1. Hyeun Sung Kim (neuros@dreamwiz.com)
Conventional Posterior Lumbar Interbody Fusion versus Mini-open Posterior Lumbar Interbody Fusion using the New Percutaneously Inserted
Spinal Transpedicular Screwing System
Hyeun Sung
S.K. Park2, H. Joy2, I.H. Park2, J.K. Ryu2 K.H. Park3
C.I. Ju4, S.W. Kim4, S.M. Lee4, H. Shin4
1Hurisarang Hospital, Department of Neurosurgery, Daejeon, Republic of Korea
2Mokpo Hankook Hospital, Department of Neurosurgery, Mokpo, Republic of Korea
3Korea Hospital, Department of Orthopedic Surgery, Jeonju, Republic of Korea
4College of Medicine, Chosun University, Department of Neurosurgery, Kwangju, Korea, Republic of

2. Hyeun Sung Kim (neuros@dreamwiz.com)
Historical Review
Disadvantages of posterior fusion
large skin incisions
extensive muscle dissection
trauma to the lumbar musculoligamentous complex
long operation time
significant blood loss
significant postoperative pain
postoperative paraspinal muscle denervation
Goals of Mini-open Posterior Decompression & Fusion
=> To reduce the approach-related morbidity associated with traditional lumbar fusion
minimal skin incision and anatomic dissection
minimal operation time
minimal blood loss & minimal transfusion
minimal postoperative pain
minimal hospital stay period
better cosmetic benefits
Hyeun Sung Kim

3. Hyeun Sung Kim (neuros@dreamwiz.com)
Material and Methods
Period : January 2004 to February 2007
Groups
Group A (n=86)
Microscopic conventional PLIF + open transpedicular screw fixation
Group B (n=145)
Microscopic Modified mini-open PLIF + percutaneous transpedicular screw fixation
Materials
Group A
Group B
Mean Age (years)
56.3 (34 – 73)
59.1 (23 – 78)
Number 86
145
Men follow-up period (months)
23.7 (6 – 43)
25.3 (6 - 43)
Cases of fusion level
1 level 73
117
2 level 11 22
3 level 4 6
Hyeun Sung Kim

4. Hyeun Sung Kim (neuros@dreamwiz.com)
Methods : Device
Newly designed percutaneous transpedicular screw fixation system
Name
Apollon System
Manufactured by
Solco medical, South Korea
Characteristics
Detachable screw extender system
Easy to rod manipulation
Can use thoracolumbar area percutaneously
Can use multi-level screwing
vertical axis
Easier to achieve compression and distraction
Threaded screw joint
Firm and secure fixation
Rimmed screw head
Decrease screw head loosening
One-touch rod locking system
Easy & quick operation
Unique alignment guide
Poly-axial screw heads
Easy to rod insertion
Hyeun Sung Kim

5. Methods : Operation Methods
Hyeun Sung Kim
Methods : Operation Methods
Spine Classics MLD
Total Foraminal Decompression
Apollon System Application
Hyeun Sung Kim

6. Methods : Operation Methods
Hyeun Sung Kim
Methods : Operation Methods
Modified midline total decompressed Mini-open PLIF technique
Hyeun Sung Kim

7. Methods : Low Back Outcome Scale
Hyeun Sung Kim
Methods : Low Back Outcome Scale
The Low-Back Outcome Scale of Greenough and Fraser
Parameter
Finding
Points
Current pain
7 to 10 cm VAS
Sex life
Severely affected impossible
5 to 6 cm VAS 3
Moderately affected difficult 2
3 to 4 cm VAS 6
Mildly affected 4
O to 2 cm VAS 9
Unaffected
employment
Unemployed because of back pain
Sleeping
Part time 1
Full time lighter
Full time original
Domestic
chores odd
jobs
None
Walking
A few but not many
Most or all but more slowly
normally
unaffected
Sport or active
social activities
Sitting
Some but much less than before
Back to previous level
resting
Resting more than half the day
Little rest needed occasional
Travelling
No need rest
Treatment or
consultation
More than once per month
About once per month
Rarely
Dressing
Never
Analgesia
Several times each day
Almost every day
Occasionally
Total 75
Score
Status
>= 65
Excellent
50 – 64
good
30 – 49
Fair
0 - 29
poor
Hyeun Sung Kim

8. Hyeun Sung Kim (neuros@dreamwiz.com)
Results
Results
Group A(n=86)
Group B(n=145)
Mean Surgical Time (minutes)
163.7 ( )
142.6 ( )
Blood loss (ml)
753 ( )
438 ( )
LBOS
56.2
63.8
Skin Incision Length (Cm) : Midline Skin Incision
Group A
Group B
1 level
6.23
3.71
2 level
11.28
6.27
3 level
15.26
8.35
Complications
Group A
Group B
Dural tear
5 cases(5.8%)
8 cases (5.5%)
Deep wound infection
4 cases(4.7%)
4 cases (2.7%)
Device failure
5 cases (3.4%)
Hyeun Sung Kim

