Clinical outcomes of Short Rod Technique in transforaminal lumbar interbody fusion surgery through Wiltse approach: A case series report

Clinical outcomes of Short Rod Technique in transforaminal lumbar interbody fusion surgery through Wiltse approach: A case series report | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Clinical outcomes of Short Rod Technique in transforaminal lumbar interbody fusion surgery through Wiltse approach: A case series report Lianjie Pu, Kai Chen, Zhen Tan, Beier Luo, Mingyuan Yang, NingFang Mao This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4180310/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Objective We present for the first time a novel entry point of pedicle screws (Short Rod Technique, SRT), which can avoid superior facet violation and has been verified as a safe screw placement method. The objective of this study is to report the clinical outcomes of SRT in transforaminal lumbar interbody fusion (TLIF) surgery through Wiltse approach. Methods We retrospectively analyzed the clinical outcomes of 64 patients who received SRT through Wiltse approach with a minimum of 2 years of follow-ups. Demographics, clinical outcomes and radiological parapmeters were recorded and analyzed. Results Less total postoperative drainage volume before removall (27.88 ± 10.27), shorter days of removal of drainage (1.08 ± 0.27) was observed in SRT through Wiltse approach. In addition, patients felt less wound pain after the surgery, improving their HRQOL. Upper adjacent segment degeneration (ASD) was found in 2 petients at final follow-up, and they also received revision surgery. Both back pain, leg pain and ODI improved after the surgery; however, due to the ASD patients, the mean value of leg pain and ODI were greater at final follow-up than they’re at post-operation. Less change of LL was observed at final follow-up than it at post-operation with significant difference. Compared with increase of SS at post-operation, SS decreased at final follow-up with significant difference of change of SS. PT decreased at post-operation, while it was found to be increased at final follow-up. PI remained constant before and after the surgery with no significant difference of change of PI. Sagittal alignment also tended to be imbalanced with the change of SVA signficantly greater at final follow-up than it at post-operation. In addition, due to the two cases of ASD, the loss of disc hight and change of slippage distance of upper adjacent segment were signficantly greater at final follow-up than they’re at post-operation. More degeneration of intervertebral disc was also observed at final follow-up. Conclusion Application of SRT through Wiltse approach in TLIF surgery has been validated as an effective technique with good clinical outcomes, especially for reducing the blood loss and postoperative wound pain and improving patients’ HRQOL. The present study provides spinal surgeons with a novel method for performing TLIF surgery. Transforaminal lumbar interbody fusion Short rod technique Wiltse approach Figures Figure 1 Figure 2 Introduction Transforaminal lumbar interbody fusion (TLIF) surgery was proved to be an effective surgical approach for the clinical treatment of various lumbar spinal disorders, due to its significant advantages in clinical application 1 , 2 . As a traditional lumbar approach, the TLIF is a surgery that the majority of spinal surgeons are well trained and comfortable in performing 3 . However, the conventional open approach technique require a large midline skin incision, extensive detachment and prolonged retraction of back muscles from the spinal processes, while it is regarded as a paraspinal iatrogenic injury associated with prolonged muscle retraction, may leading to great volumes of intra-operative blood loss, postoperative low back pain, delay recovery and mobilization 3 . According to previous study, after TLIF, strength in back muscles decreased until 3 months postoperatively but significantly increased after that period 4 . Therefore, many minimally tnvasive techniques and improved approaches have been proposed and used in TLIF surgery to protect the paraspinal muscles, such as short rod technique 5 , 6 , minimally invasive lateral lumbar interbody fusions (LLIF) with percutaneous pedicle screws (PPS) 7 , Wiltse approach, and et al. 8 We present for the first time a novel entry point of pedicle screws (Short Rod Technique, SRT, Fig. 1 ), which can avoid superior facet violation with relatively small wound incision, and the results showed better recovery of patients’ HRQOL (Health of Related Quality of Life) and reduction of the occurrence of upper adjacent segment degeneration (ASD) in TLIF surgery. In 1968, Dr. Wiltse first described a new approach by splitting the muscles between the multifidus and longissimus to retain the integrity of the posterior osseous structure and the ligamentous complex to the maximum 9 . He later modified his approach so that it could be applied in other lumbar diseases 10 . Different with traditional spine surgery which needs dissection of bilateral muscles, this approach does not need to intraoperatively strip the paraspinal muscles, and many advantages of this approach have been fverified, such as less trauma, less intraoperative bleeding, and quicker recovery 11 . Therefore, Wiltse approach has been widely used in the surgical treatment of spine surgeries, especially for elder patients who could not suffer the variety of complications including deep vein thrombosis, hypostatic pneumonia, and pressure sores. Li et al 11 reported good clinical effects of manual reduction combined with internal fixation through Wiltse approach in the treatment of thoracolumbar fracture. Song et al’s study 12 showed that this original one-stage posterior PIA (paraspinal intermuscular approach) was safe and effective in the treatment of scoliosis. Recently, we present for the first time a novel entry point of pedicle screws (Short Rod Technique, SRT), which can avoid superior facet violation and has been verified as a safe screw placement method with good clinical outcomes 6 . The key note of SRT is the protection of the posterior complex of the spine, including the supraspinous ligament, interspinous ligament, capsule of the articular process, and superior facet, which has been verified to be associated with adjacent segment degeneration (ASD), postoperative wound pain, delayed bedridden time and et al. In order to detect whether SRT through Wiltse approach could achieve good clinical outcomes in TLIF surgery, we combined these two surgical techniques toghther in the TLIF surgery. Methods Subjects 64 patients who received TLIF surgery with SRT through Wiltse approach in our hospital from January 2020 to January 2022 were recruited in this study. The inclusion criteria were: 1) Patients were diagnosed with lumbar disorders, including lumbar disc herniation and lumbar spinal stenosis, and required one -level TLIF surgery; 2) Type 10–11 cage and polyaxial screws from the same company were implanted; 3) A minimum of 2-year follow-up; 4) Sufficient radiological data on posteroanterior full-length stand film, including preoperative, postoperative (discharged), and follow-ups, as well as sufficient assessments of HRQOL; 5) Preoperative and follow-up Lumbar MRI were also required. The exclusion criteria of patients were: 1) Patients diagnosed with lumbar disorders who did not receive TLIF surgery; 2) Spondylolisthesis was excluded from this study because the location of SRT might move forward with the fronted vertebral body, making it difficult to find; 3) Insufficient radiological data and follow-up. Those who were lost to follow-up or lacked sufficient radiological data in the follow-ups were excluded from this study. All of the surgeries were performed by the same surgeon and in the same manner. To control for surgical biases that might influence the results, only patients who received TLIF surgery with cages of type 10–11 were recruited to standardize the interbody height and length of connecting rods. This study was approved by the Institutional Review Board (Review Board of Changhai Hospital, Navy Medical University), and all patients in our study provided written informed consent for the study and surgery. Surgical Technique The patient was placed on the operating table in a prone position on a Jackson table under general anaesthesia. A posterior midline incision was made in the skin. Multifidus and longisis muscle space were separated after incising the skin, subcutaneous and low back fascia layer by layer (Fig. 2 A). As illustrated in Fig. 1 and Fig. 2 B, the exposure of the entry point of SRT was achieved. Pedicle screws were inserted after satisfied fluoroscopy with positioning needles (Fig. 2 C and 2 D). Figure 2 E showed the success of implantation of pedicle screws and the intraoperative fluoroscopy showed good position of SRT (Fig. 2 F). Facet joints were removed to reveal the intervertebral disc. The disc tissue and cartilage were gradually removed with an intervertebral reamer. The screw and rod system of the opposite side were used to assist in maintaining intervertebral distraction. Then, the polyetheretherketone (PEEK) interbody cages filled with allografts of type 10–11 size were placed into the intervertebral space. Connection rods were implanted. Finally, the incision was washed and drainage tube was placed in the bilateral muscle space before suture, layer by layer. Data Collection Denographics data including age, gender, BMD (Bone Mineral Density, T value) and BMI (Body Mass Index, kg/m 2 ) were collected. Surgical variables such as operation time, length of wound, intraoperative blood loss, length of connection rods (the length between the middle point of screws in upper instrumented vertebra and it in lower instrumented vertebra), total postoperative drainage volume before removall and days of removal of drainage were collected and analysed. Radiological data before surgery, after surgery (Discharged) and at final follow-ups were collected and analyzed, including: LL (Lumbar Lordosis, the the angle between upper endplate of L1 and lower endplate of L5), SS (the angle between the horizontal and the sacral plate), PT (the angle between the vertical and the line through the midpoint of the sacral plate to femoral heads axis), PI (angle subtended by a perpendicular from the upper endplate of S1 and a line connect- ing the center of the femoral head to the center of the upper endplate of S1), SVA (the horizon- tal offset from the posterosuperior corner of S1 to the vertebral body of C7), disc hight of upper adjacent segmen (Disc Hight was average of the anterior and posterior heights of the disc and measured on anteroposterior radiographs) 13 , slippage distance of upper adjacent segment, which was measured as reported 14 , and upper disc degeneration on MRI which was defined according to the modified Pfirrmann grading system 15 . In addition, the psotoperative loss of disc hight of upper adjacent segmen and loss of disc hight of upper adjacent segmen at final follow-up was defined as: [(Postoperative disc hight of upper adjacent segment at follow-up - preoperative disc hight of upper adjacent segment)/preoperative disc hight of upper adjacent segment]*100%; and [(Disc hight of upper adjacent segment at follow-up - preoperative disc hight of upper adjacent segment)/preoperative disc hight of upper adjacent segment]*100%, respectively. The calculation of psotoperative change of slippage distance of upper adjacent segment and change of slippage distance of upper adjacent segment at final follow-up was the same as loss of disc hight. Whether there occurred ASD in these patients is defined as follows 16 : 1). Disc height reduction of more than 3 mm or 20% of the preoperative disc height seen on a lateral radiograph; 2). Upper adjacent vertebral slippage of more than 3 mm compared with the preoperative condition seen on lateral radiographs; and 3). Osteophyte formation greater than 3 mm; 4). The classification of adjacent intervertebral discs increased by more than 1 grade compared with the preoperative condition using the modified Pfirrmann grading system 15 ; or whether there occurred Adjacent Segement Disease (ASDis) which is defined by the need for a revision surgery procedure to address adjacent level pathology. Regarding HRQOL, VAS was used to assess back pain, leg pain, and wound pain 17 , and the clinical outcomes were assessed by the Oswestry Disability Index (ODI) 18 . Additionally, VAS was used to assess patients’ wound pain 3 days after surgery, which were assessed at the same time periods. All data were measured by two independent reviewers. Statistical Analysis Statistical analyses were performed using SPSS 19.0 statistics software (SPSS Inc, Chicago, IL). Descriptive statistics were listed as mean and standard deviation (SD). A χ2 test was used to compare the categorical variables, such as Pfirman classification of the upper adjacent segment. t-test was carried out for descriptive statistics pre- to postoperatively or follow-up to postoperatively. P < 0.05 was considered significant. Results A total of 64 patients who received TLIF surgery with SRT through Wiltse approach in our hospital from January 2020 to January 2022 were recruited in this study. The average age was 58.8 years-old (37–75 years-old). The ratio of male and female was 28:36. Majority of these patients (71.9%, 46/64) suffered from osteoporosis with the mean BMD of -1.59 (T value). 