Oblique Fixation from Posterior Corner in Lumbar Spine Through Kambin’s Triangle: A Neuroimaging Anatomic Assessment

Abstract Background: Traditional lumbar interbody fusion has many limitations, such as large trauma, severe damage to the normal posterior structure, and long postoperative recovery period. With the advance of minimally invasive surgery and spinal endoscopy, new fusion technologies such as percutaneous endoscopic transforaminal lumbar interbody fusion (PE-TLIF) and endoscopic transforaminal lumbar interbody fusion (Endo-LIF) through Kambin’s triangle with less trauma, less bleeding and faster recovery have been developed. However, nerve root injury and dural tears are important complications, and Kambin’s triangle is not "safe". Moreover, fusion after decompression often requires placement of a 14-mm channel, removal of more articular processes, fixation with posterior percutaneous pedicle screw, and changes of intraoperative position or anesthesia, which are inconvenient. One-stop percutaneous endoscopic transforaminal oblique fixation from posterior corner in lumbar spine overcomes the above limitations, and realizes one-stop decompression, fusion and fixation in a single regular minimally invasive channel. The purpose of this study is to measure the neuroimaging anatomic parameters of the nerves related to oblique fixation from posterior corner in lumbar spine through Kambin’s triangle, to define and evaluate the safe working area in Kambin’s triangle, and to identify the optimal target area for endoscopic fusion and fixation.Methods: Sixty volunteers (27 males and 33 females) underwent lumbar MR examination (VISTA,3D-STIR-TSE Sequence) and the data were uploaded to Philips (Achieva 1.5T MR) workstation. Three working targets (P1, P2, P3) were preset for oblique fixation from posterior corner in lumbar spine. The distances from the working targets to exiting nerve roots and dural sac/traversing nerve roots in the coronal and sagittal planes, and the distances from the exiting roots to the dural sac/traversing nerve roots in the upper and lower endplate planes were measured and statistically analyzed.Results: In L1/2–L5/S1, the P values of paired t-test for the distances (c1, c2, c3, c4, c5 and c6) from each target (P1, P2 and P3) to the ipsilateral exiting nerve roots and dural sac/traversing nerve roots were all greater than 0.05. There were no statistically significant differences between the targets at both sides of the same segment, and the mean values of both sides were calculated. The c1, c2, c3, c4, c5 and c6 all increased and then decreased, gradually increased from L1/2, maximized in L4/5, and decreased slightly in L5/S1. As the targets (P1, P2, P3) moved laterally along the horizontal midline of the posterior margin of intervertebral disc, the distance to the dural sac/traversing nerve roots gradually increased, while the distance to the exiting roots gradually decreased. The distance from P1 to exiting nerve roots was significantly greater (1–3 mm) than that to dural sac/traversing nerve roots. The distance from P3 to exiting nerve roots was significantly smaller (1–3 mm) than that to dural sac/traversing nerve roots. The distances from P2 to exiting nerve roots and to dural sac/traversing nerve roots did not different significantly in each segment, and the differences in means were within 1 mm.The distances from exiting nerve roots to dural sac/traversing nerve roots in the upper and lower endplate planes (d1, d2) gradually increased in L1/2–L5/S1 (P<0.0001) and the means of d2 were greater than d1 (P<0.05). There was no statistically significant difference between the left and right sides in the upper and lower endplates in each segment (P=0.26).In L1/2–L5/S1, the P values of paired t-test for the distances (s1, s2, s3, s4, s5, s6) from the projection points of posterior-inferior (posterior-superior) corner of upper (lower) vertebral body to exiting nerve roots in the sagittal planes passing the targets were all greater than 0.05. There was no statistically significant difference between both sides of the same segment, and thus the mean value was calculated. With the outward shift of the targets in the sagittal planes, s1, s3 and s5 gradually decreased (s1>s3>s5), and the same trend was found for s2, s4 and s6 (s2>s4>s6). The distances gradually increased in each segment from the smallest value in L1/2 to the largest value in L5/S1.Conclusion: Kambin’s triangle can be used as a working area for oblique fixation from posterior corner in lumbar spine, but the actual safe area is smaller than theoretical prediction. The intersection point between the vertical line from the medial 1/3 of pedicle and the horizontal midline of the posterior margin of intervertebral disc (P2) is an ideal "target" for oblique fixation from posterior corner in lumbar spine. It is neuroanatomically feasible to achieve one-stop complete decompression, fusion, and fixation in a single channel under spinal endoscopy. Further biomechanical studies and clinical trials are needed to determine whether it can be a new option for posterior spinal fusion.

