Modification of Magerl’s technique for the placement of translaminar facet screws in transforaminal lumbar interbody fusion: a technical note and comparative outcome analysis

Abstract

Background
To describe and illustrate a safe and effective technique for the placement of translaminar facet screws (TLFS) in transforaminal lumbar interbody fusion (TLIF).

Methods
Forty-two patients with single-level lumbar diseases were divided into two groups randomly. 21 patients were treated by traditional TLIF using bilateral pedicle screws fixation (BPS) while the other patients underwent insertion of a unilateral pedicle screw (UPS)and contralateral TLFS using our modified technique. In this technique, a small unicortical “hole” was formed adjacent to the contralateral facet joint to ensure that insertion of the screw could be directly visualized through the hole to prevent violation of the spinal canal. The ODI, JOA, VAPS questionnaire, the mean operation time, mean operative blood loss, length of stay and postoperative complications were collected for analysis.

Results
There is no significant difference between the BPS and UPS + TLFS group in the preoperative and postoperative ODI, JOA or VAPS at each follow- up visit, while the UPS + TLFS group using our modified technique significantly reduced the mean operation time, the mean estimated blood loss and the length of stay. These results demonstrated this modified technique to be safe and effective in TLIF.

Conclusions
In contrast to conventional TLIF, our modified technique for placing TLFS in TLIF can reduce soft tissue injuries, reduce the operation risk of violation of the spinal canal and the expenses, minimize radiation exposure, and shorten the length of the operation without a concurrent reduction in clinical efficacy.

Full text

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Preprint:Pleasenotethatthisarticlehasnotcompletedpeerreview.
ModificationofMagerl’stechniquefortheplacement
oftranslaminarfacetscrewsintransforaminallumbar
interbodyfusion:atechnicalnoteandcomparative
outcomeanalysis
CURRENTSTATUS:UND ERREVI EW
DaoliangXu
secondaffiliatedhospitalofWenzhouMedicalUniversity
HaiminJin
WenzhouMedicalUniversitySecondAffiliatedHospital
JiaoxiangChen
WenzhouMedicalUniversitySecondAffiliatedHospital
XiangyangWang
knightman@yeah.netCorrespondingAuthor
DOI:
10.21203/rs.3.rs-22186/v1
SUBJECTAREAS
Orthopedics OrthopedicSurgery
KEYWORDS
Modifiedtechnique,Translaminarfacetscrews,Transforaminallumbarinterbody
fusion

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Abstract
Background
Todescribeandillustrateasafeandeffectivetechniquefortheplacementoftranslaminarfacet
screws(TLFS)intransforaminallumbarinterbodyfusion(TLIF).
Methods
Forty-twopatientswithsingle-levellumbardiseasesweredividedintotwogroupsrandomly.21
patientsweretreatedbytraditionalTLIFusingbilateralpediclescrewsfixation(BPS)whiletheother
patientsunderwentinsertionofaunilateralpediclescrew(UPS)andcontralateralTLFSusingour
modifiedtechnique.Inthistechnique,asmallunicortical“hole”wasformedadjacenttothe
contralateralfacetjointtoensurethatinsertionofthescrewcouldbedirectlyvisualizedthroughthe
holetopreventviolationofthespinalcanal.TheODI,JOA,VAPSquestionnaire,themeanoperation
time,meanoperativebloodloss,lengthofstayandpostoperativecomplicationswerecollectedfor
analysis.
Results
ThereisnosignificantdifferencebetweentheBPSandUPS + TLFSgroupinthepreoperativeand
postoperativeODI,JOAorVAPSateachfollow-upvisit,whiletheUPS + TLFSgroupusingourmodified
techniquesignificantlyreducedthemeanoperationtime,themeanestimatedbloodlossandthe
lengthofstay.TheseresultsdemonstratedthismodifiedtechniquetobesafeandeffectiveinTLIF.
Conclusions
IncontrasttoconventionalTLIF,ourmodifiedtechniqueforplacingTLFSinTLIFcanreducesofttissue
injuries,reducetheoperationriskofviolationofthespinalcanalandtheexpenses,minimize
radiationexposure,andshortenthelengthoftheoperationwithoutaconcurrentreductioninclinical
efficacy.
Introduction
Transforaminallumbarinterbodyfusion(TLIF)withbilateralpediclescrews(BPS),animportant
lumbarfixationmethodinitiallypopularizedin1982byHarmsandRolinger[1],hasbeenwidely
utilizedinthetreatmentofspinalinstabilityanddegenerativediscdisease.Ithasbeenshowntobe
aneffectiveandsafetechniquethatcanproviderigidfixationandincreasetherateoffusion[2,3].
However,toimplantthepediclescrew,extensiveareasofbilateralparavertebraltissuemustbe

