Transpedicular fixation It is one of the most frequently performed operations in surgery, and in vertebrology it is the most common intervention. It is performed both for emergency, life-saving indications and routinely for chronic and non-life-threatening spinal pathologies.
TFT of the spine is a complex surgery that requires careful planning and high professionalism of the surgeon.
What is transpedicular spinal fixation?
The essence of the surgical intervention is to install special structures (screws or interbody cages) in the intervertebral space or in the bone, through the pedicle into the vertebral body, with their subsequent connection to each other using longitudinal beams, which significantly limits the mobility of the vertebrae and intervertebral joints and creates favorable conditions for regenerative processes and subsequent healing.
In the early stages of the development of vertebral surgery, durable stainless steel was used as a material for screws and beams.
In the process of further development of diagnostic technologies and the emergence of magnetic resonance methods , in which the use of steel becomes impossible, all transpedicular systems began to be made of titanium.
Titanium itself is a durable metal that does not heat up under the influence of magnetic waves from an MRI machine. The weak point titanium structures is their fragility and extreme instability under shock loads. The optimal solution is to use titanium alloys in various combinations.
Ceramic and plastic implants, which are much more durable and less traumatic for the body, are becoming increasingly relevant.
Based on the mobility of the vertebrae and facet joints, transpedicular immobilization is divided into
- Dynamic, using metal, non-metal and hybrid fixation systems, allowing to maintain mobility in the joints in a physiological amplitude. This method is used in the treatment of unstable lumbar intervertebral hernias with pain syndrome and degenerative spondylolisthesis in the initial stages.
- Rigid, in which the vertebra is fixed completely motionless. It is used mainly for injuries, oncological lesions of the spinal column, and progressive stenosis of the intervertebral canal. For this type of immobilization, intervertebral cages and body replacement titanium implants are used. The operation is performed primarily on the cervical and thoracic spine.
Based on the level of operational access, we can distinguish
- Open access techniques, “free hand techniques”. They are highly invasive and traumatic for surrounding muscles and tissues. The surgeon operates focusing on open anatomical access points. In this case, surgical defects and complications are almost completely eliminated; the intervention itself requires less time, up to 2-3 hours.
- Percutaneous methods. Minimally invasive operations, when access and installation of screws is carried out through small incisions or holes, passes through the muscles, without excision, under fluoroscopic, electromyographic control or using computer navigation.
Depending on the volume of fixed segments of the spinal column, operations can be
- Single-level - with immobilization of one vertebra
- Multi-level - with fastening of areas that include several intervertebral joints.
Spinal fusion of the lumbar spine
When performing surgical interventions on the lumbar region, surgeons try to choose a posterior approach. As we have already said, it is less traumatic and much less likely to lead to complications. The anterior approach is used only in the treatment of comminuted fractures. In rare cases, it is used in difficult clinical situations.
In people over 55 years of age, vertebral compression fractures quite often occur due to osteoporosis. According to statistics, among US residents they occur more often than hip fractures.
Table 1. Types of lumbar spinal fusion.
| Peculiarities | Advantages and disadvantages | |
| Anterior interbody, ALIF | During the operation, the surgeon gains convenient access to the vertebral bodies and IVD. It freely removes the disk and performs decompression. He then installs a cage that promotes rapid fusion of the vertebral bodies. If necessary, the specialist uses additional fixing structures. | The method avoids dislocation of nerve bundles, which is associated with a high risk of damage. However, with ALIF, the doctor is forced to displace blood vessels, which can lead to bleeding. |
| Posterior interbody, PLIF | The doctor performs a bilateral interlaminectomy and a radical discectomy. He then implants cages on either side of the vertebra. In some cases, surgeons use expandable implants. Because they have a smaller diameter, a medial bilateral facetectomy and removal of the nucleus pulposus are sufficient for their placement. After insertion, the cages are unscrewed to the required size using a special key. | PLIF makes it possible to perform circumferential fusion in one surgical procedure. To gain access to the interbody space, the doctor is forced to push back the nerve roots. During traction, he risks damaging them. Subsequently, this can lead to paresis, paralysis, dysfunction of the pelvic organs, etc. |
| Transforaminal interbody, TLIF | The most modern and low-traumatic method, which has many advantages. During the operation, the surgeon performs a discectomy and spinal fusion on one side – the maximum stenosis. | TLIF avoids destruction of the posterior supporting structures of the spine. The method makes it possible to perform surgical intervention even against the background of a pronounced scar process. |
To more firmly immobilize the PDS, many surgeons perform interbody fusion along with transpedicular fixation. The essence of the latter lies in the use of special structures that additionally fasten the vertebral bodies.
