Aims. Cervical radiculopathy is a significant cause of pain and morbidity. For patients with severe and poorly controlled symptoms who may not be candidates for surgical management, treatment with transforaminal epidural steroid injections (CTFESI) has gained widespread acceptance. However, a paucity of high-quality evidence supporting their use balanced against perceived high risks of the procedure potentially undermines the confidence of clinicians who use the technique. We undertook a systematic review of the available literature regarding CTFESI to assess the clinical efficacy and complication rates of the procedure. Methods. OVID, MEDLINE, and Embase database searches were performed independently by two authors who subsequently completed title, abstract, and full-text screening for inclusion against set criteria. Clinical outcomes and complication data were extracted, and a narrative synthesis presented. Results. Six studies (three randomized controlled trials and three non-randomized observational studies; 443 patients) were included in the final review. The aggregate data support the efficacy of CTFESI in excess of the likely minimal clinically important difference. No major complications were described. Conclusion. There is increasing evidence supporting the efficacy of CTFESI. Concerns regarding the occurrence of catastrophic complications, widely shared in the case report and anecdotal literature, were not found when reviewing the best available evidence. However, the strength of these findings remains limited by the lack of highly powered high-level studies and the heterogeneity of the studies available. Further high-quality studies are recommended to address the issues of efficacy and safety with CTFESI. Cite this article: Bone Joint J 2022;104-B(5):567–574

Introduction: Epidural steroid injection is commonly used for treatment of sciatica. Traditionally these have been administered through a needle inserted in the posterior mid line via an interlaminar (IL) route. However, in recent years the transforaminal (TF) route of administration has become popular. Potential advantages of the TF route include greater accuracy of injection (with radiological confirmation) and placement of the needle tip closer to the point at which the nerve is compressed. Methods: Consecutive patients from the practices of 2 surgeons that use an IL technique were compared with those from the practices of 2 other surgeons that use a TF technique. Inclusion criteria were leg pain accompanied by a radiological diagnosis of nerve root compression. Both patients with disc prolapse and spinal stenosis were included. Treatment outcome was measured using the Roland-Morris (RM) Score, the Sciatica Frequency and Bothersome Index (SFBI) and the Euroqol (EQ-5D) questionnaire obtained at recruitment and three months after the epidural steroid injection. A global assessment (GA) of outcome; where patients were asked whether they were. much better,. better,. un changed or. worse after treatment; was obtained at 3 months. Patients were also asked the duration of any relief obtained. Statistical methods utilized included the two tailed t-test, the Wilcoxon Rank Sum test, Odds ratio (OR) and the Chi Squared Test. Results: 39 patients received an interlaminar epidural steroid injection and 25 received a transforaminal epidural steroid injection (total 64 patients). Follow-up was achieved for 36/39 (92.3%) and 25 (100%) patients respectively. The median pre-test RM score was 11 (range 3–11) for both groups. Post test RM score was 12(6–16) for the IL group and 3 (6–10.5) for the TF group (p=0.01). Median pre-test SFBI was 25 (0–46) and 26 (4–46) for the IL and TF groups respectively. Post test SFBI was 22 (0–46) and 18 (0–41) for the IL and TF groups respectively (p=0.003). Median pre- test EQ-5D was 0.54 for both groups (range 0.06–0.72 for the IL group and 0.08–0.72 for the TF group). Post test EQ-5D was 0.55 (0.06–1) for the IL group and 0.66 (0.06–1) (p=0.21). According to their GA, 11.1% felt much better, 33.3% felt better and 55.6% felt unchanged at 3 months in the IL group. 64% felt much better, 34% better and 12% felt unchanged in the transforaminal group. The proportion of patients having relief for 3 months or more after the injections was 3/36 (8.3%) for the IL group and 10/25 (40%) for the TF group. The transforaminal injection was 7 times more likely to result in pain relief at 3 months. (OR 7.3 95% CI 1.5 – 45.8, p=0.003). Discussion: Epidural steroid injection by the transforaminal route is more effective then by the interlaminar route in the short term relief of sciatica