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stripped,andthismaycauseanincreaseinpostoperativepain,prolongedrecoverytime,and
impairedspinalfunction.Thesedisadvantagesledsurgeonstopursuealessinvasiveposterior
fixationtechnique,andaunilateralpediclescrew(UPS)wasthusproposedforlumbarfixationand
fusion.AlthoughtheUPSiscapableofachievingaclinicalfusionrateequivalenttothatoftheBPS[4],
concernsabouttheadequacyoftheUPSforstabilization,owingtoitsinherentconstructasymmetry,
havebeenraised[5].Consequently,ahybridTLIFcomposedofaUPSplusasinglecontralateral
translaminarfacetscrew(TLFS)wasproposed[6],whichwouldsignificantlyincreasethedegreeof
stabilization.Somestudieshavedemonstratedgoodclinicalresultsusingthishybridtechnique[7,8].
Thismethodwasabletomaintaininstantandlong-termequivalentbiomechanicalability,whilebeing
lessinvasivethanthetraditionalBPS[5,9].
However,theplacementoftheTLFSisalsopronetocomplicationsincludingpartialdorsallaminar
breachandviolationofthespinalcanal.Moreover,itisacomplicatedprocedurethatshouldbe
performedwiththeaidofacustomizedguidedeviceorunderX-rayguidance.Toaddressthese
issues,wehaveadjustedthehybridtechniquetocreateanewminimallyinvasivetechniqueforthe
placementofTLFSinTLIF.Inournewtechnique,weslightlymodifiedMagerl’smethodbycreatinga
smallunicortical“hole”adjacenttothefacetjointatthecontralateraldorsallaminatoensurethatthe
screwisdirectlyinlinewiththelaminaandhasnotviolatedthespinalcanalunderdirectvision;thus,
itcansafelytraversethefacetjointsandcometorestatthebaseoftheoppositetransverseprocess
ofthelowervertebra.Thisstudyistoconfirmtheclinicalcurativeeffectivenessandotheradvantages
ofourmodifiedtechnique,comparedtoconventionalTLIF.
MaterialsAndMethods
Patients
AllproceduresinthisstudywereapprovedbyTheAffiliatedHospitalandYuyingChildren’sHospitalof
WenzhouMedicalUniversityResearchEthicsCommittee.Allpatientsgaveinformedwrittenconsent
beforeinclusioninthestudy.Intactspinousprocess,laminaandanintactanteriorcolumnthatisable
toresistcompressiveforcesareprerequisitesforconsideringtheuseofTLFS[10,11],whichwas
identicallyconsideredasourinclusion&exclusioncriteria.BetweenMarch2016andDecember2016,

