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Thank you,
The intricate details of the surgery are important to me, I apologize if some of my questions are redundant.
1.) you are making an incision directly in the middle of the back, in the same place the incision is made for a PLIF ?
Most surgeons describe TLIF as an incision off to one side and then tunneling to the disc space through one side of the facet, leaving the other facet in tact.
2.) will you decompress the nerves by directly unroofing the lamina bone/pars like described in the PLIF through the direct incision in the middle ?
3.) If so, you are then taking this bone, putting it in the cage and then also packing the disc space with BNP along with the later gutters?
It sounds as though the difference between TLIF and PLIF as you describe it is that you are inserting one large cage through the side facet instead of moving the spinal cord side to side to insert two smaller cages, which could thereby aggravate the nerve root ?
4.) Who is the manufacturer of the cage or instrumentation that you like to use ? Are you able to endorse ?
Thank you kindly.
I make an incision directly in the middle of the back. This has advantages and disadvantages compared with the “minimally invasive” technique which uses two side incisions.
The best advantages are that you work in the natural plane between the muscles. Muscles are located on both sides of the spine and insert into the midline (the main muscles never enter this area and stay on the side). This allows the surgeon to see a symmetric appearance of the spine and easily deal with the spinal canal.
In the case of an isthmic spondylolisthesis, the removal of the central lamina is simple and the nerve roots are easily approached to be decompressed. This technique also allows the use of a microscope so I can illuminate and enlarge the surgical area. I like to say the microscope turns a centimeter into a football field. The microscope also allows my physicians assistant to see exactly what I am seeing to help with keeping the area dry and use retraction wisely. I can also see what my PAs are doing to make sure they are gentile with the nerves.
The drawback to this approach is that placement of pedicle screws are slightly more difficult. This drawback is overcome with the use of the O arm and Stealth (see website for complete description). These two tools are really a GPS for the spine so the screws can be easily placed under a synthetic view. The screws are visualized superimposed on the spinal structures to make placement perfect.
The “minimally invasive” technique is a wonderful name that conjures up this “tiny approach” and tiny little incisions but the reality is not accurate. This approach actually causes more trauma than my technique and has measurably longer incisions. I was told once that the “minimally invasive” technique “sells the sizzle and not the steak”.
In my experience, this “minimally invasive” technique for fusion is not as effective for surgical success. I base that knowledge on the revisions I have to do in my practice. 50% of my surgical practice is revision surgery (fixing problems that have occurred from prior surgery from other institutions). Most of the fusion and decompression failures I have seen occur from this “minimally invasive” technique.
This is not to say that the “minimally invasive” technique does not have its place. I use this technique for far lateral lumbar disc herniations and posterior cervical foraminotomies. You can see this technique in action on video on this website under those two surgical procedures. I do think that some surgeons who have mastered the “minimally invasive” technique could still do a good job with fusion but the disadvantages far outweigh the advantages in my opinion.
The bone graft originates from the removed bone (and BMP) and no longer from the hip. The bone from the lamina that is removed is cleaned, ground up to activate the trapped bone cells inside this bone and then placed into the cage implanted in the disc space, added to BMP which is also placed into the disc space and placed in the lateral gutters.
There is no spinal cord in the lumbar spine below L1. Only spinal nerves are found in the canal below this level. Spinal nerves can be retracted but not the spinal cord.
The cage I use is a Medtronic product called a Boomerang cage. I have my specific reasons for this cage but any cage made out of PEEK (polyether ether ketone) will probably work well.
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.Thank you for the detailed response. Much appreciated!
1.) You did not explain how you insert the cage. Do you insert cage from the side or or do you retract spinal cord to the side like in a PLIF and slide cage in ?
2.) If there is no spinal cord under L1 and my surgery is at L5,S1 then retracting the spinal cord side to side is not dangerous, is it ??
THANK YOU AGAIN FOR ALL OF YOUR HELP!!
Placement of the cage is between the traversing and exiting nerve roots (on the back corner of the disc space). There is about 8- 10mm of natural space between these two nerve roots. When you then retract the traversing root (which has about 8mm of natural motion), there is over 14mm of space that can be used to place the cage.
Retracting nerve roots in not inherently dangerous as long as the root is pliable and relaxed. There are times with a TLIF or PLIF that the nerve root is tethered and has to be decompressed prior to retraction or is scarred down (from prior surgery) and will not retract as far as it should.
This is why the microscope is so important. I can visualize the retraction performed by my assistant (as well as he can) and determine if the nerve is mobile or not. Accomodations are taken if the nerve does not mobilize well.
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.Thank you so very much.
1.) What kind of accommodations are taken if nerve does not mobilize well ?
2.) Will fusion bed be big enough to produce a strong enough fusion with TLIF ?
My neuro originally wanted to do ALIF to get bigger fusion bed, this then switched to PLIF because he said the two cages would provide a strong enough fusion if I didnt want to go through the front.
He originally said that going straight through the back would not be enough to support me therefore we needed the ALIF spacer with the 4 screws built in along the four screws and two rods in the back – lot of hardware. 4 hour surgery.
It has been difficult to find a good direction on how to proceed.
I will be contacting your office to send you my MRI.
If the nerve does not mobilize well, greater care has two be taken to protect the nerve while placing the cage.
TLIFs produce a great fusion. Remember that the cage is only a temporary spacer and is irrelevant when the fusion becomes solid.
4 screws are standard for a posterior fusion. There are two pedicles above and two below. Each pedicle gets one screw so there are four points of fixation to secure the two vertebra together. Again, these screws are superfluous when the fusion becomes solid.
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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