"Lateral-PLIF", modified PLIF technique for spinal arthrodesis – concept, technique, results, complications and outcomes

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Purpose: Lumbar interbody fusion surgery is an effective treatment option to treat degenerative conditions in the lumbar spine. There is still no consensus on the best operative technique, based on published inconsistent outcomes and no recent studies. We present a variant of the PLIF technique, lateral-PLIF, from a prospective consecutive series of patients.

Methods: Patients underwent consecutively a single/double level Lateral-PLIF were prospectively recruited from January to December 2017 for the primary diagnosis of isthmic or degenerative spondylolisthesis, lumbar spinal stenosis, severe degenerative disc disease, and/or recurrent disc herniation. Revision cases were not excluded.

Lateral PLIF consist of a modified PLIF technique with preservation of both lamina, bilateral foraminal opening and more lateral insertion of the cages through the supra-recessal space, between the central canal and the foramen.

Patients were asked to complete prospectively pre- and postoperative questionnaires at 4 months, 1- and 2-years assessing pain and functional scores. Phone interviews provide treatment satisfaction rate at 4 years. Data related to the surgical procedure and post-operative complications were also collected. Radiological follow up findings (fusion and lumbar lordosis) were assessed at 1-year follow up visit based on X-rays and CT-scan.

Results: A total of 104 patients were consecutively included in the study. Patients were 57.8 ± 10.5 years old and presented with mechanical low back pain (104, 100%), radicular pain (97, 93.2%), and motor weakness (23, 22.1%). 

Estimated operative time was 155.8 ± 39.7 min for single level, 172.5 ± 47.1 min for double level. Average estimated blood loss for single level was 480 ± 405.9 ml, 700 ± 461.8 ml for double level.

We found high incidence of fusion rate (95%). A statistically significant improvement of function was noted (decreased of ODI from 49.4 ± 12.5 [22-82] to 29.2 ± 17.1 [4-62] at 1-year, p<0.001, and of Roland-Morris score from 14.9 ± 4.8 [3-24] to 8.4 ± 6.4 [0-19] at 1-year, p<0.001). Walking distance increased from 812m ± 543m, to 3443m ± 712m (p<0.001).

Complication included 1 permanent nerve root dysfunction (0.9%) and 2 pedicle screws loosening (1.9%). 5 (4.8%) cases of infections/wound dehiscence, 2 (1.9%) malposition of pedicle screws, 1 (0.9%) iatrogenic arterial injury during discectomy. No CSF fistula, epidural hematoma or migration of cage were observed.

Conclusion: Our results suggest that Lateral-PLIF is a safe and efficient technique with extensive applicability to achieve lumbar fusion while restoring an appropriate disc height and a correct lordosis. Complications rates associated with the traditional PLIF technique were lower in our series compared to the rates usually reported in the literature. Although further comparative studies will be necessary to validate the final outcomes, surgeons might consider this technique before using a routine standard lumbar fusion approach.