Comparison of SpineJetrM XL and Conventional

o r l . e @ M LC o m m
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i:176
J Xo¡¿arNeu¡os.rg
Soc47:370
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P¡int IS,SN
2005-3Í1 on-llne ISSN1598?876
CopyriBntO 2010úc ror¡n NoNsu$cl
So.iery
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Comparison
of SpineJetrM
XLandConventional
Instrumentation
for DiskSpacePreparation
in Unilateral
Transforaminal
Lumbar
Interbody
Fusion
Fan.Yong
HLrh,
[4.0..]CheólJ,
M.D.,r
Kyeong-S
k Fyu ¡¡.¡).,'?Cfru¡-Kun
Park,
¡¡.0.':
Dtryntnt rl N¿worur|dr,IStPauhI lovital,l h¿CdtholnUr¡rdlfl DfKü¿a,Se.t , Kar¿a
D¿ptrEn¡dN¿uk üeañ: 5¿¡rlS¡.Ma4\ Eotpital,Th¿
C.rnto¡ic
Uhnanrr.l r!1?a,f/or|. K¡¿a
(TLIF)
Obiective:
Althor
treNforamlnal
lúmbar
nterbodyÍusion
s widey usedbecaus€
of itsbenefits.
it doeshav€some
r€chnical
slrunilateml
limilations
Rem0válof
disknraloria
andondplate
carlihge
ls difficult,
bule$enlial.
forproperfusion
in uniateclsurgery
eading
to debare
rsgarding
thssu¡lery's
lm€lions n reÍrolins
lhedisknal€rialon
th€conlralalera
side.Tlrereforc
authonhavsconducled
a ra¡domized.
comparative
cadave¡
studyinorderto
theeficisncy
evaluate
ofrhesLrrs€ry
wheñusing
conv€ntional
innruments
inire prepaErloñ
ofthedisk
space
andwhenuslng
lher6conlly
dovslop€d
higlr-pressu16
wa1€rjst
sysl€m,
SpineJetJúXl.
perfar¡od
Molhodsrfwo spnesurgeons
dlskedomies
anddiskp¡eparat
onslorTLll:in20lur¡bar
disks.
Allca¡¿ver/surgeonle\retattocar
ons
for praparalion
using
tlrsSpinsJstrXL(Hydrocslon
lnc.,Eoston[4A.LJSAIor
coñveñtionaltooh
wse r¿ndomized.
Ana$-"smenis
were
parfornred
byanindepeñdent
spine
srueonwhowasunau,?re
oflherandom
zatioñs.
Th€aulhoBmeasured
lhoareas
calcúlared
iho
kr¡1)and
propofton
of thediskprepaálon
andnumb€r
1%)olihedisk$lacos.Theduraton
of instrument
nserrions
andwirhdrawas
required
to
prccedurcs.
complet€
lhedkkpreparationwerc
r€co¡dedfarall
8ásuls: Tlreproponion
oflhe¿r€éof rcmovad
dsk tissuevorsus
thatof poleñtially
removable
dsk t ssue.rh€oroponon
of theareaof
removed
porrion
endplalo
cartilags,
andtlrsareaot renoved
dis<tissu€
intheconr€ateralposl€rior
showed
74.5117.2%,
18.5r 12.030/0,
and
6755* 16100,6,
respectiwly,
whentheSpineJetiM
! 11.84%.
XLwasused,and52.6r 16.5rA,22.8
r 19.63%,
and51.64
¡€spectivety.
whۖ
conv€nt
onaI inslru
mentations
wersusad.
Ti€r6sLrlts
ahoshowod
thatwhenlh€SpineJatrM
XLwass€d,lheprcpon¡on
oftlreareaol remov€d
d sktssueversus
lhalol potentlally
posrerl0r
ponionwer€
renrovabk
dhkthsuoandlh€ar€aofromoved
disktissuein lh€contmhtera
y h ghip < 0.001/r< 0.05,respoctivet).
statistcally
significan¡
Aho,compared
to conventioñaliñstrumenr¿tions,
rhedura¡onrequired
lo
prcpamllor
comp
eted skspace
wassho¡ter,
andthefrequ€ncy
ol nstument
usoandth€numbers
oflnsenicns/w
rhdrawals
werelowerwh€n
theSDineJetrtrr
XLwasus€d.
present
Conclusion:The
study
demomfates
lh¿thydrosu¡gery
using
theSpineJetrü
ponion
XLunitalowsforthepreparalio¡
ofa sreatei
oÍ
dis(space
andLhat
it islesstmumatic
andállows
fofmor€p€ciseendpateprep¿rction
w thortdarnaOe
to rhebonvondplate.
