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. 2023 Mar 27;15(5):1272–1280. doi: 10.1111/os.13695

Clinical Effects of Upper Facet Joint En Bloc Resection in the Transforaminal Lumbar Interbody Fusion Surgery—Two Layers and Two Tunnels Strategy

Xukang Chen 1, Wanli Jing 2, Yunguo Wang 3, Wei Lin 1, Yuan Xue 1,✉
PMCID: PMC10157721  PMID: 36973935

Abstract

Objective

The upper facet joint en bloc resection is the key step to open the intervertebral foramina for achieving the intervertebral fusion in transforaminal lumbar interbody fusion (TLIF) surgery. Our purpose is to introduce a upper facet joint resection technique which can avoid injuring the nerve root termed “two layers and two tunnels strategy” in TLIF surgery and to evaluate its clinical effects and neurological safety.

Methods

All 108 patients who underwent TLIF surgery using two layers and two tunnels strategy between December 2015 and January 2019 were analyzed for postoperative clinical treatment parameter. The visual analogue scale (VAS) method, Oswestry disability index (ODI), Japanese Orthopaedic Association (JOA) scores and the Macnab scoring system were used to evaluate the clinical effects during post‐operative check‐ups at 7 days, 3 months, 6 months, and the last follow‐up visit. Data were represented by mean and standard deviation, and repeated measures analysis of variance was performed to make comparison.

Results

The result noted that, the VAS scores for back pain decreased by 30.13% at 7 days post‐operation (3.64 ± 0.86), 63.15% at 3 months (1.92 ± 0.55), 72.17% at 6 months (1.45 ± 0.61) and 70.44% at the last follow‐up (1.54 ± 0.62) compared with pre‐operation (5.21 ± 0.93). The VAS scores for lower limb pain decreased by 44.22% at 7 days (3.86 ± 0.90), 61.42% at 3 months (2.67 ± 0.72), 66.62% at 6 months (2.31 ± 0.79) and 66.47% at the last follow‐up (2.32 ± 0.72) compared with pre‐operation (6.92 ± 1.04). The ODI scores decreased by 49.08% at 7 days (32.19 ± 5.13), 67.92% at 3 months (20.28 ± 5.50), 74.00% at 6 months (16.44 ± 4.21) and 75.42% at the last follow‐up (15.54 ± 3.85) compared with pre‐operation (63.22 ± 7.58). The JOA scores increased by 51.41% at 7 days (18.49 ± 1.48), 69.26% at 3 months (22.35 ± 1.44), 73.28% at 6 months (23.22 ± 1.18) and 77.53% at the last follow‐up (24.14 ± 0.99) compared with pre‐operation (7.37 ± 1.71). Among 108 cases, there is no neurological complications.

Conclusion

Two layers and two tunnels strategy is an effective and safe procedure that can certainly avoid nerve root injury to reduce neurological complication and increase safety of TLIF surgery.

Keywords: Lumbar degenerative disease, Neurological complication, Pedicle‐ligamentum flavum tunnel, Smith‐Petersen osteotomy, Transforaminal lumbar interbody fusion

First layer: (a) We removed the lower facet joint from its dorsal cortex to the cancellous bone and stopped at the articular surface. (b) We enlarged the bone resection by laminotomy to the isthmus and lamina of the lower facet joint through the upper PEFT. Second layer: (a) We resected the ligament flavum by the Kerrison rongeur until the contour of the upper facet joint was thoroughly isolated from its surrounding ligament. (b) We freed the upper facet joint by cutting the isthmus using the Kerrison rongeur through the lower PEFT from outside to inside.

