Hydrodissection Of Wiltse'S Plane To Facilitate Exposure During Minimally Invasive Transforaminal Lumbar Interbody Fusion

Traditional posterior lumbar approaches in a transforaminal lumbar interbody fusion (TLIF) require subperiosteal dissection of bilateral paraspinal muscles to provide adequate exposure. This may traumatize the multifidus muscle and its afferent innervations leading to postoperative paraspinal muscle atrophy. Minimizing such intraoperative trauma has been identified as an important factor in the reduction of postoperative lumbar pain. An approach via a blunt dissection through Wiltse's plane, which lies between the longissimus and multifidus muscles, may minimize postoperative pain. Definition of this plane may be facilitated by local injection of 1% lidocaine within the plane itself, as well as in the musculature defining its borders.In this paper, we demonstrate this technique with a 55-year-old female patient who presented with left-sided radicular leg pain in an L5 distribution. Wiltse plane hydrodissection was utilized in performing an L4-5 TLIF. Ultrasound images of the patient's sub-fascial musculature were obtained pre- and posthydrodissection to assess the elucidation of this plane through this technique. Intraoperative images were obtained following dissection of Wiltse's plane to further illustrate the facilitation of exposure of Wiltse's plane through hydrodissection. Postoperatively the patient did well citing a complete resolution of her radicular pain. She did not require intravenous (IV) pain medication, as her postoperative pain was well controlled with oral pain medication. She was mobilized on post-op day one, and discharged home on post-op day two with minimal back pain.Our initial experience supports the feasibility, safety, and effectiveness of hydrodissection of Wiltse's plane to facilitate exposure during a minimally invasive TLIF and thereby reducing postoperative pain.