11 patients sufffered from obesity with the BMI greater than 24 kg/m 2 . All the data were shown in Table 1 . Table 1 General characterisics, surgical variables, radiological parameters, and HRQOL of the recruiters Variables Minimum Maximum Mean Standrd Deviation Demographic Data Age (yeaars old) 37.00 75.00 58.80 9.23 Gender (Male/Female) 28/36 BMD (T value) -2.60 0.50 -1.59 0.83 BMI (kg/m 2 ) 17.10 28.50 22.16 1.98 Number of ASD (n) 2 Surgical Variables Operation time (minuts) 80.00 130.00 107.42 13.37 Length of wound (cm) 6.00 8.00 7.42 0.47 Intraoperative blood loss (ml) 168.00 300.00 230.47 44.93 Length of connection rods (mm) 15.00 24.00 19.97 1.98 Total postoperative drainage volume before removall (ml) 10.00 60.00 27.88 10.27 Days of removal of drainage (n) 1.00 2.00 1.08 0.27 Radiological Parameters Preoperative LL ( o ) 28.00 54.00 39.67 6.70 SS ( o ) 20.00 38.00 30.00 4.50 PT ( o ) 11.00 36.00 22.61 5.85 PI ( o ) 44.00 59.00 52.61 3.46 SVA (mm) 16.00 42.00 28.16 6.04 Disc hight of upper adjacent segment (mm) 10.20 16.30 13.64 1.41 Slippage distance of upper adjacent segment (mm) 1.20 4.40 3.23 0.73 Pfirman classification of upper adjacent segment (I/II/III/IV/V/VI/VII/VIIII) 2/7/33/22/0/0/0/0 Postoperative LL ( o ) 30.00 57.00 44.03 5.87 SS ( o ) 20.00 39.00 30.72 3.60 PT ( o ) 12.00 32.00 20.73 4.43 PI ( o ) 46.00 58.00 51.64 2.68 SVA (mm) 15.00 38.00 26.63 5.01 Disc hight of upper adjacent segment (mm) 10.20 16.30 13.54 1.50 Slippage distance of upper adjacent segment (mm) 1.00 4.20 3.17 0.70 Pfirman classification of upper adjacent segment (I/II/III/IV/V/VI/VII/VIIII) NA Final Follow-up LL ( o ) 25.00 55.00 41.37 5.77 SS ( o ) 20.00 36.00 28.94 3.96 PT ( o ) 13.00 33.00 21.98 4.76 PI ( o ) 46.00 55.00 50.92 2.18 SVA (mm) 21.00 43.00 30.56 4.45 Disc hight of upper adjacent segment (mm) 8.10 16.00 12.90 1.68 Slippage distance of upper adjacent segment (mm) 1.20 4.60 3.36 0.72 Pfirman classification of upper adjacent segment (I/II/III/IV/V/VI/VII/VIIII) 0/3/22/34/2/1/0/2 HRQOL Back Pain (VAS) Preoperative 4.00 8.00 6.31 0.99 Postoperative 0.00 2.00 0.61 0.63 Final Follow-up 0.00 8.00 0.92 1.40 Leg Pain (VAS) Preoperative 6.00 8.00 7.06 0.64 Postoperative 0.00 2.00 1.14 0.66 Final Follow-up 0.00 9.00 0.53 1.51 ODI Preoperative 59.00 77.00 69.28 4.66 Postoperative 10.00 40.00 18.39 7.48 Final Follow-up 2.00 70.00 10.94 11.24 Postoperative wound pain (VAS) 1st day 1.00 5.00 2.08 1.00 2nd day 0.00 3.00 0.95 0.74 3rd day 0.00 1.00 0.25 0.44 All these recruited patients received TLIF surgery with SRT through Wiltse approach in single fusion level with the average operation time of 107.42 minuts. As shown in Table 1 , the length of wound was relatively shorter than TLIF surgery with traditional entry point, with the mean value of 7.42 cm, as well as the length of connection rods with the mean value of 19.97 mm. In addition to the shorter length of wound and length of connection rods, the combition of SRT and Wiltse approach has also the following advantages: 1). Less intraoperative blood loss with the mean value of 230.47 ml. The majority of intraoperative blood loss happened during the operation of implantation of cage. 2). Less total postoperative drainage volume before removall with the mean value of 27.88 ml. Less paraspinal muscles were damaged and less blood loss happened during the procedure of implantation of pedicle screws, leading to less total postoperative drainage volume. 3). Shorter days of removal of drainage (1.08 ± 0.27) was also observed in SRT through the Wiltse approach due to the less total postoperative drainage volume. All the data were shown in Table 1 . The mean value of preoperative LL was 39.67 with the standrd deviation of 6.7 (Table 1 ). Lumbar lordosis was significantly restored after the operation with the mean vales of 44.03 ( P < 0.001, Table 2 ). However, lumbar lordosis was significantly decreased at final follow-up (41.37 ± 5.77 vs. 44.03 ± 5.87, P = 0.011, Table 2 ). Besides, less change of LL was observed at final follow-up than it at post-operation with significant difference (4.51 ± 9.60 vs. 11.94 ± 9.44, P < 0.001, Table 2 ). No significant difference of SS was observed between preoperation and postoperation (30.00 ± 4.50 vs. 30.72 ± 3.60, P = 0.320, Table 1 and Table 2 ), while SS was significantly decreased at final follow-up with the P value of 0.009 (28.94 ± 3.96 vs. 30.72 ± 3.60, Table 2 ). In addition, the change of SS between final follow-up-preoperative was significantly different with it between postoperative-preoperative as shown in Table 2 (-2.58 ± 12.96 vs. 3.43 ± 10.92, P = 0.005). PT was significantly decreased at post-operation (20.73 ± 4.43 vs. 22.61 ± 5.85, P = 0.043), while it was not significantly changed at final follow-up (21.98 ± 4.76 vs. 20.73 ± 4.43, P = 0.127), as shown in Table 2 . The change of PT between final follow-up-preoperative was significantly different with it between postoperative-preoperative as shown in Table 2 (1.99 ± 28.04 vs. -6.28 ± 14.53, P = 0.038). PI remained constant before and after the surgery with no significant difference of change of PI, as shown in Table 2 and Table 3 . As to the SVA, no significant difference was found between postoperation and preoperation (26.63 ± 5.01 vs. 28.16 ± 6.04, P = 0.121, Table 2 ), while it was increased at final follow-up with significant difference compared with postoperation (30.56 ± 4.45 vs. 26.63, P < 0.001). Table 2 Comparison of radiological parameters and HRQOL between preoperation, post-operation and final follow-up Variables Preoperative Postoperative P value (Postoperative vs Preoperative) Final Follow-up P value (Final Follow-up vs Postoperative) Radiological Parameters LL ( o ) 39.67 ± 6.70 44.03 ± 5.87 P < 0.001 41.37 ± 5.77 0.011 SS ( o ) 30.00 ± 4.50 30.72 ± 3.60 0.320 28.94 ± 3.96 0.009 PT ( o ) 22.61 ± 5.85 20.73 ± 4.43 0.043 21.98 ± 4.76 0.127 PI ( o ) 52.61 ± 3.46 51.64 ± 2.68 0.079 50.92 ± 2.18 0.098 SVA (mm) 28.16 ± 6.04 26.63 ± 5.01 0.121 30.56 ± 4.45 P < 0.001 Upper Adjacent Segments Disc hight of upper adjacent segment (mm) 13.64 ± 1.41 13.54 ± 1.50 0.689 12.90 ± 1.68 0.027 Slippage distance of upper adjacent segment (mm) 3.23 ± 0.73 3.17 ± 0.70 0.608 3.36 ± 0.72 0.133 Pfirman classification of upper adjacent segment (I/II/III/IV/V/VI/VII/VIIII) 2/7/33/22/0/0/0/0 NA NA 0/3/22/34/2/1/0/2 NA HRQOL Back Pain (VAS) 6.31 ± 0.99 0.61 ± 0.63 P < 0.001 0.92 ± 1.40 0.105 Leg Pain (VAS) 7.06 ± 0.64 1.14 ± 0.66 P < 0.001 0.53 ± 1.51 0.004 ODI 69.28 ± 4.66 18.39 ± 7.48 P < 0.001 10.94 ± 11.24 P < 0.001 Table 3 Copmarisons of change of Radiological Parameters and HRQOL between Postoperative-Preoperative and Final follow-up-Preoperative Variables Postoperative-Preoperative Final follow-up-Preoperative P value Radiological Parameters Change of LL ( o ) 11.94 ± 9.44 4.51 ± 9.60 P < 0.001 Change of SS ( o ) 3.43 ± 10.92 -2.58 ± 12.96 0.005 Change of PT ( o ) -6.28 ± 14.53 1.99 ± 28.04 0.038 Change of PI ( o ) -1.99 ± 5.00 -2.82 ± 7.36 0.459 Change of SVA (mm) -4.47 ± 9.15 12.05 ± 23.03 P < 0.001 Upper Adjacent Segments Loss of disc hight of upper adjacent segment (%) -0.72 ± 4.66 -5.41 ± 7.43 P < 0.001 Change of slippage distance of upper adjacent segment (%) -1.11 ± 13.81 4.85 ± 12.89 0.013 Pfirman classification of upper adjacent segment (I/II/III/IV/V/VI/VII/VIIII) at final follow-up 0/3/22/34/2/1/0/2 Final follow-up vs. Preoperative: P = 0.038 HRQOL Improvement of VAS of Back Pain (%) -90.24 ± 10.13 -84.36 ± 27.94 0.116 Improvement of VAS of Leg Pain (%) -83.65 ± 9.69 -92.39 ± 21.51 0.004 Improvement of ODI (%) -73.29 ± 10.97 -83.98 ± 17.22 P < 0.001 According to criteria of ASD, 2 patients suffered from ASD at final follow-up, and they also received revision surgery. Obesity was found in these two patients with BMI of 28.5 and 28.3 kg/m 2 , as well as sever osteoporosis with BMD of -2.6 and − 2.5 (T value). Due to these two patients, the loss of disc hight of upper adjacent segment between follow-up-preoperative was significantly decreased than it between postoperative-preoperative (-5.41 ± 7.43 vs. -0.72 ± 4.66, P < 0.001, Table 3 ); and change of slippage distance of upper adjacent segmen between final follow-up-preoperative was significantly increased than it betweeen postoperative-preoperative (4.85 ± 12.89 vs. -1.11 ± 13.81, P = 0.013, Table 3 ). In addition, more degeneration of intervertebral disc was also observed at final follow-up with the Pfirman classification ((I/II/III/IV/V/VI/VII/VIIII) of upper adjacent segment at final follow-up (0/3/22/34/2/1/0/2 vs. 0/3/22/34/2/1/0/2, P = 0.038, Table 1 and Table 3 ). Patients suffered from severe back pain, leg pain and disability with the mean VAS value of 6.31 in back pain, 7.06 in leg pain and ODI value of 69.28, respectively. SRT in TLIF surgery through Wiltse approach was an effective sugical technique since all these recruited patients’ back pain, leg pain and disability were significantly improved after the operation (all P < 0.001, Table 2 ). However, due to the occurrence of ASD in 2 patients, the mean value of leg pain and ODI was significantly different in final follow-up compared with the postoperation, as shown in Table 2 . In addition, due to the less damage of paraspinal muscles, patients felt mild wound pain after the operation with the VAS value of 2.08, 0.95 and 0.25 at 1st day, 2nd day and 3rd day, respectively, as shown in Table 1 . Disscussion TLIF surgery allows for circumferential decompression of the neural elements with relatively small injury compared with PLIF surgery (Posterior lumbar interbody fusion), and has been widely used in treatment of lumbar spinal disorders 19 . Dissection of bilateral muscles is widely used to access the posterior column of the vertebral body during the TLIF surgery, while it is regarded as a paraspinal iatrogenic injury. Therefore, many minimal invasive approaches have been proposed to avoid bad clinical outcomes related to the dissection of bilateral muscles, such as the Wiltse approach, the oblique trajectory anterior to psoas (ATP) approach, minimally invasive transforaminal lumbar interbody fusion (MIS TLIF), and et al. SRT has been verified as a safe screw placement method with good clinical outcomes by our previous study, such as greater reduction in wound pain, reduction of ASD and anatomical structure advantage 6 , 20 . To minimise the injury of paraspinal muscles during the TLIF surgery and accelerate patients’ recovery, we combined SRT technique with Wiltse approach, and the clinical outcomes of SRT through Wiltse approach in TLIF surgery were reported as follows: Less blood loss and better HRQOL SRT was a relatively easy technique for surgeons to learn and operate since the location of the entry point of SRT was relatively stable, did not change with vertebral degeneration, and was easy to locate in each vertebra (Fig. 1 ). While in TLIF surgery with tradtional entry points, it is common for the anatomical structures of pedicles in some elderly patients to be severely degenerative, making it harder to find the regular entry point and implant the screws, which might cause nerve injury and other severe surgical complications 21 . Besides, less exposure of the bilateral muscles, superior facet joint and facet joint capsule was required in TLIF surgery with SRT through Wiltse approach. All these factors made this surgery eariser and safter as well as the shorter operation time. In our surgry, the majority of operation time was used in the depression procedure rather than the implantation of pedicle screws which might be difficult in TLIF surgery with tradtional entry points. Furthermore, with the shift-down of the pedicle screw entry point in SRT, resulting in a shorter wound length and connection rods length in the SRT, which was consistent with our previous study 6 . More important, less injury of bilateral muscles, superior facet joint and facet joint capsule in our operation resulted in less intraoperative blood loss, especially during the procedure of exposure of the entry point. In our study, blood loss was observed during the procedure of depression of nerve roots and implantation of interbody cages rather than the implantation of pedicle screws. Consequently, the total postoperative drainage volume before removall and days of removal of drainage were both significantly decreased compared with TLIF surgery with traditional entry point, may leading to shorter hopital days and less economic burdens. In addition, due to the less damage of paraspinal muscles and less intraoperative blood loss, patients felt mild wound pain after the operation with the VAS value of 2.08, 0.95 and 0.25 at 1st day, 2nd day and 3rd day, respectively. Consequently, the less postoperative