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Study Design: Anatomic cadaver study., Objective: Translaminar facet screw fixation supplements unilateral pedicle screw-rod fixation in minimally invasive transforaminal lumbar interbody fusion (TLIF). Various screw diameters, lengths, trajectories, and insertion points are used; however, they do not represent true screw trajectory. We aimed to evaluate lumbar laminar anatomy and suggest a safe and effective insertion point and trajectory during lumbar-translaminar facet screw fixation in an anatomic cadaver study., Methods: O-arm navigation simulating the true translaminar facet screw trajectory was used to evaluate L1-S1 in cadaveric spines. The inner and outer diameters, length, and trajectory of the screw pathway were measured along the trajectory from the spinous process base through the contralateral lamina, crossing the facet joint to the transverse process base using 2 starting points: cephalad one-third (1/3SL) and one-half (1/2SL) of the spinolaminar junction., Results: Using the 1/2SL starting point, the outer and inner lamina diameters did not differ significantly from L1-L5 (7.47 ± 1.38 to 6.7 ± 1.84 mm and 4.73 ± 1.04 to 3.86 ± 1.46 mm, respectively). Screw length (36.16 ± 4.02 to 49.29 ± 10.07 mm) and lateral angle increased (50.28° ± 8.78° to 60.77° ± 8.88°), but caudal angle decreased (16.19° ± 9.01° to 1.13° ± 11.31°). Lamina diameter and screw length did not differ with different starting points. L2-L3 caudal angles were lower in the 1/2SL starting point., Conclusion: A 36- to 50-mm translaminar facet screw-with 5.0-mm diameter for L1-L2 and 4.5-mm diameter for L3-L5-can be inserted at the middle of the spinolamina, especially during minimally invasive TLIF, with a 50° to 60° lateral angle relative to the spinous process, and a caudal angle of 16° to 1° relative to the spinolamina from L1-L5.

This study aims to investigate the fixation strength of unilateral cortical bone trajectory screw fixation (UCBT) and UCBT with contralateral translaminar facet screw fixation (UCBT-TFS) by repeating the verification of three finite element models. Three healthy female models of the lumbosacral spine were constructed. For each of them, four transforaminal lumbar interbody fusion (TLIF) models with the following instruments were created: bilateral traditional trajectory pedicle screw fixation (TT), bilateral cortical bone trajectory screw fixation (CBT), UCBT, and UCBT-TFS. A 150-N compressive load with 10 N/m moments was applied to simulate flexion, extension, lateral bending, and axial rotation. The range of motion (ROM), the stress of the cages, and the stress of the posterior fixations were compared. TT and UCBT-TFS had a similar low ROM compared to the intact models, and CBT showed a higher ROM in lateral bending. UCBT resulted in the highest ROM under all loading conditions, especially in lateral bending (116% and 170% greater than TT in left bending and right bending). UCBT induced a significant increase in the peak stress of cages and instruments, followed by CBT and UCBT-TFS, and the lowest mean values were observed for TT. Among the four different fixation techniques, TT offered the highest fixation strength and lowest implant stress, followed by UCBT-TFS and CBT, while UCBT was the least stable and resulted in increased stress of the screws and cages. UCBT-TFS improved biomechanical stability and appeared to be a less invasive alternative in well-selected patients with single-level TLIF., Competing Interests: None., (AJTR Copyright © 2020.)

Background: Little is known about the biomechanical performance of various fixation constructs after oblique lumbar interbody fusion (OLIF). This study aimed to explore the stability of various fixation options for OLIF by using finite element analysis based on three-dimensional scanning models., Methods: Six validated finite element models of the L3-L5 segment were reconstructed via computed tomography images, including (1) intact model, (2) stand-alone model with no instrument, (3) lateral rod-screw model, (4) lateral rod-screw plus contralateral translaminar facet screw (LRS-CTLFS) model, (5) unilateral pedicle screw model, and (6) bilateral pedicle screw (BPS) model. Models of the OLIF cage and pedicle screw were created with three-dimensional scanning to improve the accuracy of finite element analysis. Range of motion, stress of the cage, and stress of fixation were evaluated in the different models., Results: Range of motion increased from least to greatest as follows: BPS, LRS-CTLFS, unilateral pedicle screw, lateral rod-screw, stand-alone. Differences in range of motion between BPS and LRS-CTLFS were not significant for all loading cases. Compared with the other 3 models, the stress of the cage was found to be lower in BPS and LRS-CTLFS under all loading conditions, especially in BPS. Stress exerted on the fixation was the greatest in LRS-CTLFS, and the stress experienced by the translaminar facet screw was concentrated in part of the facet joint., Conclusions: The BPS model provided the best biomechanical stability for OLIF; the stand-alone model could not provide sufficient stability. The LRS-CTLFS procedure increases the approximate stability and reduces stress at the cage-endplate interface; however, it causes an increase in screw stress., (Copyright © 2020 Elsevier Inc. All rights reserved.)

