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PLIF/TLIF/ALIF vs Anterior/posterior fusion?

AnonymousUserAAnonymousUser Posts: 49,731
edited 06/11/2012 - 8:26 AM in Back Surgery and Neck Surgery
After talking to my boyfriends uncle (who used to do a lot of work with doctors and medical implants, specifically those involving the spine) about the upcoming anterior/posterior two-level spinal fusion (L4/L5/S1), he's put out some concerns and suggestions. The first thing he suggested was to go see another doctor (he recommended one and he's covered under my plan) - a neurosurgeon. This doctor does PILF's. I currently have surgery scheduled with an orthopedic surgeon. He also had a slew of questions that I should be asking BOTH doctors prior to doing surgery.

After hearing all this and preparing myself for a second opinion, I started reading about the differences between the various versions of spinal fusions. TLIF/PLIF seem to be the same thing (posterior only approach). Overall I'm reading that an anterior/posterior approach has better fusion rates, but I'm not sure how accurate this information really is since it seems it's more based on YOUR doctor than just general stats.

What are the major benefits of doing one vs the other? Why did you choose the method you did for your fusion? If you've had both types done (PLIF/TLIF/ALIF and Anterior/Posterior), which was better overall, what was the recovery time and what were the circumstances to have each procedure done?

I was really quite comfortable with my decision and with my doctor, but now I've got a whole new set of fears regarding the whole thing, just after I was comfortable with it all. :''(
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Comments

  • I'm guessing that when you refer to anterior/posterior fusion, you're actually talking about ALIF/PLIF? If you're referring to something else, please clarify what you mean by "anterior/posterior fusion."

    ALIF is anterior lumbar interbody fusion, and PLIF is posterior lumbar interbody fusion. Interbody fusion means the disc is removed and replaced with some sort of spacer (e.g., cage) and bone graft.

    The differences aren't just that one is from the front and one is from the back, because it's not just whether you cut from the front or back, the results are not the same--the bone graft and hardware don't go in the same place. Obviously, anterior vs. posterior approach also affects what kinds of tissue, organs, and nerves are being dealt with. For example, anterior involves more muscle and some organs, but posterior involves the spinal nerves more.

    TLIF is transforaminal lumbar interbody fusion. Yes, both TLIF and PLIF have a posterior approach, but differences include exactly how the surgeon approaches your spine (e.g., the angle from which he approaches), which affects how nerves and other tissue are dealt with, etc., and what/how/where instrumentation is placed. These are significant differences.

    Whether ALIF, PLIF, TLIF, some combination of these, or a different type of fusion (e.g., posterolateral fusion, AxiaLIF) is right for you depends on many factors, including all the details of YOUR particular problem, your anatomy, whether or not you've had previous surgeries, what your doctor is comfortable with, etc. So, there are a lot of things to discuss with your doctor about why he suggests a particular approach.

    I strongly support getting multiple medical opinions before deciding to proceed with surgery.

    I met with 6 different surgeons (ortho and neuro) this past year and although their assessments and recommendations were generally similar (my main problems were quite obvious), there were a lot of differences, too. Most strongly advocated surgery for me, but the specifics of surgery varied among them.

    I believe that a combination of ALIF/PLIF has a higher success rate for MY particular condition (grade 3 spondylolisthesis + resultant associated problems), and that both an anterior and posterior approach were required to deal with my specific anatomy and problems. I recently had ALIF/PLIF performed at L5-S1, but my surgery also included a posterolateral fusion at L4-L5 (this is not an interbody fusion). I'm only 2 months post-op, so it remains to be seen if this is even going to work for me!

    It's tough to figure all this out, understand what's applicable to YOU, & find the right surgeon. Good luck!
  • The ALIF/PLIF together is typically called a 360 degree Anterior Lumbar Interbody Fusion. That is what I had done. I had L4-S1 fused. The doctor went through the front to clear the disk and place cages in the spaces. The cages had ground up bone from my pedicle and BMP. Once done there, they closed me up and flipped me over.

    He used the Sextant Minimally Invasive System posteriorly which doesn't damage as much muscle tissue as a conventional PLIF.

    Each person's situation differes from one another, so even though this is how my surgeon did my surgery, your surgeon may want to take a different approach for one of many reasons. The best thing to do is ask as many questions as you can.

