 So, the talk is about this transforminal lumbar interbody fusion, that means the tailiff procedure. Principally this tailiff procedure is a 360 degree fusion, that means it's an anterior and posterior fusion in one stage. And there are some other techniques, that is the ALIF and the payload technique, that means the ALIF is the anterior lumbar interbody fusion, that means you have to do a two-stage surgery with an anterior approach and a dorsal approach, anterior approach for the fusion of the vertebral bodies and posterior fusion for the dorsal fixation, that means the screws and the rods, with the potential errors of the anterior approach, that means the risk of vessel injury, of some retrocute ejaculation because of harm to the plexus, and the disadvantage is that this is a two-stage surgery. Another technique was the piliff technique, I show you a picture of this, but with this technique you have a removal of the dorsal posterior elements, you have enormous retraction of the dura and the nerve roots, serious risk of CSF leak and higher risk of period and the neural fibrosis, and so it was harms, and he's a well-known spine surgery who asked what to do better in interbody fusion, so he developed this tailiff technique, and you see this is an image explaining the piliff technique, that means the posterior lumbar interbody fusion, so the approach is on both sides, you remove these posterior parts and put a cage through the spinal canal, bilateral in the interbody disc base, and with the tailiff technique the idea is to come from a lateral part, to go through the foramen and not touch the medial, the spinal structures, so this was principally the idea, and you see these are the positions of the piliff cages, they are through the spinal canal, and this is the position of the tailiff cage coming from transforminal, so the first step in the tailiff technique is the placement of the screws, and on the non-approach side you will approach it here, you can place the rod in the first step, we are placing all pedicle screws with a navigation system, and we have this Akkadis 3D system, you see this is the reference frame at the spinal process, this is the acquisition of the data during the surgery, that means the approach is done, we cover the page with a sterile drape, and then we do this circular data acquisition, the camera, and what we have, we have this electric burr, and it's referenced, so we have this reference feature fixed at this Akku drill, and you see you can, this is the tip of the drill, and then you can really very precise predict your trajectory in all the planes, and in this reconstruction you see the pedicle here, and you know this, you have your trajectory, and then you're going with the drill in, you have a three millimeter hole then, and then you can place the pedicle screws, this was very early results, we begin with the tail-lift technique in 2002, and for the first five years we did about 80 procedures, meanwhile we are doing about 70 or 80 procedures a year with this technique, and we are all collecting our data in an international database, it's called Spine Tango, it has his seat in Switzerland, and we are sending all our data from spinal procedures there, they are collected there, you can ask, you have to pay them, and then provide all your data, and you can ask for your data, and they send it to you, provide also by mathematicians, and you also can make a benchmark with other departments and other centers, and we are, at the moment we are looking for the results of the tail-lift, but these were some early results, and this was the time where we changed from non-navigated to fluoroscopy, this is a navigated procedure, this flu-emerge navigated procedure to our actual Akkadis three-dimensional navigation system, and you see, since we are using that we have some tolerable screw placement, that means in between zero or two millimeter, but without neurological complications, and so since we are using this system we had to only to revise one, two screws by more than thousand, so the system works really very precise, yes, and the other thing is that spine surgeons, I post to a lot of radiation during surgery, and with this navigation system, we can go out of the theater, and so there's zero radiation exposure to the surgeon, yes, so these are really two advantages and two really important things for using the navigation system, so after placing the screws, the rod we will not put in this, in the first step you try to have access to the disc, that means you first remove the superior facet, and then the inferior facet, and you collect all the bone, and then you see you have, through the foramen, you have the access to the disc, you open the disc and do a nuclear to me, you can see and protect the nerve root, you see the dura here, and you can cover it with this piece of the disc, and there are some special curved instruments, some currets, sharp currets, and spoons to remove as much as possible of the disc and the end plates, you see there were some crasping devices, and after that the next step is to do a little distraction along the rod, so you establish your disc height again, then you put the harvested bone in the anterior part of the disc, and after that the placement of the cage, it depends there are different heights available, and for distraction there are also some special devices, so you can distract a little bit more, and the cage must be in the anterior third of the disc space, and then you can fill with some devices a little bit more bone chips, and after the placement of the cage you do a slightly compression again, and with this disc in front and with a slightly compression you re-establish the lordosis, and this is the procedure, then if possible some bone chips along the segment, and there are some open telephoreations possible, and as neurosurgeons the patient with leg pain they come to us, so they have a compression of nervous neuronal structures, and the orthopedics they are mostly treating with back pain, so they can do some percutaneous procedures, and so they place the screws where we are via percutaneous technique, and there is a tubular system to place the cage, and so you have less trauma to the tissue, but mostly we have to consider a decompression, and because neuronal structures are compressed, and there you can either select the selective inter-creatic compression, so you put your rods and then you do an undercutting bilateral decompression, and in ismic spondylolisthesis, which is almost always at level L5, you have to decompress the foramina on both sides, and the recessals, so if you are decompressing this area and this area, the lamina is completely loosened, so you can remove the whole lamina, so in ismic spondylolisthesis we do what is called the JILS procedure, that means there is actually a laminectomy at L5, and these are results taken from the Indian Journal of Autopedics, so the posterior approach allows easy access to the lamina, to the ligamentum flammum and the fascia joints, it allows a posterior instrumentation, it has less soft tissue, but these are for these percutaneous systems, shorter or hour time, less blood loss, then compared with the payload technique, and the disadvantages are that the unilateral approach, but with the tubular system, prevents decompression of the opposite nerve root, and you have to try to completely remove the disc, so indications for this telive technique, and the contraindications, I want to highlight this pyrogenic spondylolisthesis also, because we are treating it the same way, these are results of the early publication of harms, so you had some really not much complications, and to be honest we are a little bit higher with our deep infections, there are less than 0.5% so we are about 3-4% in these procedures, but we will follow it up to see our data, this is in what we do in pyrogenic spondylolisthesis, you see the first thing is you have this disc infection here, and the first thing we do in the first step to open the iliac crest with a bone flap, remove the spongiosa and harvest it, and then we close the wound in the first step, and then we go to the infected area, and again we put these rods and do a transforminal discectomy, and put only the bone in, no PKH or no other implant, only the spongiosa, and we really have good results with this, and you see this is the drill with the navigation system again, only for diagnostic procedures, if you have patient with a, you see this degenerative spondylolisthesis, and to rule out if it's mobile or not, we think these inclination and reclineation x-rays are not showing the real truth, because they have pain and they do not move very, only a little bit in your back, and so we put them in a standing position, in a prone and the supine position, and you see really in this, so this is in standing, this is in a prone position, and this is in a supine position, and you see in between those two movements, you see there is an increasement in the listesis, so this is a really instable situation, and in these cases, we do not go for a decompression, but we do for, do this tea-lift technique, so this was after, this was an ismic spondylolisthesis here, and this was the tea-lift procedure, and the laminectomy, that's called this, this gel procedure, and this is the fusion after, I think, was something like a year.