title: Transforaminal lumbar interbody fusion using one diagonal fusion cage with unilateral pedicle screw fixation for treatment of massive lumbar disc herniation.
abstract: BACKGROUND
  Large lumbar or lumbosacral (LS) disc herniations usually expand from the paramedian space to the neuroforamen and compress both the transversing (lower) and the exiting (upper) nerve roots, thus leading to bi-radicular symptoms. Bi-radicular involvement is a statistically significant risk factor for poor outcome in patients presenting with far lateral or foraminal disc herniation after facet preserving microdecompression. There is evidence showing that patients suffering from large lumbar disc herniations treated with interbody fusion have significant superior results in comparison with those who received a simple discectomy. We report our experiences on managing large LS disc herniation with bi-radicular symptoms by transforaminal lumbar interbody fusion (TLIF) using one diagonal fusion cage with unilateral pedicle screw/rod fixation.
  
  
  METHODS
  Twenty-three patients who suffered from single level lumbar or LS disc herniation with bi-radicular symptoms treated with unilateral decompression and TLIF using one diagonal fusion cage with ipsilateral pedicle screw/rod fixation operated between January 2005 and December 2009, were included in this study. Operation time and blood loss were recorded. The pain and disability status were pre- and postoperatively evaluated by the visual analog score (VAS) and Oswestry Disability Index (ODI). Interbody bony fusion was detected by routine radiographs and computed tomography scan. Adjacent segment degeneration was detected by routine radiographs and magnetic resonance imaging examination. Overall outcomes were categorized according to modified Macnab classification.
  
  
  RESULTS
  The patients were followed up for an average of 44.7 months. Pain relief in the VAS and improvement of the ODI were significant after surgery and at final followup. No severe complications occurred during hospital stay. Interbody bony fusion was achieved in every case. No cage retropulsion was observed, while 3 cases experienced cage subsidence. Adjacent segment degeneration occurred at 3 discs cephalic to the fusion segment at followup. No patients underwent revised surgery. Overall outcome was excellent in 5 patients (21.7%), good in 13 (56.5%), fine in 4 (17.5%), and poor in 1 (4.3%).
  
  
  CONCLUSIONS
  TLIF using one cage with ipsilateral pedicle screw/rod fixation is an effective treatment option for massive lumbar or LS disc herniation with bi-radicular involvement.
authors.affiliation: Department of Orthopaedics, Shanghai Key Laboratory of Orthopaedic Implants, Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200011, P. R. China.
authors.forename: Chang-Qing
authors.initials: CQ
authors.lastname: Zhao
authors.affiliation: Department of Orthopaedics, Jiangyin People' Hospital, Jiangyin 214400, P. R. China.
authors.forename: Wei
authors.initials: W
authors.lastname: Ding
authors.affiliation: Department of Orthopaedics, Shanghai Key Laboratory of Orthopaedic Implants, Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200011, P. R. China.
authors.forename: Kai
authors.initials: K
authors.lastname: Zhang
authors.affiliation: Department of Orthopaedics, Shanghai Key Laboratory of Orthopaedic Implants, Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200011, P. R. China.
authors.forename: Jie
authors.initials: J
authors.lastname: Zhao
keywords: Bi-radicular involvement; Spinal column; arthrodesis; bone screws; disc; herniation; large disc herniation; lumbar disc; spine; transforaminal interbody fusion; unilateral pedicle screw fixation