Analysis of risk factors for adjacent superior vertebral pedicle-induced facet joint violation during the minimally invasive surgery transforaminal lumbar interbody fusion: a retrospective study
- Zhi-Li Zeng†1,
- Long Jia†1,
- Wei Xu†1,
- Yan Yu1,
- Xiao Hu1,
- Yong-Wei Jia1,
- Jian-Jie Wang1 and
- Li-Ming Cheng1Email author
© Zeng et al. 2015
Received: 18 June 2015
Accepted: 14 September 2015
Published: 24 September 2015
The purpose was to explore possible risk factors of facet joint violation induced by adjacent superior vertebral pedicle screw during the minimally invasive surgery transforaminal lumbar interbody fusion (MIS-TLIF).
A total of 69 patients with lumbar degenerative disease, who underwent MIS-TLIF were retrospectively reviewed. Postoperative computed tomography images were used to assess the facet joint violation. The correlation of facet joint violations with gender, age, body mass index (BMI), the adjacent superior vertebral level, fusion segment numbers, position of screw insertion, straight leg-raising test (SLRT) results, clinical diseases and renal dysfunction were analyzed by Chi-square tests and binary logistic regression analysis.
The incidence of adjacent superior facet joint violations was 25.4 %. Chi-square test showed the patients with age <60 and high BMI (≥30 kg/m2) were more prone to have facet joint violations (P = 0.007; P = 0.006). The single segment fusion presented more facet joint violations than the double segments fusion (P = 0.048). The vertebral pedicle screw implant location at L5 showed more facet joint violations compared with that at L3 and L4 (P = 0.035). No correlation was found between gender, screw implant position, SLRT results, clinical diseases and renal dysfunction and facet joint violations. Logistic regression analysis revealed that age <60 years (OR: 2.902; 95 % CI 1.227–6.864; P = 0.015) and BMI ≥30 kg/m2 (OR: 2.825; 95 % CI 1.191–6.700; P = 0.018 < 0.05) were significantly associated with facet joint violation.
These results found a high incidence of adjacent superior vertebral facet joint violation in the MIS-TLIF. Age <60 and BMI ≥30 kg/m2 might be risk factors of facet joint violation.
Evidence level: Level 4.
KeywordsMIS-TLIF Facet joint violation Pedicle screw Risk factor
Transforaminal lumbar interbody fusion (TLIF) is prevalent in the management of some spinal disorders that require lumbar fusion [1, 2]. Recently, with development of minimally invasive concept and medical instruments, minimally invasive surgery transforaminal lumbar interbody fusion (MIS-TLIF) has been increasingly accepted due to its advantages in less intraoperative blood loss, weaker intensity of postoperative pain, and shorter hospitalization [3–5].
Recently, increasing concern has been given on the postoperative complications. The most common long-term complication is adjacent segment degeneration. There is evidence that sagittal orientation or tropism at the adjacent segment might be potential risk factors of adjacent segment degeneration . Altered Sagittal balance [7, 8] and deperiostation  also contribute to more degeneration of adjacent segment. Biochemical analysis reveals that the lumbar fusion causes increased facet loading that might lead to adjacent segment degeneration [10, 11]. Moreover, it has been established that the adjacent vertebral facet joint violation is a potential risk factor for accelerating the adjacent segment degeneration [12, 13]. Furthermore, one main contributor to the facet joint violations is placement of the pedicle screws [13, 14].
In MIS-TLIF, pedicle screws are inserted percutaneously without direct visualization of the facet joint, and suspected to be responsible for increased facet joint violations and long-term risk of adjacent segment degeneration [15–17]. To date, several studies have compared open and percutaneous pedicle screw placement and explored the risk factors of facet violation. For instance, it has been revealed that minimally invasive pedicle screw placement does not result in increased facet violation compared with open surgery, and higher BMI is a potential contributor to increased facet violation . However, another study argues that percutaneous pedicle screw placement is associated with higher incidences of high-grade facet joint violation relative to open surgery, and several potential risk factors of facet violation are identified, such as age <65, pedicle screw placement at L4 and obesity . Regardless of these controversial viewpoints, exploring the risk factors that contribute to the facet joint violations in MIS-TLIF is very imperative. There are few studies investigating the risk factors of facet joint violations specifically in patients undergoing MIS-TLIF. Therefore, in this study, we retrospectively reviewed the clinical data of 69 patients who underwent MIS-TLIF, and assessed relevant risk factors of facet joint violation caused by adjacent superior vertebral pedicle screw, including gender, age, BMI, the location of adjacent upper vertebral, fusion segment numbers, screw implant location and others.
