Pros
- An advantage of PLIF is the ability to insert large bilateral cages that accommodate a significant amount of bone grafting material
- The advantage of the PLIF and TLIF approaches is that they avoid the morbidity of the transperitoneal dissection.
Position:
- The patient is positioned prone on a Jackson table to decrease intraabdominal pressure.
- Upper extremities are well padded and placed on arm-boards in a “90-90” position.
Approach
- A metal stylus is used to confirm the operative level using a lateral image.
- The iliac crests can be used as a reference point marking the L4-5 disc space.
- A midline longitudinal incision is carried down to the spinous processes.
- Paraspinous muscles are elevated off of the spinous processes and lamina in the subperiosteal plane.
- Dissection is carried out laterally to the facet joints at the operative level, and care must be taken not to violate the facet joints above or below the operative level.
- Decompression
- Laminotomies and partial bilateral facetectomy are performed.
- Curettes are used to detach the ligamentum flavum from each of the adjacent lamina and the superior articular process of the lamina below.
- Pedicle screw insertion
- Next, the medial half of the superior and inferior articular processes is removed bilaterally using Kerrison rongeurs.
- Keep spinous process and midline ligaments
- Operative level is distracted using pedicle screws, the lamina, or the spinous processes.
- The posterolateral aspect of the annulus fibrosus can now be visualized by gentle medial retraction of the traversing nerve root as well as the dural sac.
- A more extensive facetectomy will allow for less retraction of the nerve roots.
Fusion
- All work should now be done through a triangular safe zone:
- Cephalad to pedicle of inferior vertebra
- Medial to exiting nerve root
- Lateral to the traversing nerve root and dural sac.
- A thorough discectomy is performed using rongeurs, disc shavers, disc excisors, and curettes.
- A complete discectomy and removal of the cartilaginous endplates are paramount to successful fusion.
- After adequate preparation of the disc space, the implants are trialed and inserted.
Outcome
- Reoperation rates
- PLIF: Okuda et al. (JNS 2006) – 8.0% reoperation rate.
- Open PLIF: Freudenberger et al. (Orthop 2009) – 10.3% reoperation rate; Rodgers et al. (Spine 2010) – 15% reoperation rate.
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