Fonhermorc,
rhe
MXLéppeárs
SpineJet
prepmronlorqráfrphconr pancularlywhen
to pfovdetanqlblo
berrerits
n rc¡nsofdiskspme
úsing
ti)eufilarsral
(EYW0nDS:Tra¡loranrinal
Lrmbarinlerbodyfoslon
Dls<ectomy.
INTBODUCTION
The mosr important goal of intcrbody {ision ugcr¡ in
rhe hmbrr spinc is to achicvc¡ sólid r¡d stablearthrcdesis
' Re.éived:
Nóv€mb€¡
27,2009. a€vied Apf 5,2010
'Accepléd:Moyl0,2010
. Addre$for ¡es ñ]s: Ch!ftkun Pd{ [1D
Depodmenlóf N€uro¡lrg€ry,
seo! sr Ma'y s Hospitai,
lhe Cclhoic
I-hlve6ry or Koea, 505Bonpodonq, Seochoou,Seou137¡¡0,Koréo
le +42-L225úh122,
ld +321&AüAo
Fmo| : ckpmd@calholcack
¡hltr can sus¡ah lo¡ds while m¡ineir¡ing adequ¡rcdisk
hcighf' To ensuresolid ud rablc tusion. it is essenrialto
rcmovc rhc nudeus pulposusdd ver€bnl €ndplarc cüritagcfron rhc .lisL spacewnhour dam€i¡g üc endpla¡e.
Tr:rnsfo¡aminallunb¿L lnrcrbody fusion (TLII) was
inr¡oduccd6)n¡ rhe ea¡ly I 980s and bfg¡c populü. Horvoer, until now, suryeonserp.ricnced techn;al difñcuftia
$ \ ú p o f o m i , 8 , , n i t Je n t T t r F r b , a 8ú n v e n , i o t u:tn " m rnentrr;o¡. Such technicalln¡i¡ario¡s includerl insunicienr
rnoval of rhc disk ]nd endplaG ca¡tilage,¡isk oli dsmase
370
ComparisonStúdyol splñeJéttuxt ¿ndco¡ve¡rional Inskumenratonlor DiskerlomyI HYHuh,et al.
to rmjor suround;ig r€scdr or neuJ,l snuctuft beaUle of
instmeneJon u.e.dd prolongcdi,rgiol dnc.
Rpea(ed
tuanür a nw high-prcüe mter j* qntem (QineJetr"
)o-, H¡doGsion, hc.. Bc¡on, MA, USA) w¡ i¡trcduced''r. The unir hasa slendo de,ign úd wer¿l úgled wo¡king chmnck, od n is reponodto be beneficialin te¡msofa
les tnm¿tic ud morc eficicnr disL prcpuation, panicüuly in the contralaterd portion ofthe disk sprc.
Therelbre,the ar¡tlor ha¡ conducteda randomtud, comp*ativc adaver stu<lyto *duate the eliiciency of tne sur
gerywhen uing convmtiorrl insmmcns in rhc prcpuuon
of dre disk spaceand when using the recently doreloped
high?ressue waterjet sysrcn.
MATERIALS
ANDMETHODS
Sludydesignandgroups
Thn.¡d¡ro rudyrsinsfourud¿'crs)
dc.igncd
fo¡rwo
fou hous beforecomencing rhis stud¡
Surgicaltechniques
spina wre
To sk¡dardire the mh¡at;on, the lmbt
expcd tuough a left+idedulae¡¡l paramedimapprcach.