Preoperative CT and MRI examination showed obvious lumbar disc herniation and (or) lumbar spinal stenosis in 48 cases, lumbar spondylolisthesis in 9 cases and endplate Modic changes in 12 cases. The study protocol was approved by local ethics committee. Informed consent was obtained from each patient prior to the study. The operation was performed by two deputy or chief surgeons who had more than 15-year experience in orthopedic surgery. There were 62 cases with single segment fusion and 7 cases with double segments fusion. The position of adjacent superior vertebral pedicle screw insertion in these cases was detailed as follows: L3, 4 cases; L4, 45 cases; L5, 20 cases. In addition, 69 pedicle screws were placed on the left and the right side of the spine of the patients, respectively.
Radiographic evaluation and observation index
All analyses were conducted using SPSS software, version 17.0. Gender, age, BMI, adjacent superior vertebral level, fusion segment numbers, screw implant location, SLRT results, clinical diseases and renal dysfunction were compared between patient with or without facet joint violations using Chi-square tests. Binary logistic regression analysis was performed to identify significant risk factors of facet joint violation. P < 0.05 was considered to be significant.
Comparison of gender, age, body mass index (BMI), vertebral level, fusion segment numbers, screw implant location, result of straight leg-raising test, clinical diseases and renal dysfunction between patient with or without facet joint violations
Location relationship between vertebral pedicle screw and facet joint (n)
1 + 2 Point
16 (11 + 5)
1 (11 + 8)
14 (10 + 4)
21 (12 + 9)
15 (10 + 5)
20 (12 + 8)
Adjacent superior vertebral level
21 (13 + 8)
14 (9 + 5)
35 (22 + 13)
20 (13 + 7)
15 (9 + 6)
Straight leg-raising test
19 (12 + 6)
17 (10 + 7)
Lumbar disc herniation and spinal stenosis
25 (14 + 11)
6 (4 + 2)
Endplate Modic changes
4 (3 + 0)
34 (22 + 12)
1 (0 + 1)
Result of logistic regression analysis
95 % CI
Age >60 years old
BMI >30 kg/m2
Single segment fusion
Pedicle screw implant at L5
The current study investigated the risk factors of facet joint violations in patients undergoing MIS-TLIF. The results indicated that the incidence of facet joint violations was 25.4 %. Moreover, the study found that age <60 years and high BMI (≥30 kg/m2) were suggested to be independent risk factors for facet joint violations. Gender, vertebral level, fusion segment numbers, screw implant location, result of SLRT, clinical diseases and renal dysfunction were not significantly associated with facet joint violations.
Facet joint is an important structure to maintain the stability of lumbar spine motion segments. The paired facet joint with lumbar intervertebral disc constitute the lumbar complex which is responsible for the spine movement, stability, torsion and load-bearing ability . Facet joint violations can destruct the spine stability and further accelerate the development of adjacent segment degeneration . Park et al.  have found that compared with other forms of instrumentation or with no instrumentation, transpedicular instrumentation is prone to cause symptomatic adjacent segment disease, and that the possible risk is the adjacent facet joint violations during the pedicle screw placement. Moreover, a cadaveric study also indicates that the complications are more serious when the superior facet joints were violated by the placement of pedicle screw . Therefore, in this study, the results showed that the rate of facet joint violations with percutaneous pedicle screw insertion was 25.4 %, which was not consistent with the previous studies in which the incidence of facet joint violation displays wide variation and ranges from 3.2 to 50 % [19, 25, 26]. One possible contributor to the inconsistent results is the varied definition and assessment methods of facet joint violations in different studies. Moreover, the sample was relatively small in this study which might be another reason responsible for the inconsistent results.
