As with all types of spinal fusion surgery, Posterior Lumbar Interbody Fusion or PLIF surgery involves adding bone graft to an area of spine in order to set up a biological response which will cause the bone to grow between two vertebral elements & thereby eventually stop motion at that segment. Spinal fusion basically is a technique which is used to stabilize vertebrae or spinal bones. Goal of lumbar fusion surgery is meant to create a solid bridge of bone in between two or more vertebrae. Spinal fusion is most often recommended when natural disc space of the patient has decreased or when the spine is unstable.
Unlike posterolateral gutter fusion, PLIF achieves spinal fusion in lower back by inserting a cage, either made of synthetic material (titanium or PEEK) or allograft bone, directly into the available disc space. Whenever, this surgical approach for this type of a surgical intervention is made from the back side, it is called PLIF or posterior lumbar interbody fusion. PLIF surgery is quite often supplemented by a simultaneous posterolateral spine fusion surgery.
Spine is basically composed of individual bones which are called vertebrae. Human body typically encloses five lumbar vertebrae. All these five are stacked one on top of another & which are separated by discs which eventually act as shock absorbers or elastic cushions. These spinal discs have nucleus which is a soft center surrounded by a tough outer ring called annulus. These spinal discs also allow motion between the vertebrae. Interbody space is basically the disc space which is located in between vertebral body bones. Each of these vertebral segments creates a bony circle known as the spinal canal & which protects spinal nerves & the spinal cord. Spinal cord is the nerve center of the body which connects the brain with the rest of the body parts. These nerves comprising the spinal cord travel from cervical spine all the way to the lowest point of spine known as the sacrum. Moreover, these spinal nerves exit the spinal canal in between the vertebrae at each level. Two nerves are found to exit at each level, one on the right & the other to the left, through exit openings called the foramen. Ligaments, bony structures, discs & strong muscles, all of these effectively work together in order to stabilize the spine.
Interbody fusion basically involves placement of bone graft & fusion implants into areas between two vertebral bodies. This eventually goes on to prove as an effective method of achieving fusion. Intervertebral implants are made from a variety of materials including bone, plastic or metal. Bone healing protein & bone graft are placed within the implant & within interbody space so as to encourage healing of bones. This implant eventually helps by separating & holding two vertebrae apart. This will also increase the opening around nerve roots at the level & thereby relieve pressure on nerves. Intervertebral implants are also used to correct spinal deformity by restoring proper alignment. These intervertebral implants can be placed from back, side or front of the spine. Location of the surgical intervention will eventually depend upon the specific anatomy of the individual patient, as well as the location & amount of pressure which is found to be occurring around nerves within the spinal canal. Decision of the surgical approach is based upon several factors including the anatomy of the patient, location of levels which need to be fixed, degree of spinal instability & whether the patient had undergone any abdominal surgery in the past.
However, in some cases orthopedic & spine surgeons will use additional surgical instrumentation in front so as to boost stability. This usually involves screws & plates placed in front of spine. A series of screws & rods may also be used in case support is also required from the back of spine. This technical approach is called posterior instrumentation fusion & which is helpful in achieving posterior fusion in addition to interbody fusion.
Posterior lumbar interbody fusion is commonly performed to treat the following conditions.
PLIF procedure can be performed through traditional open incision or through a minimally invasive procedure depending upon the choice of the patient & the condition which is to be treated. PLIF is generally performed under the influence of general anesthesia, which means that the patient will be sleeping during the surgical intervention. Patients will lie face down on special surgical beds during the operation as this procedure is performed through an incision on the back side. Length of this incision will however depend upon the number of levels which are to be treated. Once surgeons have safely created a window to access the spine, lamina is removed through a laminectomy procedure. This will eventually allow visualization of nerve roots. Facet joints may also be cut away in order to give nerve roots more room. Nerve roots are then carefully moved to either side so that disc space can be accessed from both ends. Pedicle screws are now inserted into bones so as to allow fixation. A rod is then subsequently placed through these screws. This is meant to provide more stability for fusion to heal & help realign spine to proper curvature.
