Introduction: Bilateral facetectomy during transforaminal lumbar interbody fusion (TLIF) is a surgical technique utilized with the intent of creating a greater degree of segmental lordosis compared to unilateral facetectomy. However, the sagittal balance and clinical benefits of both techniques have not been well compared in the literature. We seek to determine whether a clinical and radiographic difference exists between bilateral versus unilateral facetectomy during TLIF.
Methods: The electronic medical records of 107 patients who underwent single-level TLIF with either a unilateral (UF, n=63) or bilateral facetectomy (BF, n=44) were retrospectively reviewed. Patient demographic information and perioperative outcomes were collected. Clinical outcomes were measured through Patient Health Questionnaire-9 (PHQ-9), Pain Disability Questionnaire (PDQ), EuroQol 5 Dimensions (EQ-5D) Health State, and Quality Adjusted Life Year (QALY). Radiographic parameters including disc height and sagittal balance were measured on plain radiographs.
Results: All radiographic parameters showed no significant differences between the UF and BF cohorts at 1 year. While segmental lordosis increased significantly in both cohorts, there was no significant difference in the increase of segmental lordosis between the two cohorts at 1 year. Furthermore, lumbar lordosis did not increase significantly in either cohort. Perioperative complications were also similar between cohorts. EQ-5D, PDQ, and PHQ-9 scores significantly improved in both cohorts 1 year postoperatively. The PDQ score improved over the minimally clinical important difference (MCID) of 26 in only the BF cohort. A larger increase in PDQ scores following fusion in the BF cohort compared to UF cohort neared significance (-24.2± 28.9 vs. -33.4±29.8, respectively; p =0.07). There were no significant differences in other QOL measures between cohorts 1 year following operation.
Conclusions: The findings in the present study demonstrate that bilateral facetectomy during single-level TLIF may improve clinical outcomes to a greater degree compared to unilateral facetectomy without any significant differences in perioperative complications nor radiographic measurements.
Patient Care: Many spine surgeons utilize bilateral facetectomy over the traditional unilateral facetectomy (UF) during transforaminal lumbar interbody fusion (TLIF) due to its perceived sagittal balance benefits. To date, no studies have compared the implementation of BF during TLIF compared with traditional UF. Given the lack of evidence regarding the utility between these two techniques, we seek to better compare the benefits of each procedure.
The findings in the present study suggest that bilateral facetectomy can lead to greater clinical outcomes over unilateral facetectomy without any significant differences in radiographic or perioperative outcomes. As such, spine surgeons should consider this technique while performing a TLIF procedure, as it can lead to greater postoperative outcomes over unilateral facetectomy. The results of this study can spur longer follow-up studies with larger sample sizes, which could enable the spine surgery community to better understand the benefits of bilateral facetectomy over the traditional unilateral facetectomy during TLIF.
Learning Objectives: By the conclusion of this session, participants should be able to:
1) Describe the perceived sagittal balance benefits of performing a bilateral facetectomy during TLIF.
2) Discuss, in small groups, how bilateral facetectomy may lead to greater clinical outcomes compared to unilateral facetectomy during TLIF.
3) Recognize the differences in clinical, radiographic, and surgical outcomes when comparing unilateral facetectomy versus bilateral facetectomy during TLIF.