We performed a prospective study to examine the influence of the patient’s position on the location of the abdominal organs, to investigate the possibility of a true lateral approach for transforaminal endoscopic lumbar discectomy. Pre-operative abdominal CT scans were taken in 20 patients who underwent endoscopic lumbar discectomy. Axial images in parallel planes of each intervertebral disc from L1 to L5 were achieved in both supine and prone positions. The most horizontal approach angles possible to avoid injury to the abdominal organs were measured. The results demonstrated that the safe approach angles were significantly less (i.e., more horizontal) in the prone than in the supine position. Obstacles to a more lateral approach were mainly the liver, the spleen and the kidneys at L1/2 (39 of 40, 97.5%) and L2/3 (28 of 40, 70.0%), and the intestines at L3/4 (33 of 40, 82.5%) and L4/5 (30 of 30, 100%). A true lateral approach from each side was possible for 30 of the 40 discs at L3/4 (75%) and 23 of the 30 discs at L4/5 (76.7%). We concluded that a more horizontal approach for transforaminal endoscopic lumbar discectomy is possible in the prone position but not in the supine. Prone abdominal CT is more helpful in determining the trajectory of the endoscope. While a true lateral approach is feasible in many patients, our study shows it is not universally applicable.

Introduction. In daily clinical practice, progression of spinal fusion is typically monitored during clinical follow-up using conventional radiography and Computed Tomography scans. However, recent research has demonstrated the potential of implant load monitoring to assess posterolateral spinal fusion in an in-vivo sheep model. The question arises to whether such a strain sensing system could be used to monitor bone fusion following lumbar interbody fusion surgery, where the intervertebral space is supported by a cage. Therefore, the aim of this study was to test human cadaveric lumbar spines in two states: after a transforaminal lumbar interbody fusion (TLIF) procedure combined with a pedicle-screw-rod-construct (PSR) and subsequently after simulating bone fusion. The study hypothesized that the load on the posterior instrumentation decreases as the segment stiffens due to simulated fusion. Method. A TLIF procedure with PSR was performed on eight human cadaveric spines at level L4-L5. Strain sensors were attached bilaterally to the rods to derive implant load changes during unconstrained flexion-extension (FE), lateral bending (LB) and axial rotation (AR) loads up to ±7.5Nm. The specimens were retested after simulating bone fusion between vertebrae L4-L5. In addition, the range of motion (ROM) was measured during each loading mode. Result. The ROM decreased in the simulated bone fusion state in all loading directions (p≤0.002). In both states, the measured strain on the posterior instrumentation was highest during LB motion. Furthermore, the sensors detected a significant decrease in the load induced rod strain (p≤0.002) between TLIF+PSR and simulated bone fusion state in LB. Conclusion. Implant load measured via rod strain sensors can be used to monitor the progression of fusion after a TLIF procedure when measured during LB of the lumbar spine. However, further research is needed to investigate the influence of daily loading scenarios expected in-vivo on the overall change in implant load

Aims. We compared the clinical and radiological outcomes of using a polyetheretherketone cage with (TiPEEK) and without a titanium coating (PEEK) for instrumented transforaminal lumbar interbody fusion (TLIF). Materials and Methods. We conducted a randomised clinical pilot trial of 40 patients who were scheduled to undergo a TLIF procedure at one or two levels between L2 and L5. The Oswestry disability index (ODI), EuroQoL-5D, and back and leg pain were determined pre-operatively, and at three, six, and 12 months post-operatively. Fusion rates were assessed by thin slice CT at three months and by functional radiography at 12 months. Results. At final follow-up, one patient in each group had been lost to follow-up. Two patients in each of the PEEK and TiPEEK groups were revised for pseudarthrosis (p = 1.00). The rate of complete or partial fusion at three months was 91.7% in both groups. Overall, there were no significant differences in ODI or in radiological outcomes between the groups. Conclusion. Favourable results with identical clinical outcomes and a high rate of fusion was seen in both groups. The titanium coating appears to have no negative effects on outcome or safety in the short term. A future study to determine the effect of titanium coating is warranted. Cite this article: Bone Joint J 2017;99-B:1366–72