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Introduction

Symptomatic lumbar degenerative diseases which can cause mechanical back pain and neurological symptoms are common in an aging population, will reduce the capacity of movement and life quality. 1 Lumbar interbody fusion (LIF) surgery is an essential and established treatment for several spinal disorders including degenerative diseases to decompress the neural elements and restore stability. 2 , 3 , 4 , 5

In 1982, transforaminal lumbar interbody fusion (TLIF) surgery was introduced by Harms and Rolinger to treat symptomatic lumbar spondylosis. 6 , 7 Compared to the posterior lumbar interbody fusion (PLIF), TLIF has the advantages of not putting pressure on the dural sac, easily opening the intervertebral space and preserving the posterior tension band structures. Plenty of clinical studies have verified that TLIF surgery has better clinical consequence compared with PLIF in treating lumbar degenerative diseases, such as shorter operative time, less bleeding, shorter time of hospitalization, lower incidence of complications. 8 , 9 , 10 , 11 However, TLIF surgery still carries a risk of complications related to the injury of nerve root. In lumbar intervertebral level, the part of the “walking root” is just at the ventral side of upper facet joint, especially in L3‐S1. In TLIF surgery, the “walking root” is vulnerable to be injured during the upper facets en bloc resection. In the study by Hong et al., 42 patients who underwent TLIF were included, there were two cases of incomplete root damage, the incidence rate was 4.8%. 12 In the study by Modi and Shrestha, 76 patients were underwent TLIF were included, there were two cases of radicular symptoms, the incidence rate was 2.6%. 13 In the study by Stickley et al., 252 patients who underwent TLIF were included, there were 22 cases of neuropraxia related to nerve root injury, the incidence rate was 8.7%. 14

In traditional TLIF surgery, laminectomy was performed first, removal of ligamentum flavum and en bloc resection of facet joints follows. 15 The nerve roots may get injured during the procedure. Over time, a new surgery technique which was called laminotomy has developed. Laminotomy involves the removal of the inferior part of spinous process, the basal part of superior lamina, and superior portion of the inferior lamina. Many studies proved laminotomy can certainly reduce the postoperative complications compared with laminectomy used in tradition TLIF surgery. 16 , 17 , 18 However, nerve roots were still not under direct vision and vulnerable to be injured in laminotomy, which means laminotomy is also not safe procedure in TLIF surgery.

In the thoracic spine, the facets are closer to the middle line of the spinal canal than lumbar spine. And in the thoracic ossification of the ligamentum flavum (OLF) situation, the facets compress on the dome of spinal cord. In 1945, Smith‐Petersen et al. described the Smith‐Peterson osteotomy (SPO) 19 which was largely for correcting the thoracic lumbar junction hyperkyphosis from ankylosing spondylitis. 11 The facet joints en bloc resection first appeared in the SPO. 20 The indications for SPO have gradually been expanded, including the kyphosis in cervicothoracic junction, thoracic and lumbar spine, but the incidence of neurological complication is approaching 30%. 21 , 22 , 23 , 24 , 25 SPO technique is undependable for neurological safety in the thoracic OLF decompression surgery. The upper facet joint resection through the tunnel between the pedicle and the ossification ligamentum flavum (POT) was reported as a comparatively safe procedure for OLF posterior decompression in the thoracic spine. 26 , 27 , 28 The intervertebral foramen can be divided into three parts: the upper pedicle‐ligamentum flavum tunnel (PEFT), upper and lower facet joints, and the lower PEFT. The top of the upper PEFT is the lower facet joint and its junction with the pedicle, the outside aperture is the intervertebral foramen, the inside aperture is leading to the spinal canal, the anterolateral wall is vertebral pedicle, the posteromedial wall is the ligamentum flavum and the lower facet joint capsular ligament. The top of the lower PEFT is the upper facet joint and its junction with the pedicle, the outside aperture is the intervertebral foramen, the inside aperture is leading to the spinal canal, the anteromedial wall is the ligamentum flavum and the upper facet joint capsular ligament, the posterolateral wall is the vertebral pedicle. 26 , 29 , 30 In the situation of ligamentum flavum ossification, PEFT is the same as POT. The PEFT exists in both the thoracic spine and lumbar spine. In the lumbar spine, the nerve root called “walking root” is just under the upper facet, and there is no no nerve distribution in PEFT. So in TLIF surgery, it is feasible to en bloc resect the upper facet joints through the PEFT without nerve root injury.

So far, there is no standard and comparatively safe procedure to en bloc resect the upper facet joints in TLIF surgery while avoiding contacting and injuring the “walking root.” Here we illustrate the upper facet joint resection technique termed “two layers and two tunnels strategy” which can avoid nerve root injury. The most important procedure is en bloc resecting the upper facet joint through PEFT. The purpose of our study is: (i) to describe the characteristics of this strategy; (ii) to describe the advantages of this strategy; and (iii) to evaluate its clinical effects.