Aier osteotomyofthe inferior rtiorlu proe oftle upper
votebml bod¡ the factt joint m eected. Alia inosrng
rhc postcrolatcnlfibrousannuiuswith a #1l-blede,d;k
nudru movzl ad odplarc qÍlase preparationfor fision
wefe performed using eithú convcn¡ion¡l irotruments or
rhe SpineJer¡M
)O unir. Afrer removinga much disk material o posible (m rhc urcnr dut the surgeon;Nolved
wc willing ro conplete a r:nilate¡alTLII), rhe ¡* mde
mized assignedd;sk lenl ws apprcachcd.All inraopenrive data,includingthc durarionof the entneproadurc
and rhc ¡unbcr of insenionsa¡d w'thdn*zls of ¡,"
",.
tuments reqürd ro omplerc disk preparation,wen recorded by a:r independentspinesurgon during thc prcccdures.
surgeorowould havccqual uposurc to 6oth thc spincJcl M
lnslfuments
XL and conr¡donal instrumenn. Eachugeon perbrmed
r proed:ue at L1lL2, nlL3, L3lL4, L4lL5, a¡d L5ISI
Convcntion¿linsumoa :The convcntionalsu€;cal ins
using both instrumcnts. Thc avef1gcagc wa! 60.3 * 12.5 truments usedw€regcnericse¡da¡l hmd inst¡umena for
yd^ ¡EDgc: 42--6\. Thc mcdi-,| hisroryof thc spccimcn. inrcrvcncbral disk spaceprcparation GÍaight ud cu¡ved
curcnc, Kcrison punchs ald shavm, and pituiury foreps
was drakcd ¡o e<cludethosewith ;nfecdon, sscre tquma
md poious surgcryin rhc lumbarspinc.
To rchieve the aboveexposureof thc two sugcons, üc
SpilcJcr'MI'L : Thc SpindcfM )O harnesa powcrwatcr
following mcüod was used.The venebnl lwels wre de- ¡nd venr¡ri suction effect to safclyard precisclycur and
sign sl s LrlL?, L2ll3, I3lL4, L4lL5, ancl L5lS1, a¡d
evacuarctissucrvithin thc dik spacc.The SpineleCMxi
qnten containsfour basiccomponcns : a dhpomblequick
the techniqua weredsigmted a convention¡l insr¡ume¡a
= C ud SpindciLM)r1- = SJ.The sutgconswercident;ficd as conncctor,
hmdpic (SpineJet
20' X$, 7i'
a disposablc
(lis.
a
foot
witd.
The quick
#l ad #2. A coin flip dererminedrhe technique tur t*ts
XI-S)
1), ¿ powercomole,and
(C
con¡cto¡ consistsofthe connectoritsel{ a pump enr;dgc
Ll /L2 for e¡ch irlstrumc¡t
or Sl). Subscqucntlmls in
rhe cwo edwers were subjectedto thc techniquesin altcrnadng *qucnc. Small slips of paper, muked with enher
The pump camridgeis moun¡edo¡ thc uscr i¡rerface
surgeon#l or su€co¡ #2, wc phccd in a box ud dmwn whió is lered on rhe lront of the po*er con.ole(*ris conro determinewhich surgeonwor:ld operateat eachlevel nection providespowcr ro thc dispouble hmdpiae). Thc
foor sirch ¡llom remoteactuation of üc powcr omole.
