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Significantly Improved Outcomes With a Less Invasive Posterior Lumbar Interbody Fusion Incorporating Total Facetectomy

Kasis, Ata G. MRCS; Marshman, Laurence A. G. MD, FRCSN; Krishna, Manoj FRCS, MCh (Orth); Bhatia, Chandra K. MOrth, FRCS

doi: 10.1097/BRS.0b013e3181973e35
Clinical Case Series

Study Design. Original study.

Objective. Prospective comparison of clinical outcomes after a standard posterior lumbar interbody fusion (ST-PLIF) and after a limited exposure PLIF incorporating total facetectomy (LI-PLIF).

Summary of Background Data. Most groups have reported significantly improved clinical outcomes after ST-PLIF. To our knowledge, however, a comparison of outcomes between ST-PLIF and the LI-PLIF that we herein describe has not been reported before.

Methods. Patients were included who had suffered chronic low back pain for a minimum of 2 years that was unresponsive to conservative treatment. N = 114 consecutive patients underwent ST-PLIF, whereas n = 209 underwent LI-PLIF. All patients underwent pre- and postoperative evaluations for Oswestry Disability Index (ODI), short-form 36 (SF-36), and visual analogue scores (VAS). The minimum follow-up for either group was 2 years.

Results. There was a significant improvement in the ODI (22.5 ± 1.0, P < 0.001), VAS for back pain (3.8 ± 0.1, P = 0.003), VAS for leg pain (4.0 ± 0.2, P = 0.002), and SF-36 for bodily pain (14.7 ± 0.9, P = 0.012) after ST-PLIF. However, there was a significantly greater improvement in all scores after LI-PLIF: ODI (28.8 ± 1.4 vs. 22.5 ± 1.0, P < 0.001), VAS for back pain (5.4 ± 0.2 vs. 3.8 ± 0.1, P = 0.001), VAS for leg pain (5.1 ± 0.2 vs. 4.0 ± 0.2, P < 0.001), and SF-36 for bodily pain (18.5 ± 0.8 vs. 14.7 ± 0.9, P = 0.003). There was a significantly shorter duration of hospital stay after LI-PLIF (2.24 ± 0.057 days) than after ST-PLIF (4.04 ± 0.13 days) (P = 0.005). Operative complications occurred in 19.3% of ST-PLIF and in 6.7% of LI-PLIF.

Conclusion. Clinical outcomes were significantly improved after both ST-PLIF and LI-PLIF. However, outcomes were significantly better after LI-PLIF than after ST-PLIF. Significantly shortened hospital stay with LI-PLIF probably reflected the “less invasive” technique per se. Significantly better clinical outcomes with fewer complications after LI-PLIF, however, potentially reflected maneuvers singular to LI-PLIF: (1) preservation of posterior elements, (2) avoidance of far lateral dissection over the transverse processes, (3) bilateral total facetectomy, (4) fewer neurologic complications, and (5) avoidance of iliac crest autograft. LI-PLIF is therefore recommended over ST-PLIF.

Clinical outcome was significantly improved after both a standard open posterior lumbar interbody fusion and after a less invasive PLIF (LI-PLIF). However, clinical outcome, duration of hospital stay, and number of complications were significantly better still after LI-PLIF than after standard posterior lumbar interbody fusion. LI-PLIF is therefore recommended for the treatment of intractable low back pain.

From the Department of Spinal Surgery, University Hospital of North Tees, Hardwick, Stockton.

Acknowledgment date: June 9, 2008. Revision date: September 1, 2008. Acceptance date: October 9, 2008.

The manuscript submitted does not contain information about medical device(s)/drug(s).

No funds were received in support of this work. No benefits in any form have been or will be received from a commercial party related directly or indirectly to the subject of this manuscript.

Address correspondence and reprint requests to Ata Kasis, MD, MRCS, Department of Spinal Surgery, University Hospital of North Tees, Hardwick, Stockton, North Tees TS19 8PE; E-mail:

© 2009 Lippincott Williams & Wilkins, Inc.