Indications for surgery
TFT of the spine is one of the most common operations in vertebral surgery, having a wide range of indications.
- Injuries with damage to the vertebral bodies. Installation of a titanium implant significantly accelerates the process of bone tissue regeneration and restoration of function.
- Scoliosis, kyphosis and other conditions characterized by curvature of the spinal column - screws in the spine are installed and fixed to each other at angles that ensure gradual elimination of the defect.
- Spondylolisthesis (vertebral displacement) is a pathology caused by displacement or deformation of intervertebral discs. The intervertebral disc or the vertebra itself is replaced with a titanium implant, followed by immobilization.
- Stenosis (narrowing of the lumen) of the spinal canal. During the decompression phase of the operation, stenotic factors (intervertebral hernias, tumors, degenerative-dystrophic changes in the vertebrae) are removed. After this, at the stabilization stage, the operated segment is fixed using screws and a transpedicular system.
- Chronic, resistant to conservative therapy, pain syndrome due to osteochondrosis.
How is the operation performed?
The TPP operation is a rather complex surgical procedure that is carried out in several stages: planning and preparation, installation of the system, rehabilitation. Each stage should be carried out taking into account the clinical course of the disease and the characteristics of the patient’s body.
Planning (preparation)
At the preliminary stage, the operation is planned - the types and length of screws are selected, and the optimal design option is determined.
Contraindications to transpedicular fixation
The set of contraindications is standard and depends on the general condition and concomitant diseases of the patient.
Relative contraindications
- Diseases that can be treated without surgery.
- Severe osteoporosis. Pathological processes that result in softening of bone tissue call into question the reliable fixation of the transpedicular implant and the implantation of screws into the vertebral body. The prognosis for normal restoration of function in the postoperative period is questionable.
- Obesity. Increased body weight increases the static vertical load on the spinal column and contributes to relapse of the disease or poor survival of the endoprosthesis.
- Pregnancy at any stage.
- Diabetes mellitus and other severe systemic pathologies.
Absolute contraindications
- Infectious processes. For generalized infections, any surgical interventions are contraindicated, since the patient simply will not survive the operation. If the infection is local, and the process involves areas located in close proximity to the site of the planned surgical access, it is necessary to first completely cure such pathology and only then decide on performing TPF .
- Individual intolerance to foreign components, in particular titanium and its compounds.
Preparation and initial stage of surgery for transpedicular fixation of the spine
Depending on the volume of fixation, the method of visualization, the volume of surgical access, there are many methods and sub-methods for performing transpedicular fixation . But all of them are united by common principles and stages of intervention.
- At the preparation stage, the attending physician collects a detailed medical history, conducts the necessary tests and studies to exclude the presence of contraindications. Based on the results of computed tomography and magnetic resonance imaging, transpedicular systems of optimal shape and size are selected. Hospitalization in a hospital is necessary no later than one day before the operation; during these days, additional tests are taken, and general monitoring of the patient’s condition is carried out. The patient undergoes bowel cleansing and does not eat food for 12 hours before the operation.
- In the vast majority of cases, surgical manipulation is performed through the “posterior approach”, so the patient is placed in the “lying on his stomach” position. To ensure the most physiological position of the body, as well as to give the veins of the spinal column such an arrangement that avoids large blood loss, bolsters or special supports are placed under the chest and abdomen in appropriate positions.
- Surgery is performed only under general anesthesia.
Cervical spinal fusion
For severe degenerative-dystrophic diseases of the cervical spine, doctors prefer to perform posterior cervicospondylodesis. During surgery, they can immobilize one, two, or several PDS at once. The most modern and reliable method is considered to be transpedicular fixation of the vertebrae. Unfortunately, in some cases it is associated with a high risk of iatrogenic damage to nerves and blood vessels.
In view of this, many experts give preference to metal structures that fix the rear support complex of the PDS. With their help, surgeons connect the processes of the cervical vertebrae with each other. Let us note that today there is no consensus among doctors about the advantages of one or another method of posterior cervical fusion.