Grming at L1/L2, followed by l2ll.3, L3lL4, erc.). This
procctlure wm nrveLtedfor the third cad¿ver;that is, the The s¡rcm ir designedto work wirh my óspouble handsurgons operatedoo levelsnor operac
Table 1. Dlsldbulionof lech¡ q!es, $€eons levelsot ope¡alm, a¡d cadale6
ed on with rhe firt c¡davcr lor the Codovei Level N¡eihod sLreeon codovd
Level l¡eilod Sorgeon
sond od founh qdarcn the whole
c
l
L)lt2
c
t
l)tL2
proces was rcpcated by rcdnwing
aL3
s
J
2
t2lt3
sl
L3lLA
c
slipsofpaper. Gble 1 providesthe
L3/14
c
2
SJ
L4l15
s
J
t
l4lL5
dctailsof the cadaverAurgeon/level
L5/St
c
l
Ls/Sr c
s
J
2
up
SJ
2
Ltlt2
The surgeonsh¿d only been fanilc
2
aL3
c
2
t2lt3
ir prwiously widl rh. ure of conve¡2
L3/14
s
J
l
r3lu
5J
tional insruments. The surgeons
L4lL5
c
2
U
l
l
S
C
l
feniliarized ¡henselves with the
2
LsAt
SJ
2
Ls/Sl
SJ
SpineJetrM
XL techn;quefor about a .o¡renlroo inlrumeriolonSJ &nelefaXL
371
J Kor$n Neurosurg
Soc47 I May2010
pi€c€.Th€ powerconsolepr€ssuü€s
ir useFco¡t¡olsterilewate¡(pressur€
edÉomapp¡dxir¡¿tely
1,200to 15,000
poundsper quare inch) that is snp
plied Éon a standard3L irigant slp
ply bag.The prEssl.¡rized
w¿teris pufnndpGa and
mpedto thedisposable
then exitsüe distaltip of the handjet, which
piecex a high-velocit¡,
gap
crose-ra shon
and is collectcdin
an evacuationtube. Thsue direaed
into drcap is e<cirodanddnwn into
rhe e\a€uariontube alongwirh rh€ Flú1,T¡€!6rioutlyp€s
ófdwos8$€
h¿ndpl€co.
Inprs€rtstudy,
20'6¡d7v ¿ngl€d
8f¿jghd1áfr
waterja, Thc cncuationtubeh conn€ctedto e standard\rrJtecon|¿in€r,
Disposable
haadpiecedi.staltips may
be conñgurcdto incorpor*cdiFcrcnt
(Fig.2). The mo'r eficuttingfeatur€s
cientpreprntionof üe diskspac for
imcrbodyfusionusingthc SpincJcttu
proccss
)O followsa thrcc-step
r First,
the nudeuspr.:lposus
is evacuatod.
Second, the ¡nnulus is thinned;thi¡ i¡
[,1A,US4 unil A: Layor,t
ol hs
accompüshed
usingawindshiddüpcr Flg.2 ft6 ctmN€fionol Spnaldnx: (tlldro(rsbnlnc.,Boslon,
SplneJaln
XLcysl6¡¡rlh6 d+oello qrlckc!ín€dor,h6 d$osabl€handd#, h6 po.$rcolsol€,
motion to scnpethe heeland toc of aú $r€ibol$,ihh B: Dbgmm
oltl€ dislalhofth€dls{o$aH€
hon+isc€.
the hardpiecealongthe inna surñce
ofdre arurulus.
Thild, thccndplates
art scrapddean,completingúe diskpreta¡¡tion.The lnenl cuningsid* ofúe
handpiece
areusedto dcarrdrecanilagc
in ordcrro inoesc
thesurÉace
artafor int*body lunbar tusion(Fig.3).
lmaglng
Añer complctingrhc su€icalprocdures,eachdlsklewl
warpreparedfor imageanalysis.
Spine,w€r€dba.niculat€d,
disksrcre aially sectioned
at drelevelofthe endplates,
and
(Fig.4).
üe endplataweredigitallyphotog¡¿phed
diskecomyare* andendplate
Aau¿l¿ndaqilablesurf¿ce
prepantions
ofead diskwereperformod
usingS€ionI¡nAe
(S€ion
Analris software
Co., Frederick,
MD, USA),Nn+
on the endplare!
sectiongiió (3 x 3) wercsuperimposed
to enablethe asse*sment
ofthe diskspacesectors,
asdescribct byJawnick a al.'r.
A¡alysls
The etrective¡ess
of the diskectomies
ard odplare pre
pmrions uins convnrionaltoolsand the SpineJef")O
wre eqrlu¡tedi¡ tems of üe onpletoes of diskprcparuion andthepreparingdificuJryir accasingdlk porions
G.9., the conüláieral region).This authormmured rle
aIm (cm) a¡d c¡lculatedde proportio¡s(o/o)ofthe fol-
Flg.3.Í¡Éeslep p.oaess
usrrESphaJePXL
0f dlskspaceprepadion
(Hldrccbion
pllposus
Inc.,8oslon,
MA.USA).
