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#10698

Hey Dr. Corenman:

I have a Grade one spodylolisthesis (bi-lateral pars fracture) at L5,S1 with major disc herniation at the same level. Everything else seems to be in tact.

I have gone through all conservative modalities for 3.5 years. It is now time to get it fixed.

As a 40 yr old male with no children, 6’1 – 225 lbs it sounds as though a PLIF is the best option for me. Surgeon will be removing pars defect/lamina and putting two cages in disc space.

1.) Are you a fan of PLIF for grade one sopndy with bi-lateral pars fracture? PLIF seems to be a painful and long recovery, but makes the most sense to me.

2.) If a MIS TLIF was performed would the single cage with bone graft give me a strong enough fusion considering my size ?

3.) With MIS TLIF would it be ok to leave PARS fracture/Lamina where it is… ?

What is your suggestion ?

Thank you !

[Donald Corenman, MD, DC]

#10725

First, you need to consider the goals for this surgery. The three goals would be a solid fusion, good alignment and decompression of the nerve roots.

Generally this is done with one or two cages implanted into the disc space to realign the vertebra to the sacrum. Bone graft (and BMP if it is used) is placed into the disc space to produce a fusion of the two vertebra.

The posterior lamina and facets (which have been disconnected from the L5 vertebra due to the spondylolisthesis for many years) are removed to gain access to the L5 nerve roots and free them from bone spur or herniation. Removal of this lamina also allows this bone to be used as bone graft-very important.

Finally, bone graft is placed into the lateral gutters (the side area of the transverse processes and sacrum) to allow a posterolateral fusion.

This sequence can be performed by a TLIF, PLIF or “minimally invasive procedure”. You must understand that the term “minimally invasive” is not really correct as two incisions have to be made on the sides of the spine to do this “minimally invasive” procedure. Measure the length of these incision and they will be greater than one small central incision.

There really is no benefit for a fusion, especially of an isthmic spondylolisthesis with this procedure. “Minimally invasive” is a great term with lots of “curb appeal” but the surgery is not really “minimally invasive” and the success rate is not equal to minimal central incision in my opinion.

PLIF or TLIF will both be effective. It really depends upon the ability of the surgeon.

Dr. Corenman

PLEASE REMEMBER, THIS FORUM IS MEANT TO PROVIDE GENERAL INFORMATION ON SPINE ANATOMY, CONDITIONS AND TREATMENTS. TO GET AN ACCURATE DIAGNOSIS, YOU MUST VISIT A QUALIFIED PROFESSIONAL IN PERSON.
 
Donald Corenman, MD, DC is a highly-regarded spine surgeon, considered an expert in the area of neck and back pain. Trained as both a Medical Doctor and Doctor of Chiropractic, Dr. Corenman earned academic appointments as Clinical Assistant Professor and Assistant Professor of Orthopaedic Surgery at the University of Colorado Health Sciences Center, and his research on spine surgery and rehabilitation has resulted in the publication of multiple peer-reviewed articles and two books.

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#10727

Thank you Dr. Corenman:

1.) If TLIF only has one cage would that provide a strong enough fusion for a guy my size 6,1 – 225 going through the foramina.

2.) Sounds like PLIF would provide better access to removing pars defect with 2 cages and still provide a stronger fusion. Is this accurate ?

3.) It appears that PLIf is more invasive with greater risk of blood loss than a TLIF with the incisions on both sides ??

Thank you !!

[Donald Corenman, MD, DC]

#10728

First you have to know that the cage is a temporary spacer and you are depending upon the fusion to carry the load. One large TLIF cage is the equivalent of two smaller PLIF cages with regards to surface area.

A PLIF is a fine fusion technique but placing the cage requires nerve root retraction which on rare occasions aggregates a nerve root. Placing one cage (TLIF) requires only one nerve root to retract. A PLIF requires two nerve retractions. Again, normally not a significant point but on rare occasions, can be important.

The pars defect should be removed in my opinion on both sides to decompress the L5 root. This can be done with both the PLIF and TLIF.

The PLIF should have no greater blood loss than a TLIF.

I do think a “minimally invasive” surgery is actually more invasive than a minimal central incision surgery or what I call minimal incision spine surgery.

Dr. Corenman

PLEASE REMEMBER, THIS FORUM IS MEANT TO PROVIDE GENERAL INFORMATION ON SPINE ANATOMY, CONDITIONS AND TREATMENTS. TO GET AN ACCURATE DIAGNOSIS, YOU MUST VISIT A QUALIFIED PROFESSIONAL IN PERSON.
 
Donald Corenman, MD, DC is a highly-regarded spine surgeon, considered an expert in the area of neck and back pain. Trained as both a Medical Doctor and Doctor of Chiropractic, Dr. Corenman earned academic appointments as Clinical Assistant Professor and Assistant Professor of Orthopaedic Surgery at the University of Colorado Health Sciences Center, and his research on spine surgery and rehabilitation has resulted in the publication of multiple peer-reviewed articles and two books.

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#10732

Thank you.

I agree about the nerve root retraction. It concerns me.

Inserting one large cage with TLIF sounds easier than two smaller cages with with PLIF. My neuro did say, however, that with the PLIF if one cage doesn’t fuse that the second cage is a good back up??

1.) Is PLIF with the two cages a newer type of procedure ?

2.) Do you perform a TLIF through one incision off to the side through a tube to dilate muscle or through two incisions on either side with retractor tubes ?

3.) Do you insert BNP laterally as well as into the disc space to supplement cage ?

4.) Can BNP cause inflammation/pain at a later date ?

Sorry for all the questions!!! Thank you so much!

[Donald Corenman, MD, DC]

#10735

The amount of cages used in the disc space is not important for fusion. One or two does not matter for fusion. My fusion rate for a TLIF is about 99% using one cage.

The PLIF is actually an older procedure than the TLIF. I started performing PLIFs about 15 years ago and switched to the TLIF about 12 years ago. This does not invalidate the PLIF procedure however.

I perform the TLIF through a central incision using a microscope. When the minimally invasive surgeons state they “split muscle”, this is really incorrect. In order to get pedicle screws in, you have to disconnect muscle from its insertion. In addition, when you fuse a segment, this segmental muscle becomes unimportant.

In addition, the muscles that cross one segment are the ones that need to be displaced or there is no fusion bed for the posterior fusion. The preservation of these small muscles that cross the segment you are fusing is not needed as there will be no motion of this segment after successful fusion.

I use BMP for fusion in most cases. Yes, I use BMP in the lateral gutters (between the transverse processes and facets) as well as in the disc space.

BMP if not used correctly can irritate the nerve root. Care must be taken to separate the root from the BMP.

Dr. Corenman

PLEASE REMEMBER, THIS FORUM IS MEANT TO PROVIDE GENERAL INFORMATION ON SPINE ANATOMY, CONDITIONS AND TREATMENTS. TO GET AN ACCURATE DIAGNOSIS, YOU MUST VISIT A QUALIFIED PROFESSIONAL IN PERSON.
 
Donald Corenman, MD, DC is a highly-regarded spine surgeon, considered an expert in the area of neck and back pain. Trained as both a Medical Doctor and Doctor of Chiropractic, Dr. Corenman earned academic appointments as Clinical Assistant Professor and Assistant Professor of Orthopaedic Surgery at the University of Colorado Health Sciences Center, and his research on spine surgery and rehabilitation has resulted in the publication of multiple peer-reviewed articles and two books.

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