Introduction and Objective. Posterior and transforaminal lumbar interbody fusion (PLIF, TLIF) represent the most popular techniques in performing an interbody fusion amongst spine surgeons. Pseudarthrosis, cage migration, subsidence or infection can occur, with subsequent failed surgery, persistent pain and patient’ bad quality of life. The goal of revision fusion surgery is to correct any previous technical errors avoiding surgical complications. The most safe and effective way is to choose a naive approach to the disc. Therefore, the anterior approach represents a suitable technique as a salvage operation. The aim of this study is to underline the technical advantages of the anterior retroperitoneal approach as a salvage procedure in failed PLIF/TLIF analyzing a series of 32 consecutive patients. Materials and Methods. We performed a retrospective analysis of patients’ data in patients who underwent ALIF as a salvage procedure after failed PLIF/TLIF between April 2014 to December 2019. We recorded all peri-operative data. In all patients the index level was exposed with a minimally invasive anterior retroperitoneal approach. Results. Thirty-two patients (average age: 46.4 years, median age 46.5, ranging from 21 to 74 years hold- 16 male and 16 female) underwent salvage ALIF procedure after failed PLIF/TLIF were included in the study. A minimally invasive anterior retroperitoneal approach to the lumbar spine was performed in all patients. In 6 cases (18.7%) (2 infection and 4 pseudarthrosis after stand-alone IF) only anterior revision surgery was performed. A posterior approach was necessary in 26 cases (81.3%). In most of cases (26/32, 81%) the posterior instrumentation was overpowered by the anterior cage without a previous revision. Three (9%) intraoperative minor complications after anterior approach were recorded: 1 dural tear, 1 ALIF cage subsidence and 1 small peritoneal tear. None vascular injuries occurred. Most of patients (90.6%) experienced an improvement of their clinical condition and at the last follow-up no mechanical complication occurred. Conclusions. According to our results, we can suggest that a favourable clinical outcome can firstly depend from technical reasons an then from radiological results. The removal of the mobilized cage, the accurate endplate and disc space preparation and the cage implant eliminate the primary source of pain reducing significantly the axial pain, helping to realise an optimal bony surface for fusion and enhancing primary stability. The powerful disc distraction given by the anterior approach allows inserting large and lordotic cages improving the optimal segmental lordosis restoration

In a prospective observational study we compared the two-year outcome of lumbar fusion by a simple technique using translaminar screws (n = 57) with a more extensive method using transforaminal lumbar interbody fusion and pedicular screw fixation (n = 63) in consecutive patients with degenerative disease of the lumbar spine. Outcome was assessed using the validated multidimensional Core Outcome Measures Index. Blood loss and operating time were significantly lower in the translaminar screw group (p < 0.01). The complication rates were similar in each group (2% to 4%). In all, 91% of the patients returned their questionnaire at two-years. The groups did not differ in Core Outcome Measures Index score reduction, 3.6 (. sd. 2.5) (translaminar screws) vs 4.0 (. sd. 2.8) (transforaminal lumbar interbody fusion) (p = 0.39); ‘good’ global outcomes, 78% (translaminar screws) vs 78% (transforaminal lumbar interbody fusion) (p = 0.99) or satisfaction with treatment, 82% (translaminar screws) vs 86% (transforaminal lumbar interbody fusion) (p = 0.52). The two fusion techniques differed markedly in their extent and the cost of the implants, but were associated with almost identical patient-orientated outcomes. Extensive three-point stabilisation is not always required to achieve satisfactory patient-orientated results at two years

To compare outcomes and costs of transforaminal endoscopic surgical discectomy (TES) with those of microdiscectomy (Micro). 48 patients with a primary lumbar disc prolapse were randomly allocated by computer to surgery. Assessments were made of leg and back pain (VAS), Oswestry Disability index (ODI), and SF-36 as primary outcomes. Cost data was collated. 25 TES and 23 Micro patients are reported with similar age, sex, smoking status and affected disc levels (14 v.17 L5/S1). Three months following surgery leg pain scores had decreased by 55 and 65% in the two groups. Patient satisfaction ratings were equal. ODI had decreased 15 points in both groups by 1yr and this improvement was maintained to 2 years (final scores: 7±3 TES v.14±13 Micro - means ±SD; p<0.05). Similar changes were noted in SF36-P. Mean bed stay was lower in the TES group (16 v. 40 hours). Other post-operative costs were similar. There were no immediate complications. One revision was required at 12 months (TES) and one at 18 months (Micro). Two patients presented with a disc prolapse at a different level and side (both TES). Results at up to two years follow-up are similar following the two interventions. Recovery was more rapid in those patients undergoing endoscopic surgery