drainage volume, less days of removal of drainage and mild postoperative wound pain accelerate patients’ recovery and improved patients’ quality of life, which was the most be the most significant advantage of SRT in TLIF surgery through Wiltse approach. Therefore, SRT through Wiltse approach is recommended in TLIF surgery, especially for long fusion levels, since less posterior complex, facet joint, and paraspinal muscles are incised, resulting in greater improvement of wound pain. Reduction of ASD with SRT through Wiltse approach Adjacent segment degeneration (ASD) is among the most recognized long-term complications of lumbar surgery for degenerative spine pathologies with a relevant impact in spine surgical and clinical practice 22 . It has been verified that several factors are associated with ASD. The posterior complex, including the superior facet joint, facet joint capsule, and paraspinal muscles, plays an important role in lumbar stabilization, and intraoperative superior facet joint violation might cause deduced adaptability to biomechanical change and has been verified as an important risk factor for ASD after spine fusion surgery 23 . We compared the incidence of ASD in PLIF surgery with SRT and regular PLIF surgery with traditional entry points, and our results 6 showed that in one-level and three-level fusions, there was a significant difference in the incidence of ASD between SRT and regular PLIF surgery, indicating that applying SRT in PLIF surgery could play a protective role against ASD development. In our opinion, the application of SRT during TLIF surgery could protect the superior facet joint, facet joint capsule, and muscles and could help avoid superior facet joint violation, ultimately decreasing the occurrence of ASD as well. Furthermore, since the protection of paraspinal muscles has been verified to play important role in reduction of ASD during the spine surgery, Wiltse approach has been proposed and used in the operation, and good clinical outcomes have been reported 24 . We combined SRT and Wiltse approach in TLIF surgery, hoping to avoid the occurrence of ASD as far as possible. In our study, only 2 patients suffered from ASD with low back pain and leg pain at final follow-up according to the criteria of ASD. MRI showed disc herniation with nerve root compression at upper adjacent segment above the first surgery. Consequently, these two patients received revision surgery, and their symptoms were significantly relieved. Interestingly, obesity was found in both patients with BMI of 28.5 and 28.3 kg/m 2 , as well as sever osteoporosis with BMD of -2.6 and − 2.5 (T value). Our results were consistent with Cannizzaro et al’s study 22 which reported that obesity were relevant risk factors for developing lumbar adjacent segment degeneration, indicating that SRT through Wiltse approach was recommended in obese patients. The incidence of ASD in our study was 3.12%, whch was significantly lower than it reported in previous study 22 , 23 , which might be contributed the protection of superior facet joint, facet joint capsule, and paraspinal muscles in both SRT technique and Wiltse approach. Therefore, the application of SRT through Wiltse approach as a noval surgical method, is recommended in TLIF surgery to reduce the occurrence of ASD. However, smple size, measurement erors and selection biases might influence our results, and extensive multicenter studies will be needed. Restoration of Sagittal Parameters Lumbar lordosis was restored in our study as a result of cage implantation, which has been verified as a primary contributor 25 . Combined with the significant change of LL and the lower incidence of ASD in the SRT group through Wiltse approach, we speculated that better postoperative sagittal alignment might play an important role in the development of ASD, which was consistent with Wang et al.’s meta-analysis 25 . Interestingly, the reason why the SRT technique could increase lumbar lordosis could be due to the direction of SRT’s projection, as verified in our previous study 5 . In SRT, the screws are implanted in the direction of 10-20 o to the endplate in the sagittal plane (Fig. 1 C), which might result in more compression pressure, leading to greater lumbar lordosis 5 . Besides, the protection of paraspinal muscles in Wiltse approach might provide sufficient lumbar stabilization, leading to the stable lumbar lordosis. Pelvic incidence (PI) is a key morphological parameter that reflects the relation between the sacrum and iliac wings. It is well accepted that PI remains constant after reaching maturity 26 . PI remained constant in our study no matter after operation or at final follow-up, which was constient with previoud study 6 . Pelvic tilt (PT) and sacral slope (SS) are pelvic compensatory parameters which paly important role in the sagittal balance, which is widely evaluated by SVA (Sagittal Vertical Axis). Lumbar lordosis decreased with aging possibly due to disc degeneration, whereas PT increases to restore sagittal balance as a compensatory mechanism. In our study, due to the restoration of lumbar lordosis and sagittal balance (SVA), PT decreased significantly after the operation with increased SS. Wang et al. 27 speculated that abnormal sagittal alignment could negatively affect the adjacent segments, and our findings also indicated that restoring sagittal alignment, especially for the lumbar lordosis, is the key to reducing ASD. Notably, SRT could provide more compression pressure during the sagittal restoration procedures, leading to lower rates of ASD as well as the providence of lumbar stabilization by Wiltse approach. Limitation In this study, we present for the first time a novel entry point of pedicle screws (Short Rod Technique, SRT) through Wiltse approach in TLIF surgery. Although good clinical outcomes have been reported, some limitations in this study should not be neglected. First, First, all the patients recruited in our study were outpatients of a single center in China, which may result in selection bias and compromise the statistical power. Second, the sample size and the average follow-up time was relatively small. Thus, future studies with longer follow-ups and larger sample sizes should be conducted. Besides, only 2 patients suffered from ASD and were analyzed in our study. Larger number of ASD should be recruited and studied to detect whether SRT with through Wiltse approach could reduce the occurrence of ASD in TLIF surgery. Conclusion Application of SRT through Wiltse approach in TLIF surgery has been validated as an effective technique with good clinical outcomes, especially for reducing the blood loss and postoperative wound pain and improving patients’ HRQOL. The present study provides spinal surgeons with a novel method for performing TLIF surgery. Declarations Ethics approval and consent to participate: This study was approved by the Institutional Review Board (Review Board of Changhai Hospital, Navy Medical University), and all patients in our study provided written informed consent for the study and surgery. Consent for publication: All authors agreed with this publication. Availability of data and materials: The datasets used and/or analysed during the current study available from the corresponding author on reasonable request. Competing interests: There is no competing interests in this study. Author contributions: Lianjie Pu, Kai Chen: Data collection Zhen Tan and Beier Luo: Data analysis Mingyuan Yang and NingFang Mao: supervision and proofread Lianjie Pu, Kai Chen and Zhen Tan wrote the main manuscript text. All authors reviewed the manuscript. Funding: This study was supported by National Natural Science Foundation of China (82102525) Acknowledgments: We thank Zhijian Wang (Shanghai Hebu Film Culture Co., Ltd) for the paintings of Figure 1. References Fang X, Zhang M, Wang L, Hao Z. Comparison of PLIF and TLIF in the Treatment of LDH Complicated with Spinal Stenosis. J Healthc Eng 2022; 2022 : 9743283. de Kunder SL, van Kuijk SMJ, Rijkers K, et al. Transforaminal lumbar interbody fusion (TLIF) versus posterior lumbar interbody fusion (PLIF) in lumbar spondylolisthesis: a systematic review and meta-analysis. Spine J 2017; 17 (11): 1712-21. Mobbs RJ, Phan K, Malham G, Seex K, Rao PJ. Lumbar interbody fusion: techniques, indications and comparison of interbody fusion options including PLIF, TLIF, MI-TLIF, OLIF/ATP, LLIF and ALIF. J Spine Surg 2015; 1 (1): 2-18. Lee CS, Kang KC, Chung SS, Park WH, Shin WJ, Seo YG. How does back muscle strength change after posterior lumbar interbody fusion? J Neurosurg Spine 2017; 26 (2): 163-70. Huang ZB, Nie MD, Zhang NZ, et al. Biomechanical evaluation of a short-rod technique for lumbar fixation surgery. Front Bioeng Biotechnol 2022; 10 : 959210. Yang M, Pu L, Liu S, et al. Clinical outcomes of short rod technique in posterior lumbar interbody fusion surgery: a minimum of 2-year follow-up. Eur Spine J 2023. Kameyama K, Ohba T, Endo T, et al. Radiological Assessment of Postoperative Paraspinal Muscle Changes After Lumbar Interbody Fusion With or Without Minimally Invasive Techniques. Global Spine J 2023; 13 (2): 295-303. Sun Y, Zhang W, Zhang F, Li J, Guo L. Study of single-level lumbar degenerative diseases treated by unilateral wiltse access with unilateral nail rod fixation assisted by a new automatic retraction device. J Orthop Surg Res 2023; 18 (1): 66. Wiltse LL, Bateman JG, Hutchinson RH, Nelson WE. The paraspinal sacrospinalis-splitting approach to the lumbar spine. J Bone Joint Surg Am 1968; 50 (5): 919-26. Wiltse LL, Spencer CW. New uses and refinements of the paraspinal approach to the lumbar spine. Spine (Phila Pa 1976) 1988; 13 (6): 696-706. Li Y, Du Y, Ji A, et al. The Clinical Effect of Manual Reduction Combined with Internal Fixation Through Wiltse Paraspinal Approach in the Treatment of Thoracolumbar Fracture. Orthop Surg 2021; 13 (8): 2206-15. Song Q, Leng J, Qu Z, et al. Treatment of Scoliosis with One-Stage Posterior Pedicle Screw System by Paraspinal Intermuscular Approach: A Minimum of Two Years of Follow-Up. Orthop Surg 2022; 14 (11): 3100-10. Tu Z, Li L, Wang B, Li Y, Lv G, Dai Y. Stand-Alone Anterolateral Interbody Fusion Versus Extended Posterior Fusion for Symptomatic Adjacent-Segment Degeneration: A Retrospective Study of 2 Years' Follow-up. World Neurosurg 2018; 115 : e748-e55. Timon SJ, Gardner MJ, Wanich T, et al. Not all spondylolisthesis grading instruments are reliable. Clin Orthop Relat Res 2005; (434): 157-62. Griffith JF, Wang YX, Antonio GE, et al. Modified Pfirrmann grading system for lumbar intervertebral disc degeneration. Spine (Phila Pa 1976) 2007; 32 (24): E708-12. Tsuji T, Watanabe K, Hosogane N, et al. Risk factors of radiological adjacent disc degeneration with lumbar interbody fusion for degenerative spondylolisthesis. J Orthop Sci 2016; 21 (2): 133-7. Abdullah F, Bai A, Sahil F, et al. Lumbar Disc Herniation: Comparing Pain Relief After Medical and Surgical Intervention. Cureus 2021; 13 (6): e15885. Ma Z, Huang S, Sun J, Li F, Sun J, Pi G. Risk factors for upper adjacent segment degeneration after multi-level posterior lumbar spinal fusion surgery. J Orthop Surg Res 2019; 14 (1): 89. Meng B, Bunch J, Burton D, Wang J. Lumbar interbody fusion: recent advances in surgical techniques and bone healing strategies. Eur Spine J 2021; 30 (1): 22-33. Chen S, Li B, Liu S, et al. Sagittal imaging study of the lumbar spine with the short rod technique. Eur Spine J 2022. Modi HN, Suh SW, Hong JY, Yang JH. Accuracy of thoracic pedicle screw using ideal pedicle entry point in severe scoliosis. Clin Orthop Relat Res 2010; 468 (7): 1830-7. Cannizzaro D, Anania CD, Safa A, et al. Lumbar adjacent segment degeneration after spinal fusion surgery: a systematic review and meta-analysis. J Neurosurg Sci 2023; 67 (6): 740-9. Epstein NE. Adjacent level disease following lumbar spine surgery: A review. Surg Neurol Int 2015; 6 (Suppl 24): S591-9. Wang ZA, Zeng ZY, Zhang JQ, et al. [Different interbody fustion cages and combined fixation through intermuscular approach for lumbar diseases:a case control study]. Zhongguo Gu Shang 2020; 33 (4): 337-47. Wang T, Ding W. Risk factors for adjacent segment degeneration after posterior lumbar fusion surgery in treatment for degenerative lumbar disorders: a meta-analysis. J Orthop Surg Res 2020; 15 (1): 582. Hu Z, Tseng CC, Li J, et al. Dynamic change of pelvic incidence after long fusion to pelvis with S2-alar-iliac screw: a 2-year follow-up study. Eur Spine J 2022; 31 (12): 3566-72. Wang H, Ma L, Yang D, et al. Incidence and risk factors of adjacent segment disease following posterior decompression and instrumented fusion for degenerative lumbar disorders. Medicine (Baltimore) 2017; 96 (5): e6032. Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4180310","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":286832644,"identity":"7ab294b9-4506-4922-9baa-f6384f432279","order_by":0,"name":"Lianjie Pu","email":"","orcid":"","institution":"Kunming Dongchuan District People's Hospital","correspondingAuthor":false,"prefix":"","firstName":"Lianjie","middleName":"","lastName":"Pu","suffix":""},{"id":286832645,"identity":"883ac328-3a24-4455-b102-7eb44fe3cd1c","order_by":1,"name":"Kai Chen","email":"","orcid":"","institution":"Navy Medical University","correspondingAuthor":false,"prefix":"","firstName":"Kai","middleName":"","lastName":"Chen","suffix":""},{"id":286832647,"identity":"87f1b65b-55af-40bf-a749-83d613b405d3","order_by":2,"name":"Zhen Tan","email":"","orcid":"","institution":"General Hospital of Western Theater Command","correspondingAuthor":false,"prefix":"","firstName":"Zhen","middleName":"","lastName":"Tan","suffix":""},{"id":286832649,"identity":"e04bdf04-2053-4b6b-a5b6-0ad947464360","order_by":3,"name":"Beier Luo","email":"","orcid":"","institution":"Navy Medical University","correspondingAuthor":false,"prefix":"","firstName":"Beier","middleName":"","lastName":"Luo","suffix":""},{"id":286832651,"identity":"e887b216-d3bb-4e00-a355-bf95a505ae96","order_by":4,"name":"Mingyuan Yang","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABBklEQVRIiWNgGAWjYNACAyid8KOGh5+Z+fAD4rV87DkmJ9nOlmaAVzUyYJzBxmxscJ5HQQKv+cfPHn51o+CO3YYbyc8e8/CwJW4+zAO0tcYmGqeWM3lp1jkGz5I33EgzN+axkEncdpj3wAOGY2m5Dbi0HMgxM84xOJxscCPBTBpky7bDfAkGjA2HcWs5/wamJf2bNA8bc+LmZh4DCbxabuQYPwZqsQMyzCTB3mcmoEXyxhszZqCWBMkzb8okQIEscRgYyAl4/MJ3Psf4c86fw/Z8x9O3SYCjsv/w4QcfamxwalE4wMAGioXEBQeQhRNwKAcB+QYG5g9A2l4el6GjYBSMglEwCgCBDGF1qI505QAAAABJRU5ErkJggg==","orcid":"","institution":"Navy Medical University","correspondingAuthor":true,"prefix":"","firstName":"Mingyuan","middleName":"","lastName":"Yang","suffix":""},{"id":286832652,"identity":"cf5e131a-5c0a-439a-8529-7b843fd964b2","order_by":5,"name":"NingFang Mao","email":"","orcid":"","institution":"Navy Medical University","correspondingAuthor":false,"prefix":"","firstName":"NingFang","middleName":"","lastName":"Mao","suffix":""}],"badges":[],"createdAt":"2024-03-28 07:27:21","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4180310/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4180310/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":54043002,"identity":"8e814ff6-cd89-464d-853c-f5a13e6b4854","added_by":"auto","created_at":"2024-04-03 18:27:08","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":705271,"visible":true,"origin":"","legend":"\u003cp\u003eThe illustration of this novel entry point of implantation of pedicle screws. A. The pars interarticularis ridge and accessory process ridge of the superior facet cranially along the lateral of the lamina were firstly exposed (Red line), and the bony surface of the recessed triangular region between the two ridges and the entry point was the midpoint of this internal recess (Yellow point). B. The illustration of this novel entry point during the operation. C. The illustration of this novel entry point in lateral X ray.\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-4180310/v1/f4b2d53739b5dfab1ed79f48.png"},{"id":54043003,"identity":"d82bbef2-1e4e-4e4f-85ed-ff72102e6007","added_by":"auto","created_at":"2024-04-03 18:27:08","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":2307702,"visible":true,"origin":"","legend":"\u003cp\u003eThe surgical technique of SRT through intermuscular approach in PLIF surgery\u003c/p\u003e\n\u003cp\u003eA. A posterior midline incision was made in the skin. Multifidus and longisis muscle space were separated after incising the skin, subcutaneous and low back fascia layer by layer\u003c/p\u003e\n\u003cp\u003eB. The exposure of the entry point of SRT was achieved\u003c/p\u003e\n\u003cp\u003eC and D. Pedicle screws were inserted after satisfied fluoroscopy with positioning needles\u003c/p\u003e\n\u003cp\u003eE. The success of implantation of pedicle screws through intermuscular approach\u003c/p\u003e\n\u003cp\u003eF. Intraoperative fluoroscopy showed good position of SRT\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-4180310/v1/70dfa621340b2b28f6b53355.png"},{"id":71201321,"identity":"28b106a4-a170-4265-ba48-4388b28a7727","added_by":"auto","created_at":"2024-12-12 06:17:45","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":5312097,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4180310/v1/2af05b66-64be-41ee-97a7-9c162078a848.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Clinical outcomes of Short Rod Technique in transforaminal lumbar interbody fusion surgery through Wiltse approach: A case series report","fulltext":[{"header":"Introduction","content":"\u003cp\u003eTransforaminal lumbar interbody fusion (TLIF) surgery was proved to be an effective surgical approach for the clinical treatment of various lumbar spinal disorders, due to its significant advantages in clinical application\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e. As a traditional lumbar approach, the TLIF is a surgery that the majority of spinal surgeons are well trained and comfortable in performing\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e. However, the conventional open approach technique require a large midline skin incision, extensive detachment and prolonged retraction of back muscles from the spinal processes, while it is regarded as a paraspinal iatrogenic injury associated with prolonged muscle retraction, may leading to great volumes of intra-operative blood loss, postoperative low back pain, delay recovery and mobilization\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e. According to previous study, after TLIF, strength in back muscles decreased until 3 months postoperatively but significantly increased after that period\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e. Therefore, many minimally tnvasive techniques and improved approaches have been proposed and used in TLIF surgery to protect the paraspinal muscles, such as short rod technique\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e,\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e, minimally invasive lateral lumbar interbody fusions (LLIF) with percutaneous pedicle screws (PPS)\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e, Wiltse approach, and et al.\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e We present for the first time a novel entry point of pedicle screws (Short Rod Technique, SRT, Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e), which can avoid superior facet violation with relatively small wound incision, and the results showed better recovery of patients\u0026rsquo; HRQOL (Health of Related Quality of Life) and reduction of the occurrence of upper adjacent segment degeneration (ASD) in TLIF surgery.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eIn 1968, Dr. Wiltse first described a new approach by splitting the muscles between the multifidus and longissimus to retain the integrity of the posterior osseous structure and the ligamentous complex to the maximum\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e. He later modified his approach so that it could be applied in other lumbar diseases\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e. Different with traditional spine surgery which needs dissection of bilateral muscles, this approach does not need to intraoperatively strip the paraspinal muscles, and many advantages of this approach have been fverified, such as less trauma, less intraoperative bleeding, and quicker recovery\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e. Therefore, Wiltse approach has been widely used in the surgical treatment of spine surgeries, especially for elder patients who could not suffer the variety of complications including deep vein thrombosis, hypostatic pneumonia, and pressure sores. Li et al\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e reported good clinical effects of manual reduction combined with internal fixation through Wiltse approach in the treatment of thoracolumbar fracture. Song et al\u0026rsquo;s study\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e showed that this original one-stage posterior PIA (paraspinal intermuscular approach) was safe and effective in the treatment of scoliosis.\u003c/p\u003e \u003cp\u003eRecently, we present for the first time a novel entry point of pedicle screws (Short Rod Technique, SRT), which can avoid superior facet violation and has been verified as a safe screw placement method with good clinical outcomes\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e. The key note of SRT is the protection of the posterior complex of the spine, including the supraspinous ligament, interspinous ligament, capsule of the articular process, and superior facet, which has been verified to be associated with adjacent segment degeneration (ASD), postoperative wound pain, delayed bedridden time and et al. In order to detect whether SRT through Wiltse approach could achieve good clinical outcomes in TLIF surgery, we combined these two surgical techniques toghther in the TLIF surgery.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eSubjects\u003c/h2\u003e \u003cp\u003e64 patients who received TLIF surgery with SRT through Wiltse approach in our hospital from January 2020 to January 2022 were recruited in this study.\u003c/p\u003e \u003cp\u003eThe inclusion criteria were: 1) Patients were diagnosed with lumbar disorders, including lumbar disc herniation and lumbar spinal stenosis, and required one -level TLIF surgery; 2) Type 10\u0026ndash;11 cage and polyaxial screws from the same company were implanted; 3) A minimum of 2-year follow-up; 4) Sufficient radiological data on posteroanterior full-length stand film, including preoperative, postoperative (discharged), and follow-ups, as well as sufficient assessments of HRQOL; 5) Preoperative and follow-up Lumbar MRI were also required.\u003c/p\u003e \u003cp\u003eThe exclusion criteria of patients were: 1) Patients diagnosed with lumbar disorders who did not receive TLIF surgery; 2) Spondylolisthesis was excluded from this study because the location of SRT might move forward with the fronted vertebral body, making it difficult to find; 3) Insufficient radiological data and follow-up. Those who were lost to follow-up or lacked sufficient radiological data in the follow-ups were excluded from this study.\u003c/p\u003e \u003cp\u003eAll of the surgeries were performed by the same surgeon and in the same manner. To control for surgical biases that might influence the results, only patients who received TLIF surgery with cages of type 10\u0026ndash;11 were recruited to standardize the interbody height and length of connecting rods. This study was approved by the Institutional Review Board (Review Board of Changhai Hospital, Navy Medical University), and all patients in our study provided written informed consent for the study and surgery.\u003c/p\u003e \u003cdiv id=\"Sec4\" class=\"Section3\"\u003e \u003ch2\u003eSurgical Technique\u003c/h2\u003e \u003cp\u003eThe patient was placed on the operating table in a prone position on a Jackson table under general anaesthesia. A posterior midline incision was made in the skin. Multifidus and longisis muscle space were separated after incising the skin, subcutaneous and low back fascia layer by layer (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eA). As illustrated in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e and Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eB, the exposure of the entry point of SRT was achieved. Pedicle screws were inserted after satisfied fluoroscopy with positioning needles (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eC and \u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eD). Figure\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eE showed the success of implantation of pedicle screws and the intraoperative fluoroscopy showed good position of SRT (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eF). Facet joints were removed to reveal the intervertebral disc. The disc tissue and cartilage were gradually removed with an intervertebral reamer. The screw and rod system of the opposite side were used to assist in maintaining intervertebral distraction. Then, the polyetheretherketone (PEEK) interbody cages filled with allografts of type 10\u0026ndash;11 size were placed into the intervertebral space. Connection rods were implanted. Finally, the incision was washed and drainage tube was placed in the bilateral muscle space before suture, layer by layer.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eData Collection\u003c/h2\u003e \u003cp\u003eDenographics data including age, gender, BMD (Bone Mineral Density, T value) and BMI (Body Mass Index, kg/m\u003csup\u003e2\u003c/sup\u003e) were collected.\u003c/p\u003e \u003cp\u003eSurgical variables such as operation time, length of wound, intraoperative blood loss, length of connection rods (the length between the middle point of screws in upper instrumented vertebra and it in lower instrumented vertebra), total postoperative drainage volume before removall and days of removal of drainage were collected and analysed.