    Keith
    Several Epidurals, L4-S1 360 ALIF, Numerous Facet Joint Injections, RFA x2
  • (before insurance change) wanted to do an anterior/posterior fusion because, like your doc said, it's a better fusion rate, having more access to the disk space, and being able to fill it completely. As opposed to a very minimal amount of space simply going in just thru the back. He said he does posterior only on his older patients that want to be able to get up and walk across the room without pain. But because I am so young, an anterior fusion would be a good solid choice. Like with Keith, he would have gone in thru the front, removed the disk and put the cages in, then flipped me over to put the rods and screws in.

    I needed to lose weight tho, and dragged my butt doing it, and then my husband switched jobs.

    Caity
  • I had a 360 fusion and I'm glad I did. Obviously the recovery is a bit different than having a single approach... Seeing as how it's quite crappy to be sliced and diced through both your stomach and your back, and I still have issues with my anterior incision... But for me it was because I was so young, they wanted to be extra careful and secure.
  • I know that what my surgeon wants to do is commonly referred to as a 360 (or "around the world") where they first go in anterior then posterior. Anterior they move everything aside, remove the disc space, insert cages and bone graft. Posterior they go in through the back to insert the hardware and do another bone graft. I understand the procedure he wants to do quite well.

    I'm 27 years old and it does seem to me like the younger you are, the more it benefits you to go this route so you aren't faced with surgery again any time soon. I know my doctor did mention that he felt because of my age this would be appropriate so that the chance of me needing surgery again would go down. Apparently having a two level spine fusion is a Big Deal (tm) at my age and not a common route people want to take. My doctor did send me to a class their office offers for people preparing or thinking about surgery and I was the youngest person in the room by at least 15 years.

    After 4 years, I just want to feel better and I almost don't care how that happens at this point because the pain has been worsening. I'm sure my extra weight doesn't help, but it's impossible for me to work out and portion control only does so much for me.

    The doctor I was referred to does minimally invasive PILF's. I sort of feel like (from what I've read) that this might not be the right way to go, but I'm willing to hear him out at the very least. Who knows... he could suggest the same thing as my other doctor (360 fusion). I'm just really nervous about going to another doctor. :S Doctors make me uncomfortable and I'm not even sure what questions I need to be asking.
  • I'm having an ALIF because for my doc to go in thru my back, I risk increasing the degeneration of the levels above. So there is no textbook answer, your surgeon needs to tailor the right approach & what makes sense for you.

    It certainly would not hurt to get the 2nd opinion, and hear what the surgeon has to say on what approach he would take and why. Worth the time, its a big decision.
  • A 360 does not reduce your chance for needing another surgery. It doesn't affect it at ALL. I don't really know who told you that, but they weren't telling you the truth. The reason most people who have fusions end up needing more surgery is because the adjacent discs end up going... That has absolutely nothing to do with which approach your surgeon uses. That is based on the fact that the segment of the spine fused no longer has any range of motion. So basically, no matter the technique, the adjacent levels will be affected no matter what. This is not to say that everyone who has one fusion will need another, but fusion itself increases that risk. The only possible way the approach could increase or decrease chance for future surgery is if you don't fuse, which really won't depend very much at all on which technique they use, but more so how your body handles the surgery and recovers. For hardware removal, the hardware will generally be in the same place no matter if they do a PLIF or a 360. So that won't change.

    People here can only give their own opinions based on their experiences. If two different doctors gave me two different options, personally, I'd get a third, fourth, or even fifth. None of us here are really qualified to tell you why you should or shouldn't go with a specific approach, but different surgeons can. Personally, I prefer a Neurosurgeon. I've seen Orthos and absolutely hated my experience with them, and now see a Neurosurgeon and have never been happier. That's just my preference, no need for anybody else to jump in and start arguing over their choice to see an Ortho. JUST speaking for myself. It's fairly common for Ortho vs. Neuro to have different opinions on approaches and techniques. I really think your best bet is as minimally invasive as possible. The less muscle and tissue disrupted, the better you are going to feel and the sooner. When it comes to muscle dissection and things of the sort, it never heals 100 percent back to normal. There is really no productive reason to voluntarily do that. If it's necessary and nothing else is available, fine, but there is no reason to damn yourself to that kind of future. If there is a minimally invasive technique available by a doctor who is qualified and you trust, then I would say without a doubt, go that route.

