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

Introduction: Transforaminal lumbar interbody fusion (TLIF) is a surgical procedure used to treat spinal instability, radiculopathy, and degenerative disc diseases. These operations involve a facetectomy, removal of the facet joint, which can be performed unilaterally or bilaterally depending on the patient’s pathology. This study investigates whether there is a difference in patient satisfaction, as measured by Hospital Consumer Assessment of Healthcare Providers Systems (HCAHPS) survey, between unilateral and bilateral facetectomy.

Methods: One- and two-level TLIF procedures at a tertiary academic center were retrospectively reviewed for unilateral or bilateral facetectomies between 04/2016 and 12/2023. Variables collected included demographic, clinical, and surgical data. Patient satisfaction was measured by collecting HCAPHS scores which includes various domains such as communication, pain management, and overall rating of care. When comparing the outcomes between groups, continuous variables were examined using a t-test. Categorical variables were analyzed using chi-square tests. Logistic modeling was used 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.