Methods

This study was reviewed and approved by the Ethical Committee of Tianjin Medical University General Hospital (No. IRB2021‐WZ‐177). Written Informed consent of surgery treatment was obtained from all patients included in the study.

Inclusion Criteria

Inclusion criteria: (i) typical symptoms and signs of lumbar and lower limb pain and difficulty walking; (ii) radiological examination supported the diagnosis of lumbar degenerative disease; (iii) no effect after more than 3 months of formal conservative treatment; and (iv) the follow‐up period was at least 16 months. Surgical contraindications were excluded.

Patients' Information

Retrospective analysis was performed on 108 patients who underwent TLIF surgery using two layers and two tunnels strategy between December 2015 and January 2019 and met the inclusion criteria. There are 58 males and 50 females, with a mean age of 58.3 years (range 45–70 years). There are 35 cases of lumbar spondylolisthesis, 73 cases of degenerative disc disease. All the cases were single segment level lesions.

Surgical Technique

All the patients were under general anesthesia and in a prone position with soft underbelly cushions and suspended abdomen. After positioning, the posterior median approach was taken to expose the posterolateral structure of the target vertebral body.

At the begin of our surgery strategy, we removed the lower facet joint from its dorsal cortex to the cancellous bone and stopped at the articular surface. Then enlarging the bone resection by laminotomy to the isthmus and lamina of the lower facet joint through the upper PEFT (first layer and tunnel, Fig. 1).

Fig. 1.

Fig. 1

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First layer: (A) We removed the lower facet joint from its dorsal cortex to the cancellous bone and stopped at the articular surface. (B) We enlarged the bone resection by laminotomy to the isthmus and lamina of the lower facet joint through the upper PEFT

First layer: (A) we removed the lower facet joint from its dorsal cortex to the cancellous bone and stopped at the articular surface. (B) we enlarged the bone resection by laminotomy to the isthmus and lamina of the lower facet joint through the upper PEFT. Now the two structures were under vision, one is the exiting nerve root between the pedicle of upper vertebra and the upper facet joint of lower vertebra, the other is the ligament flavum in the medial side of the upper facet joint.

We applied the nerve hook to free the ligament flavum from its profundus tissue. Resecting the ligament flavum by the Kerrison rongeur or other instrument under direct vision, until the contour of the upper facet joint was thoroughly isolated from its surrounding ligament. For isolating the upper facet joint, the isthmus of the upper facet joint connection was thinned out by the motor bur, after detecting the dorsal surface of the isthmus, en bloc resecting the upper facet joint by using the Kerrison rongeur to cut the isthmus through the lower PEFT from outside to inside. Finally, lifting the upper facet joint by a forceps, if there was adhesion, detaching the nerve root or dura from the upper facet joint under direct vision (second layer and tunnel, Fig. 2).

Fig. 2.

Fig. 2

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Second layer: (A) We resected the ligament flavum by the Kerrison rongeur until the contour of the upper facet joint was thoroughly isolated from its surrounding ligament. (B) We freed the upper facet joint by cutting the isthmus using the Kerrison rongeur through the lower PEFT from outside to inside

Second layer: (A) we resected the ligament flavum by the Kerrison rongeur until the contour of the upper facet joint was thoroughly isolated from its surrounding ligament. (B) We freed the upper facet joint by cutting the isthmus using the Kerrison rongeur through the lower PEFT from outside to inside.

Then we resected the intervertebral disc tissue, fully and effectively expanded the vertebral canal and nerve root tube. Finally, the fusion and fixation are performed.

Follow‐up Method and Therapeutic Evaluation

The retrospective inspection was carried out after 3 and 6 months post‐operation, and the last follow‐up visit was carried out for approximately 2 years or so (informed by calling). The visual analogue scale (VAS) method, Oswestry disability index (ODI), Japanese Orthopaedic Association (JOA) scores and the Macnab scoring system were used to evaluate the clinical effects during post‐operative check‐ups at 7 days, 3 months, 6 months, and the last follow‐up visit.