For severe injuries of the cervical spine, surgeons prefer spinal fusion through an anterolateral approach. The fixation method is chosen individually, after a comprehensive examination of the patient. As practice has shown, for vertebral fractures, the combination of interbody cervical fusion and anterior fixation plate is most effective. Such fixation is more reliable and ensures early mobilization of the patient.
Installation of titanium implants
- Skin incisions are made at pre-marked points above the spinous processes of the vertebrae, usually 2-3 centimeters outward from the roots of the vertebral arches. Through these incisions, access to the legs is made: the muscles and tendons are moved apart (or excised, depending on the chosen volume of access), and recesses are marked on the surfaces of the legs through which the channels for the screws .
- The canals in the vertebrae are deepened to accommodate screws up to a maximum of 80% of their length.
- are inserted and secured .
- The screws in the spine are fixed to each other by longitudinal and transverse rods.
- The wound is inspected and sutured.
Spinal fusion method in spine surgery - yesterday and today
In spine surgeries, the method of spinal fusion has been used for quite a long time since the 50s of the last century. With the development of medicine, and in particular spinal surgery, methods and techniques of spinal fusion are being improved. For example, previously a patient after spinal surgery had to be in a plaster corset for 4 months to a year to achieve fusion of the vertebrae.
Currently, internal vertebral fixation devices are used, which can significantly reduce the process of fusion and rehabilitation of the patient. Many proprietary methods for performing spinal fusion have been developed, including minimally invasive ones, and the latest developments in spinal systems, vertebral fixators and other materials for performing operations for injuries and diseases of the spine are appearing.
Interbody cage for fixation of vertebrae
The cage is a hollow structure matched to the diameter of the vertebral body. It is installed in place of the removed intervertebral disc and rigidly fixes the space between the vertebral bodies. This type of fixation is used for spinal fractures or degenerative-destructive processes leading to complete or partial destruction of intervertebral discs.
The implant itself is made of titanium alloy or ceramic; after installation, its cavity is filled with special cement, similar in structure to bone tissue.
During the rehabilitation period, the intervertebral cage and the surrounding bone tissue grow into each other, ensuring, over time, complete restoration of the function of the damaged spinal segment.
Types of spinal fusion
Operations can be performed through an anterior or posterior approach. In the first case, the surgeon “makes his way” to the spine through the abdominal cavity or the tissue spaces of the neck, in the second, through the soft tissues from the back. In this case, the doctor first cuts the skin and dissects the fascia, then moves the deep back muscles to the side.
- The anterior approach is rarely used today due to enormous technical difficulties, large blood loss and high surgical risk. It is used only for comminuted vertebral fractures, scoliosis and some degenerative diseases.
- The posterior approach is being used increasingly due to its low invasiveness, low likelihood of complications and rapid rehabilitation. It became especially popular after the advent of titanium cages with bone chips. Doctors use them to replace damaged discs and reliably connect the vertebrae. Note that previously bone or artificial implants were used for this purpose.
As for fixation methods, they are anterior and posterior. In the first case, the surgeon works with the vertebral bodies, in the second - with their spinous and transverse processes. Numerous studies have shown higher effectiveness of interbody fusion. The vertebral bodies are better supplied with blood, have more cellular elements and have good osteogenic potential. Consequently, the grafts installed between them take root much better than those that connect the processes.
Curious! Statistics show that the rate of successful fusion with interbody fusion is 96%. When fixing the vertebral processes, it is much lower.
Rehabilitation after transpedicular fixation
- Prevention of postoperative complications in the form of bleeding, infection, implant rejection.
- Correcting poses, posture, giving the body the correct physiological position, restoring the tone and endurance of the muscular system.
- Complete restoration of the function of the operated spine.
- The result is the maximum possible restoration of quality of life.
Immediately after the surgical intervention, for 7-10 days, the patient is in a hospital setting. He is prescribed therapy aimed at speedy discharge and prevention of complications.
- Supportive - vitamins, mineral complexes, anticoagulants.
- Symptomatic - anti-inflammatory, painkillers.
- Antibacterial - broad-spectrum antibiotics.
- Physiotherapy - electrical and neurostimulation, iontophoresis, magnetic and thermotherapy, massage, hydrotherapy, hyperbaric oxygenation.