    For me, I am glad they did the 360, BUT, I really do hate how my stomach incision site is really gross. I had a c-section 6 years ago with a 10" incision from hip bone to hip bone, and it was nothing compared to the incision I have from my fusion. I can feel the scar tissue through my skin, parts of my stomach are totally numb, I still get pain and aching around the area, my stomach even LOOKS funny now... If it were possible to get the same effect going through just the back, I would have done that... But I needed ALL of my disc taken out, not just most of it like they typically do for fusions. So they HAD to do the anterior. This is just my experience, and my take on it.

    I think it's a wise idea to get more opinions and then make your decision after collecting enough information and specific reasoning as to why each doctor feels the way they do. Making a list of all your questions and taking notes is really helpful.

    Good luck, whichever way you choose to go!
  • Regardless of the approach taken for a fusion; anterior vs posterior, the disc above may have future problems b/c of the immobilitiy the rigid fusion causes. There is a system that was fda approved in oct 2008 called Dynasis that is a flexible system, meaning that in years to come the disc above should be preserved. You can google it for your own knowledge. Since I am a very young 49 year old I opted for this system. Some insurance companies will pay for it, unfortunately mine would not so I paid $4,000 out of pocket for it. I couldn't put a price on my health. Perhaps chosing this system depends on your age. Check to see if your doctor uses this system. If your doc doesn't then I would question how up-to-date they are. And not to open a can of worms, but I chose a neurosurgeon to work around my delicate nerves rather than a doctor that saws bones for most of their practice. Just my own opinion. I also chose to have a minimally invasive TLIF for my surgery, I have a small posterior incision. No way did I want an anterior approach. Keep doing your research. Also, make sure the surgeon you chose actually does the surgery,not a resident doc that he is supervising. And . . . make sure they take the time to close the incision nicely, NO staples for closure - that is their quick easy way to close and it leaves alot of scars. I'm a nurse so I see these things all the time. So, take a deep breath, do your research as you still have time. Best wishes to you!
  • I forgot to mention that you need to find out what type of material your chosen doc is going to use to fuse you. Some of your choices are a cadavier bone graft, your own bone taken from your hip or bmp. Taking your own bone is painful and honestly antiquated, also another place that has to heal. My neurosurgeon said that the best material he has ever worked with is bmp, I have seen it written also as rhBMP. It is a synthetic bone growth stimulator protien that is injected around the implant or cage they put between your vertebra in place of the disc that is removed. This bmp then causes the fusion. The fusion is said to take place quicker than other methods. Please check it out, you need to know what your surgeon is going to use and that you have a chose.
  • I had staples in the back and stitches in the front, and my back definitely looks cooler. I absolutely LOVE my scars. In fact, I collect them. I am creepy, I know. I am just fascinated by scars. Some here can tell you, I am always requesting incision and scar pictures. Lol. I LOVE the way staples make scars look. Like frankenstein stuff. Heh.
  • I do realize that this is all opinion here and no one is qualified to give me advice on what to do. All I'm looking for is people's opinions and experiences. I'm not even asking for anyone to make a decision for me, just want to get as much info/opinions/experiences I possibly can. In no way am I having this forum replace doctor's advice.

    I actually read somewhere that people who have 360's end up with better fusions (statistic wise) and I wish I could remember where I read that. I suppose I just assumed that better fusion means less chance of going back to the doctor for that same area, but I guess that's always up in the air. The only thing I meant by what I said was that better fusion (in my mind) would mean less chance of future surgery, but no one ever told me that - that was simply based on my own opinion from what I have read.

    I have had two doctors tell me that the full disc should be removed and it doesn't seem like a TILF/PLIF would accomplish this (from what I've read they only remove partial disc space). I feel quite comfortable with the orthopedic surgeon, which is no small feat for me since I've had a lot of doctors that didn't treat me well or the way they should have. I know that there are differences between an ortho and a neuro surgeon, but they're both doing the same job (at the core) and my comfort level with them and the procedure is the most important thing to me.

    I suppose I will see what this other doctor says. I see him on the 19th.
  • Thanks for the info, I will definitely look into that system, and keep those things in mind. You've given me some things to think about and ask!

    The orthopedic surgeon I'm seeing uses bank bone. The office and all doctors at it only work on spines, nothing else. My neurologist actually referred me to him.