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Biomechanical comparison between cortical screw–rod construct versus pedicle screw–rod construct in transforaminal lumbar interbody fusion

Journal of Orthopaedic Surgery ◽

10.1177/2309499017690656 ◽

2017 ◽

Vol 25 (1) ◽

pp. 230949901769065

Author(s):

Chris Chan Yin Wei ◽

Sem Sei Haw ◽

Elrofai Suliman Bashir ◽

Saw Lim Beng ◽

Rukmanikanthan Shanmugam ◽

...

Keyword(s):

Lumbar Spine ◽

Pedicle Screw ◽

Interbody Fusion ◽

Testing Machine ◽

Transforaminal Lumbar Interbody Fusion ◽

Axial Rotation ◽

Lumbar Interbody Fusion ◽

Lateral Flexion ◽

Cortical Screw ◽

Significant Difference

Objective: To compare construct stiffness of cortical screw (CS)-rod transforaminal lumbar interbody fusion (TLIF) construct (G2) versus pedicle screw (PS)-rod TLIF construct (G1) in the standardized porcine lumbar spine. Methods: Six porcine lumbar spines (L2–L5) were separated into 12 functional spine units. Bilateral total facetectomies and interlaminar decompression were performed for all specimens. Non-destructive loading to assess stiffness in lateral bending, flexion and extension as well as axial rotation was performed using a universal material testing machine. Results: PS and CS constructs were significantly stiffer than the intact spine except in axial rotation. Using the normalized ratio to the intact spine, there is no significant difference between the stiffness of PS and CS: flexion (1.41 ± 0.27, 1.55 ± 0.32), extension (1.98 ± 0.49, 2.25 ± 0.44), right lateral flexion (1.93 ± 0.57, 1.55 ± 0.30), left lateral flexion (2.00 ± 0.73, 2.16 ± 0.20), right axial rotation (0.99 ± 0.21, 0.83 ± 0.26) and left axial rotation (0.96 ± 0.22, 0.92 ± 0.25). Conclusion: The CS-rod TLIF construct provided comparable construct stiffness to a traditional PS-rod TLIF construct in a ‘standardized’ porcine lumbar spine model.

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Clinical and radiographic comparison of mini–open transforaminal lumbar interbody fusion with open transforaminal lumbar interbody fusion in 42 patients with long-term follow-up

Journal of Neurosurgery Spine ◽

10.3171/spi.2008.9.08142 ◽

2008 ◽

Vol 9 (6) ◽

pp. 560-565 ◽

Cited By ~ 234

Author(s):

Sanjay S. Dhall ◽

Michael Y. Wang ◽

Praveen V. Mummaneni

Keyword(s):

Blood Loss ◽

Interbody Fusion ◽

Transforaminal Lumbar Interbody Fusion ◽

Open Group ◽

Lumbar Interbody Fusion ◽

Estimated Blood Loss ◽

Significant Difference ◽

The Mean ◽

Mini Open

Object As minimally invasive approaches gain popularity in spine surgery, clinical outcomes and effectiveness of mini–open transforaminal lumbar interbody fusion (TLIF) compared with traditional open TLIF have yet to be established. The authors retrospectively compared the outcomes of patients who underwent mini–open TLIF with those who underwent open TLIF. Methods Between 2003 and 2006, 42 patients underwent TLIF for degenerative disc disease or spondylolisthesis; 21 patients underwent mini–open TLIF and 21 patients underwent open TLIF. The mean age in each group was 53 years, and there was no statistically significant difference in age between the groups (p = 0.98). Data were collected perioperatively. In addition, complications, length of stay (LOS), fusion rate, and modified Prolo Scale (mPS) scores were recorded at routine intervals. Results No patient was lost to follow-up. The mean follow-up was 24 months for the mini-open group and 34 months for the open group. The mean estimated blood loss was 194 ml for the mini-open group and 505 ml for the open group (p < 0.01). The mean LOS was 3 days for the mini-open group and 5.5 days for the open group (p < 0.01). The mean mPS score improved from 11 to 19 in the mini-open group and from 10 to 18 in the open group; there was no statistically significant difference in mPS score improvement between the groups (p = 0.19). In the mini-open group there were 2 cases of transient L-5 sensory loss, 1 case of a misplaced screw that required revision, and 1 case of cage migration that required revision. In the open group there was 1 case of radiculitis as well as 1 case of a misplaced screw that required revision. One patient in the mini-open group developed a pseudarthrosis that required reoperation, and all patients in the open group exhibited fusion. Conclusions Mini–open TLIF is a viable alternative to traditional open TLIF with significantly reduced estimated blood loss and LOS. However, the authors found a higher incidence of hardware-associated complications with the mini–open TLIF.

