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Original article
310
Combined Mini Transforaminal Lumbar inter Body Fusion with
Percutaneous Pedicle Screw Fixation in Degenerative Lumbar Diseases
Moustafa M. Saad, Mamdouh M. El Karamany, Emad S Hussein, Ashrf A. Negm
Abstract
Background : MIS-TLIF (minimally invasive transforaminal lumbar
interbody fusion) is a well-known surgical procedure. However, there
are just a few instances of MIS-TLIF employing a single cage and a
midline approach. Aim : to know the results of performing combined
mini TLIF fusion with percutaneous pedicle screw fixation for the
treatment of degenerative lumbar diseases. Subjects and Methods :
A total of 12 patients were done at Benha university hospital and
tracked for a total of 12 months. The rate of fusion and the change in
disc height are among the radiological data. Clinical outcomes were
measured using the visual analogue score (VAS) and the Oswestry
disability index (ODI). Results. The mean age of these patients at
operation was 50 years (range, 45–62 years). Evidence of fusion was
observed radiologically in 64.71% at 6 months and 87.5% at 12
months after surgery. The mean VAS scores for back and leg pain and
ODI scores improved significantly at the final follow-up. Conclusions
: The clinical and radiologic results of MIS-TLIF employing a midline
approach and a banana cage in patients suggest that it is a viable therapeutic option for a variety of
degenerative lumbar spine disorders.
Keywords (MIS-TLIF) , ODI ,VAS
Department of Orthopaedic
surgery, Benha faculty of
medicine, Benha University,
Egypt.
Correspondence to:
Moustafa M. Saad, Department
of Orthopaedic surgery, Benha
faculty of medicine, Benha
University, Egypt.
Email:
dr_safsaf_2009@yahoo.com
Received: 17 August 2022
Accepted: 20 December 2022
Print ISSN 1110-208X
Online ISSN 2357-0016
311
Introduction:
The number of people requiring spine
surgery increases as the population ages (1).
Comorbidities and decreased bone density
are more common in the elderly, which may
lead to worse results (2).
Surgery time, comorbidities and a patient's
age correlate with posterior spine surgery
(3–6).
Patients who receive lumbar spine surgery
are more likely to be hospitalised and to die,
according to several studies (7).
As people become older, their risk of death
and disease rises (5).
Transforaminal lumbar interbody fusion
(MIS-TLIF) has been used effectively to
treat a variety of lumbar spinal diseases
since its introduction in 2002. (8).
MIS-advantages There is less blood loss, a
shorter stay in the hospital, fewer
complications, less postoperative pain, and a
faster recovery time with TLIF's (9-13)
Subjects and methods:
This is a single center, prospective study
investigating the clinical and radiological
outcomes of MIS-TLIF in patients with
degenerative lumbar diseases using midline
approach and banana cage at single level.
Between mars 2019 and January 2021, 12
MIS-TLIF procedures were performed at
Benha university hospital. The patients
included in this study were between 45 and
62 years old, who satisfied the clinical and
radiological criteria at Benha university
hospital.
Clinical and radiological evaluations had
been completed on all of the participants, all
of whom were between the ages of 45 and
62.
To be considered for inclusion, the
following must be met:
At the time of surgery, the patient was
between the ages of 45 and 62.
tried everything to get rid of the discomfort,
but it just won't go away, that fluctuates in
intensity and duration A person's
neurological deficits are becoming more
severe.
Single level degenerative disc disease with
spinal instability, spondylolytheis with
spinal instability and spinal canal stenosis
are the three conditions that need
radiographic examinations in order to rule
out other conditions.
A patient's clinical symptoms and
radiological results must be consistent in
order to qualify as having spinal stenosis.
After a three-month trial, the safest and most
effective therapeutic options were
exhausted.
Benha medical journal, vol. 40, special issue (surgery), 2023
Only if the following conditions are satisfied
may an individual be exempted:
Life-threatening medical disorders (high-
risk group) and past fusion surgery further
increase the risk of spinal infection, trauma,
and spinal metastases. Evaluation in the
clinical setting:
Data was gathered on 12 patients who
underwent one level of MIS-TLIF between
March 2019 and January 2021. Preoperative
information was obtained up to a year
following surgery, and the results were
analysed during that time period.
Preoperative and postoperative data were
collected for less than a month before the
procedure, and 3, 6, and 12 months after the
procedure, respectively. Clinical data
included visual analogue scale (VAS, 0–10)
and Oswestry disability index (ODI, 0–
100%) values. Perioperative data included
the amount of spinal fusion, kind of
decompression (unilateral laminectomy vs.
bilateral laminectomy), date of drain
removal, duration of surgery, and duration
of anaesthesia.
Routine X-ray pictures were taken before
surgery, as well as two months, four months,
six monthes and one year after the
procedure, for radiological assessment. The
disc height was measured in the middle of
the spinal column using conventional
standing lateral radiography. Severe spinal
stenosis may be caused by misaligned
vertebral bodies, which is why it's important
to know the segmental lordotic angle for
each level that has undergone surgery (15).
A CT scan was performed both before and
after the procedure. Fusion was defined by
using modified Bridwell criteria (16, 17).
Observations were made of any sinking or
dislodgment of the cages or hardware
failures.
