Review and Meta-Analysis.”BMC Musculoskeletal Disorders 15 (2014): 367. PMC. Web. 22 Oct. 2015 • Park JS, Kim YB, Hong HJ, Hwang SN. Comparison between posterior and transforaminal approaches for lumbar interbody fusion. J Korean Neurosurg Soc.2005;37:340–344. • Yan DL, Li J, Gao LB, Soo CL. Comparative study on two different methods of lumbar interbody fusion with pedicle screw fixation for the treatment of spondylolisthesis. Zhonghua Wai Ke Za Zhi. 2008;467:497–500. • Zhuo X, Hu J, Li B, Sun H, Chen Y, Hu Z. Comparative study of treating recurrent lumbar disc protrusion by three different surgical procedures. Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi. 2009;23:1422–1426. 

35. PLIF Complications • Transient/ Permanent Nerve Injury • Graft Displacement • Intervertebral space collapse with neuroforaminalstenosis • Loosening • Subsidence • Pseudoarthrosis

36. TLIF Complications • Pedicle screw misplacement • Transient Neurological deficit • Dural/Neural injury • Graft extrusion

37. Other Complications • Blood loss • Durotomy • Arachnoiditis • Wound infection • Delayed wound healing • Haematoma • Screw misplacement

38. Other Complications • Intraoperative pedicle fracture • Urinary retention • Pulmonary embolism • Seroma • Epidural fibrosis/scar

39. Our Study • Rate of interbody fusion using PLIF/TLIF with a missed screw technique. • Fusion was performed at two levels with no intervening screw at the middle pedicle

40. Methods • Retrospective radiological analysis • Fusion at 2 levels with missed screw technique • Radiographs were assessed independently by Radiologist and Spinal Surgeon

41. Assessment Criteria • Brantigan-Steffee fusion: -Denser and more mature bone fusion area than originally achieved at surgery -No interspace between the cage and the vertebral body -Mature bony trabeculae bridging the fusion area.

42. Demographics • Total No: 40 • Males: 24 • Females: 16 • Avg Age: 44.7 years • Time period: 3 years & 6 months • Mean Follow up: 19.8 months

43. Cages Used CARBON FIBER CAGES PEEK CAGES

44. Results • Fusion achieved (assessed by Independent Observer) • 29 patients (76%) at both levels • 3 patients (7%) at one level • No definite fusion was observed in the remaining 6 patients (15%) • 2 excluded from study- inadequate follow up.

45. 57 yr old female • Back pain & radiculopathy • L3/4 Spondy Disc Degeneration Spondy L3/4 Reduced Disc Height

46. MRI L Spine • Disc Degeneration L3/4,4/5,L5/S1 • Minor Disc bulge L4/5

47. 2 level fusion • Spondy reduced

48. 44 yr old male • Chronic Back Pain

49. MRI L Spine • Modic changes L4/5, L5/S1 • Disc bulges L4/5, L5/S1

50. 2 level fusion • Disc heights maintained • Lordosis restored