9. Results : Skin Incision Length
Hyeun Sung Kim
Results : Skin Incision Length
Conventional Skin Incision
1 level
Mini-open Skin Incision
1 level
2 level
3 level
Hyeun Sung Kim

10. Discussion : Evolution of Minimal Invasive Lumbar Fusion
Hyeun Sung Kim
Discussion : Evolution of Minimal Invasive Lumbar Fusion
Leu HF, Hauser RK. Percutaneous endoscopic lumbar spine fusion. Neurosurg Clin N Am 1996:7;107-17
Foley KT, Smith MM. Microendoscopic dicectomy. Tech Neurosurg 1997:3;
Mathews HH. Percutaneous interbody fusions. Orthop Clin North Am 1998:29:
Foley KT, Gupta SK, Justis JR, Sherman MC. Percutaneous pedicle screw fixation of the lumbar spine. Neurosurg Focus 2001:10;1-9.
Foley KT, Gupta SK. Percutaneous pedicle screw fixation of the lumbar spine: preliminary clinical results. J Neurosurg 2002:97;7-12.
Kim DH, Jaikumar S, Kam AC. Minimally invasive spine instrumentation. Neurosurgery 2002;51:S15-25.
Khoo LT, Palmer S, Laich DT, Fessler RG. Minimally invasive percutaneous posterior lumbar interbody fusion. Neurosurgery 2002;51:S
Foley KT, Holly LT, Schwender JD. Minimally Invasive Lumbar Fusion. Spine 2003:28:S26-S35
Lee SH, Choi WG, Lim SR, et al. Minimally invasive anterior lumbar interbody fusion followed by percutaneous pedicle screw fixation for isthmic spondylolisthesis. The Spine Journal 2004:4;
Mummaneni PV, Rodts GE Jr.. The mini-open transforaminal lumbar interbody fusion. Neurosurgery 2005:57;
Schwender JD. Holly LT. Rouben DP. Foley KT. Minimally Invasive Transforaminal Lumbar Interbody Fusion (TLIF): Technical Feasibility and Initial Results. J Spinal Disord Tech 2005:18;S1-6.
Holly LT, Schwender JD, Rouben DP, Foley KT. Minimally invasive transforaminal lumbar interbody fusion: indications, technique, and complications. Neurosurg Focus 2006:20;E6.
Deutsch H. Musacchio MJ Jr.. Minimally invasive transforaminal lumbar interbody fusion with unilateral pedicle screw fixation. Neurosurg Focus 2006:20;E10.
Anand N, Baron EM, Thaiyananthan G, et al. Minimally invasive multilevel percutaneous correction and fusion for adult lumbar degenerative scoliosis: a technique and feasibility study. J Spinal Disord Tech 2008:21;
Gepstein R, Shabat S, Reichel M, et al. Treatment of postdiscectomy low back pain by percutaneous posterior lumbar interbody fusion versus open posterior lumbar fusion with pedicle screws. The Spine Journal 2008:8;
Hyeun Sung Kim

11. Discussion : Mini-open PLIF Versus TLIF
Hyeun Sung Kim
Discussion : Mini-open PLIF Versus TLIF
Mini-open Posterior Lumbar Interbody Fusion(PLIF)
The PLIF technique requires significant bilateral retraction on the thecal sac and nerve roots, whereas TLIF provides less extensive neural retraction and injury by accessing the spinal canal and disc via a path that runs through the far-lateral portion of the vertebral foramen.
Transforaminal Lumbar Interbody Fusion(TLIF)
In Mini-open PLIF and TLIF
Not easy to resolve the lateral recess stenosis
Not easy to decompress central stenosis
Not easy to restore the spinal balance
Not easy to operate on multi-level fusion
Hyeun Sung Kim

12. Discussion : Modified Mini-open PLIF
Hyeun Sung Kim
Discussion : Modified Mini-open PLIF
Modified midline total decompressed Mini-open PLIF
the Modified Mini-open PLIF + Newly Designed Pedicle Screwing
Minimized the skin incision
Minimized the muscle retraction and surround structural damage
Maximized the spinal decompression
More familiar to spine surgeon
More easy to compression and distraction procedure
Benefit of a multilevel PLIF
Hyeun Sung Kim