Transforaminal lumbar interbody fusion (TLIF) using an implanted cage is the gold standard surgical treatment for disc diseases such as disc collapse and spinal cord compression, when more conservative medical therapy fails. Titanium (Ti) alloys are widely used implant materials due to their superior biocompatibility and corrosion resistance. A new Ti-6Al-4V TLIF cage concept featuring an I-beam cross-section was recently proposed, with the intent to allow bone graft to be introduced secondary to cage implantation. In designing this cage, we desire a clear pathway for bone graft to be injected into the implant, and perfused into the surrounding intervertebral space as much as possible. Therefore, we have employed shape optimization to maximize this pathway, subject to maintaining stresses below the thresholds for fatigue or yielding. The TLIF I-beam cage (Fig. 1(a)) with an irregular shape was parametrically designed considering a lumbar lordotic angle of 10°, and an insertion angle of 45° through the left or right Kambin's triangles with respect to the sagittal plane. The overall cage dimensions of 30 mm in length, 11 mm in width and 13 mm in height were chosen based on the dimensions of other commercially available cages. The lengths (la, lp) and widths (wa, wp) of the anterior and posterior beams determine the sizes of the cage's middle and posterior windows for bone graft injection and perfusion, so they were considered as the design variables for shape optimization. Five dynamic tests (extension/flexion bending, lateral bending, torsion, compression and shear compression, as shown in Fig. 2(b)) for assessing long term cage durability (10. 7. cycles), as described in ASTM F2077, were simulated in ANSYS 15.0. The multiaxial stress state in the cage was converted to an equivalent uniaxial stress state using the Manson-Mcknight approach, in order to test the cage based on uniaxial fatigue testing data of Ti-6Al-4V. A fatigue factor (K) and a critical stress (σcr) was introduced by slightly modifying Goodman's equation and von Mises yield criterion, such that a cage design within the safety design region on a Haigh diagram (Fig. 2) must satisfy K ≤ 1 and σcr ≤ SY = 875 MPa (Ti-6Al-4V yield strength) simultaneously. After shape optimization, a final design with la = 2.30 mm, lp = 4.33 mm, wa = 1.20 mm, wp = 2.50 mm, was converged upon, which maximized the sizes of the cage's windows, as well as satisfying the fatigue and yield strength requirements. In terms of the strength of the optimal cage design, the fatigue factor (K) under dynamic torsion approaches 1 and the critical stress (σcr) under dynamic lateral bending approaches the yield strength (SY = 875 MPa), indicating that these two loading scenarios are the most dangerous (Table 1). Future work should further validate whether or not the resulting cage design has reached the true global optimum in the feasible design space. Experimental validation of the candidate TLIF I-beam cage design will be a future focus. For any figures or tables, please contact authors directly (see Info & Metrics tab above).

Purpose: Circumferential arthrodesis of the lumbar spine is necessary in certain selected situations (lumbar stenosis with instability and preserved disc height or spondylolisthesis). Posterior lumbar interbody fusion (PLIF) raises the risk of significant bleeding and fibrosis around the roots as well as neurological complications. Transforaminal lumbar interbody fusion (TLIF) can avoid excessive bleeding and root displacement. The cages are inserted via a unilateral approach. Material and methods: This prospective single-centre study included twenty patients (nine men and eleven women), mean age 49 years. Indications for lumbar surgery were degenerative spondylolisthesis in nine patients and discal lumbar pain with foraminal stenosis in five. The clinical status was assessed with the Oswestry score, SF-36 and a visual analogue scale (VAS). Radiological assessment was based on inter-body fusion, segmentary lordosis, and lumbopelvic parameters. TLIF was associated with a posterior approach for insertion of titanium pedicular screws (CDH, Medtronic Sofamor Danek). Temporary unilateral distraction opened the foramen. Unilateral arthrectomy enabled a lateral approach to the disc without involving the roots and avoiding any movement of the dural sac. The disc was resected and the body endplates were prepared before introducing two cages (pyramesh) filled with macroporous ceramic granules (BCP) mixed with autologous bone marrow. Installation to two contourned rods enabled segmentary compression to stabilise the cages in association with posterolateral fusion. Results: Mean operative time was three hours. Mean blood loss was 400 ml. The patients were verticalised on day three without a corset. Mean follow-up was six months with retrospective evaluation of the Oswestry score, SF-36, and VAS. Postoperative pain resolved rapidly. Two patients developed transient incomplete L5 deficit. Bony bridges around the cases and posterolaterally were identified on the six-month x-rays. Spine view confirmed the quality of the fusion and lumbopelvic parameters revealed restoration of segmentary lordosis. Conclusion: The unilateral approach for TLIF is a reliable technique which does not compromise the roots. It enables very reliable primary stability and recovery of local segmentary lordosis. We are developing a minimally invasive percutaneous technique for this procedure

