-
AuthorPosts
-
Thank you again. I follow your logic but I guess not everyone has the same logic. Again, many surgeons seem very enthused with the ALIF recovery time and the fact that there is no nerve retraction. However, it sounds like the cons of ALIF could far out weigh the pros especially for a male patient…
“The pars fractures that caused the isthmic spondylolisthesis separates the facets from the entire vertebra. Preserving the facets will not make a difference in stability, but there are detriments to not removing them.”
“These facets are great bone graft sources and should be used for graft. Not using them again makes absolutely no sense. This graft can make the difference between a solid fusion and no fusion at all. In addition, there is typically a large spur that grows off the bottom of the pedicle of L5 where the fracture originates. This spur compresses the L5 root and can cause compression if the disc is distracted by a intradiscal cage.”
Questions:
1.) In a PLIF the pars defect is removed, leaving the facets in tact. The pars defect is used for bone fusion in the two cages and also posterolaterally?
2.) In a TLIF the entire pars defect is removed along with spinal process and the one facet joint off to the side where my disc herniation is ? OR is the pars defect removed along with both facet joints and tranverse proceses ? This would sound like the entire portion of lower back at L5,S1 is being removed and replaced by interbody and posterolateral fusion ? Are there any bones left behind?
3.) When you place TLIF cage in, do you leave some of the wall of the disc to hold the cage in ?
4.) Do you also fill the disc space with BNP to supplement the cage ?
5.) How long is the recovery in terms of pain meds and returning to normal activity with TLIF ?
6.) Will patients require the use of oral steriods or IV steriods after surgery to reduce inflammation ?
Thank you again for sharing your knowledge and expertise!!!
PLIF and TLIF are sister surgeries. In either surgical technique, the facets should be removed as these facets are useless due to the pars fractures. Leaving the facets do not yield any stability to the post-surgical construct and again, the facets need to be removed to access the bone spur off the inferior aspect of the L5 pedicle.
The technique of PLIF vs. TLIF in a non-isthmic spondylolisthesis surgery is slightly different. In a PLIF, cages are placed in both sides of the disc and generally (although not always), the outer 1/3 to 1/2 of the facets are preserved to allow a region for the posterolateral fusion.
In a TLIF, the entire facet on only one side is removed. This allows the complete uncovering of the exiting nerve and less retraction of the descending (traversing) nerve to place the cage.
In the case of an isthmic spondylolisthesis regardless of PLIF or TLIF, the entire facet on both sides are removed as these facets are already disconnected from the vertebra. The spinous process is generally partially removed (the bottom 1/2 only).
I use to do the PLIF but switched to the TLIF about 8 years ago due to less retraction of the nerve root and a still high fusion rate.
Again, a TLIF for an isthmic spondylolisthesis is a different surgery than a standard TLIF for a degenerative disc. The entire back wall of the vertebra has been sheared off due to the pars fractures (but not the superior facets which remain attached and still function normally). This sheared off back wall is totally non-functional and “hides” the bone spur formation that typically compresses the L5 nerve (at the L5-S1 level). This back wall has no function and leaving it has no purpose but has detriments as noted previously.
Yes, BMP is placed in the disc space to augment fusion.
Recovery time depends upon the patient. There are some patients who walk out of the hospital in 2-3 days only taking tylenol and some that have some pain for 4-5 weeks and use narcotics. I cannot pre-determine the pain levels for the first six weeks.
Review the “recovery by surgery-lumbar fusion” thread on this website. It explains the typical process and stages of recovery.
About one in twenty patients will need oral or IV steroid to reduce inflammation.
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.Hi Dr. Corenman:
I wanted to follow up with you once again regarding the stand alone ALIF. Although you make excellent points regarding TLIF over ALIF, I don’t believe that many surgeons can perform the TLIF as well as others and therefore they choose ALIF because it is an easier and shorter surgery for them. As a matter of fact, most Dr’s that I have consulted with locally have now moved to ALIF for grade one isthmic spondylolisthesis and claim to have very good results vs TLIF.
1.) They “claim” the surgery is about one hour with one night in the hospital, minimal blood loss and no need for back up pedicle screws.
2.) They “claim” that if the fusion doesn’t take place that they will bring me back in for minimally invasive pedicle screws, but that rarely happens.
3.) I am also hearing that all the negative press of BNP with the stand alone ALIF was not true and it is safe to use now.
4.) They claim at the L5,S1 nerve plexis does not endanger retrograde ejaculation and with a good access surgeon they hardly ever see hernia or digestive issues.
Most have downplayed TLIF because or nerve irritation and claim there is no need to cut muscle and bone to access the disc space when it can be done minimally invasive through the front.
What are your thoughts ? This almost sounds too good to be true !
Thank you
Surgery time for an ALIF in a thin patient is about two hours. For a muscular patient or heavier belly, add about an hour to that.
The fusion rate for a stand alone ALIF in the case of isthmic spondylolisthesis is about 85 to 90% using meticulous technique. If you don’t fuse, a posterior fusion is called for- the “minimally invasive pedicle screws” which they are not minimally invasive by the way.
The use of BMP with a stand alone ALIF cage should be standard as you need a fast fusion with an ALIF to prevent instability.
The papers regarding retrograde ejaculation with anterior BMP usage notes an increased risk. Since I rarely use an ALIF with BMP, I cannot comment on increased risk-just point to the papers that have been written about this subject. A good access surgeon will reduce the risk of muscular wall hernia or diastasis as well as small bowel obstruction but those risks are still present.
When they say “minimally invasive” from the front, that is not accurate. “Cutting muscle and bone” is what happens with an anterior approach, and their claim that it is deleterious from the back is not accurate. These small muscles that cross from segment to segment (multiifiti and transversals) are just that, small segmental muscles that are not needed when a fusion of the segment is planned. Moving these muscles (they are not removed) is necessary to get to their insertion site to allow bone formation to cross from L5 to S1.
The ALIF is not a bad operation but it does not address the typical pedicle spurs that grow off the inferior pedicle of L5 where the fracture initially occurred. If those spurs are not removed, many patients will have continued leg pain. You can with a second operation at a later point go into the back and remove these spurs but the point of this is to try and get only one operation to complete all the tasks at hand.
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.“The third problem with an ALIF for an isthmic spondylolisthesis is that there already is a defect in the posterior elements. The ALIF does provide some stability with the screw in cage, but without the stability of the posterior elements (due to the pars fractures-see website), this construct is not as stable as with a posterior approach”
Thank you always ! Your comment above is where my apprehension lies with just having a stand alone ALIF.
1.) When you say the construct is not as stable as with the stability of the posterior elements, what does this mean exactly ? Is it fair to say the the TLIF with the posterolateral fusion provides that much more stability with isthmic spondylolisthesis ?
2.) Also, if I am not having any leg pain, do you still believe it is absolutely necessary to remove pars defect!
You are correct, my intention is to have one surgery, not having to go back for more.
The ALIF generally depends upon the intact side and back walls of the annulus as well as the posterior elements for stability until the fusion “sets up”. With an isthmic spondylolisthesis, the posterior elements are “disconnected” so the stability of the fusion is not as strong as with an ALIF with intact posterior elements. This is why a posterior construct is stronger as pedicle screws take the place of the disconnected posterior elements.
If you have no leg pain, the need for decompression is less imperative. Nonetheless, I have seen patients with an ALIF and no previous leg pain develop leg pain after an ALIF surgery. You do have to remember that the patients who seek me out with a failure of a previous surgery seek me out due to that failure. This means that the patients with success obviously do not come into my office.
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. -
AuthorPosts
- You must be logged in to reply to this topic.