\u003c/p\u003e \u003cp\u003eRadiological data before surgery, after surgery (Discharged) and at final follow-ups were collected and analyzed, including: LL (Lumbar Lordosis, the the angle between upper endplate of L1 and lower endplate of L5), SS (the angle between the horizontal and the sacral plate), PT (the angle between the vertical and the line through the midpoint of the sacral plate to femoral heads axis), PI (angle subtended by a perpendicular from the upper endplate of S1 and a line connect- ing the center of the femoral head to the center of the upper endplate of S1), SVA (the horizon- tal offset from the posterosuperior corner of S1 to the vertebral body of C7), disc hight of upper adjacent segmen (Disc Hight was average of the anterior and posterior heights of the disc and measured on anteroposterior radiographs)\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e, slippage distance of upper adjacent segment, which was measured as reported\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e, and upper disc degeneration on MRI which was defined according to the modified Pfirrmann grading system\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e. In addition, the psotoperative loss of disc hight of upper adjacent segmen and loss of disc hight of upper adjacent segmen at final follow-up was defined as: [(Postoperative disc hight of upper adjacent segment at follow-up - preoperative disc hight of upper adjacent segment)/preoperative disc hight of upper adjacent segment]*100%; and [(Disc hight of upper adjacent segment at follow-up - preoperative disc hight of upper adjacent segment)/preoperative disc hight of upper adjacent segment]*100%, respectively. The calculation of psotoperative change of slippage distance of upper adjacent segment and change of slippage distance of upper adjacent segment at final follow-up was the same as loss of disc hight.\u003c/p\u003e \u003cp\u003eWhether there occurred ASD in these patients is defined as follows\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e: 1). Disc height reduction of more than 3 mm or 20% of the preoperative disc height seen on a lateral radiograph; 2). Upper adjacent vertebral slippage of more than 3 mm compared with the preoperative condition seen on lateral radiographs; and 3). Osteophyte formation greater than 3 mm; 4). The classification of adjacent intervertebral discs increased by more than 1 grade compared with the preoperative condition using the modified Pfirrmann grading system\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e; or whether there occurred Adjacent Segement Disease (ASDis) which is defined by the need for a revision surgery procedure to address adjacent level pathology.\u003c/p\u003e \u003cp\u003eRegarding HRQOL, VAS was used to assess back pain, leg pain, and wound pain\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e, and the clinical outcomes were assessed by the Oswestry Disability Index (ODI)\u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e. Additionally, VAS was used to assess patients\u0026rsquo; wound pain 3 days after surgery, which were assessed at the same time periods. All data were measured by two independent reviewers.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eStatistical analyses were performed using SPSS 19.0 statistics software (SPSS Inc, Chicago, IL). Descriptive statistics were listed as mean and standard deviation (SD). A χ2 test was used to compare the categorical variables, such as Pfirman classification of the upper adjacent segment. t-test was carried out for descriptive statistics pre- to postoperatively or follow-up to postoperatively. \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered significant.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 64 patients who received TLIF surgery with SRT through Wiltse approach in our hospital from January 2020 to January 2022 were recruited in this study. The average age was 58.8 years-old (37\u0026ndash;75 years-old). The ratio of male and female was 28:36. Majority of these patients (71.9%, 46/64) suffered from osteoporosis with the mean BMD of -1.59 (T value). 11 patients sufffered from obesity with the BMI greater than 24 kg/m\u003csup\u003e2\u003c/sup\u003e. All the data were shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eGeneral characterisics, surgical variables, radiological parameters, and HRQOL of the recruiters\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMinimum\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMaximum\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMean\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eStandrd Deviation\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDemographic Data\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (yeaars old)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e37.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e75.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e58.80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e9.23\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender (Male/Female)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c5\" namest=\"c2\"\u003e \u003cp\u003e28/36\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBMD (T value)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-2.60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-1.59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.83\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBMI (kg/m\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17.10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e22.16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.98\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of ASD (n)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c5\" namest=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSurgical Variables\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOperation time (minuts)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e80.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e130.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e107.42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e13.37\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLength of wound (cm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7.42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.47\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntraoperative blood loss (ml)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e168.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e300.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e230.47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e44.93\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLength of connection rods (mm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e19.97\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.98\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal postoperative drainage volume before removall (ml)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e60.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e27.88\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e10.27\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDays of removal of drainage (n)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.08\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.27\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eRadiological Parameters\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePreoperative\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLL (\u003csup\u003eo\u003c/sup\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e28.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e54.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e39.67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6.70\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSS (\u003csup\u003eo\u003c/sup\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e38.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e30.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4.50\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePT (\u003csup\u003eo\u003c/sup\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e36.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e22.61\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5.85\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePI (\u003csup\u003eo\u003c/sup\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e44.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e59.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e52.61\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3.46\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSVA (mm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e42.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e28.16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6.04\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDisc hight of upper adjacent segment (mm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10.20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16.30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13.64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.41\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSlippage distance of upper adjacent segment (mm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.73\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePfirman classification of upper adjacent segment\u003c/p\u003e \u003cp\u003e(I/II/III/IV/V/VI/VII/VIIII)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"4\" morerows=\"1\" nameend=\"c5\" namest=\"c2\" rowspan=\"2\"\u003e \u003cp\u003e2/7/33/22/0/0/0/0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePostoperative\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLL (\u003csup\u003eo\u003c/sup\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e57.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e44.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5.87\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSS (\u003csup\u003eo\u003c/sup\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e39.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e30.72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3.60\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePT (\u003csup\u003eo\u003c/sup\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e32.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e20.73\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4.43\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePI (\u003csup\u003eo\u003c/sup\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e46.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e58.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e51.64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.68\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSVA (mm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e38.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e26.63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDisc hight of upper adjacent segment (mm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10.20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16.30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13.54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.50\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSlippage distance of upper adjacent segment (mm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.70\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePfirman classification of upper adjacent segment\u003c/p\u003e \u003cp\u003e(I/II/III/IV/V/VI/VII/VIIII)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c5\" namest=\"c2\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFinal Follow-up\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLL (\u003csup\u003eo\u003c/sup\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e55.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e41.37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5.77\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSS (\u003csup\u003eo\u003c/sup\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e36.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e28.94\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3.96\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePT (\u003csup\u003eo\u003c/sup\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e33.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e21.98\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4.76\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePI (\u003csup\u003eo\u003c/sup\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e46.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e55.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e50.92\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.18\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSVA (mm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e43.