The purpose of this study was to investigate the efficacy and fusion rates of a unilateral pedicle screw construct supplemented with a translaminar screw in transforaminal lumbar interbody fusion (TLIF). The construct was used with an aim of providing suitable spine stiffness with minimal implant load for spinal fusion. Nineteen consecutive patients who underwent single level TLIF were included in the study. All patients had posterior spinal instrumentation using a unilateral pedicle screw construct with a contralateral translaminar screw. Patients were assessed preoperatively and at two, six, twelve and twenty-four weeks following surgery and at the end of one and two years. At every visit Oswestry disability index score,Visual analogue scale for pain and a pain diagram were recorded. A radiographic exam was also conducted and CT scan was done if there was concern about fusion. The average follow up was twenty-four months. There were twelve males and seven females with an average age of forty-eight years. All patients went on to clinical and radiographic union. Sixteen of nineteen patients had significant clinical improvement on VAS for pain, Oswestry scores and pain medication. Three patients had recurrence of radicular pain on the side of the TLIF leading to reexploration. In all three patients solid fusion was observed but scar tissue was evident and symptoms resolved following redecompression of the foramen. The biomechanical competence of a construct is evidenced by successful fusion. With the advent of minimally invasive techniques to achieve spinal fusion the goal is to use minimal instrumentation without compromising on the final stiffness of the spine. The construct of unilateral pedicle screws supplemented with a trans-laminar screw led to fusion in all our cases. It requires lesser soft tissue dissection and the posterior implants are 56% cheaper

Study design. Prospective randomized study. Objective. Primary aim of this study was to compare clinical and radiological results of transforaminal lumbar interbody fusion (TLIF) with posterolateral (interlaminar) instrumented lumbar fusion (PLF) in adult low grade (Meyerding 1 & 2) spondylolisthesis patients. Background data. Theoretically, TLIF has better radiological result than PLF in spondylolisthesis in most of the studies. Method. 24 patients of low grade adult spondylolisthesis were randomly allocated to one of the two groups: group 1- PLF and group 2-TLIF. Study period was between August 2010 to March 2013. All patients were operated by a single surgeon (CN). Posterior decompression was performed in all patients. Average follow up period was 18.4 months. Quality of life was accessed with Visual analogue scale and Oswestry Low Back Pain Disability Index. Fusion was assessed radiologically by CT scan and X-ray. Result. Though fusion was significantly better in TLIF group, clinical outcome including relief of back pain and neurogenic claudication were better in PLF group. Rate of complication was also lower in PLF group. Conclusion. Considering the low complication rate and similar or better clinical results, posterolateral instrumented lumbar fusion is the better option in low grade adult spondylolisthesis