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42patientswithsingle-levelandunilateralsymptomaticlumbardiseasesweredividedintotwo
groupsrandomly.PatientsinonegroupunderwentinsertionofaUPSsupplementedwithasingle
contralateralTLFSviaourtechnique,whiletheothergroupwastreatedbytraditionalTLIFusingBPS.
Allpatientsunderwentpreoperativemagneticresonanceimaging,computedtomography(CT),and
lumbarspineX-raysforthepurposesofpreoperativeevaluationandplanning.Postoperatively,the
dynamicX-raysandCTwereobtainedtoassessthebiomechanicalstabilityandfusion.
SurgicalTechnique
Intraoperatively,theneurophysiologicalmonitoringoflumbarspinalnerverootswasusedtoensure
noneurologicaldeficit.Undergeneralanesthesia,patientswereplacedintothepronepositionwith
thehipsatmaximumextensionconducivetomaintaininglumbarlordosis.Then,a4cmmedian
incisionwasmade.Followingsatisfactoryexposureoftheposteriorlumbarspineonthesideofthe
mostseriouslesionornerverootsymptomsthroughsubperiostealapproach,thepediclescrewwas
initiallyinsertedontheipsilateralside.IntheBPSgroup,thecontralateralpediclescrewwasinserted
similarlytothepriorsidefromthesameincision.Subsequentdecompressionoftheneuralstructures,
discectomy,end-platedecortication,andfusionwereperformedintheconventionalmanner.
IntheUPS + TLFSgroup,furtherdecompressionwouldbeinevitableincaseswheresomepatients
experiencedpreoperativenerverootcompressionsymptomsonthecontralateralside.Then,along
withthespinousprocess,thecontralateralpartialparavertebraltissuesweredissectedtoexposethe
laminathatadjacenttothefacetjoint(approximately1.0–1.5cmlateraltothemidline),tocreatethe
unicortical“hole”.Adiamonddrillwasusedtoformasmallcorticalwindowinthemiddleofthe
exposedlamina,andcancellousbonewasremovedwithraspsandcuretteswhilepreservingthe
mediallamina.Aftercreationofaunicortical“hole,”thenextstepwastoinserttheTLFS.Theentry
pointastheipsilateralanatomicalmarkerwasidentifiedasthejunctionofthelaminaandthebaseof
theupper1/3spinousprocess[12],consistentwithpreviousstudy.Usingahanddrill,the
contralaterallaminawascarefullydrilledtowardthefacetjoint.Accordingtothepreviousliterature
[13],thedrillalignedalongtheangleoftheexposedcontralaterallaminarsurface,aimingforthe
unicortical“hole”oftheexposedlamina.Thedrillwasvisuallyconfirmedtobedrillingthroughthe

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“hole”andintothecancellouslaminarbonetopreventthedrillfromviolatingthespinalcanal.Then,
abluntball-tippedprobewasinsertedtoensurenocorticalbreakthroughintothespinalcanal,and
thelengthofthetrajectorywaspalpated.Finally,acorticalbonescrewofanappropriatediameter,
wastheninsertedagainstthedorsalcorticesofthelamina(Fig.1).Afterhemostasisandrinsingwith
normalsaline,adrainwasinsertedasrequiredandtheincisionwassuturedinlayers.
ClinicalAssessment
ThepreoperativeandpostoperativeODI,JOAandVAPSquestionnairewerecompleted.Theoperative
timeandintraoperativebloodlosswererecorded.Thepostoperativemeanfollow-upwas31.2 ±
8.7months(range6–42months)inBPSgroupand28.5 ± 2.9(range22–33months)intheUPS + TLFS
group,respectively.PostoperativeAP,lateralanddynamicX-rays,andthree-dimensionalCTscans
wereobtainedtoevaluatetheimagingoutcomesandbiomechanicalstabilityattheintervalsof6
weeks,3,6months,1,2and3years.Thecriteriaforradiologicbonyfusionaccordingtotheprevious
study[14].
Statisticalanalysis
ThedatawasanalyzedbytheWilcoxonRanksumandTtestwereusingtheSPSS15.0(SPSS,Chicago,
IL,USA).Apvaluelessthan0.05wasconsideredstatisticallysignificant.
Results
ComparedwiththeBPSgroup(210.2 ± 48.3min),themeanoperationtimeinUPS + TLFSgroup
(126.3 ± 28.8min)significantlydecreased.Likewise,boththemeanestimatedintraoperativeblood
lossandthelengthofstayUPS + TLFSgrouphadasignificantdecrease,240.3 ± 72.7versus428.5 ±
79.6ml,3.8 ± 1.2versus4.8 ± 1.4days,respectively.ThepreoperativeandpostoperativeODI,JOA
andVAPSscoresexhibitednosignificantdifferencesbetweentheBPSandUPS + TLFSgroup
(Table1).Noimmediateintraoperativeorearlypostoperativecomplicationsoccurredinanyofthe42
patients.Onlyonecaseofsuperficialinfectionwasfoundandanotherpatientwaslosttofollow-upin
theBPSgroupat6postoperativemonths.PostoperativedynamicX-raysandCTscansshowedthat
thepostoperativestabilityandfusionrateinbothgroup(95.2%inUPS + TLFSversus90.5%inBPS
group)wereexcellent,andthepositionofthescrewsinourmodifiedtechniqueweresatisfactoryin
allpatientswithoutviolationofthespinalcanal(Fig.2).