It is technically demanding and requires rich experience to insert the translaminar facet screw(TFS) via the paramedian mini-incision approach. It seems that it is easy to place the TFS using computer-assisted design and rapid prototyping(RP) techniques. However, the accuracy and safety of these techniques is still unknown. The aim of this study is to assess the accuracy and safety of translaminar facet screw placement in multilevel unilateral transforaminal lumbar interbody fusion using a rapid prototyping drill guide template system. A patient-matched rapid prototyping translaminar facet screw guide was examined in fourteen cadaveric lumbar spine specimens. A three-dimensional (3D) preoperative screw trajectory was constructed using spinal computed tomography scans, from which individualized guides were developed for the placement of translaminar facet screws. Following bone tunnel establishment, the 3D positioning of the entry point and trajectory of the screws was compared to the preoperative plan as found in the Mimics software.Among 60 trajectories eligible for assessment, no cases of clinically significant laminar perforation were found. The mean deviation between the planned and the actual starting points on spinous process was 1.22 mm. The mean tail and submergence angle deviation was found to be 0.68°and 1.46°, respectively. Among all the deviations, none were found to have any statistical significance. These results indicate that translaminar facet screw placement using the guide system is both accurate and safe.

Background: There are various posterior fixations utilized with transforaminal lumbar interbody fusion (TLIF). Previous studies have focused on the comparison of two fixation techniques., Materials and Methods: Sixty five patients with single-level lumbar disease were included in this retrospective study. Group A was treated by TLIF with bilateral pedicle screw (BPS), Group B treated by TLIF with unilateral pedicle screw (UPS), and Group C treated by TLIF with UPS plus contralateral translaminar facet screw (UPSFS). The operative time, blood loss, Oswestry disability index (ODI), Japanese Orthopaedic Association Scores (JOA), and visual analog scores (VAS) were recorded. Radiographic examination was used to assess fusion rates and incidence of screw failure., Results: The blood loss and operative times were 188.69 ± 37.69 ml and 132.96.5 ± 8.69 min in BPS group, 117.27 ± 27.11 ml and 99.32 ± 12.94 min in UPS group, and 121.50 ± 22.54 ml and 112.55 ± 9.42 min in UPSFS group; UPS and UPSFS were better than BPS ( P < 0.05). The mean followup time was 38.2 months. Fusion rates were - BPS group: 95.6%, UPS group: 90%, UPSFS: 95% ( P > 0.05). Screw and/or rod failures were found in three groups (BPS group: 1, UPS group: 2 and UPSFS: 1, P > 0.05). The average postoperative VAS, ODI, and JOA scores of BPS, UPS, and UPSFS were improved significantly in each group compared to preoperative scores ( P < 0.05); there were no significant differences between any two groups at each followup time point ( P > 0.05)., Conclusion: UPSFS with TLIF is a viable treatment option that provides satisfactory clinical results; the clinical outcome and the complication rate were comparable to BPS. In addition, the invasive of UPSFS cases was comparable to UPS and better than BPS cases. For UPS, it could be used in suitable patients., Competing Interests: There are no conflicts of interest.