Purpose of the study: Revision surgery for scoliosis in adults is a technical challenge. Indications include flat back, non-union, and syndromes adjacent to the instrumentation The purpose of this work was to evaluate the pertinence of the transforaminal lumbar interbody fusion (TLIF) method for revision surgery for scoliosis in adults. Material and methods: In our spinal surgery unit, 23 patients underwent revision surgery for thoracolumbar and lumbar scoliosis. A unique posterior approach was used. The TLIF was performed systematically at the lumbosacral level, at the non-union when it was present, and at the level of the Smith-Petersen osteotomies, as well as the levels above and below a transpedicular osteotomy. Seventeen patients presented flat back, ten non-union, five degenerative disease distal to the instrumentation and one degeneration proximal to the instrumentation. Nine patients had several indications for surgical revision. Five transpedicular osteotomies were performed in five patients. Results: Mean follow-up was 30 months (range 18–48). On average 2.3 levels (range 1–4) were involved in the TLIF. The fusion was extended to the sacrum in 22 patients. The mean operative time was 5h50m (range 3–8 hours). Mean blood loss was 2100ml (400–4500). Postoperative lumbar lordosis (L1S1) was 53.5°, giving an improvement of 23° copared with the preoperative lordosis. Among the postoperative complications, there was one neurological complications which recovered partially at last follow-up one case of deep infection of the operative site which require partial removal of the implants and one case of recurrent non-union. There was no loss of correction in the frontal or sagittal planes with the exception of one patient who developed an infection. None of the patients in the series required complementary anterior surgery. Conclusion: For revision surgery of scoliosis in the adult, a circumferential arthrodeis is needed to maintain the fusion. The TLIF method has the advantage of allowing intersomatic fusion via the posterior approach alone without opening the spinal canal. We consider that the TLIF technique is an alternative to two-phase procedures for revision surgery for scoliosis in adults. This method has given a good percentage of fusion in our series with little loss of correction

Introduction Circumferential fusion is becoming increasingly popular and has been advocated by many authors to improve the fusion rates and clinical outcomes of the degenerative lumbosacral spine. Anterior lumbar interbody fusion (ALIF) with posterolateral fusion does provide direct access to the disc via a separate incision/ approach but has inherent neurovascular risks. Posterior lumbar interbody fusion (PLIF) with posterolateral fusion mandates bilateral exposure with significant retraction of neural elements with higher incidence of postoperative radiculitis. PLIF also reduces surface area for fusion and disrupts the posterior tension band. TLIF allows for a circumferential fusion through a single posterior incision with only slight retraction of the thecal sac and nerve roots, with much less morbidity and costs as compared to traditional PLIF and ALIF techniques. To our knowledge, there are no studies that report radiographic and clinical results of using recombinant human bone morphogenic protein (rhBMP-2) and allograft in a TLIF setting. The purpose of this study was to assess clinical & radiographic outcomes of patients treated with one or two level instrumented transforaminal lumbar interbody fusions (TLIF) performed with allograft and rh-BMP2 for treatment of symptomatic spondylolisthesis or degenerative disc disease. Methods During a consecutive 13 month period, 77 patients underwent TLIF procedures utilizing rhBMP-2 by one spine surgeon for lumbosacral degenerative and deformity conditions with simultaneous posterolateral fusions with allograft. Pedicle screw instrumentation (Monarch, DePuy Spine) provided distraction and a carbon-fiber curvilinear cage (Leopard, Depuy Spine) packed with rhBMP-2 (Large II Kit, total graft volume 8ml onto 77.4 sq. cm collagen sponge; Infuse: Medtronic Sofamor Danek) was placed into the disk space after hemifacetectomy and discectomy. The patients were followed at two weeks and three, six, 12 and 24 months after surgery patients were followed with several functional parameters such as the visual analog scale (VAS), SF-36 and Oswestry Disability Index (ODI) questionnaires. Fusion was assessed by static and dynamic radiographs at 6, 12, and 24 months as well as CT scans at 24 months. Results 71 patients were available for follow-up (92%) evaluation (mean 16 months; range 6–24 months). At 24 months, 85 percent and 81 percent of patients had improvement over preoperative ODI and SF-36 measures respectively. At 24 months, 70% of patients had good to excellent outcomes by both ODI and SF-36. We achieved 94% fusion rate with only four pseudarthroses. There was one wound infection treated with hardware removal and intravenous antibiotics. One patient had excessive bone growth into the foramen, necessitating surgical decompression with subsequent excellent clinical outcome. Ten patients had paresthesias on the side of the TLIF, all of which resolved by three weeks. There were no permanent neurologic deficits. Discussion The use of rhBMP-2 inside the cage, in combination with posterolateral allograft, can provide a high fusion rate and good clinical outcomes in a TLIF setting. The morbidity associated with iliac crest bone graft is avoided, with fusion rates approaching that of a true anterior/posterior circumferential fusion. Complications were few, with no significant neurologic sequelae from the placement of a structural graft into the anterior column through a posterior approach. Overgrowth of bone into the neural foramen, likely related to the residue of rhBMP-2 at the TLIF entry site, can occur. Care must be taken to place the TLIF cage device and the contained rhBMP-2 into the anterior half of the disk space to minimize the risk of this complication