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Table1
Demographicdataandtheresultsofpatients
UPS + TLFS BPS pvalue
0DI(Preoperative) 28.9 ± 6.0 30.4 ± 6.3 0.4
0DI(3months) 3.6 ± 1.3 3.4 ± 1.3 0.6
JOA(Preoperative) 11.4 ± 1.8 10.7 ± 1.6 0.2
JOA(3months) 23.3 ± 3.0 22.8 ± 2.8 0.5
VAPS(Preoperative) 6.7 ± 1.7 7.1 ± 18 0.5
VAPS(3months) 1.5 ± 0.6 1.8 ± 0.9 0.2
Operativetime(min) 126.3 ± 28.8 210.2 ± 48.3 0.01
Estimatedbloodloss(ml) 240.3 ± 72.7 428.5 ± 79.6 0.01
Lengthofstay(d) 3.8 ± 1.2 4.8 ± 1.4 0.05
Meanfollow-up 30.5 ± 8.7 32.0 ± 4.9 0.5
Fusionatlastfollow-up 20(95.2%) 19(90.5%) 
Complications 0(0%) 1(5%) 
Discussion
Withthedevelopmentofsurgicaltechnology,bilateralnerverootscanbedecompressedviathe
singletransforaminalapproach[8].Withthismethod,thehybridtechniqueusingacombinationofa
UPSplusasinglecontralateralTLFSinTLIF,pioneeredbyJangetal.in2005[6],hasgained
increasingpopularityduetodiminishedsofttissueinjuries,reducedestimatedbloodloss,lower
operativecosts,andreducedpotentialriskofneurologicalinjury[6,8,15],comparedwiththe
standardBPSmethod.Recentbiomechanicaldatasuggestthatthenewfixationsystemprovidesthe
samedegreeofstabilityandsupportsthesameamountofstiffnessinalldirections,suchasflexion–
extension,lateralbending,andaxialrotation,comparedwiththeBPSmethod[9,16–18].Moreover,
someclinicalassessmentsdemonstratedthatalthoughtherewasnosignificantdifferencebetween
thetwomethodsintermsofclinicaloutcome,fusionrate,orcomplicationrate,theoperativetime,
bloodloss,andcostweresignificantlyreducedinthehybridmethod[7,8].
However,thehybridtechniqueistechnicallymorechallengingandhasbeenassociatedwith
neurologicalinjuries.DuringinsertionoftheTLFS,whichwasdevisedbyMagerl[19]asalessinvasive
alternativeforposteriorpediclescrewstabilization,theincidenceofintraoperativecomplications
includingpartialdorsallaminarbreachorpenetrationofthescrewintothespinalcanalcouldnotbe
completelyavoided[20,21].Inaddition,increasedexposuretointraoperativeradiationshouldnotbe
ignored.ToincreasethesafetyandaccuracyofTLFSplacement,GrobandHumke[10]describeda
prototypedevicethattheyinventedtopercutaneouslyinserttheTLFSasasupplementaryposterior
fixationmethodtoanteriorlumbarinterbodyfusion(ALIF).However,theirstudylackedtechnical
detailsandclinicaloutcomes.Jangetal.[22]introducedaguidedeviceforthepercutaneous