AandB: F|slsbp,nud€us
renr l. CandD: Sécmdslep,annubrüin¡ing.
E-H: Tlirdslep,endphle
cartage
remo€Iardcomd€lion
0fdskprcpar¿tm.
372
Compár¡son Study of Spi¡le.Jetfl X! and Convonrional Insl¡uFental¡on lor Disk4l@y
lowing disk surfaces: 1) rhe overall
disk cros sectional rem; 2) the porcnrially removable dkk areas (ideal
prepmtion uo) (60010of :m of úe
ov€¡all disk cross{ectional üeú); 3)
dre proponion ofthe areaofremo'ed
disk tisue vcnus that of potentially
remorabledisk tissuc,including rhe
onualateral ponion; 4) the proponion
ofadplare canlagearearemor.ed;and
5) the proponion of endplatearea
damage.In addition, the duntion of
enti¡e disk prep¡Jation ánd the numbe¡ ofirsau¡nent insenionsand withdra*als requiredto complete rhe disk
prepantion wete also rccoded for all
dish procedures.
AII asesmentsand
nourcmcnts werc performed by an
jndependcnt spinc surgcon who wa.s
unaw¿reof the mdomiation dcraiis.
Bccauseúe samespeimen rm used
6r eachof the measuredralues,paircd
t-tcst wr used to idcntifr statistically
significant differences.2-values of
< 0.05 wcrc coDsideredstatisdcnlly
signific1nt.
psrlormdin lhosludy.A andB : Anafcomplefng
dlsk
Flg.4. Phoiographs
of d sk prcpafaüon
prcpaaton,
1¡€
al üo lovdol énddah€.
spln€sa|Bdisaniqrlalsd
andho dislcáÉ adaltsscljorsd
D:
inshrmsnh.
C : Endpl¡lepr€paalion
lsingconvsnlionsl
€ndplatos
arodigl¡llyphologiaphed.
Endpal€prepaÉton
usngSplnsj€l"XL.
frblé 2 AGásóisóildsue ándendpl8io
22.lnl,3.ó2
13,38
+ 2.17
Alldlsk
Endpole codllogoromovol Spn€!€IMXt
RESULfS
Areasof soltt¡ssueand
cartllaqe
removal
endplale
The ¡nea¡ ove¡alldisk cus scctiod i¡e1war22.30* 3.62cm',andúc
nrau crosssectionalareaof potentiallyrcmovablc
dislcm 13.38t 2.17
cnl. The megncrosssectionalucx of
I l lY Huh, et al
t@
$8 r 3.32 7 4 5 i 1 7 2 p < 0 , m 1
*2.23
7.47
2,t81t.43 l&5112.03 p= 0.372
3 1 8 1 2 ' A 2 2 8 +\ 7 . U
poñion
olh€ di6kspac€
Tabl€3,Rsu[6 ol d 6krgmoval
inlhécontmlale€l
M€lhod
CalcLrlotedproporfon(%)
Pvolue
Endplqlocodiogérómovol
dr disk tisss ¡emovedusing rhe SpineJer'" XL ¡¡d on-.4¡
v c n r i o n ¿, ln ' r r u m e n ou c r c q . 3 8 ¡ J . l 2 ú r ¡ d
2.23 cm¡, lespectively.The mo¡ cros+rcrion¡l area of
cndplatc onilags Lomd using the SpineJel" lt md
insÍumentswcre2.18 + 1.43ct# dd 3.18j
conventional
2.43 o', cpectiveiy
Arot3'l of 74.5 r. 17.2o/opotstially remmble disk usue
wc movod using the SpheJet >d- aÁ 52.6 x 16.9%
was renovcd using conventional insÍuments (1 < 0.001).