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Clinical results of percutaneous biportal endoscopic lumbar interbody fusion with application of enhanced recovery after surgery

Neurosurgical FOCUS ◽

10.3171/2019.1.focus18695 ◽

2019 ◽

Vol 46 (4) ◽

pp. E18 ◽

Cited By ~ 16

Author(s):

Dong Hwa Heo ◽

Choon Keun Park

Keyword(s):

Interbody Fusion ◽

Enhanced Recovery ◽

Enhanced Recovery After Surgery ◽

Transforaminal Lumbar Interbody Fusion ◽

Clinical Results ◽

Fusion Rate ◽

Lumbar Interbody Fusion ◽

Estimated Blood Loss ◽

Significant Difference ◽

The Mean

OBJECTIVEThe aims of enhanced recovery after surgery (ERAS) are to improve surgical outcomes, shorten hospital stays, and reduce complications. The objective of this study was to introduce ERAS with biportal endoscopic transforaminal lumbar interbody fusion (TLIF) and to investigate the clinical results.METHODSPatients were divided into two groups based on the fusion procedures. Patients who received microscopic TLIF without ERAS were classified as the non-ERAS group, whereas those who received percutaneous biportal endoscopic TLIF with ERAS were classified as the ERAS group. The mean Oswestry Disability Index (ODI) and visual analog scale (VAS) scores were compared between the two groups. In addition, demographic characteristics, diagnosis, mean operative time, estimated blood loss (EBL), fusion rate, readmissions, and complications were investigated and compared.RESULTSForty-six patients were grouped into the non-ERAS group (microscopic TLIF without ERAS) and 23 patients into the ERAS group (biportal endoscopic TLIF with ERAS). The VAS score for preoperative back pain on days 1 and 2 was significantly higher in the non-ERAS group than in the ERAS group (p < 0.05). The mean operative duration was significantly higher in the ERAS group than in the non-ERAS group, while the mean EBL was significantly lower in the ERAS group than in the non-ERAS group (p < 0.05). There was no significant difference in fusion rate between the two groups (p > 0.05). Readmission was required in 2 patients who were from the non-ERAS group. Postoperative complications occurred in 6 cases in the non-ERAS group and in 2 cases in the ERAS group.CONCLUSIONSPercutaneous biportal endoscopic TLIF with an ERAS pathway may have good aspects in reducing bleeding and postoperative pain. Endoscopic fusion surgery along with the ERAS concept may help to accelerate recovery after surgery.

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Increased incidence of cage migration and nonunion in instrumented transforaminal lumbar interbody fusion with bioabsorbable cages

Journal of Neurosurgery Spine ◽

10.3171/2010.3.spine09587 ◽

2010 ◽

Vol 13 (3) ◽

pp. 388-393 ◽

Cited By ~ 28

Author(s):

Arien J. Smith ◽

Marc Arginteanu ◽

Frank Moore ◽

Alfred Steinberger ◽

Martin Camins

Keyword(s):