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e30.56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4.45\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDisc hight of upper adjacent segment (mm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8.10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12.90\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.68\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSlippage distance of upper adjacent segment (mm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.72\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePfirman classification of upper adjacent segment\u003c/p\u003e \u003cp\u003e(I/II/III/IV/V/VI/VII/VIIII)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c5\" namest=\"c2\"\u003e \u003cp\u003e0/3/22/34/2/1/0/2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHRQOL\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBack Pain (VAS)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreoperative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6.31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.99\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostoperative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.61\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.63\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFinal Follow-up\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.92\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.40\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLeg Pain (VAS)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreoperative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.64\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostoperative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.66\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFinal Follow-up\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.51\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eODI\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreoperative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e59.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e77.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e69.28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4.66\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostoperative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e40.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e18.39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e7.48\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFinal Follow-up\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e70.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10.94\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e11.24\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePostoperative wound pain (VAS)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1st day\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.08\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2nd day\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.95\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.74\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3rd day\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.44\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eAll these recruited patients received TLIF surgery with SRT through Wiltse approach in single fusion level with the average operation time of 107.42 minuts. As shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, the length of wound was relatively shorter than TLIF surgery with traditional entry point, with the mean value of 7.42 cm, as well as the length of connection rods with the mean value of 19.97 mm. In addition to the shorter length of wound and length of connection rods, the combition of SRT and Wiltse approach has also the following advantages: 1). Less intraoperative blood loss with the mean value of 230.47 ml. The majority of intraoperative blood loss happened during the operation of implantation of cage. 2). Less total postoperative drainage volume before removall with the mean value of 27.88 ml. Less paraspinal muscles were damaged and less blood loss happened during the procedure of implantation of pedicle screws, leading to less total postoperative drainage volume. 3). Shorter days of removal of drainage (1.08\u0026thinsp;\u0026plusmn;\u0026thinsp;0.27) was also observed in SRT through the Wiltse approach due to the less total postoperative drainage volume. All the data were shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003eThe mean value of preoperative LL was 39.67 with the standrd deviation of 6.7 (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Lumbar lordosis was significantly restored after the operation with the mean vales of 44.03 (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001, Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). However, lumbar lordosis was significantly decreased at final follow-up (41.37\u0026thinsp;\u0026plusmn;\u0026thinsp;5.77 vs. 44.03\u0026thinsp;\u0026plusmn;\u0026thinsp;5.87, P\u0026thinsp;=\u0026thinsp;0.011, Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Besides, less change of LL was observed at final follow-up than it at post-operation with significant difference (4.51\u0026thinsp;\u0026plusmn;\u0026thinsp;9.60 vs. 11.94\u0026thinsp;\u0026plusmn;\u0026thinsp;9.44, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001, Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). No significant difference of SS was observed between preoperation and postoperation (30.00\u0026thinsp;\u0026plusmn;\u0026thinsp;4.50 vs. 30.72\u0026thinsp;\u0026plusmn;\u0026thinsp;3.60, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.320, Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e and Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e), while SS was significantly decreased at final follow-up with the \u003cem\u003eP\u003c/em\u003e value of 0.009 (28.94\u0026thinsp;\u0026plusmn;\u0026thinsp;3.96 vs. 30.72\u0026thinsp;\u0026plusmn;\u0026thinsp;3.60, Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). In addition, the change of SS between final follow-up-preoperative was significantly different with it between postoperative-preoperative as shown in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e (-2.58\u0026thinsp;\u0026plusmn;\u0026thinsp;12.96 vs. 3.43\u0026thinsp;\u0026plusmn;\u0026thinsp;10.92, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.005). PT was significantly decreased at post-operation (20.73\u0026thinsp;\u0026plusmn;\u0026thinsp;4.43 vs. 22.61\u0026thinsp;\u0026plusmn;\u0026thinsp;5.85, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.043), while it was not significantly changed at final follow-up (21.98\u0026thinsp;\u0026plusmn;\u0026thinsp;4.76 vs. 20.73\u0026thinsp;\u0026plusmn;\u0026thinsp;4.43, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.127), as shown in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. The change of PT between final follow-up-preoperative was significantly different with it between postoperative-preoperative as shown in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e (1.99\u0026thinsp;\u0026plusmn;\u0026thinsp;28.04 vs. -6.28\u0026thinsp;\u0026plusmn;\u0026thinsp;14.53, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.038). PI remained constant before and after the surgery with no significant difference of change of PI, as shown in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e and Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. As to the SVA, no significant difference was found between postoperation and preoperation (26.63\u0026thinsp;\u0026plusmn;\u0026thinsp;5.01 vs. 28.16\u0026thinsp;\u0026plusmn;\u0026thinsp;6.04, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.121, Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e), while it was increased at final follow-up with significant difference compared with postoperation (30.56\u0026thinsp;\u0026plusmn;\u0026thinsp;4.45 vs. 26.63, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of radiological parameters and HRQOL between preoperation, post-operation and final follow-up\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePreoperative\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePostoperative\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e value\u003c/p\u003e \u003cp\u003e(Postoperative \u003cem\u003evs\u003c/em\u003e Preoperative)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eFinal Follow-up\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e value\u003c/p\u003e \u003cp\u003e(Final Follow-up \u003cem\u003evs\u003c/em\u003e Postoperative)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRadiological Parameters\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLL (\u003csup\u003eo\u003c/sup\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e39.67\u0026thinsp;\u0026plusmn;\u0026thinsp;6.70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e44.03\u0026thinsp;\u0026plusmn;\u0026thinsp;5.87\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003eP\u003c/b\u003e\u0026thinsp;\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e41.37\u0026thinsp;\u0026plusmn;\u0026thinsp;5.77\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.011\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSS (\u003csup\u003eo\u003c/sup\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30.00\u0026thinsp;\u0026plusmn;\u0026thinsp;4.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30.72\u0026thinsp;\u0026plusmn;\u0026thinsp;3.60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.320\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e28.94\u0026thinsp;\u0026plusmn;\u0026thinsp;3.96\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.009\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePT (\u003csup\u003eo\u003c/sup\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22.61\u0026thinsp;\u0026plusmn;\u0026thinsp;5.85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20.73\u0026thinsp;\u0026plusmn;\u0026thinsp;4.43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.043\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e21.98\u0026thinsp;\u0026plusmn;\u0026thinsp;4.76\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.127\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePI (\u003csup\u003eo\u003c/sup\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e52.61\u0026thinsp;\u0026plusmn;\u0026thinsp;3.46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e51.64\u0026thinsp;\u0026plusmn;\u0026thinsp;2.68\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.079\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e50.92\u0026thinsp;\u0026plusmn;\u0026thinsp;2.18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.098\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSVA (mm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e28.16\u0026thinsp;\u0026plusmn;\u0026thinsp;6.04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26.63\u0026thinsp;\u0026plusmn;\u0026thinsp;5.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.121\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e30.56\u0026thinsp;\u0026plusmn;\u0026thinsp;4.45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003eP\u003c/b\u003e\u0026thinsp;\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eUpper Adjacent Segments\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDisc hight of upper adjacent segment (mm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13.64\u0026thinsp;\u0026plusmn;\u0026thinsp;1.41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13.54\u0026thinsp;\u0026plusmn;\u0026thinsp;1.