Vith regud to edplate onilxge juoval, 18.5 t 12.0370
m rcmovcd using rie Spin+JM )O- and 22.8 t 17.8470
wasremovcduing convenrionalrools Q = 0.37) (Table2).
tuga¡ding rhe Émol€l of tissue in üe contral eral p6ofporen¡ialy r€molable
Érior portion, 67.55 j 16.10010
Conv€¡lonol
Spln€JetM
Xt
coñv€nTlonol
! ró.r0
ó7.55
p<0.05
23¡ i 9.95
2 t . 4 tt ó 5 0
P=0ó5
XL, whcre*
disk rissucws rernovedusingdr SpineJeir¡1
51.64+ lt.6J0ó6 nroKd uing conlcnüonJin\rrucanihge
was
ment¡(1< 0.05);23.4t 9.957o
ofcndplate
wu
XI- md 21.4+ 16.50%
moved usingrheS/neJet'N
removed
usingonvotional insrtmarts(2= 0.65)(Iablc3l
Area of lhe endpláledamage
The meancrossscction¡lalo ofmdplatedanagcmre
0 40 t 0 69 cm'?md 1 l l t 1.36cn'for üe SpineJet*)ainstrunc¡G,Bpectively.\üith reg¿rdro
andconventional
endplaredmage, m€andañageM signiliently lesslbr
M){- rhu tbr conventionál
instrumoc (3.2 r
üe SpineJel
I
¡esF{rivü
|
<
vs.8.0 10.12%,
5.18o/o
r' 0.05)(Tabba).
in thecontnlateral
In termsof damge to the endplates
J KorcanNeurosurg
Soc47I [4ay2010
pore¡iof ponion, 1.6012.050/0of porenliauyremove¡le
disk tisue w¿s removedusing úe Spin€J€fM)O- ard 5.95
I 9.93% ws removedurinC coNrntional in$runlent5 (1<
0.05)(?ble 4).
ciendyto carrytheload,andtheresron¡ionof lunbu lordosis"'r'o. Of these,d;slcctomyand disk spaceprcp.*
tion re rtie6nt stcpstwad achioingsuestul inrerbody
a¡tb¡odes;s.
Lumba¡i¡terbodytuion surger/is usualyperformedusinga posteriorapprcachmd a wicty offision
Numberol inshumentinserlionsandwithdrawals tcchniqus (c.g.,oday interlm;nú Édon, intenransr€rse
The ¡umbe¡ ofnanual inserrions/withdrawelsw¡
prces tusion,6r lateraltusion,poseriorlumba interbody
significandy
lss for üe spineje¡'M
xr- (20.44 r5.4 vs. tusion)'¡'.Howwe¡ dree tedniquo havcdiffcrcnrsuces
69.7+ 36.7. ?- 0.002)(hbte 5).
Sina theintroductlon
andpropagdonofthe TUF appc
pfeparalion
Durat¡onsof ent¡redlsk
achx ¿n ¡[ern¡ti'ero thePLIr od ALII re.hniquoin
Disk preparationtook tendedto be fasterfor the Spinc- rheedly 1980sby Hrms andRolingep9¡ldBlumer),the
yll (12ninures,
i 12minur€s,39
seconds procedute
hasgrownin populriry beeuseit hm mmy
58seconds
Je¡iM
vs.14 mi¡utes,41 rco¡ds + 9 ninurs, 43 sconds:1 =
0.739)(Table6).
Aúough wious lumbu interbodytusionmethodshave
beenint¡oducctl,
a srand¡¡d
on howmuchdiskmd odplrte
D¡ference
between
surgeons
en;lage shouldbe removedrc ensure0rm tus¡onhasnor
No signifiont difFeren@
wereobservclbewen the¡¡o
yet bcencstablished,
paniculrly in unilatetalTLIF. Cloin termsof theproportionof soft tissueandend- wrd, introdued thePLII proceduein 194i. The/ claiñsurgeons
platecanilageremorecl,cndplaredamage,and numl,cr of ed ü¿t almostthe entired¡k shouldbe rcmoved
in thc
inst¡¡mcnt i¡rsctionsmd withd¡aw¿ls.Howqer, ¡ signi adjacent
disksurfaces
to becompleelyfreeÉomsuroundfior diflirqe in ¡hcms n rimcforcnIircdiskprep¿radon ing softt¡süe,emphasizing
rharasmuchofihe dhk as
(10minutes,
forconventional
insruments
warobserved
49 possibleshouldbe remoredard that tbe approachshould
sco¡dr i 5 ninufts, 58 scconls s. 17 mjnure!,50 scconds beasdoscasposibleto theantcriorlongirudináligamenc
* 12minutcs,56
seconds:2<
0.05).
ln spilc of üis d¡im, somcrcportsindicarethar in actual
pr¡.ticc,only8G90%of rhepcteriordiskspace
is removed
duringtotaldiskcctomy").
