New Implants and Techniques in Minimally Invasive Spine Surgery: True Percutaneous Transforaminal Lumbar Interbody Fusion (pTLIF) with the Posterolateral Transforaminal Endoscopic Approach

  • Rudolf MorgensternEmail author
  • Christian Morgenstern


The standard treatment for degenerative disk disease is interbody fusion by open discectomy. However, this technique requires open tissue dissection with the disadvantages of higher risk of infection, blood loss and a relatively long recovery period.

The posterolateral transforaminal approach is the standard approach in endoscopic spine surgery that allows direct access to the intervertebral disk with progressive tissue dilatation and no tissue dissection. In this chapter, we present the posterolateral approach to percutaneously insert an interbodyimplant (PEEK rigid cage, as well as B-Twin and Opticage expandable devices) into a lumbar disk. The implants can be inserted either as a stand-alone cage or with a posterior fixation with the goal to achieve a 360° interbody fusion. A typical indication for this technique are patients suffering from degenerative disk disease with or without spondylolisthesis in the lumbar spine. The percutaneous transforaminal posterolateral fusion approach is also helpful for revision surgery as it allows bypassing fibrous tissue generated by previous open surgery. In selected cases, central spinal stenosis can also be successfully addressed with this technique without additional open posterior decompression surgery, by employing an expandable device that opens the central canal with indirect decompression. t.

In a first part, we will review our previous experience with various interbody implants (PEEK rigid cage and the B-Twin expandable device) that were percutaneously inserted in the lumbar spine with the aforementioned endoscopic transforaminal approach. Based upon this experience, we will then explain the development process of a whole new set of instruments (Optiport) and a new expandable device (Opticage) to optimize and streamline percutaneous spine fusion surgery with a method that we call percutaneous transforaminal lumbar interbody fusion (pTLIF). We present a single-center, single-surgeon prospective study of 40 consecutive pTLIF cases using the Opticage expandable device. The outcome of this study showed a significant (p < 0.001) decrease between pre-operative and post-operative pain and disability scores for a mean follow-up of 33.4 ± 20.6 months. Our results show the efficacy of the posterolateral approach to safely and quickly achieve a percutaneous fusion of the lumbar spine and successfully treat patients with degenerative disk disease with or without spondylolisthesis up to grade 2 and in revision surgery. Our outcome does not differ from standard open surgery, while the advantages of the pTLIF procedure comprise less invasiveness with lower risk of bleeding and infection, as well as a shorter time to post-operative walking (median 6h) and hospital discharge (median post-operative time until hospital discharge 25h). This disruptive percutaneous fusion technique opens the way for ambulatory lumbar spinal fusion surgery in an out-patient setting.


Posterolateral transforaminal approach Endoscopic spine surgery Percutaneous implants Expandable cage percutaneous transforaminal lumbar interbody fusion (pTLIF) 