Background and Aims. Transforaminal epidurals (TFEs) have been widely used as a treatment for lumbar radicular pain since its introduction by Krempen and Smith in 1974. 1. Originally used as a diagnostic tool, it is now becoming increasingly recognised as a definitive treatment. 2. This study investigates the use of TFEs by a single surgeon over 4 years. We hoped that the study would add to our understanding and the discussion of the actual benefit of therapeutic steroid and local anaesthetic injections by this route. 3. . Methods and Results. A total of 181 patients were identified. At injection 10mls 0.25% Marcaine and 40mg Depomedrone was injected under fluoroscopic guidance. Clinic notes and MRI reports for all patients were reviewed. Of the 176 patients included in the study, 127 showed a symptomatic improvement. Of these patients, 59 proceeded to surgical decompression. For 50 patients, TFE was the definitive treatment. 13 patients were offered but declined surgery. 5 patients were too frail to proceed to surgery. 49 patients showed no symptomatic improvement. Of this group, 34 were deemed unsuitable for surgical intervention. 15 patients did proceed to surgery. Conclusions and Discussion. These results are comparable to other similar case series. Vad et al. 3. demonstrated that 78% of patients studied were satisfied with the outcome of TFE. Riew et al. 2. showed that 53% of their study group avoided surgery due to positive long term effect of TFE. The operative notes of the 15 patients who proceeded to surgery despite a negative TFE outcome are being reviewed and will be presented. Conflicts of Interest. None. Source of Funding. None

Introduction: A far lateral access is required in fullen-doscopic operations of sequestered lumbar disc herniations to achieve a sufficient decompression of the ventral epidural space. The conventional endoscopes and instruments had very narrow limits especially in the mobility and possibility to resect hard tissue and to clean the intervertebral space sufficiently. The aim of this prospective study was to investigate the extended possibilities of the new endoscopes and instruments with regard to the efficacy of decompression, the advantages and problems of this technique in comparison to previous data. Methods: 368 patients with lumbar disc herniations have been treated in 2002 and 2003 in a full endoscopic transforaminal technique using a lateral access. A 7-mm endoscope with 4 mm-working canal and new designed instruments were used. Follow-up lasted at least 12 months. 298 patients (81%) could be followed. Results: No intraoperative complication occurred. 6 patients reported a transient dysaesthesia postoperatively. The average operation time was 28 minutes. A sufficient decompression could be achieved in all cases. 244 patients (82%) reported no more leg pain after surgery, 42 patients (14%) had transient persistence in the first 6 weeks. 8 patients (2,7%) showed a recurrent herniation, 7 of those were reoperated in the same technique. Discussion/Conclusion: As a minimally invasive technique wich efficacy of decompression is equal to an open procedure we see advantages over conventional operations of lumbar disc herniations. Within the inclusion criterias of indication this technique is sufficient and safe. The technical developments on endoscopes and instruments lead to a decrease of recurrence, increase of mobility as well as the possibility of resection of hard tissue and sufficient cleaning of the intervertebral space. The combination of a far lateral access with other approaches extends the spectrum of indications with regard to full endoscopic bony decompression and fusion

Purpose: To review the sagittal lumbar and clinical profile of the two surgical procedures: TLIF (transforaminal lumbar interbody fusion and ALIF (anterior lumbar interbody fusion).

Materials and methods: We carried out a retrospective study of 46 patients who underwent circumferential fusion in 2000–2001. TLIF was used in the first group (21) and ALIF in the second (25). The posterior approach with pedicle instrumentation was used in all patients. Lateral radiographs of the lumbar spine in neutral position and bipedestation were used for evaluation before and after surgery and during follow-up. The results were compared statistically using the Wilcoxon matched pairs test.

