1. Back to
Living
A patient’s
guide to
low back
pain

2. If you’ve been struggling with back pain The least invasive
solution to lumbar fusion
then you know firsthand the impact that the
pain can have on your life. Fortunately there
are advancements in treating back pain that,
after conservative treatments have failed,
can help ease your pain and help get you
back to living.
A new fusion procedure called AxiaLIF® is
changing the way many doctors approach
spine fusion — and is making the road to
recovery for patients much easier.
Unlike the open spine surgeries of the past, the
AxiaLIF® procedure gives surgeons the ability
to stabilize painful joints in the spine through
very small incisions. The procedure spares the
muscles and supporting soft-tissues of the
spine which means less surgical trauma and an
overall less painful post-operative experience
— many patients are released from the hospital
the day after surgery.
This guide to low-back pain has been
developed to help patients better
understand how the spine works, and
the conditions that may be causing their
pain. Along with highlighting the various
procedures used to treat pain in the lumbar
spine, this guide will introduce you to the
AxiaLIF® procedure that is changing the
way people think about back surgery —
and helping them get back to living.
The information in this guide is provided for general
education and is not intended to replace professional
medical care or advice. Only your physician and/or surgeon
is qualified to diagnose or recommend treatment for your
pain or related conditions.

3. The
Table of Healthy
Contents Spine
The Healthy Spine 5
Understanding the Low Back 7
How We Talk About the Spine 7
The Bones in the Lumbar Spine 8
The Bones in the Sacral Spine 8
The Vertebrae 9
Intervertebral Discs 10
The Spinal Cord and Nerve Roots 11
Facet Joints 12
Conditions Causing Low Back Pain 13
Degenerative Disc Disease 16
Spondylolisthesis 17
Spinal Stenosis 18
Treatments 19
Surgical Treatments 21
Fusion Techniques 22
ALIF 23
PLIF 24
TLIF 25
Lateral Approach 26
AxiaLIF® 27
A Different Approach to Fusion 32
AxiaLIF Step-by-Step
®
30
AxiaLIF Patient Testimonials
®
33
What to Expect from the Procedure 34
Glossary of Terms 36

4. 6 7
The human spine is a well-protected
structure of bones and joints surrounded
by muscles and supporting soft-tissues.
We often only come to learn about its
unique structure at the time we may be
experiencing a problem, such as leg or back
pain. In order to understand the source of
(7) your pain, it is important to understand the
Cervical
Vertebrae structure of the healthy spine.
The spine consists of 33 bones
and is divided into 5 main areas:
(12)
Thoracic - Cervical Spine (Neck) 7 - Vertebrae
Vertebrae
- Thoracic Spine (Ribs) 12 - Vertebrae
- Lumbar Spine (Lower Back) 5 - Vertebrae
(5)
Lumbar - Sacral Spine (Pelvis) 5 – Vertebrae
Vertebrae
(naturally fused)
Sacral
Spine - Coccyx (Pelvis) 4 – Vertebrae
(naturally fused)
Coccyx
Understanding Your Low Back
Your low back, or lumbar spine, bears the
majority of the load for the spine. It holds
the weight and supports almost every type
of movement that your body performs.
Because the lumbar spine is under almost
constant physical stress its structure may
begin to fail over time. This is why the
lumbar spine is so commonly the source of
back pain.
How We Talk About the Spine
When doctors talk about the spine they
refer to each bone in the spine by a letter
and a number. As a patient, this initially may
be confusing. To simplify the terms, we will
focus on how we identify each vertebra in
your lower back.

5. 8 9
L1
L2 Transverse
Process Pedicle
5 Lumbar
L3 Vertebrae
L4
L5
Lamina
Spinous
Process
The Bones in Lumbar Spine The Vertebrae
The lumbar spine consists of five numbered The vertebrae bear the majority of weight
vertebrae: L1, L2, L3, L4, and L5. The “L” for the spine. The outermost layer of each
represents the lumbar spine, and the vertebra consists of hard bone called
number represents the order in which the cortical bone while the inside of the
vertebrae appear. L5 is the closest vertebra vertebra consists of cancellous bone, a
to your tailbone, farthest away from your porous bone structure.
head. The numbers of the vertebrae
get smaller as you move away from the The spinal cord passes through the vertebra
tailbone. Therefore L1 is the farthest lumbar via a bony ring called the spinal canal. The
vertebra from the tailbone. posterior elements of the spinal cord break
into the cauda equina, which is a series
of nerves and nerve roots that continues
The Bones in Sacral Spine through the spinal canal.
The bones of the sacral spine are normally
fused together. The five fused vertebrae The spinal canal is made up
however are still labeled S1 through S5 as if of different parts:
they were separate. The S1 vertebra is the • lamina
closest to the lumbar spine. The L5/S1 disc
• spinous process
space connects the lumbar and sacral spine
and is a common source of low back pain. • transverse processes
• pedicle

6. 10 11
Nucleus
Pulposus
Intervertebral Discs
Nerve
Roots
Annulus
Spinal
Cord
Intervertebral Discs The Spinal Cord and Nerve Roots
Between each vertebrae in the spine is The spinal cord passes through each
a disc that, when healthy, functions as vertebra via the spinal canal. When healthy,
a natural shock absorber between the the vertebral structure helps protect the
vertebra and helps maintain proper disc spinal cord and the sensitive nerves that
height. The intervertebral disc is made up extend from it. Most low back pain and
of two different parts: leg pain associated with spine conditions
• Annulus – a strong, outer ring of fibers originates from pressure that is placed on
that helps keep the vertebra intact these nerve roots when the bones in the
spine become misaligned or move too
• Nucleus – a soft, jelly-like center closely together.
consisting mostly of water that helps
absorb pressure

7. 12
Conditions
Facet Joint
Contributing
T Low
o
Back Pain
Facet Joints
Facet joints act as connectors for the
vertebrae in your spine and are involved in
the overall motion of the spine.
There is one facet joint on each side of a
vertebra. Known as synovial joints, these
joints allow the movement between two
bones. Ligaments and soft tissue surround
the facet joints and hold synovial fluid
which “grease” the joints to decrease
friction as they rub together.

