Comparing Unilateral and Bilateral Facetectomy in Transforaminal Lumbar Interbody Fusion: Impact on Patient Satisfaction and Surgical Outcomes

Introduction: Transforaminal lumbar interbody fusion (TLIF) treats spinal instability, radiculopathy, and degenerative disc diseases. The operation involves a facetectomy which can be either unilateral or bilateral, based on the patient’s pathology. This study investigates whether patient satisfaction, as measured by Hospital Consumer Assessment of Healthcare Providers Systems (HCAHPS) survey, differs between unilateral and bilateral facetectomy.

Methods: A retrospective review of one- and two-level TLIF procedures at a tertiary care center from 04/2016 to 12/2023 analyzed unilateral and bilateral facetectomies. Variables collected included demographic, clinical, and surgical data. Patient satisfaction was measured using HCAPHS scores which includes various domains such as communication, pain management, and overall rating of care. Outcome comparisons used t-tests for continuous variables and chi-square tests for categorical variables, with logistic modeling for multivariable regression.

Results: In a cohort of 71 unilateral and 143 bilateral facetectomy TLIF patients, the average follow-up was 25.8 and 21.0 months, respectively, with no significant demographic differences between groups. No differences were noted in operative time, length of stay, number of levels fused or decompressed between cohorts. Open operations more often involved bilateral facetectomy (116 vs. 41 cases), while minimally invasive surgeries more frequently had unilateral facetectomy (30 vs. 27) (p = < 0.001). The bilateral cohort had higher rates of postoperative infections, instrument failure, DVT, revision surgery, and 90-day readmission or ED visits (p = < 0.001). The unilateral cohort had more future surgeries at different levels (p < 0.001). There was no difference in HCAPHS outcomes for “Overall Health” or “Mental Health” between cohorts. Bilateral facetectomy was associated with worse “Overall Health” and improved “Mental Health” scores; however, this was not statistically significant. Increased BMI and active smoking status was associated with poorer “Overall Health” scores (p = 0.018) and “Mental Health” scores (p = 0.030), respectively.

Conclusion : TLIF procedures with unilateral versus bilateral facetectomies have similar HCAPHS outcomes; however, bilateral cohort incurred significantly increased postoperative complications. Surgical consent discussions should weigh the benefit of the bilateral facetectomy with the increased surgical risks.