Damaged disc is partially removed with the help of surgical tools. However, this approach does not allow much of the disc to be removed as it can be through the side or frontal approach. Once surgeons have cleared out the disc space, they will prepare the bony surfaces for fusion. Implants filled with bone grafts are subsequently placed in the now empty disc space in-between two vertebrae. Bone grafts within disc spaces will eventually go on to fuse by healing the two bones together within this area. Screws & rods are fixed in order to provide compressive force for optimal fusion after the interbody implant is placed. Additional bone graft materials may also be placed along the back of spine so as to allow additional area for spinal fusion to occur. Vertebrae will move on as one unit when fusion is finally successful. This will also eventually reduce problems at this segment of spine in future. In case bone fail to fuse as planned, it is called a pseudarthrosis or nonunion. All spine surgeries involve surgical risks. Therefore, patients need to discuss these with their surgeon during the preoperative appointment.
There are several options for bone graft materials for lumbar interbody fusion & spinal fusion in general. Orthopedic & spine surgeons may often use patient’s own locally harvested bone & which are known as autograft bones. Autograft bones can come from a combination of bones from areas of the spine operated upon and/or from the patient’s hip bone. Moreover, bone grafting may also come from donated & prepared bones & which are called allograft bones.
The spine is first approached through a 3-inch to 6-inch long incision which is made in the midline of the back & to the left & right of the back muscles known as erector spinae. These muscles are stripped off the lamina on both the sides & at multiple levels of spine. After approaching the spine surgeons will remove the lamina (laminectomy) & which will subsequently allow visualization of nerve roots. Facet joints which directly hover over nerve roots may then be trimmed or undercut in order to give nerve roots more room. Nerve roots are now retracted to one side & disc space is cleaned of remaining disc material. A cage is subsequently made of allograft bones or posterior lumbar interbody cages with bone graft which is inserted into the disc space & which eventually allows bone growths from one vertebral body to the other vertebral body.
Performing pure PLIF surgery has the advantage of providing anterior fusion of disc space without having any need for a second incision as it would be necessary with anterior or posterior spine fusion surgery. However, pure PLIF surgery also has some disadvantages which are mentioned below.
Nevertheless, PLIF surgery allows a higher potential for better chances of solid fusion rates than posterolateral fusion procedures because bone is inserted into anterior front portion of the spine. Bone in anterior portion is found to fuse better as there is more surface area available than in posterolateral gutter & also because bone is under compression. It is an accepted fact that bone under compression heals better mostly because bone responds to stress, whereas bone under tension like in posterolateral fusions does not involve as much of stress.
Principal risk of PLIF surgery is that solid fusion will not be obtained in case of nonunion & will further call for surgery so as to re-fuse spine. However, fusion rates of PLIF surgery are as high as 90 – 95 percent. Nonunion rates are only higher for patients who have undergone prior spine surgery, patients who are obese & smokers, patients who have already undergone multiple level fusion surgeries & patients who have earlier been treated with radiation for cancer treatments. However, not all patients who have nonunion will require another spine fusion surgery. More of back surgery is not required long as the joint is stable & symptoms of the PLIF surgery patients are better. Risks of PLIF surgery other than nonunion include bleeding or infection. However, these complications are also fairly uncommon & approximately occur among 1 – 3 percent of cases. Additionally, there is risk of achieving successful spinal fusion but the experience of pain in the patient will not subside.
PLIF surgery patients generally remain in hospitals for about 2 – 4 days following surgery. Postoperative control over pain can be achieved with administration of IV pain medications or oral pain medicines. Patients are usually discharged to go home on oral pain medications. PLIF surgery patients commonly begin physical therapy walking programs on the day after surgery when a physical therapist would work with them & teach how to get out of bed so as to walk safely. PLIF patients will however need to be comfortable while walking & climbing stairs or while getting in & out of bed before returning home. Final goal of PLIF surgery is to ensure that urinary systems & gastrointestinal working of the patient is appropriate. PLIF patients should be able to effectively tolerate foods & be able to urinate without any difficulty prior to taking discharge from the hospital.
Posterior Lumbar Interbody Fusion is an effective & approved technique for fusing lumbar spine. Goal of PLIF surgery is to decrease pain, improve stability & effectively correct spinal deformity. Complications involved in this procedure may sometimes occur but are quite uncommon. Majority of patients however, are satisfied with pain relief & by the results of PLIF surgery. Nevertheless, it is quite important that all PLIF surgery patients are physically & psychologically prepared for the procedure. All PLIF surgery patients are required to stop smoking prior to undergoing surgery, as smoking is extremely detrimental to health of spine, potential healing of bone & for a successful surgical outcome. Moreover, it is also important that PLIF surgery patients review additional details with orthopedic or spine surgeons prior to undergoing this surgical intervention.
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