Objective: To discuss the advantages and disadvantages of two different surgical approaches combined fixation with lumbar interbody fusion in treating single segmental lumbar vertebra diseases., Methods: The clinical data of 86 patients with single segmental lumbar vertebra diseases treated from June 2011 to June 2013 was retrospectively analyzed. There were 33 males and 53 females, aged from 28 to 76 years old with an average of 53.0 years. Among them, there were 39 cases of lumbar disc degeneration, 22 cases of lumbar disc herniation complicated with spinal canal stenosis, 9 cases of huge lumbar disc herniation and 16 cases of lumbar degenerative spondylolisthesis (Meyerding degree I ). Lesion sites contained L3, 4 in 5 cases, L4, 5 in 70 cases and L5S1 in 11 cases. All the patients were treated with internal fixation and lumbar interbody fusion with 45 cases by midline incision approach (median incision group) and the other 41 cases by channel-assisted by muscle-splitting approach(channel group). Incision length, operation time, intraoperative bleeding and postoperative drainage were recorded in two groups. Visual analogue scale(VAS) was used to assess lumbar incision pain 72 h after operation. Depended on imaging results to compare the changes of the disc space height in lesion in preoperative, postoperative and final follow-up, the coronal and sagittal Cobb angle in preoperative and final follow-up, the area of multifidus and the degree of multifidus fat deposition before and after operation between two groups. Loosening or fragmentation of internal fixation, displacement of intervertebral cage and interbody fusion were observed in each group. Japanese Orthopedic Association (JOA) scoring system was used to evaluate the function before operation and at the final follow-up., Results: The channel group was superior to the median incision group in incision length and postoperative drainage while the median incision group was less than the channel group in the operation time and intraoperative bleeding. The average VAS score of lumbar incision 72 h after operation was 1.50 points in median incision group and 0.97 points in channel group, and there was significant difference between two groups( P <0.05). No incision infection was found, but there were 4 cases of incisional epidermal necrosis, 1 case of incision healed badness, and 3 cases of nerve injury in channel group. The incidence of cacothesis of pedicle screw were 5.0% and 3.6% in median incision group and channel group respectively, and there was no significant difference between two groups( P >0.05). The incidence of cacothesis of translaminar facet screw were 6.6% and 12.2% in median incision group and channel group respectively, and there was significant difference between two groups( P <0.05). All the patients were followed up for 12 to 36 months with a mean of 22.8 months. The changes of disc space height had statistical difference between preoperative and postoperative( P <0.05) in all patients, but there was no significant difference between postoperative and final follow-up( P >0.05), however, there was no significant difference 3 days after operation and final follow-up between two groups( P >0.05). At final follow-up, coronal and sagittal Cobb angle were obviously improved in all patients( P <0.05), but there was no significant difference between two groups( P >0.05). One year after operation, the area of multifidus in median incision group was (789.00±143.15) mm² less than preoperative(1 066.00±173.55) mm² ( P <0.05), and in channel group, was(992.00±156.75) mm² at 1 year after operation and(1 063.00±172.13) mm² preoperatively, there was no significant difference between them( P >0.05), however, there was significant difference one year after operation between two groups ( P <0.05) . About the degree of multifidus fat deposition, there was significant difference between one year after operation and preoperation in median incision group ( P <0.05), but there was no significant difference between one year after operation and preoperation in channel group ( P >0.05), and there was significant difference at one year after operation between two groups( P <0.05). During the follow-up period, neither pedicle screw and/or translaminar facet screw loosening, displacement or fragmentation nor displacement of intervertebral cage were found. The lumbar interbody fusion rate was 95.6% in median incision group and was 95.1% in channel group, and there was no significant difference between two groups( P >0.05). No obvious adjacent segmental degeneration was observed in fixed position. JOA score in median incision group was significantly increased from 8-16 points (average: 12.77±2.56) preoperative to 21-29 points (average: 25.20±2.43) at final follow-up( P <0.05); and in channel group was significantly increased from 8-16 points (average: 12.64±2.37) preoperative to 23-29 points(average: 26.7±1.82) at final follow-up( P <0.05); there was also significant difference between two groups at final follow-up., Conclusions: Compared to the median incision approach, unilateral pedicle screw combined with contralateral translaminar facet screw fixation using channel-assisted by muscle-splitting approach has advantages of small incision, less trauma, fast recovery and so on. However, it also has shortages such as high surgical complications incidence, especially in cases that., Competing Interests: The authors of this article and the planning committee members and staff have no relevant financial relationships with commercial interests to disclose.

Background: Transforaminal lumbar interbody fusion (TLIF) has been used in lumbar degenerative diseases. Some researchers have applied unilateral fixation in TLIF to reduce operational trauma without compromising the clinical outcome, but it is always suspected biomechanically unstable. The supplementary contralateral translaminar facet screw (cTLFS) seemed to be able to overcome the inherent drawbacks of unilateral pedicle screw (uPS) fixation theoretically. This study evaluates the safety, feasibility and efficacy of TLIF using uPS with cTLFS fixation in the treatment of lumbar degenerative diseases (LDD)., Materials and Methods: 50 patients (29 male) underwent the aforementioned surgical technique for their LDD between December 2009 and April 2012. The results were evaluated based on visual analogue scale (VAS) of the leg and back, Japanese Orthopedic Association (JOA) score and Oswestry Disability Index (ODI) were recorded. The radiographic examinations in form of X-ray, computed tomography (CT) or magnetic resonance imaging was done preoperatively and 1 week, 3 months, 6 months, 12 months and 24 months postoperatively. The student t-test was used for comparison between the preoperative values and postoperative counterparts. P < 0.05 was considered to be statistically significant., Results: Among 50 patients, 22 received one level fusion and 28 two level's, with corresponding operation time and estimated blood loss being approximately 90 min, 150 ml and 120 min, 200 ml, respectively. No severe complications happened perioperatively. The mean VAS (back, leg) scores dropped from (7.6, 7.5) preoperatively to (2.1, 0.6) at 12 months' followup, ODI from 49.1 preoperatively to 5.6 and JOA score raised from 10.6 preoperatively to 28.5, all P < 0.001, suggesting of good clinical outcome. From the three-dimensional reconstructed CT, 62 out of 70 segments displayed solid fusion with fusion rate of 88.6% at 12 months postoperatively., Conclusions: TLIF using uPS fixation plus cTLFS fixation is a safe, feasible and effective technique in the treatment of one or two level lumbar degenerative diseases short termly.