DtscusstoN
Convenrionai
TLIF har beenshownro reduceconpl;caThe bionechanical
md biological
sueesesof lumbar tions;ciinic¡l studia üü follow-upsbe|wÉn 12 ¿nd 64
intcóody tusionsurgcrydcpendon vaious ácton suchas nonrh have6und rhattusionrata for TUF a¡esimilu to
rhc
ropreprerfe di.l, T'.e \ilily. ,hecellulrcnvi- thoseepectedfor otherinterbodytuion rahnique+hat
"bil,y
rr'?0'j.
ronncnt in üe diskspace,thestructuralinterbodysuppon ¡, mo,r lh¡n 90ol05rr:
Howoc¡ rhcmjor crilicismof
atrordedñ¡ loadnansmisionuntil the bons marue sulü- urilarcralTLIF proccdurcsis that unilateraldiskectomy
Tabls4 Ar€as
oldmaged€ndp
al6
colculoiedproporlion('¿) pvols
3.2r 5.t8
8 0 ! t 0t 2
p< 0.05
Table5. Frequencies
ol nslruñentinseñions^rilhdrawáls
N,lonual
inseriion
ol rslrument
/ \Mhdrowols
24,4!t5A
p <0.0s
Tablod fmes rcolt€d lbr e¡fte d sk oreoaaÍon
Ihe duol onord I p€porolio.
t 12.fnLtrtes39
12mn!tés,58
seconcls
seconch
i 9 mnuies43ieco¡ds
14rn¡!tes, 4l seconds
374
p=0.739
reduco the probabiliry of tusion be
causeof úe linirado¡s imposedby
using convendonaltools and becaure
n is more di6cuh ro roovc suÍficimr
disk matenJ during diskectomy md
endplate preparation than during
PUf; cpecially fron the conralareral
posteriorside using a unilareralappmach.Sulovich et al.'" reponed that
most eidual d;k mae¡ial ¡ro loetcd i¡ rhc co¡iráleier¿l posreriorquadrant ofrhe disk space.lavemick er al."
alo recomoded a büteral rpproachfor someimplantsin oder o avoid
posibie ontralateral neurá comprodse due rc reropulsed disl narerial
aÍid gflli d inplmr i¡senion. Addi-
r HYHuh,etal.
lor Diskeclomy
xL andconvenrional
Inslrunrenlallon
comp8lsonslüdyof splneJerrM
rionall¡ when conventional instruments were used, the
lat€ral and anterolatenl disk spaceon the ipsilatenl side
also rendcd to contain rai<lual <liskmaterial. On rhe other
hmd, overagpssiveendpleiecrnilage rmoval o uulr in
perfomrion and *caution of the bony endplate, ma me
ontr¿latcral mte¡ior onulus is most ar risk ofbeing per
forated byconventional instnmens.
Recent reporu hare suggsted that the majoriry of sur
gcons probably over*tirna¡e the thoroughnessof diskecromyud cndplrtcprcpmüonperformedusng.onwnrional ;nstrummurionLa).Javernicket ¡1.') rendy orcluded
dut disk rcrnorzl through a unilat€nl TUF approach removed 69% of the available80o/osuráce ¿ru, which ¡m
only 56% of rhc disk. Sukovich er al.''r reponed that the
ovcrall endplate surfaceareapercentageeposed using ihe
TLIF approachms 60% Gmge : 48.8-72.6010)
of the toúl
availableend plate surfacearea. Sim;la¡ ¡esuhshave ¡lso
thar the endplareswere damagednore by conventional
insrrunmn than by the Spinelei'" XL.
