Do we need a transforaminal lumbar interbody fusion cage to increase the stability of functional spinal unit when comparing unilateral and bilateral fixation?

Transforaminal lumbar interbody fusion was an alternative to posterior lumbar interbody fusion for decompression surgeries. This study investigates the biomechanical responses of the unilateral and bilateral pedicle screw fixations with/without transforaminal lumbar interbody fusion cages under axial compression, flexion, and torsional loads. Ovine vertebrae were used in this study. Cadavers, randomly divided into five, were intact control group, bilateral pedicle screw fixation group, bilateral pedicle screw fixation group with transforaminal lumbar interbody fusion cage, unilateral pedicle screw fixation group, and unilateral pedicle screw fixation group with transforaminal lumbar interbody fusion cage. Axial compression, flexion, and torsion tests were performed on specimens. All study groups provided higher stiffness and yield load values than control group under axial compression. Addition of transforaminal lumbar interbody fusion cage to bilateral fixation increased the stiffness under axial compression. Moreover, additional use of transforaminal lumbar interbody fusion in unilateral fixation increased the yield load values under axial compression. Control group was the stiffest in flexion test. Placing a transforaminal lumbar interbody fusion cage to both unilateral and bilateral fixations did not significantly change the stiffness values. Additional transforaminal lumbar interbody fusion cage increased the yield moment of the bilateral fixation. In torsion test, control group had the highest stiffness and yield torque. The facet joints are the most important parts of the vertebrae on the stability. When comparing the bilateral and unilateral fixations with transforaminal lumbar interbody fusion addition, the more facet preserving approach has significantly higher stability under axial compression, flexion, and torsion. Unilateral fixation with transforaminal lumbar interbody fusion cage can be said biomechanically stable and advantageous fixation system because of the advantage on the less facet and soft tissue resection compared to bilateral fixation with transforaminal lumbar interbody fusion.