Biportal Endoscopic Transforaminal Lumbar Interbody Fusion

Abstract

Background:

The present video article describes transforaminal lumbar interbody fusion (TLIF), a common spine procedure, performed with use of a less common technique—utilizing a biportal endoscopic spine surgery (BESS) approach. This procedure is performed for the treatment of degenerative spondylolisthesis.

Description:

The procedure is performed with the patient in the supine position. An endoscopic portal and a working portal are developed at the level of interest. Fluid is pumped into the working space with use of a standard arthroscopy tower. Using the camera endoscope to visualize; shavers, burrs, and a Kerrison rongeur are passed through the working portal to clear the disc and to create space for insertion of an interbody device. Trial TLIF cages are placed through the disc defect, which can be observed both directly and on radiograph. An appropriate final implant is placed, and percutaneous pedicle screws are typically placed at the instrumented level.

Alternatives:

Alternatives include nonoperative treatment with physical therapy, weight loss, and/or corticosteroid injection. Surgical options for degenerative spondylolisthesis include lumbar decompression and instrumented fusion. Interbody fusion can provide indirect decompression and increase fusion success rates.

Rationale:

This procedure utilizes a minimally invasive endoscopic approach with small incisions, resulting in decreased muscle trauma, which has been shown to reduce postoperative pain and recovery time.

Expected Outcomes:

Outcomes of the biportal endoscopic technique are similar to those reported for open or conventional TLIF, with the benefit of improved postoperative pain compared with those procedures.

Important Tips:

• Position the patient on a Jackson frame with hip and thigh pads to maintain lordosis for the fusion procedure.

• Utilize fluoroscopic guidance when determining starting points. The goal is for the portals to be centered over the ipsilateral pedicles of the targeted level.

• It is best to maintain the camera portal in your non-dominant hand and the working portal in your dominant hand.

• Stand on the side that the patient reports has worse pain.

• When dissecting, there is no need to go to the lateral edge of the facet; going further can result in excessive bleeding and decreased visualization.

Acronyms and Abbreviations:

• BESS = biportal endoscopic spine surgery

• TLIF = transforaminal lumbar interbody fusion

• MRI = Magnetic Resonance Imaging

• PEEK = polyetheretherketone

• K-wire = Kirschner wire

• CT = computed tomography

• PROM = patient-reported outcome measure

• VAS = visual analog scale

• ODI = Oswestry Disability Index

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DOI: 10.2106/JBJS.ST.24.00005.vid1

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