  1. 1.
    Shunwu F, Xing Z, Fengdong Z, Xiangqian F. Minimally invasive transforaminal lumbar interbody fusion for the treatment of degenerative lumbar diseases. Spine (Phila Pa 1976). 2010;35:1615–20. doi: 10.1097/BRS.0b013e3181c70fe3.CrossRefGoogle Scholar
  2. 2.
    Kim JS, Jung B, Lee SH. Instrumented minimally invasive spinal-transforaminal lumbar interbody fusion (mis-tlif); minimum 5-years follow-up with clinical and radiologic outcomes. J Spine Disord Tech. 2012; doi: 10.1097/BSD.0b013e31827415cd.
  3. 3.
    Morgenstern R. Transforaminal endoscopic stenosis surgery: a comparative study of laser and reamed foraminoplasty. Eur Musculoskeletal Rev. 2009;4:1–6.Google Scholar
  4. 4.
    Ahn Y, Lee SH, Park WM, et al. Posterolateral percutaneous endoscopic lumbar foraminotomy for L5-S1 foraminal or lateral exit zone stenosis. Technical note. J Neurosurg. 2003;99(3 Suppl):320–3.PubMedGoogle Scholar
  5. 5.
    Hoogland T, van den Brekel-Dijkstra K, Schubert M, et al. Endoscopic transforaminal discectomy for recurrent lumbar disc herniation: a prospective, cohort evaluation of 262 consecutive cases. Spine (Phila Pa 1976). 2008;33:973–8.CrossRefGoogle Scholar
  6. 6.
    Morgenstern R, Morgenstern C, Yeung AT. The learning curve in foraminal endoscopic discectomy: experience needed to achieve a 90% success rate. SAS J. 2007;1:100–7.CrossRefPubMedPubMedCentralGoogle Scholar
  7. 7.
    Ruetten S, Komp M, Merk H, et al. Full-endoscopic interlaminar and transforaminal lumbar discectomy versus conventional microsurgical technique: a prospective, randomized, controlled study. Spine (Phila Pa 1976). 2008;33:931–9. doi: 10.1097/BRS.0b013e31816c8af7.CrossRefGoogle Scholar
  8. 8.
    Morgenstern R, Morgenstern C. Assessment and selection of the appropriate individualized technique for endoscopic lumbar disc surgery. Clinical outcome of 400 patients. In: Menchetti PPM, editor. Minimally invasive surgery of the lumbar spine. London: Springer-Verlag; 2014. p. 107–20. doi: 10.1007/ 978-1-4471-5280-4_5.CrossRefGoogle Scholar
  9. 9.
    Morgenstern R, Morgenstern C. Percutaneous transforaminal lumbar interbody fusion (pTLIF) with a posterolateral approach for the treatment of degenerative disk disease: feasibility and preliminary results no. IJSSURGERY-D-15-00047R1. Int J Spine Surg. 2015;9:Article 41. doi: 10.14444/2041.Google Scholar
  10. 10.
    Yeung AT, Tsou PM. Posterolateral endoscopic excision for lumbar disc herniation: surgical technique, outcome, and complications in 307 consecutive cases. Spine (Phila Pa 1976). 2002;27:722–31.CrossRefGoogle Scholar
  11. 11.
    Kambin P, Gellman H. Percutaneous lateral discectomy of the lumbar spine: a preliminary report. Clin Orthop Relat Res. 1983;174:127–32.Google Scholar
  12. 12.
    Ruetten S, Komp M, Godolias G. An extreme lateral access for the surgery of lumbar disc herniations inside the spinal canal using the full-endoscopic uniportal transforaminal approach-technique and prospective results of 463 patients. Spine (Phila Pa 1976). 2005;30:2570–8.CrossRefGoogle Scholar
  13. 13.
    Lee SH, Kang BU, Ahn Y, et al. Operative failure of percutaneous endoscopic lumbar discectomy: a radiologic analysis of 55 cases. Spine (Phila Pa 1976). 2006;31:E285–90.CrossRefGoogle Scholar
  14. 14.
    Choi G, Lee SH, Lokhande P, et al. Percutaneous endoscopic approach for highly migrated intracanal disc herniations by foraminoplastic technique using rigid working channel endoscope. Spine (Phila Pa 1976). 2008;33:E508–15.CrossRefGoogle Scholar
  15. 15.
    Morgenstern R, Morgenstern C. Endoscopically assisted transforaminal percutaneous lumbar interbody fusion. In: Lewandrowski KU, Lee SH, Iprenburg M, editors. Endoscopic spinal surgery. London: JP Medical Publishers; 2013. p. 127–34.CrossRefGoogle Scholar
  16. 16.
    Morgenstern R. Full endoscopic TLIF approach with percutaneous posterior transpedicular screw fixation in a case of spondylolisthesis grade I with L4–L5 central stenosis. J Crit Spine Cases. 2010;3:115–9.Google Scholar
  17. 17.
    Morgenstern R, Morgenstern C, Jané R, Lee SH. Usefulness of an expandable interbody spacer for the treatment of foraminal stenosis in extremely collapsed disks: preliminary clinical experience with the endoscopic posterolateral transforaminal approach. J Spinal Disord Tech. 2011;24:485–91.PubMedGoogle Scholar
  18. 18.
    Berthonnaud E, Dimnet J, Roussouly P, Labelle H. Analysis of the sagittal balance of the spine and pelvis using shape and orientation parameters. J Spinal Disord Tech. 2005;18:40–7.CrossRefPubMedGoogle Scholar
  19. 19.
    Kim TY, Kang KT, Yoon DH, et al. Effects of lumbar arthrodesis on adjacent segments: differences between surgical techniques. Spine (Phila Pa 1976). 2012;37:1456–62.CrossRefGoogle Scholar
  20. 20.
    Davis R, Auerbach J, Bae H, Errico TJ. Can low-grade spondylolisthesis be effectively treated by either coflex interlaminar stabilization or laminectomy and posterior spinal fusion? Two-year clinical and radiographic results from the randomized, prospective, multicenter US investigational device exemption trial Spondylolisthesis treated with coflex stabilization of fusion. J Neurosurg Spine. 2013;19:174–84.CrossRefPubMedGoogle Scholar
  21. 21.
    Syed H, Voyadzis JM. True percutaneous transforaminal lumbar interbody fusion: case illustrations, surgical technique, and limitations. J Neurol Surg A Cent Eur Neurosurg. 2016;77(4):344–53. doi: 10.1055/s-0035-1558821. ISSN 2193-6315CrossRefPubMedGoogle Scholar
  22. 22.
    Powers CJ, Podichetty VK, Isaacs RE. Placement of percutaneous pedicle screws without imaging guidance. Neurosurg Focus. 2006;20:E3.CrossRefPubMedGoogle Scholar
  23. 23.
    Copay AG, Glassman SD, Subach BR, et al. Minimum clinically important difference in lumbar spine surgery patients: a choice of methods using the Oswestry Disability Index, Medical Outcomes Study questionnaire Short Form 36, and pain scales. Spine J. 2008;8:968–74. doi: 10.1016/j.spinee.2007.11.006.CrossRefPubMedGoogle Scholar
  24. 24.
    Macnab I. Negative disc exploration. An analysis of the causes of nerve-root involvement in sixty-eight patients. J Bone Joint Surg Am. 1971;53:891–903.CrossRefPubMedGoogle Scholar
  25. 25.
    Karikari IO, Isaacs RE. Minimally invasive transforaminal lumbar interbody fusion: a review of techniques and outcomes. Spine (Phila Pa 1976). 2010;35(26 Suppl):S294–301.CrossRefGoogle Scholar

Copyright information

© Springer International Publishing AG 2018

Authors and Affiliations

  1. 1.Centro Médico TeknonMorgenstern Spine InstituteBarcelonaSpain
  2. 2.Department of Orthopedics, Centrum für Muskuloskeletale ChirurgieCharité-UniversitätsmedizinBerlinGermany

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