Carbon Fiber ◽

Interbody Fusion ◽

Demographic Data ◽

Transforaminal Lumbar Interbody Fusion ◽

Complication Rates ◽

Lumbar Interbody Fusion ◽

Significant Difference ◽

Screw Breakage ◽

The Mean ◽

Cage Migration

Object Recent advances in the field of spinal implants have led to the development of the bioabsorbable interbody cage. Although much has been written about their advantageous characteristics, little has been reported regarding complications associated with these cages. The authors conducted this prospective cohort study to compare fusion and complication rates in patients undergoing transforaminal lumbar interbody fusion (TLIF) with carbon fiber cages versus biodegradable cages made from 70/30 poly(l-lactide-co-d,l-lactide) (PLDLA). Methods Between January 2005 and May 2006, 81 patients with various degenerative and/or structural pathologies affecting the lumbar spine underwent single- or multilevel TLIF with posterior segmental pedicle screw fixation using implants made of carbon fiber (37 patients) or 70/30 PLDLA (44 patients). Clinical and radiological follow-up was performed at 6 weeks, 3 months, 6 months, and 1 year, and is ongoing. The incidence of nonunion, screw breakage, and cage migration were compared between the 2 groups. Results There was no significant difference in demographic data between the 2 groups, the mean number of lumbar levels operated, or distribution of the levels operated. There was a significantly increased incidence of nonunion (8 patients, 18.2%) and cage migrations (8 patients, 18.2%) in patients receiving the PLDLA implants compared with carbon fiber implants (no patients) (p = 0.006 and 0.007, respectively). There was no significant difference in demographic data between patients with cage migration and the rest of the patient population. Five of the 8 cases of migration occurred at the L5–S1 level while the remaining 3 occurred at the L4–5 level. The mean time to implant failure was 9.3 months. Conclusions This study showed an increased incidence of nonunion (18.2%) and postsurgical cage migration (18.2%) in patients undergoing TLIF with biodegradable cages versus carbon fiber implants (0%) (p = 0.006 and 0.007, respectively).

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A Prospective Randomized Study of the Safety and Efficacy of Transforaminal Lumbar Interbody Fusion Versus Posterior Lumbar Interbody Fusion in the Treatment of Lumbar Spondylolisthesis: A Cost utility from a Lower-middle-income Country Perspective and Review of Literature

Open Access Macedonian Journal of Medical Sciences ◽

10.3889/oamjms.2021.6569 ◽

2021 ◽

Vol 9 (B) ◽

pp. 636-645

Author(s):

Nasser El-Ghandour ◽

Mohamed Sawan ◽

Atul Goel ◽

Ahmed Assem Abdelkhalek ◽

Ahmad M. Abdelmotleb ◽

...

Keyword(s):

Interbody Fusion ◽

Posterior Lumbar Interbody Fusion ◽

Transforaminal Lumbar Interbody Fusion ◽

Cost Utility ◽

Lumbar Interbody Fusion ◽

Safety And Efficacy ◽

Significant Difference ◽

The Mean ◽

Lumbar Spondylolisthesis

BACKGROUND: The safety and efficacy of transforaminal lumbar interbody fusion (TLIF) and posterior lumbar interbody fusion (PLIF) in lumbar spondylolisthesis have not been validated in many prospective randomized trials. AIM: We aimed to validate the safety and efficacy of TLIF and PLIF surgery in lumbar spondylolisthesis using the clinical, radiographic, and cost-utility outcomes. METHODS: The data of surgically treated single-level spondylolisthesis patients were randomized prospectively into two groups. The groups were compared regarding demographics, perioperative complications, hospital stay, total expenditure, fusion rate, and clinical outcomes (visual analog scale, Oswestry disability index, Zurich claudication scale, and Odom’s criteria). A review of literature was done to compare the outcomes with the ones from higher-income nations. RESULTS: Thirty-three patients underwent prospective randomization. The improvement in the clinical outcomes at 12-month follow-up showed improvement in the TLIF group more than the PLIF group but with no significant difference. The mean operative time was significantly longer in the PLIF (p < 0.05), also, the blood loss was significantly less in the TLIF (p < 0.001). The complications frequency did not show any statistical significance between both groups and no significant difference in the patient’s post-operative patient satisfaction (p = 0.6). The mean hospital stay was non-significantly longer in the PLIF (p = 0.7). At 12-month follow-up, 93.3% of the TLIF patients were fused versus 86.7% of the PLIF (p = 0.5). The total cost of the TLIF was significantly less (p < 0.001). CONCLUSION: Both PLIF and TLIF could achieve similar fusion rates and clinical satisfaction in the management of lumbar spondylolisthesis. The TLIF group was significantly better in terms of financial burden, operative time, and blood loss.

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Segmental lumbar sagittal correction after bilateral transforaminal lumbar interbody fusion

Journal of Neurosurgery Spine ◽

10.3171/2012.4.spine111013 ◽

2012 ◽

Vol 17 (1) ◽

pp. 37-42 ◽

Cited By ~ 22

Author(s):

Sharon C. Yson ◽

Edward Rainier G. Santos ◽

Jonathan N. Sembrano ◽

David W. Polly

Keyword(s):