Results: Lumbar lordosis was achieved with both techniques: TLIF+PF(posterior fusion) −33° (preoperative), −46° (postoperative) and ALIF+ PF −49° (preoperative), −54° (postoperative). However the height of the disc improved significantly with the anterior approach: TLIF+ PF 0.62 (preoperative), 1.35 (postoperative) and ALIF+PF 1 (preoperative), 4.65 (postoperative).

The duration of surgery, blood loss and hospital stay were greater with ALIF+PF than with TLIF+PF.

Conclusions: TLIF+PF has clinical and economic advantages over ALIF+PF. Lumbar lordosis and the area of instrumented lordosis was achieved with both circumferential fusion procedures and the only radiographic difference was the restoration of the disc height with ALIF.

The April 2023 Spine Roundup. 360. looks at: Percutaneous transforaminal endoscopic discectomy versus microendoscopic discectomy; Spine surgical site infections: a single debridement is not enough; Lenke type 5, anterior, or posterior: systematic review and meta-analysis; Epidural steroid injections and postoperative infection in lumbar decompression or fusion; Noninferiority of posterior cervical foraminotomy versus anterior cervical discectomy; Identifying delays to surgical treatment for metastatic disease; Cervical disc replacement and adjacent segment disease: the NECK trial; Predicting complication in adult spine deformity surgery

The December 2024 Spine Roundup. 360. looks at: Rostral facet joint violations in robotic- and navigation-assisted pedicle screw placement; The inhibitory effect of non-steroidal anti-inflammatory drugs and opioids on spinal fusion: an animal model;L5-S1 transforaminal lumbar interbody fusion is associated with increased revisions compared to L4-L5 TLIF at two years; Immediate versus gradual brace weaning protocols in adolescent idiopathic scoliosis: a randomized clinical trial; Effectiveness and cost-effectiveness of an individualized, progressive walking, and education intervention for the prevention of low back pain recurrence in Australia (WalkBack): a randomized controlled trial; Usefulness and limitations of intraoperative pathological diagnosis using frozen sections for spinal cord tumours; Effect of preoperative HbA1c and blood glucose level on the surgical site infection after lumbar instrumentation surgery; How good are surgeons at achieving their alignment goals?

Aims. People with severe, persistent low back pain (LBP) may be offered lumbar spine fusion surgery if they have had insufficient benefit from recommended non-surgical treatments. However, National Institute for Health and Care Excellence (NICE) 2016 guidelines recommended not offering spinal fusion surgery for adults with LBP, except as part of a randomized clinical trial. This survey aims to describe UK clinicians’ views about the suitability of patients for such a future trial, along with their views regarding equipoise for randomizing patients in a future clinical trial comparing lumbar spine fusion surgery to best conservative care (BCC; the FORENSIC-UK trial). Methods. An online cross-sectional survey was piloted by the multidisciplinary research team, then shared with clinical professional groups in the UK who are involved in the management of adults with severe, persistent LBP. The survey had seven sections that covered the demographic details of the clinician, five hypothetical case vignettes of patients with varying presentations, a series of questions regarding the preferred management, and whether or not each clinician would be willing to recruit the example patients into future clinical trials. Results. There were 72 respondents, with a response rate of 9.0%. They comprised 39 orthopaedic spine surgeons, 17 neurosurgeons, one pain specialist, and 15 allied health professionals. Most respondents (n = 61,84.7%) chose conservative care as their first-choice management option for all five case vignettes. Over 50% of respondents reported willingness to randomize three of the five cases to either surgery or BCC, indicating a willingness to participate in the future randomized trial. From the respondents, transforaminal interbody fusion was the preferred approach for spinal fusion (n = 19, 36.4%), and the preferred method of BCC was a combined programme of physical and psychological therapy (n = 35, 48.5%). Conclusion. This survey demonstrates that there is uncertainty about the role of lumbar spine fusion surgery and BCC for a range of example patients with severe, persistent LBP in the UK. Cite this article: Bone Jt Open 2024;5(7):612–620