13. Discussion : Bone Cement Augmentation for Osteoporosis
Hyeun Sung Kim
Discussion : Bone Cement Augmentation for Osteoporosis
Burval DJ, McLain RF, Milks R, Inceoqlu S. Primary pedicle screw augmentation in osteoporotic lumbar vertebrae: biomechanical analysis of pedicle fixation strength. Spine 2007:32:
Frankel BM, Jones T, Wang C. Segmental polymethylmethacrylate-augmented pedicle screw fixation in patients with bone softening caused by osteoporosis and metastatic tumor involvement: a clinical evaluation. Neurosurgery. 2007:61:531-7.
Kim HS, Park IH, Ryu JK, Kim SW, Shin H. Bone Cement Augmentation of Pedicular Screwing in severe Osteoporotic Spondylolisthetic Patients. J Korean Neurosurg Soc 2007:42;6-10.
Tan JS, Balley CS, Dvorak MF, et al. Cement augmentation of vertebral screws enhances the interface strength between interbody device and vertebral body. Spine 2007:32;E
Chang MC, Liu CL, Chen TH. Polymethylmethacrylate augmentation of pedicle screw for osteoporotic spinal surgery: a novel technique. Spine 2008:33;
Kim HS, Park SK, Joy H, Ryu JK, Kim SW, Ju CI. Bone Cement Augmentation of Short Segment Fixation for Unstable Burst Fracture in Severe Osteoporosis. J Korean Neurosurg Soc 2008:44;8-14
Hyeun Sung Kim

14. Cases : One Level – Non-osteoporotic
Hyeun Sung Kim
Cases : One Level – Non-osteoporotic
70/F : Isthmic Spondylolisthesis L5 on S1
6Months F/U
51/F : Isthmic Spondylolisthesis L4 on L5
1yrs F/U
58/F : Spinal stenosis L4 on L5
6Months F/U
Hyeun Sung Kim

15. Cases : One Level - Osteoporotic
Hyeun Sung Kim
Cases : One Level - Osteoporotic
62/F :Degenerative Spondylolisthesis L4 on L5, L2 osteoporotic VCFs
6Months F/U
59/F : Isthmic Spondylolisthesis L4 on L5
1yrs F/U
65/M : Isthmic Spondylolisthesis L4 on L5
1yrs F/U
Hyeun Sung Kim

16. Cases : Two Level – Non-osteoporotic
Hyeun Sung Kim
Cases : Two Level – Non-osteoporotic
60 /M : Spinal stenosis and instability L3-4-5
1yrs F/U
60/F : both foraminal stenosis L4-5-S1
6Months F/U
56/F : Isthmic Spondylolisthesis L4 on L5 on S1
1yrs F/U
Hyeun Sung Kim

17. Cases : Two Level –Osteoporotic
Hyeun Sung Kim
Cases : Two Level –Osteoporotic
78/F : degenerative Spondylolisthesis L3 on L4 on L5, osteoporotic VCFs L4
6Months F/U
71/F : spinal stenosis L4-5-S1
1 yrs F/U
Hyeun Sung Kim

18. Cases : Three Level – Non-osteoporotic
Hyeun Sung Kim
Cases : Three Level – Non-osteoporotic
53/F : Degenerative Spondylolisthesis L3 on L4 on L5, Foraminal stenosis L5-S1
Hyeun Sung Kim

19. Cases : Three Level – Non-osteoporotic
Hyeun Sung Kim
Cases : Three Level – Non-osteoporotic
60/F : Spinal stenosis L3-4-5-S1
1yrs F/U
68/F : spinal stenosis L3-4-5-S1
6Months F/U
51/F : Spinal stenosis and instability L3-4-5-S1
6Months F/U
Hyeun Sung Kim

20. Cases : Three Level – Non-osteoporotic
Hyeun Sung Kim
Cases : Three Level – Non-osteoporotic
67/F : Spinal stenosis L3-4-5-S1 and instability, Spondylitis
6Months F/U
68/M : Spinal stenosis and Instability L3-4-5-S1, HNP L5-S1
6Months F/U
Hyeun Sung Kim

21. Cases : Three Level – Osteoporotic
Hyeun Sung Kim
Cases : Three Level – Osteoporotic
59/M : Spinal stenosis and instability L
9Months F/U
Metal failure
51/F : Spinal stenosis L4-5-S1 and Iatrogenic intraoperative joint damage L3-4
6Months F/U
Hyeun Sung Kim

22. Hyeun Sung Kim (neuros@dreamwiz.com)
Conclusion
A vertical axis and detachable screw extender system makes it easier to perform rod manipulation as well as compression and distraction. As compared with conventional PLIF, it can decrease the length of the midline skin incision. It is therefore useful in reducing operative time and intra-operative blood loss, thus minimizing the postoperative occurrence of back pain and complications. Accordingly, a prompt recovery and a good clinical outcome can be expected.
Hyeun Sung Kim