Statistical Analysis

Statistical analysis on all parameters was performed using SPSS 25.0 software (IBM, Armonk, NY, USA). Data were expressed as mean and standard deviation (mean ± SD) and were compared using repeated measures analysis of variance. A P‐value less than 0.05 was considered statistically significant.

Results

General Condition and Clinical Outcomes

The operation time was 178 ± 31 min (range, 120–250 min), with an average intraoperative blood loss of 260 ± 50 mL (range, 150–400 mL). The time that patients needed to get out of bed after surgery was 52 ± 8 h (range, 36–78 h), and the hospitalization cost was 2.7 ± 0.6 ten thousand yuan (range, 19–41 thousand yuan). All 108 patients showed up at the scheduled follow‐up visits, and the follow‐up period was 16–29 months (mean, 22 months) (Figs 3 and 4).

Fig. 3.

Fig. 3

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A 68‐year‐old male patient who was admitted to hospital for low back pain and radiating pain of the left lower limb with intermittent claudication for 1 year and aggravated for 1 month, and underwent TLIF surgery on L4/5 segment. (A) and (B) are preoperative X‐ray, (C) is preoperative CT, we can find the patient got mild lumbar spondylolisthesis on L4 and L5. (D) is preoperative MRI, we can find the patient got severe lumbar disc herniation on L4/5. (E) and (F) are postoperative X‐rays, there were pedicle screws on L4‐5, and an interbody fusion cage in L4/5 intervertebral space, the stability of the lumbar spine was corrected

Fig. 4.

Fig. 4

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A 45‐year‐old female patient who was admitted to hospital for low back pain and radiating pain of the right lower limb for 4 months and aggravated for 3 weeks, and underwent TLIF surgery on L5/S1 segment. (A) and (B) are preoperative X‐ray; (C) and (D) are preoperative CT and MRI, we can find the patient got severe lumbar disc herniation on L5/S1. (E) and (F) are postoperative X‐rays, there were pedicle screws on L5‐S1, and an interbody fusion cage in L5/S1 intervertebral space, and the lumbar curvature was improved

We evaluated the clinical outcomes by the SF‐36 scale, and the outcomes confirmed that the scores for Physical Functioning, Role‐Physical, Bodily Pain, General Health, Vitality, Social Functioning, Role‐Emotional and Mental Health had improved obviously by the last follow‐up. Compared with pre‐operation, Physical Functioning score increased by 25.19%, Role‐Physical score increased by 74.82%, Bodily Pain score increased by 61.20%, General Health score increased by 43.26%, Vitality score increased by 8.23%, Social Functioning score increased by 58.22%, Role‐Emotional score increased by 76.11%, Mental Health score increased by 49.96%. (Table 1).

TABLE 1.

The SF‐36 score for 108 cases at pre‐operation and last follow‐up (−x ± s)

Content Physical functioning Role‐physical Bodily pain General health Vitality Social functioning Role‐emotional Mental health
Pre‐operation 51.44 ± 5.25 34.03 ± 17.58 41.93 ± 6.92 45.05 ± 5.18 47.27 ± 3.16 45.72 ± 6.43 34.87 ± 11.51 42.63 ± 3.38
Post‐operation 64.40 ± 6.93 59.49 ± 18.63 67.59 ± 4.96 64.54 ± 4.19 51.16 ± 5.10 72.34 ± 5.42 61.41 ± 13.79 63.93 ± 5.36
t  value −41.06 −31.66 −46.01 −85.75 −14.63 −53.69 −20.45 −75.374
p‐ value 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000
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Therapeutic Evaluation

Visual Analogue Scale (VAS)

The VAS scores for back pain were 3.64 ± 0.86 at 7 days post‐operation, 1.92 ± 0.55 at 3 months post‐operation, 1.45 ± 0.61 at 6 months post‐operation, and 1.54 ± 0.62 at the last follow‐up, P = 0.000 (7 days), P = 0.000 (3 months), P = 0.000 (6 months), P = 0.000 (last follow up) (Table 2). Compared with pre‐operation, the back pain VAS score at 7 days post‐operation decreased by 30.13%, at 3 months decreased by 63.15%, at 6 months decreased by 72.17%, and at the last follow‐up decreased by 70.44%.

TABLE 2.