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.689\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e12.90\u0026thinsp;\u0026plusmn;\u0026thinsp;1.68\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.027\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSlippage distance of upper adjacent segment (mm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.23\u0026thinsp;\u0026plusmn;\u0026thinsp;0.73\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.17\u0026thinsp;\u0026plusmn;\u0026thinsp;0.70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.608\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3.36\u0026thinsp;\u0026plusmn;\u0026thinsp;0.72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.133\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePfirman classification of upper adjacent segment\u003c/p\u003e \u003cp\u003e(I/II/III/IV/V/VI/VII/VIIII)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2/7/33/22/0/0/0/0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0/3/22/34/2/1/0/2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHRQOL\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBack Pain (VAS)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6.31\u0026thinsp;\u0026plusmn;\u0026thinsp;0.99\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.61\u0026thinsp;\u0026plusmn;\u0026thinsp;0.63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003eP\u003c/b\u003e\u0026thinsp;\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.92\u0026thinsp;\u0026plusmn;\u0026thinsp;1.40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.105\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLeg Pain (VAS)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7.06\u0026thinsp;\u0026plusmn;\u0026thinsp;0.64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.14\u0026thinsp;\u0026plusmn;\u0026thinsp;0.66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003eP\u003c/b\u003e\u0026thinsp;\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.53\u0026thinsp;\u0026plusmn;\u0026thinsp;1.51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.004\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eODI\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e69.28\u0026thinsp;\u0026plusmn;\u0026thinsp;4.66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18.39\u0026thinsp;\u0026plusmn;\u0026thinsp;7.48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003eP\u003c/b\u003e\u0026thinsp;\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e10.94\u0026thinsp;\u0026plusmn;\u0026thinsp;11.24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003eP\u003c/b\u003e\u0026thinsp;\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCopmarisons of change of Radiological Parameters and HRQOL between Postoperative-Preoperative and Final follow-up-Preoperative\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePostoperative-Preoperative\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFinal follow-up-Preoperative\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRadiological Parameters\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChange of LL (\u003csup\u003eo\u003c/sup\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11.94\u0026thinsp;\u0026plusmn;\u0026thinsp;9.44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.51\u0026thinsp;\u0026plusmn;\u0026thinsp;9.60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003eP\u003c/b\u003e\u0026thinsp;\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChange of SS (\u003csup\u003eo\u003c/sup\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.43\u0026thinsp;\u0026plusmn;\u0026thinsp;10.92\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-2.58\u0026thinsp;\u0026plusmn;\u0026thinsp;12.96\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.005\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChange of PT (\u003csup\u003eo\u003c/sup\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-6.28\u0026thinsp;\u0026plusmn;\u0026thinsp;14.53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.99\u0026thinsp;\u0026plusmn;\u0026thinsp;28.04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.038\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChange of PI (\u003csup\u003eo\u003c/sup\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-1.99\u0026thinsp;\u0026plusmn;\u0026thinsp;5.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-2.82\u0026thinsp;\u0026plusmn;\u0026thinsp;7.36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.459\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChange of SVA (mm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-4.47\u0026thinsp;\u0026plusmn;\u0026thinsp;9.15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12.05\u0026thinsp;\u0026plusmn;\u0026thinsp;23.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003eP\u003c/b\u003e\u0026thinsp;\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eUpper Adjacent Segments\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLoss of disc hight of upper adjacent segment (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-0.72\u0026thinsp;\u0026plusmn;\u0026thinsp;4.66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-5.41\u0026thinsp;\u0026plusmn;\u0026thinsp;7.43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003eP\u003c/b\u003e\u0026thinsp;\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChange of slippage distance of upper adjacent segment (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-1.11\u0026thinsp;\u0026plusmn;\u0026thinsp;13.81\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.85\u0026thinsp;\u0026plusmn;\u0026thinsp;12.89\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.013\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePfirman classification of upper adjacent segment\u003c/p\u003e \u003cp\u003e(I/II/III/IV/V/VI/VII/VIIII) at final follow-up\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003e0/3/22/34/2/1/0/2\u003c/p\u003e \u003cp\u003eFinal follow-up vs. Preoperative: \u003cb\u003eP\u003c/b\u003e\u0026thinsp;\u003cb\u003e=\u0026thinsp;0.038\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHRQOL\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eImprovement of VAS of Back Pain (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-90.24\u0026thinsp;\u0026plusmn;\u0026thinsp;10.13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-84.36\u0026thinsp;\u0026plusmn;\u0026thinsp;27.94\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.116\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eImprovement of VAS of Leg Pain (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-83.65\u0026thinsp;\u0026plusmn;\u0026thinsp;9.69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-92.39\u0026thinsp;\u0026plusmn;\u0026thinsp;21.51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.004\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eImprovement of ODI (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-73.29\u0026thinsp;\u0026plusmn;\u0026thinsp;10.97\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-83.98\u0026thinsp;\u0026plusmn;\u0026thinsp;17.22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003eP\u003c/b\u003e\u0026thinsp;\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eAccording to criteria of ASD, 2 patients suffered from ASD at final follow-up, and they also received revision surgery. Obesity was found in these two patients with BMI of 28.5 and 28.3 kg/m\u003csup\u003e2\u003c/sup\u003e, as well as sever osteoporosis with BMD of -2.6 and \u0026minus;\u0026thinsp;2.5 (T value). Due to these two patients, the loss of disc hight of upper adjacent segment between follow-up-preoperative was significantly decreased than it between postoperative-preoperative (-5.41\u0026thinsp;\u0026plusmn;\u0026thinsp;7.43 vs. -0.72\u0026thinsp;\u0026plusmn;\u0026thinsp;4.66, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001, Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e); and change of slippage distance of upper adjacent segmen between final follow-up-preoperative was significantly increased than it betweeen postoperative-preoperative (4.85\u0026thinsp;\u0026plusmn;\u0026thinsp;12.89 vs. -1.11\u0026thinsp;\u0026plusmn;\u0026thinsp;13.81, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.013, Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). In addition, more degeneration of intervertebral disc was also observed at final follow-up with the Pfirman classification ((I/II/III/IV/V/VI/VII/VIIII) of upper adjacent segment at final follow-up (0/3/22/34/2/1/0/2 vs. 0/3/22/34/2/1/0/2, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.038, Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e and Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003ePatients suffered from severe back pain, leg pain and disability with the mean VAS value of 6.31 in back pain, 7.06 in leg pain and ODI value of 69.28, respectively. SRT in TLIF surgery through Wiltse approach was an effective sugical technique since all these recruited patients\u0026rsquo; back pain, leg pain and disability were significantly improved after the operation (all \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001, Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). However, due to the occurrence of ASD in 2 patients, the mean value of leg pain and ODI was significantly different in final follow-up compared with the postoperation, as shown in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. In addition, due to the less damage of paraspinal muscles, patients felt mild wound pain after the operation with the VAS value of 2.08, 0.95 and 0.25 at 1st day, 2nd day and 3rd day, respectively, as shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e"},{"header":"Disscussion","content":"\u003cp\u003eTLIF surgery allows for circumferential decompression of the neural elements with relatively small injury compared with PLIF surgery (Posterior lumbar interbody fusion), and has been widely used in treatment of lumbar spinal disorders\u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e. Dissection of bilateral muscles is widely used to access the posterior column of the vertebral body during the TLIF surgery, while it is regarded as a paraspinal iatrogenic injury. Therefore, many minimal invasive approaches have been proposed to avoid bad clinical outcomes related to the dissection of bilateral muscles, such as the Wiltse approach, the oblique trajectory anterior to psoas (ATP) approach, minimally invasive transforaminal lumbar interbody fusion (MIS TLIF), and et al. SRT has been verified as a safe screw placement method with good clinical outcomes by our previous study, such as greater reduction in wound pain, reduction of ASD and anatomical structure advantage\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e,\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e. To minimise the injury of paraspinal muscles during the TLIF surgery and accelerate patients\u0026rsquo; recovery, we combined SRT technique with Wiltse approach, and the clinical outcomes of SRT through Wiltse approach in TLIF surgery were reported as follows:\u003c/p\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eLess blood loss and better HRQOL\u003c/h2\u003e \u003cp\u003eSRT was a relatively easy technique for surgeons to learn and operate since the location of the entry point of SRT was relatively stable, did not change with vertebral degeneration, and was easy to locate in each vertebra (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). While in TLIF surgery with tradtional entry points, it is common for the anatomical structures of pedicles in some elderly patients to be severely degenerative, making it harder to find the regular entry point and implant the screws, which might cause nerve injury and other severe surgical complications\u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e. Besides, less exposure of the bilateral muscles, superior facet joint and facet joint capsule was required in TLIF surgery with SRT through Wiltse approach. All these factors made this surgery eariser and safter as well as the shorter operation time. In our surgry, the majority of operation time was used in the depression procedure rather than the implantation of pedicle screws which might be difficult in TLIF surgery with tradtional entry points. Furthermore, with the shift-down of the pedicle screw entry point in SRT, resulting in a shorter wound length and connection rods length in the SRT, which was consistent with our previous study\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eMore important, less injury of bilateral muscles, superior facet joint and facet joint capsule in our operation resulted in less intraoperative blood loss, especially during the procedure of exposure of the entry point. In our study, blood loss was observed during the procedure of depression of nerve roots and implantation of interbody cages rather than the implantation of pedicle screws. Consequently, the total postoperative drainage volume before removall and days of removal of drainage were both significantly decreased compared with TLIF surgery with traditional entry point, may leading to shorter hopital days and less economic burdens. In addition, due to the less damage of paraspinal muscles and less intraoperative blood loss, patients felt mild wound pain after the operation with the VAS value of 2.08, 0.95 and 0.25 at 1st day, 2nd day and 3rd day, respectively. Consequently, the less postoperative drainage volume, less days of removal of drainage and mild postoperative wound pain accelerate patients\u0026rsquo; recovery and improved patients\u0026rsquo; quality of life, which was the most be the most significant advantage of SRT in TLIF surgery through Wiltse approach. Therefore, SRT through Wiltse approach is recommended in TLIF surgery, especially for long fusion levels, since less posterior complex, facet joint, and paraspinal muscles are incised, resulting in greater improvement of wound pain.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eReduction of ASD with SRT through Wiltse approach\u003c/h2\u003e \u003cp\u003eAdjacent segment degeneration (ASD) is among the most recognized long-term complications of lumbar surgery for degenerative spine pathologies with a relevant impact in spine surgical and clinical practice\u003csup\u003e\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e. It has been verified that several factors are associated with ASD. The posterior complex, including the superior facet joint, facet joint capsule, and paraspinal muscles, plays an important role in lumbar stabilization, and intraoperative superior facet joint violation might cause deduced adaptability to biomechanical change and has been verified as an important risk factor for ASD after spine fusion surgery\u003csup\u003e\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e. We compared the incidence of ASD in PLIF surgery with SRT and regular PLIF surgery with traditional entry points, and our results\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e showed that in one-level and three-level fusions, there was a significant difference in the incidence of ASD between SRT and regular PLIF surgery, indicating that applying SRT in PLIF surgery could play a protective role against ASD development. In our opinion, the application of SRT during TLIF surgery could protect the superior facet joint, facet joint capsule, and muscles and could help avoid superior facet joint violation, ultimately decreasing the occurrence of ASD as well.