Previously, several studies have investigated the potential risk factors for the joint violations. A retrospective study performed by Ranjith Babu et al. has demonstrated that patients’ age <65 and obesity contribute to the increased difficulty in avoiding the facet joint violations . BMI >29.9 is a potential contributor to increased facet violation . Similarly, in the present study, the logistic regression analysis found that patients younger than 60 years old, with BMI ≥30 kg/m2 were independent risk factors of facet joint violations in the MIS-TLIF. The greater skin elasticity and stronger muscle of younger patients may make it more difficult to get the tactile sensation of the facet and to achieve an appropriate entry site. Moreover, it has been reported that clear radiological intraoperative images are not easy to be observed from the obese patients [16, 27], and that the hypertrophic tissue in obese patients increases the distance from the skin to the spine. The above factors make it more difficult to achieve an ideal entry site with appropriate angulation and further decrease the accuracy of percutaneous pedicle screws placement. However, Park et al.  have found no significant relationships between patients’ age, BMI and the incidence of facet joint violations. These controversies are needed to be further investigated.
In addition, facet joint violations caused by the placement of pedicle screw are more frequent at the L4, L5 pedicel level than at the L3. The results from Park et al.’s research indicate that violations occur more frequently at the cranial pedicle screws of L5 pedicle than at other pedicels . In the current study, the Chi-square test results also indicated that the incidence of facet joint violations at L5 pedicle was significantly higher than that at the L3 and L4 pedicel levels. The possible explanation is that the facet joint and the caudal portions of the laminae are more toward the frontal plane at L5-S1 level than other levels, which may increase the difficulty of percutaneous screws placement . Moreover, the increased lordosis and paravertebral muscles at the L5-S1 level may also contribute to the increased facet joint violation . Besides, a retrospective study of Moshirfa et al. indicates that a higher incidence of superior-level facet joint violation is observed in single-level fusion compared with that in multiple-level fusion . However, Park et al.  have found no correlation between the number of fused segment and facet joint violation. In this study, the Chi-square test also found the single segment fusion was more prone to experience facet joint violation than the double segments fusion. The pedicle screws insertion with single segment fusion in this study was mostly at L5 level where the facet joint violation was more difficult to avoid. It seemed to provide a rational explanation for the results of this study. However, the logistic regression analysis revealed that single segment fusion and pedicle screws insertion at L5 were not significantly associated with the facet joint violation. Further studies of large sample size were needed to validate the results. Meanwhile, Moshirfa et al.  found that the screw implant at the left side was prone to cause facet joint violation. Conversely, the present results indicated no significant difference of facet joint violation between the screw placement at the left side and at the right side (left vs. right), which might be attributed to the assistance of C arm fluoroscopy. These controversies and assumption are worthy to be further investigated.
The study is presented with several limitations. First, the sample size of the study was small. Therefore, larger and multiple-center studies are needed in future study to confirm the results. Second, due to the limited duration of follow-up, the correlation between adjacent superior pedicle facet joint violation and late clinical outcome was incapable to be investigated, which will be a focus in the future study. In addition, the association between preoperative lumbar degeneration and facet joint violation was also an intriguing research direction.
The results from this retrospective study found a high incidence of adjacent superior vertebral facet joint violation in the MIS-TLIF. Age <60 years old and BMI ≥30 kg/m2 were independent risk factors of facet joint violation.
ZLZ and LJ participated in the design of this study, and they both performed the statistical analysis. WX, YY and XH carried out the study and collected important background information. YWJ, JJW and LMC drafted the manuscript. All authors read and approved the final manuscript.
This study was supported by Research Funding from Shanghai Hospital Development Center (SHDC-12013108).
Compliance with ethical guidelines
Competing interests The authors declare that they have no competing interests.
Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
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