Thoracolumbar Instrumentation and Fusion for Degenerative Disc Disease

Abstract

With the increase of an aging population worldwide, patient’s expectations and demands for an improved independent lifestyle have led to innovative strategies in the treatment of degenerative disc disease. Aside from all conservative modalities, new surgical techniques attempt to enable a rapid recovery by reducing iatrogenic injury and complications with shorter operative times. Over the past two decades, the debate over which approach may achieve the highest fusion rates has been opened to a more global view on its efficacy of restoring the overall coronal and sagittal balance of the spine. Thus, the analyses of respective spinopelvic interrelations using modern full body radiographic imaging in an upright standing position have received closer attention and have since been fully included in our therapeutic management and strategical planning. Furthermore, the increasing number of failed primary surgeries and/or adjacent segment degeneration with secondary kyphotic deformity constitute a distinct entity of challenges with rather individual and case-dependent solutions. Today’s advances in spinal instrumentation allow almost any operation to be performed in a minimally-invasive fashion. Regardless of selecting either the retroperitoneal corridor (ALIF, OLIF, LLIF) or traversing the spinal canal with or without osteotomy of the facet joints for segmental mobilsation (PLIF, TLIF, minimally-invasive-surgery (MIS)-TLIF), none of today’s standard techniques have proven to be superior to another. Although each approach has its own risks and benefits, fusion rates or clinical outcomes appear to be similar. However, there is fundamental consensus, that interbody fusion itself is preferable to posterolateral “on-lay” fusion techniques with less postoperative complications and lower rates of pseudarthrosis. In conclusion, the surgeon must always consider all technical options to tailor the treatment to the patient’s individual, but none the less realistic expectations.