Interbody Fusion ◽

Sagittal Plane ◽

Statistical Significance ◽

Inverse Correlation ◽

Transforaminal Lumbar Interbody Fusion ◽

Lumbar Interbody Fusion ◽

Significant Difference ◽

The Mean ◽

The Difference ◽

Contour Change

Object In this paper the authors sought to determine the segmental lumbar sagittal contour change after bilateral transforaminal lumbar interbody fusion (TLIF). Methods Between March 2007 and October 2010, 42 consecutive patients (57 levels) underwent bilateral TLIF. Standard preoperative and 6-week postoperative standing lumbar spine radiographs were examined. Preoperative and postoperative segmental lordosis was determined by manual measurements using the Cobb method. The difference between the preoperative and postoperative values were calculated and analyzed for statistical significance. Results The mean preoperative segmental alignment was 8.1°. The mean postoperative alignment was 15.3°, with a mean correction of 7.2° per segment. The largest gain in lordosis was obtained at the L5–S1 level (10.1°). There was a significant difference between the preoperative and postoperative values (p = 5 × 10−9). There was no significant difference in mean segmental correction between levels. Improvement in lordosis was higher in multilevel fusions (9.8°) than in single-level fusions (5.2°) (p = 0.047). There was an inverse correlation between preoperative sagittal lordosis measurement and change in lordosis (r = −0.599). Conclusions A significant improvement in lumbar lordosis can be gained by preforming bilateral facetectomies in TLIF with posterior compression. This procedure provides an additional option to a spine surgeon's armamentarium in dealing with significant lumbar sagittal plane deformities.

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Comparative analysis of transforaminal lumbar interbody fusion versus posterolateral instrumented fusion in degenerative lumbar spine disorders

Journal of Orthopaedics Trauma and Rehabilitation ◽

10.1177/2210491720941212 ◽

2020 ◽

Vol 27 (2) ◽

pp. 173-178

Author(s):

Sanjay Yadav ◽

Saurabh Singh ◽

Raj Kumar Arya ◽

Alok Kumar ◽

Ishan Kumar ◽

...

Keyword(s):

Lumbar Spine ◽

Blood Loss ◽

Interbody Fusion ◽

Transforaminal Lumbar Interbody Fusion ◽

Fusion Rate ◽

Lumbar Interbody Fusion ◽

Inclusion Criteria ◽

Degenerative Lumbar Spine ◽

Significant Difference ◽

Spine Disorders

Objectives: Spinal fusion is an effective treatment for degenerative lumbar spine; however, conflicting results exist regarding the best procedure. This study compares the clinical and radiological outcomes of transforaminal lumbar interbody fusion (TLIF) versus instrumented posterolateral fusion (PLF) in patients of degenerative lumbar spine disorders. Methods: Of the total 37 patients, 16 patients were operated with TLIF and 21 were operated with instrumented PLF with bone grafting. Duration of the study was from June 2017 to June 2019. Patients fulfilling the inclusion criteria were included in the study. Inclusion criteria were (1) age of patient ranging from 18 years to 70 years, (2) involvement of single level, (3) diagnosis of degenerative spine disease, and (4) minimum follow-up of 1 year. Radiographic parameters such as slippage of vertebrae, anterior and posterior disc heights, local disc lordosis, T12–S1 angle were measured, and fusion were assessed; comparison between preoperative and postoperative parameters was also done. Clinical outcome score was obtained using visual analog scale (VAS) and Oswestry disability index (ODI). Statistical analysis was done using SPSS software. Results: No significant difference was found in ODI and VAS between TLIF and PLF. Restoration of disc height and improvement of local disc lordosis was better in the TLIF group than in the PLF group. The fusion rate was 87.5% in the TLIF group and 81% in the instrumented PLF group. Amount of blood loss was slightly higher in the TLIF group (319.69 ± 53.8 mL) than in the instrumented PLF group (261.19 ± 34.9 mL). Operating time was also slightly higher in TLIF (133 ± 6.02 min) than in instrumented PLF (90.71 ± 6.3 min). Conclusion: TLIF is superior to instrumented PLF in terms of restoration of anterior and posterior disc heights and improvement in local disc lordosis and higher fusion rate, however it requires greater surgical expertise and more experience. Because of anterior cage support, early weight-bearing mobilization can be allowed in the TLIF group compared to the PLF group. Surgical time and blood loss were slightly higher in cases of TLIF than instrumented PLF.

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Imaging anatomy and clinical significance of percutaneous endoscopic transforaminal oblique fixation from posterior corner in lumbar spine

10.21203/rs.3.rs-28074/v1 ◽

2020 ◽

Author(s):

Feifei Chen ◽

Xiaoyang Liu ◽

Jianmin Sun ◽

Jun Xin ◽

Cheng Su ◽

...