Table 1: Modified Bridwell fusion criteria
313
Surgical technique:
Decompression and cage insertion were accomplished using a tubular retractor.
Fig 1: Decompression and cage insertion using a tubular retractor
Under loop guidance, total facetectomy and
partial laminectomy were done. The
ligamentum flavum was resected. Complete
discectomy was done and grinding of the
central and contralateral endplates was done
with angled ring curettes.
Fig 2: Under C-arm fluoroscopic supervision, the cage was introduced.
Benha medical journal, vol. 40, special issue (surgery), 2023
Bilateral decompression was performed at
the unilateral laminofacetectomy site. The
contralateral inferior articular process,
lamina, and ligamentum flavum were
dissected along the corridor established by
the ipsilateral laminofacetectomy site. The
tubular retractor had to be positioned so that
the distal end was facing the base of the
spinous process, away from the surgeon, in
order to get a better viewing field on the
contralateral side. The cage was installed
once the discectomy and foraminal
decompression were completed. In this
investigation, banana cages were used. The
cage was filled with a mixed variety of
autologous cancellous bone collected
locally. Under C-arm fluoroscopic
supervision, the screws were introduced
percutaneously. Irrigation was applied to the
wounds, drainage catheters were implanted,
and the wounds were closed layer by layer.
Percutaneous pedicle screw insertion:
Fig 3: Technique for screw insertion using fluoroscopy. (A) Entry point on the AP fluoroscopy; (B, C) When only
the Jamshidi needle passes the posterior wall of the vertebral body, it is allowed to touch the inner border of the
pedicle on the AP image; (D) The guide wire is then inserted in the cannula with care not to pass the anterior wall of
the vertebral body; (E) After the insertion of all guidewires, taping is carried out with caution not to remove the
guidewires; (F) Screw insertion is carried out and the guidewire may be removed when the screw tip reaches the
posterior vertebral wall.
315
Fig 4 :Post-operative x-ray (AP) & (Lat.) after 6 months showing complete fusion of the graft with restoration of
lumbar lordosis
Ethical considerations
The study was conducted after approval of
the protocol by the Local Research
Committee and the Studies Committee as
well as the Research Ethics Committee of
Faculty of Medicine, Benha University.
An informed written consent was obtained
from all patients.
Statistical analysis
Gathered data were processed using
SPSS version 26.0 (SPSS Inc., Chicago,
IL, USA).
Quantitative data were expressed as
means ±SD while qualitative data were
expressed as numbers and percentages
(%).
Student t-test was used to compare
statistical difference for quantitative
data while Chi Square will be used for
qualitative data.
A probability value (p-value) < 0.05
was considered statistically significant.
Collected data were presented in a
suitable tables and suitable graphs after
statistically analyzed by computer
Software using appropriate statistical
methods.
Benha medical journal, vol. 40, special issue (surgery), 2023
Results:
Pain in the back and legs reduced from 6.7
to 2.5 on the visual analogue scale. Oswetry
dis ability index scores went from 55.6 to
25.2 during the course of the study.
Radioactive fusion was detected in 88.5
percent of the samples. The average disc
height rose from 9.1 to 12.3 millimetres. Six
instances were graded as grade 1, four were
grade 2, one was grade 3, and one was grade
4 based on the modified bridwell criterion.
The following is the subject of our
conversation:
Those with degenerative lumbar illnesses
were treated using a single-level banana
cage and a midline approach in this clinical
experiment.
During the months of March 2019 through
January 2020, our facility performed
12MIS-TLIF procedures.
Clinical and radiological evaluations had
been completed on all of the participants, all
of whom were between the ages of 45 and
62.
To be considered for inclusion, the
following must be met:
Practicing Clinical Medicine
At the time of surgery, the patient was
between the ages of 45 and 62.
you've tried everything to get rid of the
discomfort, but it just won't go away,
that fluctuates in intensity and duration
A person's neurological deficits are
becoming more severe.
Degenerative disc disease and spinal
instability are the three conditions that need
radiographic examinations in order to rule
out other conditions.
A patient's clinical symptoms and
radiological results must be consistent in
order to qualify as having spinal stenosis.
After a three-month trial, the safest and most
effective therapeutic options were
exhausted.
Only if the following conditions are satisfied
may an individual be exempted:
Life-threatening medical disorders (high-
risk group) and past fusion surgery further
increase the risk of spinal infection, trauma,
and spinal metastases.
A banana cage approach to MIS-TLIF yields
in favourable clinical and radiological
outcomes in patients.
Patients over the age of 60 seem to have a
slower fusion process with MIS-TLIF using
the midline technique with a banana cage.
317
Conclusions:
The clinical and radiologic results of MIS-
TLIF employing a midline approach and a
banana cage in patients suggest that it is
viable therapeutic option for a variety of
degenerative lumbar spine disorders.
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To cite this article: Moustafa M. Saad, Mamdouh M. El Karamany, Emad S Hussein, Ashrf A.
Negm. Combined Mini Transforaminal Lumbar inter Body Fusion with Percutaneous Pedicle
Screw Fixation in Degenerative Lumbar Diseases. BMFJ 2023;40(surgical issue):310-319.
Benha medical journal, vol. 40, special issue (surgery), 2023