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placementoftheTLFSafterALIF.Unfortunately,theirdeviceisnotcommerciallyavailableand,thus,
theirtechniquecannotyetbewidelyused.Shimetal.[23]reportedontheirexperiencewitha
fluoroscopy-assistedpercutaneousTLFSfixationtechniquewithouttheuseofaguidedevice.
Althoughthistechniqueallowsthesurgeontoobtainsimultaneousintraoperativemultilevel
visualizationoftheproposedscrewtrajectoryunderfluoroscopicguidance,10%ofthescrews
violatedthelaminawall,with15%ofthescrewsfoundtobeinanimperfectposition.Recently,some
studieshavedemonstratedthattheuseofCT,oracombinationofCTandfluoroscopicguidance,can
dramaticallyreducethedifficultyinimplantingtheTLFSbyprovidingboththree-dimensional
landmarksandreal-timeimaging[24,25].However,thesetechniquesmayincreasetheexposureto
radiationandtheoperationtime,andthepotentialforinaccuratescrewplacementcannotbe
completelyavoided.
Besidestheauxiliarymethods,adetailedknowledgeoffacetanatomyandcorresponding
radiographiccriteriaisrequiredforthesafeplacementofacontralateralTLFS.Luetal.[13]
conductedananatomicstudyin30driedlumbarspinestomeasurethescrewpathlength,caudaland
lateralangles,andsuperiorandinferiorlaminaborderthicknessesfromL1toL5forinsertionofthe
TLFS.InthehumancadavericstudybyPhillipsetal.[26]theradiographicdatasuggestedthatthe
radiographicviewsidentifiedtoachieveproperplacementoftheTLFSwereatruelateral,AP,45º
oblique,andAPviewwiththeX-raybeamata30ºto45ºcephaladangle(“spinaloutlet”view).These
studiesprovidetherelevantdataforuseoftheTLFSandmaygreatlyincreasethesafetyofscrew
placement.Inourstudy,mostpatientsobtainedbicorticalpurchase.Ontheonehand,basedonthe
preoperativemeasurementof3-dimensionalimagereconstructionoftheCTdataofpatientsandthe
intraoperativelengthofprobe,thelengthofTLFSwasensuretobelongenoughtotraversethefacet
joints.Ontheotherhand,consideringthatAsiansaresmallerinsizethanWesterner,theTLFSusedin
ourstudywas4.0mmindiameter,whichhadbeenprovedtobeeffective[8].(Magerlinserteda
4.5mmcorticalscrewforplacingTLFS.)Itisvitaltoensurethatthediameterofscrewwasnogreater
thanthethicknessofinferiorborderofthelamina,topreventthelaminafromoccurringthebicortical
purchase.

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ToensurethesafeplacementofacontralateralTLFSinthehybridtechnique,weslightlymodified
Magerl’stechniquebyaddingasmallunicortical“hole”adjacenttothefacetjointatthecontralateral
dorsallamina.Directvisualizationoftheinsertionofthescrewagainstthedorsalcorticesofthe
laminaprovidesassurance,withouttheneedforfluoroscopy,thattheTLFScanbecorrectlylocated
withinthelaminaandnotenteredthespinalcanal.ComparedwiththeconventionalTLIFtechnique,
ourmodifiedtechniqueappearstobetechnicallysimpleandsafe,lessinvasive,andlessexpensive.
Weencounterednoscrewlooseningorbreakageandnoneurologicinjuries,andweattributethe
absenceofintraoperativecomplicationstothefactthattheinsertionofthescrewswastechnically
easyunderdirectvision.
Clinically,comparedtoTLIF,thetotaloperatingtimeandestimatedbloodlossofthepatientstreated
withourmodifiedtechniquewerereduced,whichindicatesthatthenewtechniquecouldhelp
minimizethedegreeofsurgicalinvasionandreducethelengthofhospitalstay.Moreover,thefusion
rate(90.5%)atlastfollow-upandthepositionofthescrewsweresatisfactoryaccordingtothe
postoperativeCT.BiomechanicalstabilitywasensuredbypostoperativedynamicX-rays.These
resultsdemonstratethatourtechniquehasclinicalefficacyandsafety,andthisappearstobe
consistentwithsomeofthemorerecentstudies[6–8].
Insummary,ourmodifiedtechniqueresultsinsignificantimprovementsinbothclinicalsafetyand
efficacyduringtheplacementofTLFS.Moreover,itreducestheoperationtimeandbloodlossand
incursaloweroperativecost.However,therearesomelimitationsinourstudy.Firstly,thesample
sizeisrelativelysmall,furtherstudiesarerequiredtoconfirmtheapplicationofthismodified
techniqueinthefuture;Secondly,thismodificationlacksthepartialbicorticalpurchase,andthis
differencemayaccountforthereducedTLFSstiffnessinaxialrotationandlateralbendingbecause
thescrewsmaytogglewithinthecancellouslaminarbone.Therefore,thequestionofwhetherthis
techniqueisbiomechanicallyaseffectiveasthetraditionalTLFSmethodisstillopentofurther
research.Finally,although,comparewithconventionalTLIF,ourmodifiedtechniqueseemstobe
moreminimalinvasive,abettercomparisontootherminimalinvasivefixation(suchasMIS-TLIF,in
whichnocontralateralsubperiostealdissectionisneededcausecontralateralscrewsreplaced