Keyword(s):

Lumbar Spine ◽

Interbody Fusion ◽

Axial Plane ◽

Minor Trauma ◽

Lumbar Interbody Fusion ◽

Significant Difference ◽

One Stop ◽

Anatomic Basis ◽

Fusion Cage ◽

Interbody Fusion Cage

Abstract BackgroundPercutaneous endoscopic transforaminal lumbar interbody fusion (PE-TLIF) has been widely discussed due to its advantages of less trauma, less bleeding, quick recovery, high safety, and relatively fewer complications, as well as other adverse factors such as incomplete decompression, steep learning curve, low fusion rate, and high radiation risk. It can keep the posterior structure of spine intact to the greatest extent, ensure the stability of spine after surgery, and achieve decompression with minor trauma. However, posterior percutaneous pedicle screws are often needed for fusion and fixation after decompression, and additional posterior trauma, postural changes and anesthesia methods are often required. Interbody fixation and fusion are often independent and not one-stop completion. The authors consider whether the percutaneous spinal endoscopy can be used to achieve complete decompression and fusion under a single minimally invasive channel, while achieving one-stop endoscopic decompression, fusion and fixation. The purpose of this paper is to provide the anatomic feasibility for oblique fixation by measuring the imaging anatomic parameters, especially to provide the anatomic basis for the design of new endoscopic lumbar interbody fusion cage.Methods Sixty volunteers (22 men and 38 women) who underwent lumbar CT scans were collected and sent to the GEAW4.4 workstation. The distances from posterior corner in the lumbar spine to the corresponding targets of the contralateral anterior corner and the included angles between each path line in sagittal and axial plane were measured and analyzed statistically.Results In the medium group, PC path was the shortest, PA path and PB path had little difference (P=0.123), with no statistical significance. In the full-length group, PF path was the shortest, and there was no significant difference between PD path and PE path (P =0.177). PE was the optimal path. The included angles a1, a2, a3, b1, b2, and b3 in sagittal plane and c1, c2 and c3 in axial plane were significantly different (P=0.000), namely, a1 >a2>a3, b1>b2>b3, and c1<c2<c3. Conclusions This study provides anatomic feasibility for percutaneous endoscopic transforaminal oblique fixation from posterior corner in lumbar spine and particularly provides anatomic basis for the design of new endoscopic lumbar interbody fusion cage.

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Modification of Magerl’s technique for the placement of translaminar facet screws in transforaminal lumbar interbody fusion: a technical note and comparative outcome analysis

10.21203/rs.3.rs-22186/v1 ◽

2020 ◽

Author(s):

Daoliang Xu ◽

Haimin Jin ◽

Jiaoxiang Chen ◽

Xiangyang Wang

Keyword(s):

Length Of Stay ◽

Blood Loss ◽

Spinal Canal ◽

Interbody Fusion ◽

Operation Time ◽

Transforaminal Lumbar Interbody Fusion ◽

Lumbar Interbody Fusion ◽

Modified Technique ◽

Significant Difference ◽

The Mean

Abstract Background To describe and illustrate a safe and effective technique for the placement of translaminar facet screws (TLFS) in transforaminal lumbar interbody fusion (TLIF). Methods Forty-two patients with single-level lumbar diseases were divided into two groups randomly. 21 patients were treated by traditional TLIF using bilateral pedicle screws fixation (BPS) while the other patients underwent insertion of a unilateral pedicle screw (UPS)and contralateral TLFS using our modified technique. In this technique, a small unicortical “hole” was formed adjacent to the contralateral facet joint to ensure that insertion of the screw could be directly visualized through the hole to prevent violation of the spinal canal. The ODI, JOA, VAPS questionnaire, the mean operation time, mean operative blood loss, length of stay and postoperative complications were collected for analysis. Results There is no significant difference between the BPS and UPS + TLFS group in the preoperative and postoperative ODI, JOA or VAPS at each follow- up visit, while the UPS + TLFS group using our modified technique significantly reduced the mean operation time, the mean estimated blood loss and the length of stay. These results demonstrated this modified technique to be safe and effective in TLIF. Conclusions In contrast to conventional TLIF, our modified technique for placing TLFS in TLIF can reduce soft tissue injuries, reduce the operation risk of violation of the spinal canal and the expenses, minimize radiation exposure, and shorten the length of the operation without a concurrent reduction in clinical efficacy.

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