Purpose of the study: The aim of this prospective study was to evaluate clinical and radiographic results in the patients who underwent L5-S1 fixation using the technique of percutaneous lumbar interbody fusion (AxiaLIF).
Material: The study comprised 23 patients, 11 women and 12 men, who ranged from age of 21 to 63 years, with an average of 48.2 years. In all patients surgical posterior stabilisation involving the L5-S1 segment had previously been done. The initial indications for surgery were L5-S1 spondylolisthesis in 20 and L5-S1 spondylosis and stenosis in three patients.
Methods: The AxiaLIF technique for L5-S1 fixation was indicated in overweight patients and in those after repeated abdominal or retroperitoneal surgery. A suitable position and shape of the sacrum or lumbosacral junction was another criterion. The patients were evaluated between 26 and 56 months (average, 40.4 months) after primary surgery and, on the basis of CT and radiographic findings, bone union and lumbosacral junction stability were assessed. The clinical outcome was investigated using the ODI and VAS systems and the results were statistically analysed by the Wilcoxon test for paired samples with statistical significance set at a level of 0.05.
Results: The average VAS value was 6.6 before surgery and, after surgery, 5.2 at three months, 4.2 at six months, 3.1 at one year, 2.9 at two years and 2.1 at three years (n=18). At two post-operative years, improvement in the VAS value by 56.1% was recorded. The average pre-operative ODI value was 25.1; the post-operative values were 17.0 at six months, 12.3 at one year, 10.6 at two years and 8.2 at three years (n=18). At two years after surgery the ODI value improved by 57.8%. To the question concerning their willingness to undergo, with acquired experience, surgery for the same diagnosis, 21 patients (91.3%) gave an affirmative answer. Neither screw breakage nor neurovascular damage or rectal injury was found. CT scans showed complete interbody bone fusion in 22 of the 23 patients (95.6%), In one patient the finding was not clear. Also, posterolateral fusion was achieved in all but one patients (95.6%). A stable L5-S1 segment was found in all patients at all follow-up intervals. The improvement in both VAS and ODI values was statistically significant.
Discussion: In addition to indications usual in degenerative disc disease, overweight patients, those who had repeated trans- or retroperitoneal surgery in the L5-S1 region or who underwent long posterior fixation to stabilise the caudal margin of instrumentation are indicated for the AxiaLIF procedure. The clinical results of our study are in agreement with the conclusions of other studies and are similar to the outcomes of surgery using other types of fusion or dynamic stabilisation for this diagnosis. The high rate of fusion in our group is affected by use of a rigid transpedicular fixator together with posterolateral arthrodesis. On the other hand, no negative effects of only synthetic bone applied to interbody space were recorded.
Conclusions: The percutaneous axial pre-sacral approach to the L5-S1 interbody space with application of a double-treaded screw is another option for the management of this much strained segment. The technique is useful particularly when contraindications for conventional surgical procedures are present in patients with anatomical anomalies, in overweight patients or in those who have had repeated surgery in the region. Clinical outcomes and the success rate for L5-S1 bone fusion are comparable with conventional techniques. Complications are rare but their treatment is difficult.