Preoperative and postoperative several evaluation scores (−x ± s)

Content VAS (back) T‐value VAS (leg) T‐value ODI score T‐value JOA score T‐value
p‐value p‐value p‐value p‐value
Pre‐operation 5.21 ± 0.93 6.92 ± 1.04 63.22 ± 7.58 7.37 ± 1.71
After 7 days 3.64 ± 0.86 31.40 a 3.86 ± 0.90 102.00 a 32.19 ± 5.13 114.96 a 18.49 ± 1.48 −158.86 a
0.000 a 0.000 a 0.000 a 0.000 a
After 3 months 1.92 ± 0.55 55.00 a 2.67 ± 0.72 85.00 a 20.28 ± 5.50 153.36 a 22.35 ± 1.44 −166.44 a
0.000 a 0.000 a 0.000 a 0.000 a
After 6 months 1.45 ± 0.61 75.20 a 2.31 ± 0.79 76.83 a 16.44 ± 4.21 111.38 a 23.22 ± 1.18 −176.11 a
0.000 a 0.000 a 0.000 a 0.000 a
Last follow‐up 1.54 ± 0.62 73.60 a 2.32 ± 0.72 76.50 a 15.54 ± 3.85 110.91 a 24.14 ± 0.99 −167.70 a
0.000 a 0.000 a 0.000 a 0.000 a
Greenhouse–Geisser's epsilon of Mauchley's sphericity assumption test ω =0.74 ω =0.59 ω =0.37 ω =0.54
F‐value F (2.95, 315.3) = 2084.18 F (2.35, 251.84) = 3222.46 F (1.46, 156.64) = 11344.78 F (2.16, 230.97) = 18647.85
p‐value p < 0.005 p < 0.005 p < 0.005 p < 0.005
η2 η2 = 0.95 η2 = 0.97 η2 = 0.99 η2 = 0.99
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a

Means compared with preoperative data.

The VAS scores for lower limb pain were 3.86 ± 0.90 at 7 days post‐operation, 2.67 ± 0.72 at 3 months post‐operation, 2.31 ± 0.79 at 6 months post‐operation, and 2.32 ± 0.72 at the last follow‐up visit, P = 0.000 (7 days), P = 0.000 (3 months), P = 0.000 (6 months), P = 0.000 (last follow up) (Table 2). Compared with preoperative data, the lower limb pain VAS score at 7 days post‐operation decreased by 44.22%, at 3 months decreased by 61.42%, at 6 months decreased by 66.62%, and at the last follow‐up decreased by 66.47%.

Oswestry Disability Index (ODI)

The ODI scores were 32.19 ± 5.13 at 7 days post‐operation, 20.28 ± 5.50 at 3 months post‐operation, 16.44 ± 4.21 at 6 months post‐operation, and 15.54 ± 3.85 at the last follow‐up visit, P = 0.000 (7 days), P = 0.000 (3 months), P = 0.000 (6 months), P = 0.000 (last follow up) (Table 2). Compared with preoperative data, the ODI score at 7 days post‐operation decreased by 49.08%, at 3 months decreased by 67.92%, at 6 months decreased by 74.00%, and at the last follow‐up decreased by 75.42%.

Japanese Orthopaedic Association (JOA) scores

The JOA scores were 18.49 ± 1.48 at 7 days post‐operation, 22.35 ± 1.44 at 3 months post‐operation, 23.22 ± 1.18 at 6 months post‐operation, and 24.14 ± 0.99 at the last follow‐up visit (P = 0.000 [7 days], P = 0.000 [3 months], P = 0.000 [6 months], P = 0.000 [last follow up]) (Table 2). The treatment improvement rate = ([post‐treatment score ‐ pre‐treatment score]/[29 ‐ pre‐treatment score]) × 100%, and 100% means cure; 60%–100% means excellent; 25%–60% means good; 0–25% means poor. Compared with preoperative data, the JOA score at 7 days post‐operation increased by 51.41%, at 3 months increased by 69.26%, at 6 months increased by 73.28%, and at the last follow‐up increased by 77.53%.

Following the Macnab standard of evaluation, 64 patients' results were excellent, 36 patients' results were fine, and four patients' results were tolerable. The satisfaction rate was 96.30%.