9
percutaneously.)mayleadtomoreclinicalsignificance,whichwarrantfurtherstudies.
Conclusions
Inourmodifiedtechnique,atinyunicortical“hole”wascreatedatthedorsallaminaadjacenttothe
contralateralfacetjoint.Byallowingdirectvisualizationoftheinsertionofthescrewagainstthe
dorsalcorticesofthelamina,themodifiedtechniquecanreducesofttissueinjuries,reducetheriskof
violatingthespinalcanal,minimizeradiationexposure,andshortentheoperationtimewithouta
concurrentreductioninclinicalefficacy,incontrasttoconventionalTLIF.
Abbreviations
TLFS:Translaminarfacetscrews;TLIF:Transforaminallumbarinterbodyfusion;BPS:Bilateralpedicle
screws;UPS:Unilateralpediclescrew;CT:Computedtomography;AP:Anteroposterior.
Declarations
Ethicsapprovalandconsenttoparticipate
ThisstudywasapprovedbytheethicscommitteeoftheSecondAffiliatedHospitalandYuying
Children’sHospitalofWenzhouMedicalUniversity.TheapprovalnumberisL-2016-09.Asforthis
research,anoptoutoftheinformedconsent,theinformationdisclosure,andanegativeopportunity
areguaranteedintheEthicalapproval.
Consentforpublication
Allthepatientsinthisstudyhavegiventheirinformedconsentforthearticletobepublished.
Availabilityofdataandmaterials
Thedatasetsusedand/oranalyzedduringthecurrentstudyareavailablefromthecorresponding
authoronreasonablerequest.
Competinginterests
Theauthorsdeclarethattheyhavenocompetinginterests.
Funding
Nofundingwasprovidedspecificallyforthisstudy.
Authors’contributions
Allauthorshavemadesubstantialcontributionstotheconceptionanddesign,acquisitionofdata,and
analysisandinterpretation.Allauthorshavebeeninvolvedindraftingthemanuscriptorrevisingit

10
criticallyforimportantintellectualcontent.Allauthorshavegivenfinalapprovaloftheversiontobe
published.Allauthorsagreetobeaccountableforallaspectsoftheworkinensuringthatquestions
relatedtotheaccuracyorintegrityofanypartoftheworkareappropriatelyinvestigatedand
resolved.
Acknowledgements
Notapplicable.
References
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Figures

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Figure1
(A)Superiorviewofthelumbarvertebralbody.(B,E,H)Asmallunicortical“hole”adjacent
tothefacetjointatcontralaterallaminawasmadebyadiamonddrill.(C,F,I)Withthedrill
visuallyalignedalongtheangleoftheexposedcontralaterallaminarsurface,thelamina
wascarefullydrilledalongitslength,aimingfortheunicortical“hole”adjacenttothe
contralateralfacetjoint.(D,G,K)Thescrewcanbedirectlyvisualizedthroughthe
unicortical“hole”.

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Figure2
(A,B)PostoperativeplainlumbarspineX-rayviewsshowedtheTLIFwithUPS+TLFS.(C,D)
PostoperativeaxialandsagittalreconstructedCTscansshowedthatthepositionofthe
screwwassatisfactoryandnoviolatingofthespinalcanal(blackarrowinCandredarrows
inD)