Additionally, the number of insenio¡s/withdsr¿ls rcre
signilicudy les for the Spinc.ld'MXl (20.4 t 15.4vs.
69.7 t 36.7 : P = 0.002), wl\ich indiots that rhe ue of rhe
SpineJetrMXl- during unilaeral TUI redúcs rhe risk of
dmagins ¡eural sttuctus.
Reg ding the ünr quircd to complctcdlk 'paa prepmtion, rhc Spinqj€i'" XL enabledus to perforn rhc trk
ñster tban when using convcnrionalinstruñen$. Furihünore, re found no sig 6ot diFcrenca betweenthe two
surgeonsin tcrm of the *tent of soli tissueemorzl, endplatccanilageremoval,ratesofmdplatc danage,and numbersofin.enions¡d wiüdn"ul'. thoughtherew. inusurgeondifhrcncc in the duration of üe entie disk prcpainsrdmcnts.
ndon usingconventionel
CONCLUSION
Funhermore,the conventionalinstruncnts currcndy uscd
dudns TLIF requnemultiple p*ses into md out of rhc
dkk spacc,wh;ch placesrascula¡ and ¡eur¿l a¡ucturs at
¡isk md qtcndi opc¡¿tiontimc!. C-onvcn¡ionrlinstrume¡ts
aho requüe a significanra¡nounr of mcchanicalforcc,
which placcsthe endplateatisk of damage,panicularly in
thc ostcoporcticcldc y
In the prcsent study, authors used a ncw high-presurc
wrtcr jcr systcn (SpincJei'"xr) to preparedisk spaces
during unlarnl TLlt. and comparcdrl'c re<ulnqrrrritatively ard qualitatircly with thoseobmined using convenrional irstomen¡r. \7e pr€sumedthat the arcaof pototially
renorzblc dhk-üe ideal prepamrion ae-wa 600loof the
h our stu{r conventional instruñents allowcd for thc
rcmo\"lofa m@ 52.6t 16.9%of the dkk from auilable
disk are¡-s.Howos, in nuked contrmt, dre SpineJeirM)1,
pernined removal of a nean 74.5 + I7.2o/o of ¡\e dsll:
l-unhermorc.rmord of,he di* on ,onrmJareml
ponion
w¡ achiwerl no¡e effecrivelyusing the SpineJet'" XL
(67.55I 16.100/0),
ar compa¡edwith the 319opr*iously
reponedbyJavernickcr J.' using thc TLIF apprcach.
The mount ofthe endplateca.¡ihge renoved rlsing the
SpineJelMxL rm insigni6ondy smalle thm rhat remor
ed using conventionálinsÍuments (18.t t 12.03%vs.
22.8 r 17.84o/a: ? = 0.37). On the other hand, the amou¡t
of endplate damge m signifimdy lower for the Spine
vs. 8.0 + 10.12%: p < 0.0t). we
JerrM)(, (3.2 r 5.18o/o
att¡ibote the rcmor¿l of smalleLmounts of endphre <*
tihse when using óe Spinelei'" Xl to r lack of skill or
operience ar odplate prepuation md incomplee remoral
of enilage ñom the endplates.Nevertheles, we did fi¡d
In conclusion,the presentstudy demommrc thar hydrcsrrgcry uing drc SpineJei'MXL has thc following adwuges r it allow rhe prepatationof a lafgcr portion of ihe
disk .prcc. ir is lar rmumri.. and n cndblc!morcpr€ise
mdplar prcpantion without damagingthe bony endplare.
In addition,rhc Sp;ne.lef"XL isaleñde¡un;t thatprovid- vuiors rnglc, uh longwo't;ng ch.rnnchrd. drus,i'
los intrusivethan convcntion¿lrooh. Iunhe¡morc, thc
XL appeamto providc tangiblcbcncfitsin terms
SpincJciLM
of disk spacepreparationfor graft placemenr,panicularly
whcn a unilateral TLIF appro¿chh used.Future 6(mh
should be ained at dcrsmining rhe effectof improveddisk
prepantion on tuion and on di¡ic¿l cults.
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