In addition to the spinal fusion approach used, there are a number of other factors to be considered before spine fusion surgery. The following discusses several other considerations.
PLIF and TLIF surgery
The posterior lumbar interbody fusion (PLIF) and transforaminal lumbar interbody fusion (TLIF) surgeries allow for placement of bone or a cage in the disc space, increasing the fusion rate and hopefully a better clinical outcome. There is more neurologic risk because of the need to retract the nerve roots, however, major nerve injury is unusual. It has the advantage of placing a structural graft or device in the major weight-bearing part of the spine while avoiding a separate incision.
Traditionally, bone graft has been harvested from the patient’s own iliac crest (pelvis) to stimulate the fusion site. Cadaver bone often is useful in anterior fusions, but it works poorly in posterior applications. Recent advances have allowed spine surgeons to decrease the need for bone graft harvest by using substitutes, e.g., collagen sponges, demineralized bone matrix, platelet derived growth factors and, most promising, bone morphogenic protein (BMP).
The bone morphogenic protein currently in use (Infuse) has FDA approval for anterior application only. Further research is ongoing to document the utility of these products, which allow for diminished patient trauma that can occur from harvesting bone graft from the patient's own hip.
Minimally Invasive Surgery (MIS)
Much work is in development to try to decrease the trauma patients incur by placing pedicle screws through smaller incisions. This is thought to result in less muscle trauma and allow for more rapid recovery after spine surgery.
Caution needs to be exercised, however, as even though a technique is less traumatic, if the spine fusion rate is much lower, then there is really not an advantage. Also, it has yet to be demonstrated that minimally invasive spine fusion systems actually cause better outcomes than some other surgical techniques used in the traditional open approach.