You will also find many varied opinions from people who say that having surgery is the worst thing you can do to those that swear by it. My consultant/surgeon gave me the opportunity to speak to one of his former patients and I found this very helpful. I also did a search on my surgeon and found that he was one of the leading surgeons for my area so I felt a lot more comfortable facing the prospect of surgery. I personally wanted to be assured 100% that I was making the right decision because there is a very long list of risks associated with this surgery and I needed to make an informed decision.
Posterior Lumbar Interbody Fusion (PLIF)
Posterior lumbar interbody fusion (PLIF) is a surgical technique for placing bone graft between adjacent vertebrae (interbody). Typically, screws and rods or other types of spinal instrumentation are used to hold the spine in position while the bone heals. Indications for this procedure may include pain and spinal instability resulting from spondylolisthesis degenerative disc disease or when a discectomy is performed to relieve nerve compression and the patient has associated mechanical low back pain.
Spinal fusion uses bone graft to promote specific vertebrae to grow or fuse together into a solid and stable construct. Instrumentation, also called internal fixation, incorporates the use of rods, screws, cages, and other types of medical hardware to provide immediate stability to the spine and facilitate fusion.
Minimal Access Spinal Technologies
Today, spinal surgery has advanced to a new level that utilizes Minimal Access Spinal Technologies (MAST). These technologies replace traditional open surgical procedures with innovative minimally invasive techniques and tools. To grasp the importance and benefits of minimally invasive spine surgery, review the following comparison:
Open Approach
A longer incision along the middle of the back is necessary. Large bands of muscle tissue are stripped from the underlying spinal elements including the spinous process, lamina, and facets. These tissues are pulled aside (retracted) during surgery to provide the surgeon a good view of the spine and room for performing the procedure. During complex spine surgeries, these surrounding tissues (paraspinous) may need to be retracted for long periods of time. Stripping the paraspinous tissues and retracting them can contribute to post-operative pain and prolong the patient's recovery.Minimally Invasive Approach
In minimally invasive procedures, the surgical incisions are small, there is no need (or minimal need) for muscle stripping, there is less tissue retraction, and blood loss is minimized. Special surgical tools allow the surgeon to achieve the same goals and objectives as the open surgery while minimizing cutting and retracting of the paraspinous muscles. Therefore, tissue trauma (injury) and post-operative pain are reduced, hospital stays are shorter, and patients can recover more quickly.
Open PLIF Procedure
A typical PLIF procedure involves an open incision (approximately 6 inches long) in the middle of the lower back followed by stripping the paraspinous muscles away from the spine. Bone removal (laminectomy) and lumbar discectomy are performed to remove pressure from affected spinal nerve roots. When the offending disc is removed an empty space is left between the upper and lower vertebrae (interbody). This is filled with bone graft. Implants made of bone, metal, or other materials are typically inserted into the interbody space. Finally, pedicle screws are placed into the upper and lower vertebrae and connected with rods or plates.
This info was taken from the spine universe website. The following links discuss the PLIF further and is the most informative site I have come across.
http://www.spineuniverse.com/displayarticle.php/lumbar-fusion-3115.html Discusses the history of the operation
http://www.spineuniverse.com/displayarticle.php/lumbar-fusion-3116.html Discusses the advantages and Indications
http://www.spineuniverse.com/displayarticle.php/lumbar-fusion-3117.html Discusses the surgical techniques
Anterior Lumbar Interbody Fusion (ALIF)
Introduction
Spinal fusion for the management of lumbar degenerative disc disease has been available for several decades. The results of this procedure remain under constant scrutiny and progressive development. Anterior lumbar fusion was initially introduced in the early 1920s. Fibula and iliac struts, femoral rings and dowel, as well as synthetic metallic devices have been applied as fixation implements to aid in lumbar interbody fusion. Approaches to the spine have experienced similar evolutionary changes. Prior to the 1950s most anterior lumbar approaches were extensive transperitoneal exposures (i.e. through the membrane lining the walls of the abdominal and pelvic cavities). In 1957, Southwick and Robinson introduced the retroperitoneal approach (i.e., behind the peritoneum). Transperitoneal exposures (i.e., through the peritoneum) require incision of both the anterior and posterior peritoneum. In contrast, retroperitoneal expoures maintain the integrity of the peritoneum and approach the spinal column laterally behind the bowel and peritoneal contents. This has the advantage of less post-operative bowel problems. Additional changes in technique have seen the advent of minimally invasive approaches, including endoscopic and laparoscopic methods. Minimally invasive approaches are generally directed at one or two-level disease processes. Anterior lumbar interbody fusion (ALIF) may be useful in the treatment of unyielding low-back pain. The cause of this pain is often difficult to diagnose. Broad categories of pathology that may be associated with persistent low-back pain include degenerative disc disease spondylolysis, spondylolisthesis or iatrogenic segmental instability.
ALIF should only be considered following the patient's unsuccessful completion of an organizednonoperative rehabilitation program. Aids to diagnosis in the case of a patient with mechanicallow-back pain expand upon a thorough history and physical examination. Radiographic studies;plain films, bone scan (SPECT), CT scan, MRI and discography, all play a role in patient evaluation. Frequently more than one of these diagnostic studies is needed for an accurate diagnosis. ALIF may be utilized as an isolated procedure or in conjunction with posterior spinal fusion. The method with which ALIF is accomplished depends largely on the surgeon's preference and experience. Minimally invasive techniques - open or laparoscopic - require greater intraoperative attention to detail and preoperative surgical planning.
Indications for ALIF Degenerative Disc Disease
The suspected lumbar level requires confirmation as a pain generator by diagnostic testing. Multilevel disease, i.e., greater than two levels of the spine, is less predictable and therefore rarely indicated for ALIF. We have found that single-level disease in a psychologically stable patient, responds well to ALIF.
Spondylolysis and Spondylolisthesis
The vast majority of patients with spondylolysis or spondylolisthesis do not require surgery. Patients with spondylolysis or spondylolisthesis (grade I) may be effectively treated with ALIF as an isolated procedure. Present data is inconclusive regarding the effectiveness of isolated ALIF in grade II spondylolisthesis. Furthermore, biomechanical data related to the degree of vertebral translation concomitant with grade III or greater spondylolisthesis implies that isolated ALIF may be associated with a high pseudoarthrosis rate (failure of fusion). Therefore, in grade III or greater spondylolisthesis, a posterior fusion in addition to ALIF is strongly recommended. ALIF as the only procedure (i.e. without a posterior operation), is not recommended in a spondylolesthesis above grade I.
Iatrogenic Segmental Instability
Hypermobility of a lumbar-motion segment requires rigid fixation to improve fusion rate. Limited sagittal translation may be addressed by isolated ALIF. As inferred above, high degrees of translation are difficult to stabilize; therefore circumferential fusion is often required.
Surgical Technique
While the technique is both skilled and complex, it can be explained in three basic phases:
1) Pre-operative Templating Before the surgery, the surgeon will refer to various MRI and CAT scans of the patient to determine what size implant(s) the patient will need. The implant(s) are used to help promote fusion of two vertebra in the spine.
2) Preparing the Disc Space After the patient is positioned on the OR table and carefully prepared for the surgery, the surgeon begins the procedure. Some of the disc and anaulus is carefully removed, thus preparing the disc space for insertion of the implant(s).
3) Implants Inserted After correct preparation of the disc space a dowel or other implant will be inserted, to promote fusion of the two adjacent vertebra.
No comments:
Post a Comment