    It will be interesting to see what the neurosurgeon says.
  • Just as Lo prefers staples, I prefer anterior approach, I don't want the muscles in my back cut. (aside from the fact that my Ortho feels very strongly about anterior for my situation anyhow). But everyone has their preferences, so these are 2 examples of the types of things to consider.
  • I had staples in the front and glue on the back incisions. This year at the pool, my sister in law commented that she couldn't see my scars unless she was specifically looking for them.

    The glue took forever to wear of, but at least it wasn't staples or stitches.

    Keith
    Several Epidurals, L4-S1 360 ALIF, Numerous Facet Joint Injections, RFA x2
  • It is important to do your research. In minimally invasive approachs which is what a TLIF is (posterior approach) the muscles are NOT cut, they are moved aside with athroscopic instruments. Therefore a much quicker recovery. I'll be back to work 3 weeks post op in a flexible teaching capacity. Also, found Lo's comments regarding incision closure a little confusing. I guess according to that post, if you want an ugly scar you ask for staples. Personally, I prefer a clean, minimally visible incisison site.
  • I'm confused by your confusion. Lol. Not everyone thinks the same things are ugly. Personally, I prefer staples. I have had dissolvable stitches, internal stitches, staples, and glue. Basically every available option for closing wounds. I have personally experienced them all, and that is what I prefer. They healed faster, better, and a lot more painless than the rest. For me, that's what I like. My stomach is crooked and my belly button looks like it's winking, because of the internal stitching. My hip has like, a ROLL in it from the stitches from my c-section... And I'm not fat enough to have rolls. Lol. My stomach has like, a T shape in it from my horizontal incision from the c-section, and my vertical incision from the fusion. My back looks soooooo much better. I like the way my staple scars look... And I really hate my scars from my stitches. That's just my preference. To each his own. Not everyone is going to like the same things, and I just prefer cool looking scars over disfigured looking scars, which is what happened in my case.
  • So glad that worked to your advantage. In my professional opinion, as I have seen thousands of incisions, it is not what I would personally recommend (staples). It is known as a doctors "quick" close. Another option for closure not mentioned is underlying sutures and steri-strip closure for the outmost close. That heals up very nicely. Also, everyone heals differently, some people get keloids naturally. So, lots of options and to each his own. At least be educated on what choices you may have.
  • I had underlying sutures with steri strip closure... That's what internal stitching is. I asked before my surgery what would be used to close my incisions up, and she was originally going to use glue. HOWEVER, she had to make the incisions bigger than she thought, and also, when surgery goes on for a certain period of time, they want to cut down the amount of time under anesthesia and especially lying face down. My surgery was 6 hours long. I'm not an ignorant person, and I've done PLENTY of research. Just because I'm 22 and I like scars doesn't mean I'm not educated. My Neurosurgeon is one of the best in the area, and the head Neurosurgeon of the practice has written book chapters and spoken all over the WORLD. They are very accredited and advanced. I explained to her that I was not concerned with scars, I was more concerned with the quality of my surgery and my recovery. Personally, I didn't care if she had to use staples. I would MUCH rather have less anesthesia and a shorter surgery than lay there for extra time being stitched up. That's my choice. Just because you work in the medical field doesn't mean that your view is the right view. Just like every doctor has their own views and beliefs, so does everyone else in the field. It's not a matter of right and wrong, it's a matter of a surgeon's personal choice. I trust my surgeon... A lot more than I trust people on a forum. I wouldn't let them operate on me, but I would let her. And I am 100 percent happy with my back, and I wish they could have used stitches on my stomach, but at my 2 week post op appt she explained to me why they can't. Staples are not just used as a quick fix. My staple incisions look even better than my incision closed with dermabond, and dermabond is much more on the newer state of the art side. You're entiteld to your own opinions, as am I... But I'd appreciate it if you wouldn't insinuate that because I feel differently than you, that I am not educated. I am VERY knowledgeable in the area of spinal surgery and in fact, my Neurosurgeon was extremely impressed. I've spent literally YEARS doing research every day, and I haven't been working, so I have had plenty of time to read and research, and have spoken to plenty of professionals... I am VERY educated and informed and do absolutely nothing regarding my health in ignorance. THAT I make sure of.
  • Lo, I found your reply very interesting. I'm re-reading my post trying to figure out how it became offensive to you, and how I insinuated anything about your personal education. My post was to say that everyone has there own opinion and we should all do our research and make our choice based on that. Period. Again, I'm truly glad things worked out for you. Over and out.
  • HeidiG said:
    I'm guessing that when you refer to anterior/posterior fusion, you're actually talking about ALIF/PLIF? If you're referring to something else, please clarify what you mean by "anterior/posterior fusion."

