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Posterior Lumbar Inter-body Fusion (PLIF)
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Introduction to PLIF
Like with other spinal fusion surgeries, a posterior lumbar interbody fusion (PLIF) surgery involves adding bone graft to the spine to set up a biological response that causes the bone to grow between the two vertebral elements and stop the motion at that segment. Unlike posterolateral gutter fusion, PLIF achieves spinal fusion in the low back by inserting a bone graft and/or spinal implant directly into the disc space. When the surgery is performed from the back, it is called a posterior lumbar inter body fusion (PLIF). It is often supplemented by a simultaneous posterolateral spine fusion surgery.
Surgical Procedure of PLIF
- Patients are administered general anesthesia during most spine surgeries. As they sleep, their breathing may be assisted with a ventilator, a device that controls and monitors the flow of air to the lungs.
- A special table supports the patient so the abdomen is relaxed and free of pressure. This position reduces blood loss during surgery, and gives the surgeon more room to work.
- Two measurements are taken before surgery begins. The first one ensures that the surgeon chooses a fusion cage or bone wedge that will fit inside the disc space. To correctly measure the fusion cage or bone wedge, the surgeon uses an X-ray image to measure the disc space in a healthy disc, above or below the problem segment. Second, to size the length of the pedicle screws, a CT scan is used to measure the length of the pedicle bone on the back of the vertebrae to be fused. The CT scan is a special type of X-ray that lets doctors view slices of bone tissue.
- To begin the procedure, an incision is made down the middle of the low back. The tissues just under the skin are separated. Then the small muscles along the low back are moved aside, exposing the back of the spinal column. Next, the surgeon takes an X-ray to make sure that the procedure is being performed on the correct vertebrae.
- The bone graft is prepared. When the bone taken from your body is used, the same incision made at the beginning of the surgery can be used. The surgeon reaches through the first incision and opens the tissues that cover the back of the pelvis. An osteotome is used to cut the surface of the pelvis bone. An instrument is used to gather a small amount of the pelvis bone. The graft material is prepared and later packed into the fusion cages. The tissues covering the pelvis bone are sutured. Then the surgeon prepares to implant bone graft into the space between the vertebral bodies. The surgeon removes the lamina bones that cover the back of the spinal canal. Then the surgeon cuts a small opening in the ligamentum flavum, an elastic ligament separating the lamina bones and the spinal nerves. Removing the ligamentum flavum allows the surgeon to see inside the spinal canal. The nerves are checked for tension where they exit the spinal canal. If a nerve root is under tension, the surgeon enlarges the neural foramen, the opening where the nerve travels out of the spinal canal.
- The surgeon locates the spot where the pedicle screws are to be placed. A fluoroscope is used to visualize the pedicle bones. The surgeon uses fluoroscope to guide one screw through the back of each pedicle, one on the left and one on the right. The nerve roots inside the spinal canal are then pulled aside with a retractor so the problem disc can be examined. With the nerves held to the side, the surgeon can view the disc where it sits just in front of the spinal canal. A hole is cut into the rim of the back of the disc. Forceps are placed inside the hole in order to clean out disc material within the disc.
- The surgeon prepares the disc space where the fusion cages or bone wedges are to be inserted. Special spreaders hold the two vertebral bodies apart. A layer of bone is shaved off the flat surfaces of the two vertebrae, causing the surfaces to bleed. Bleeding stimulates the bone graft to heal the bones together.
- With the disc space held apart by the spreaders, the surgeon has enough room to place the bone graft between the two vertebral bodies. For the fusion cage method, the surgeon packs two cages with bone taken from the pelvis bone or with a suitable bone substitute. Two cages are inserted, one on the left and one on the right. When allograft bone wedges are used, the surgeon inserts the wedges and aligns them within the disc space. The surgeon uses a fluoroscope to check the position and fit of the graft. The spreaders used to hold the disc space apart are released. Then the doctor tests the graft by bending and turning the spine to make sure the graft is in the right spot and is locked in place. Some surgeons add strips of bone graft along the back of the vertebrae to be fused. This is called posterolateral fusion. The bones that project out from each side of the back of the spine are called transverse processes. The back surface of the transverse processes is shaved, causing the surfaces to bleed. Small strips of bone, usually taken from the pelvis bone at the beginning of the surgery, are placed over the transverse processes. The combination of this graft material with the pedicle screws helps hold the spine steady as the interbody fusion heals. A drainage tube may be placed in the wound. The muscles and soft tissues are then put back in place. The skin is stitched together. The surgeon may place you in a rigid brace that straps across the chest, pelvis, and low back to support the spine while it heals.
Post-Operative Care after PLIF
Most patients are usually able to go home 3-5 days after surgery. Before patients go home, physical therapists and occupational therapists work with patients and instruct them on proper techniques of getting in and out of bed and walking independently. Patients are instructed to avoid bending at the waist, lifting (more than five pounds), and twisting in the early postoperative period (first 2-4 weeks) to avoid a strain injury. Patients can gradually begin to bend, twist, and lift after 4-6 weeks as the pain subsides and the back muscles get stronger.
FAQ - Posterior Lumbar Inter-body Fusion (PLIF)
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