- Research is being carried out to determine the body's response to stress and to take timely measures to stop unwanted reactions. Consultations are held periodically with the obligatory participation of the operating surgeons; X-ray control of the operated area is carried out 3, 6 and 12 months after the operation.
- Physical therapy is prescribed already in the first days after surgery. Passive and active movements in the joints and isometric exercises are prescribed.
The orthopedist and rehabilitation specialist individually select a set of exercises that normalizes blood circulation, restores the ability to exercise, and stimulates the flexibility and elasticity of the spinal column. The patient must understand that physical therapy is now an integral and obligatory part of his life.
In order to unload the segment of the spine weakened by the operation, all patients are prescribed to wear orthopedic fixation corsets. The shape of the corset is selected individually, the corset is used 4-6 hours daily. Depending on the speed of recovery processes, the corset is used continuously from six months to one and a half years.
In general, the entire process of rehabilitation and return to the preoperative level of physical activity takes about six months.
Rehabilitation and possible consequences
After surgery, the patient is recommended to spend at least 7 days in the hospital under the supervision of doctors. You can move a few days after installing the fixation system. For approximately 1-2 months, wearing a special corset will be relevant.
In the clinical hospital named after. A.K. Eramishantsev will describe to you in detail an effective recovery plan, which includes:
- professional gentle massage;
- physiotherapy procedures;
- breathing exercises;
- physical therapy to strengthen muscles;
- mechanotherapy using simulators.
During the rehabilitation period, proper nutrition is important. The daily diet should include vegetables and fruits, fermented milk products, fish, and lean meat. You should stop drinking alcohol and smoking.
Complications during TFT surgery are observed only in 10% of cases. 90% of patients return to their normal lifestyle a few months after surgery. At the same time, it is important to ensure that the load on the spine is gentle.
Advantages of TPF
Transpedicular fixation of the spine is a universal method for the treatment of a variety of both chronic and acute pathologies of the spine.
The technique has been used since the mid-1960s of the 20th century; vast experience has been gained and studied in carrying out the surgical intervention itself and in managing the patient in the postoperative period.
With a correctly selected titanium implant, a carefully planned and performed operation, and compliance with all rehabilitation recommendations, the patient completely restores his physical and social activity, and there is no need for a repeat operation throughout his life.
Patient reviews
Transpedicular fixation of the spine is a serious intervention for which many patients are not psychologically prepared. Not only general information, but also reviews and comments from people who have already undergone this type of operation will help you understand how everything happens.
Pavel L., 56 years old “Transpedicular fixation was required after a strong fall. I was afraid of the operation like hell, but thank God I found a surgeon with golden hands. Everything went well, although the lumbar region is usually the worst affected area. Without treatment, there was a risk of disability, the condition worsened almost every day, but everything worked out. Now I am undergoing rehabilitation, exercise therapy is constantly being adjusted, as motor activity is gradually restored. Therefore, I can say, you shouldn’t be afraid of surgery, you should be afraid of being immobilized, and the main thing is to get to a good doctor.”
Dmitry M., 43 years old “I didn’t understand how I survived with an intervertebral hernia like this, but surgery was required. I decided to use the services of a private clinic and found a good surgeon. He advised me to have transpedicular fixation. It took several months to collect money, during which time the condition deteriorated greatly. As a result, I fell into the hands of a good doctor, he performed the operation and prescribed recommendations for the recovery period. Today I already feel great, I regret that I spent a lot of time on doubts and did not immediately agree to trust the surgeon. Of course, it will still take a long time to recover, but it’s better than remaining disabled.”
Tatyana T., 48 years old “I received a spinal injury at work, and for a long time I hoped that everything would work out. But conventional conservative treatment did not produce any results. As a result, the pain became more and more severe, serious complications developed, and disability was threatened. The surgeon recommended transpedicular fixation to stabilize the spine, as some of the vertebrae had already begun to shift. It took me a long time to decide on it, but my condition only worsened. After the operation, no complications arose, but a long rehabilitation process was required. I’m going through it in a rehabilitation center, under the supervision of specialists.”
Transpedicular fixation of the spine is a type of surgical intervention. It is used by modern surgeons in the treatment of dystrophic diseases and spinal injuries. The main indications for its use are spinal canal stenosis, instability, trauma and the development of tumors. It is carried out in a hospital setting, after which rehabilitation will be required for the patient’s full recovery.