Percutaneous Translaminar and Ipsilateral Facet Fixation Technique

23 Percutaneous Translaminar and Ipsilateral Facet Fixation Technique

Ricardo B. V. Fontes and Richard G. Fessler

23.1 Introduction

The pioneering description of the ipsilateral facet fixation technique was made by King in 1948. As a stand-alone construct, the technique was associated with significant failure rates and a necessity for bed rest that were virtually the same as for noninstrumented (Hibbs) fusion: particularly in multilevel cases, fusion rates declined to ~ 50%.1,2 In 1984, Magerl described a translaminar modification of the trajectory, but with the advent of pedicle-based instrumentation and its more favorable biomechanical properties, facet fixation fell into disuse. Facet fixation has regained popularity in the 21st century due to increased numbers of interbody fusions and its ease of percutaneous placement. It is a particularly attractive form of posterior supplementation to lateral lumbar interbody fusion because it maintains the minimally invasive philosophy of the latter operation (Video 23.1).³

23.2 Patient Selection

Indications for the procedure are:

• Posterior supplementation for interbody fusion, particularly anterior lumbar interbody fusion (ALIF) and lateral lumbar interbody fusion (LLIF), from L1 to S1

Contraindications are:

• Extensive laminectomy or facetectomy

• Nonreduced degenerative spondylolisthesis after insertion of the interbody graft

• Isthmic spondylolisthesis or spondylolysis

• More than two levels of fixation

23.3 Technique

23.3.1 Preoperative Planning

MRI or CT myelography (preferred) of the lumbar spine is obtained, as well as flexion/extension lumbar spine radiographs.

23.3.2 Anesthesia and Positioning

General anesthesia (without neuromuscular blockade) and neurophysiological monitoring (SSEP and EMG) are used. The patient is positioned prone on a Jackson open-frame table to maximize lumbar lordosis (Fig. 23.1). Checks are made for ocular pressure or contact points.

23.3.3 Localization

Fluoroscopic localization of the levels to be operated in the lumbar spine is used. Anteroposterior (AP) fluoroscopy is preferred for marking the incision; lateral fluoroscopy is utilized during most of the case.

Fig. 23.1 Patient positioned prone on a Jackson open-frame table to maximize lordosis.

23.3.4 Entry Point

Under AP fluoroscopy, the midline over the caudal margin of the spinous process of the level cranial to be operated is marked longitudinally (e.g., the caudal margin of the spinous process of L3 is marked for L4–5 fixation) (Fig. 23.2).

Skin and soft tissue analgesia is obtained using lidocaine 2% with 1:100,000 epinephrine. A longitudinal 1-cm skin incision is made.

Fig. 23.2 Lumbar vertebrae demonstrating the entry point for facet fixation (red circle). The arrow demonstrates the planned trajectory of fixation across the zygapophysial joint. (a) Posterior view. (b) Lateral view.

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