Complications

Among 108 cases, wound infection and delayed healing occurred in two cases, which was resolved by antibiotics application, debridement and suturing and periodically changing the dressing. Urinary tract infection occurred in one case, which was resolved by applying antibiotics. There was no complication such as nerve root injuries, cerebrospinal fluid leakage and aggravation of symptoms of spinal cord injury after surgery.

Discussion

There are 108 patients undergoing our modified TLIF surgery which applied “two layers and two tunnels strategy” technique, we evaluated clinical effects by using several rating scales. According to the above statistical results, the postoperative general clinical outcomes reflected by the SF‐36 scale score were significantly improved. The postoperative VAS scores (including back pain and lower limb pain), ODI scores and JOA scores were all conspicuously improved, and there was no nerve root injury related complication. All these results means our operation is safe and effective.

Characteristics of Two Layers and Two Tunnels Strategy

It is certainly that facet joint resection pathway away from the nerve root would reduce the neurological complication. Here, we report a upper facet joint resection technique called “two layers and two tunnels strategy,” by which the facet joint resection pathway avoid to contact the nerve root as we illustrated in the surgical technique in brief above. The characteristics of it were: (i) the facet joint resection is beginning at the lower facet joint, and stopping at the upper facet joint surface; (ii) enlarging the facet joint resection to expose the ligament flavum and cephalic pedicle through the PEFT. Now the superficial layer resection is completed; and (iii) the profundus layer resection pathway is designed not crossing the nerve root pathway. It includes two steps, first is removing the ligament flavum under the direct vision, and second is resecting the en bloc upper facet joint through the PEFT.

In the study by Stickley et al., there are 252 open TLIF surgery cases, and the incidence rate of nerve injury was 8.7%. 14 And in the study by Han et al., there were three patients who got nerve injury related symptom of 33 patients, the rate was 9.1%. 31 But in our study, there is no complication related to nerve damage because our strategy can avoid hurting nerve roots.

Advantages of Two Layers and Two Tunnels Strategy in TLIF

There are two advantages of our procedure: (i) the border of ligamentum flavum and dural sac is under direct vision through PEFT, so we can reduce the danger of dural sac injury; and (ii) there is no nerve distribution in PEFT, so we can reduce the risk of nerve roots injury during the facet joints resection.

There are some matters needing attention about our strategy. First and most important, we need to be familiar with the anatomical structure of PEFT and its orientation. Second, we need to release the nerve root and resect part of ligament flavum with a nerve hook under direct vision. Third, after isolating the upper facet joint and thinning out its isthmus connection by using a motor bur, we can en bloc resect the upper facet joint through the lower PEFT. However, our strategy is currently only applicable in open TLIF surgery because of the relatively large operating space and visual field required compared with minimally invasive TLIF (MIS‐TLIF) or other minimally invasive lumbar surgery like foraminoscope, unilateral biportal endoscopy, etc.

Strengths and Limitations

The strength of our study is that we proposed a new surgical technique called “two layers and two tunnels strategy” in the process of traditional TLIF surgery. The critical step is resecting upper facet joints through PEFT, in which there is no nerve distribution. This provides a feasible method for completing TLIF surgery safely by avoid nerve roots injury in the process of upper facet joints resection. In the future, we will continue to collect more patient sample to better demonstrate the safety and effectiveness of our surgery.

The limitations includes: (i) we only involved single segment level lesions and did not mention the surgical situation of multiple segments level lesions. We will include multiple segments level lesions patients in the future study to prove our technique safety in multiple segments TLIF surgery and analyze its clinical effects; and (ii) the patient sample number is small and the time of follow‐up visit is not very long, we will accumulate, calculation and analyze more samples and continue to follow up patients in the future.

Conclusion

Our surgery technique termed “two layers and two tunnels strategy” is an effective and safe procedure which can avoid contacting the nerve root pathway to reduce the risk of nerve root injury and can increase the safety in TLIF surgery.

Acknowledgments

This work was supported by the National Natural Science Foundation of China (grant numbers: 81871124), the Natural Science Foundation of Tianjin (grant number: 20JCZDJC00310) and Tianjin Health Research Project (grant number: TJWJ2022ZD002).

Xukang Chen, Wanli Jing, Yunguo Wang contributed equally to this work, are co‐first authors.

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