    ALIF is anterior lumbar interbody fusion, and PLIF is posterior lumbar interbody fusion. Interbody fusion means the disc is removed and replaced with some sort of spacer (e.g., cage) and bone graft.

    The differences aren't just that one is from the front and one is from the back, because it's not just whether you cut from the front or back, the results are not the same--the bone graft and hardware don't go in the same place. Obviously, anterior vs. posterior approach also affects what kinds of tissue, organs, and nerves are being dealt with. For example, anterior involves more muscle and some organs, but posterior involves the spinal nerves more.

    TLIF is transforaminal lumbar interbody fusion. Yes, both TLIF and PLIF have a posterior approach, but differences include exactly how the surgeon approaches your spine (e.g., the angle from which he approaches), which affects how nerves and other tissue are dealt with, etc., and what/how/where instrumentation is placed. These are significant differences.

    Whether ALIF, PLIF, TLIF, some combination of these, or a different type of fusion (e.g., posterolateral fusion, AxiaLIF) is right for you depends on many factors, including all the details of YOUR particular problem, your anatomy, whether or not you've had previous surgeries, what your doctor is comfortable with, etc. So, there are a lot of things to discuss with your doctor about why he suggests a particular approach.

    I strongly support getting multiple medical opinions before deciding to proceed with surgery.

    I met with 6 different surgeons (ortho and neuro) this past year and although their assessments and recommendations were generally similar (my main problems were quite obvious), there were a lot of differences, too. Most strongly advocated surgery for me, but the specifics of surgery varied among them.

    I believe that a combination of ALIF/PLIF has a higher success rate for MY particular condition (grade 3 spondylolisthesis + resultant associated problems), and that both an anterior and posterior approach were required to deal with my specific anatomy and problems. I recently had ALIF/PLIF performed at L5-S1, but my surgery also included a posterolateral fusion at L4-L5 (this is not an interbody fusion). I'm only 2 months post-op, so it remains to be seen if this is even going to work for me!

    It's tough to figure all this out, understand what's applicable to YOU, & find the right surgeon. Good luck!
    hello, my name is Lena and sounds like you would be a good person to talk to, before i start with me , hope yr healing well and everything has gone good for you and yr family. Im talking with a nero & spine surgeon , i have a grade 2 spondylolisthesis with degenerative disk , spine doc is saying 360 fusion L4-5 & L5-s ,with cage /screws / bone graft , nero surgeon says theres no need to go though the belly, just seen the nero yesterday and didnt ask the right questions. dont know a lot about all this . been doing my best to learn bye reading everything on here and im getting overwhelmed , what would be best?
    Lena Johnson
  • all spinal operations are big so don't be in a rush to have any if there is a suitable alternative ,first make sure that you have all the diagnostic test like a discography and medical imaging and a full and frank consultation with the consultant of your choice please be aware that a fusion is a mechanical fix and is done for spinal stability and not pain relief ..any pain relief would be a bonus and with ALL fusions or ADR {replacement disk} recovery is long and hard up to 3 years .and in many cases will be life changing ..so gather a much information and don't be in a rush ..beware of consultants promising the earth !! and speedy recoveries
    tony{UK}
    1997 laminectomy
    2007 repeat laminectomy and discectomy L4/L5
    2011 ALIF {L4/L5/S1}
    2012 ? bowel problems .still under investigation
    2014 bladder operation may 19th 2014
  • Different surgeons feel that different approaches are based on your spine condition and the particular type of surgery they are recommending. My first surgery was a PLIF/TLIF fusion......they used both approaches due to the complexity of my spine issues, and nerve involvement. My second was a redo of the same two types combined.
    At the top of the forum are several sticky threads regarding surgical necessities and I will give you a few links that have questions you may want to discuss with your surgeon. One question you may want to add , is why each is recommending a different approach.

    http://www.spine-health.com/treatment/back-surgery/ask-doctor
    http://www.spine-health.com/forum/treatment/back-surgery-and-neck-surgery
    http://www.spine-health.com/blog/sleep-and-insomnia/38-questions-ask-your-surgeon-having-back-surgery
    http://www.spine-health.com/treatment/back-surgery/preparing-meet-a-spine-surgeon-or-spine-specialist
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