\u003c/p\u003e \u003cp\u003eFurthermore, since the protection of paraspinal muscles has been verified to play important role in reduction of ASD during the spine surgery, Wiltse approach has been proposed and used in the operation, and good clinical outcomes have been reported\u003csup\u003e\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e. We combined SRT and Wiltse approach in TLIF surgery, hoping to avoid the occurrence of ASD as far as possible. In our study, only 2 patients suffered from ASD with low back pain and leg pain at final follow-up according to the criteria of ASD. MRI showed disc herniation with nerve root compression at upper adjacent segment above the first surgery. Consequently, these two patients received revision surgery, and their symptoms were significantly relieved. Interestingly, obesity was found in both patients with BMI of 28.5 and 28.3 kg/m\u003csup\u003e2\u003c/sup\u003e, as well as sever osteoporosis with BMD of -2.6 and \u0026minus;\u0026thinsp;2.5 (T value). Our results were consistent with Cannizzaro et al\u0026rsquo;s study\u003csup\u003e\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e which reported that obesity were relevant risk factors for developing lumbar adjacent segment degeneration, indicating that SRT through Wiltse approach was recommended in obese patients.\u003c/p\u003e \u003cp\u003eThe incidence of ASD in our study was 3.12%, whch was significantly lower than it reported in previous study\u003csup\u003e\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e,\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e, which might be contributed the protection of superior facet joint, facet joint capsule, and paraspinal muscles in both SRT technique and Wiltse approach. Therefore, the application of SRT through Wiltse approach as a noval surgical method, is recommended in TLIF surgery to reduce the occurrence of ASD. However, smple size, measurement erors and selection biases might influence our results, and extensive multicenter studies will be needed.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eRestoration of Sagittal Parameters\u003c/h2\u003e \u003cp\u003eLumbar lordosis was restored in our study as a result of cage implantation, which has been verified as a primary contributor\u003csup\u003e\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e. Combined with the significant change of LL and the lower incidence of ASD in the SRT group through Wiltse approach, we speculated that better postoperative sagittal alignment might play an important role in the development of ASD, which was consistent with Wang et al.\u0026rsquo;s meta-analysis\u003csup\u003e\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e. Interestingly, the reason why the SRT technique could increase lumbar lordosis could be due to the direction of SRT\u0026rsquo;s projection, as verified in our previous study\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e. In SRT, the screws are implanted in the direction of 10-20\u003csup\u003eo\u003c/sup\u003e to the endplate in the sagittal plane (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eC), which might result in more compression pressure, leading to greater lumbar lordosis\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e. Besides, the protection of paraspinal muscles in Wiltse approach might provide sufficient lumbar stabilization, leading to the stable lumbar lordosis.\u003c/p\u003e \u003cp\u003ePelvic incidence (PI) is a key morphological parameter that reflects the relation between the sacrum and iliac wings. It is well accepted that PI remains constant after reaching maturity\u003csup\u003e\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e. PI remained constant in our study no matter after operation or at final follow-up, which was constient with previoud study\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e. Pelvic tilt (PT) and sacral slope (SS) are pelvic compensatory parameters which paly important role in the sagittal balance, which is widely evaluated by SVA (Sagittal Vertical Axis). Lumbar lordosis decreased with aging possibly due to disc degeneration, whereas PT increases to restore sagittal balance as a compensatory mechanism. In our study, due to the restoration of lumbar lordosis and sagittal balance (SVA), PT decreased significantly after the operation with increased SS.\u003c/p\u003e \u003cp\u003eWang et al.\u003csup\u003e\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u003c/sup\u003e speculated that abnormal sagittal alignment could negatively affect the adjacent segments, and our findings also indicated that restoring sagittal alignment, especially for the lumbar lordosis, is the key to reducing ASD. Notably, SRT could provide more compression pressure during the sagittal restoration procedures, leading to lower rates of ASD as well as the providence of lumbar stabilization by Wiltse approach.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eLimitation\u003c/h2\u003e \u003cp\u003eIn this study, we present for the first time a novel entry point of pedicle screws (Short Rod Technique, SRT) through Wiltse approach in TLIF surgery. Although good clinical outcomes have been reported, some limitations in this study should not be neglected. First, First, all the patients recruited in our study were outpatients of a single center in China, which may result in selection bias and compromise the statistical power. Second, the sample size and the average follow-up time was relatively small. Thus, future studies with longer follow-ups and larger sample sizes should be conducted. Besides, only 2 patients suffered from ASD and were analyzed in our study. Larger number of ASD should be recruited and studied to detect whether SRT with through Wiltse approach could reduce the occurrence of ASD in TLIF surgery.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eApplication of SRT through Wiltse approach in TLIF surgery has been validated as an effective technique with good clinical outcomes, especially for reducing the blood loss and postoperative wound pain and improving patients\u0026rsquo; HRQOL. The present study provides spinal surgeons with a novel method for performing TLIF surgery.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate:\u0026nbsp;\u003c/strong\u003eThis study was approved by the Institutional Review Board (Review Board of Changhai Hospital,\u0026nbsp;Navy Medical University), and all patients in our study provided written informed consent for the study and surgery.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u0026nbsp;\u003c/strong\u003eAll authors agreed with this publication.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials:\u0026nbsp;\u003c/strong\u003eThe datasets used and/or analysed during the current study available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u0026nbsp;\u003c/strong\u003eThere is no competing interests in this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eLianjie Pu, Kai Chen: Data collection\u003c/p\u003e\n\u003cp\u003eZhen Tan and Beier Luo: Data analysis\u003c/p\u003e\n\u003cp\u003eMingyuan Yang and NingFang Mao: supervision and proofread\u003c/p\u003e\n\u003cp\u003eLianjie Pu, Kai Chen and Zhen Tan wrote the main manuscript text.\u003c/p\u003e\n\u003cp\u003eAll authors reviewed the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e This study was supported by National Natural Science Foundation of China (82102525)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments:\u0026nbsp;\u003c/strong\u003eWe thank Zhijian Wang (Shanghai Hebu Film Culture Co., Ltd) for the paintings of Figure 1.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eFang X, Zhang M, Wang L, Hao Z. Comparison of PLIF and TLIF in the Treatment of LDH Complicated with Spinal Stenosis. \u003cem\u003eJ Healthc Eng\u003c/em\u003e 2022; \u003cstrong\u003e2022\u003c/strong\u003e: 9743283.\u003c/li\u003e\n\u003cli\u003ede Kunder SL, van Kuijk SMJ, Rijkers K, et al. Transforaminal lumbar interbody fusion (TLIF) versus posterior lumbar interbody fusion (PLIF) in lumbar spondylolisthesis: a systematic review and meta-analysis. \u003cem\u003eSpine J\u003c/em\u003e 2017; \u003cstrong\u003e17\u003c/strong\u003e(11): 1712-21.\u003c/li\u003e\n\u003cli\u003eMobbs RJ, Phan K, Malham G, Seex K, Rao PJ. Lumbar interbody fusion: techniques, indications and comparison of interbody fusion options including PLIF, TLIF, MI-TLIF, OLIF/ATP, LLIF and ALIF. \u003cem\u003eJ Spine Surg\u003c/em\u003e 2015; \u003cstrong\u003e1\u003c/strong\u003e(1): 2-18.\u003c/li\u003e\n\u003cli\u003eLee CS, Kang KC, Chung SS, Park WH, Shin WJ, Seo YG. 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Incidence and risk factors of adjacent segment disease following posterior decompression and instrumented fusion for degenerative lumbar disorders. \u003cem\u003eMedicine (Baltimore)\u003c/em\u003e 2017; \u003cstrong\u003e96\u003c/strong\u003e(5): e6032.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Transforaminal lumbar interbody fusion, Short rod technique, Wiltse approach","lastPublishedDoi":"10.21203/rs.3.rs-4180310/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4180310/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eObjective\u003c/h2\u003e \u003cp\u003eWe present for the first time a novel entry point of pedicle screws (Short Rod Technique, SRT), which can avoid superior facet violation and has been verified as a safe screw placement method. The objective of this study is to report the clinical outcomes of SRT in transforaminal lumbar interbody fusion (TLIF) surgery through Wiltse approach.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eWe retrospectively analyzed the clinical outcomes of 64 patients who received SRT through Wiltse approach with a minimum of 2 years of follow-ups. Demographics, clinical outcomes and radiological parapmeters were recorded and analyzed.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eLess total postoperative drainage volume before removall (27.88\u0026thinsp;\u0026plusmn;\u0026thinsp;10.27), shorter days of removal of drainage (1.08\u0026thinsp;\u0026plusmn;\u0026thinsp;0.27) was observed in SRT through Wiltse approach. In addition, patients felt less wound pain after the surgery, improving their HRQOL. Upper adjacent segment degeneration (ASD) was found in 2 petients at final follow-up, and they also received revision surgery. Both back pain, leg pain and ODI improved after the surgery; however, due to the ASD patients, the mean value of leg pain and ODI were greater at final follow-up than they\u0026rsquo;re at post-operation. Less change of LL was observed at final follow-up than it at post-operation with significant difference. Compared with increase of SS at post-operation, SS decreased at final follow-up with significant difference of change of SS. PT decreased at post-operation, while it was found to be increased at final follow-up. PI remained constant before and after the surgery with no significant difference of change of PI. Sagittal alignment also tended to be imbalanced with the change of SVA signficantly greater at final follow-up than it at post-operation. In addition, due to the two cases of ASD, the loss of disc hight and change of slippage distance of upper adjacent segment were signficantly greater at final follow-up than they\u0026rsquo;re at post-operation. More degeneration of intervertebral disc was also observed at final follow-up.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eApplication of SRT through Wiltse approach in TLIF surgery has been validated as an effective technique with good clinical outcomes, especially for reducing the blood loss and postoperative wound pain and improving patients\u0026rsquo; HRQOL. The present study provides spinal surgeons with a novel method for performing TLIF surgery.\u003c/p\u003e","manuscriptTitle":"Clinical outcomes of Short Rod Technique in transforaminal lumbar interbody fusion surgery through Wiltse approach: A case series report","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-04-03 18:27:04","doi":"10.21203/rs.3.rs-4180310/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"f5e5fdea-4ac5-4ee7-a444-010cc8e3fcea","owner":[],"postedDate":"April 3rd, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-02-18T05:23:23+00:00","versionOfRecord":[],"versionCreatedAt":"2024-04-03 18:27:04","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4180310","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4180310","identity":"rs-4180310","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}