8. 14 15
Painful conditions of the spine may be
difficult to understand because often the
pain is felt elsewhere, such as in your legs
or buttocks. This pain is caused by pressure
placed upon the nerves that pass through
your spine and extend through the rest of
your body.
We’ve seen how the healthy spine works
to protect its own structure, including
Stenosis
the spinal cord and the nerves that pass
through it. We’ll now focus on some
conditions that can compromise the normal
structure of the spine resulting in nerve
Spondylolisthesis compression and pain.
• Degenerative Disc Disease
• Spondylolisthesis
• Stenosis
Degenerative
Disc Disease

9. 16 17
Bone Spurs
Degenerative Forward Slip
Disc Disease at L5-S1
Vertebral Bodies
Degenerative Disc Disease (DDD) Spondylolisthesis
Degenerative disc disease is not truly a Spondylolisthesis occurs when one vertebra
disease. It’s a term used to describe the slips forward in relation to an adjacent
gradual deterioration of intervertebral discs vertebra. The symptoms that accompany
that may occur naturally with the aging spondylolisthesis include pain in the low
process or as result of injury. back, thighs and/or legs, muscle spasms,
• Loss of hydration in the disc can shrink weakness, and/or tight hamstring muscles.
the disc and compromise its ability to • Degree of slippage classified in grades,
act as a shock absorber between each Grade 1 being the least amount, Grade
vertebra IV the most
• Loss of disc height can place pressure • Many people affected experience
on the nerve roots causing pain in the no pain or symptoms
buttocks and legs
• May result from improper lifting of
• Ruptured discs can bulge and put heavy items, weightlifting, or high
pressure on nerves causing leg and impact sports, such as football or
back pain gymnastics
Common Symptoms Common Symptoms
• Low back pain • Low back pain
• Pain in legs and/or buttocks • Lordosis (swayback)
• Pain may increase while sitting or • Pain and/or weakness in legs
standing for extended time
• Tightness in the hamstrings
• Pain may decrease while walking, (muscles at back of thigh)
or laying down
• Symptoms grow worse with exercise

10. 18
Treatments
Spinal
Stenosis
Bone Spurs
Spinal Stenosis
Spinal stenosis is the narrowing of the
canal that surrounds the spinal cord.
The narrowing can be caused by the
enlargement of joints, arthritis, bone spurs
or the calcification of ligaments in the
spine. As the canal narrows, pressure may
be placed on nerves causing pain and/or
numbness felt in the back and legs.
• A degenerative condition that is
most common in older adults
• Years of wear-and-tear contribute
to the condition
• It is possible to be born with
spinal stenosis
Common Symptoms
• Low back pain
• Weakness, tingling, numbness
or pain in legs
• Standing or walking brings on
symptoms
• Rest may reduce symptoms
• Leaning forward often relieves
symptoms

11. 20 21
There are various methods of treating
low-back pain including both non-surgical,
and surgical techniques. Your doctor will
work closely with you to isolate the source
of your low-back pain and recommend
the course of treatment that is most
appropriate for you.
In most cases, a non-surgical treatment will
be recommended. Treatments can range
from exercise and behavior modification, to
medications that reduce pain or swelling,
or epidural injections. While some patients
may improve with non-surgical treatments,
others may try several treatments without
success. In such cases, doctors may
recommend a surgical treatment.
Surgical Treatments
To alleviate low-back pain there are
surgical processes, called spine fusion, that
help restore disc height, and immobilize
vertebrae to stop motion at painful joints
and reduce any unnatural pressure on the
neighboring nerve roots. These treatments
utilize surgical implants and natural bone
graft material that is placed between two
vertebrae after the surgical removal of the
damaged intervertebral disc material. In
healing, the graft material grows in the disc
space, joining the two vertebrae together
effectively eliminating the painful motion.

12. 22 23
Fusion Techniques
There are several surgical techniques
available for spine fusion. Traditional
techniques approach the spine directly
through open incisions, while newer,
minimally invasive techniques approach the
spine through small incisions. If you require
spine fusion, the fusion techniques selected
may depend on the treatment required for
your particular case, individual anatomy, or
on the preferences of your surgeon.
ALIF
Traditional Fusion
The ALIF procedure takes an anterior (from
• ALIF the front) approach to the spine through
(Anterior Lumbar Interbody Fusion)
an incision in the abdomen. The procedure
• PLIF is often performed by two surgeons. One
(Posterior Lumbar Interbody Fusion) general/vascular surgeon may provide
• TLIF access to the spine through the abdomen
(Transforaminal Lumbar Interbody Fusion)
and ensure all major vessels are successfully
retracted away from the surgical approach.
Minimally Invasive Techniques (MIS) The spine surgeon will then proceed to
remove all, or a portion of the damaged
• Lateral Interbody Fusion
disc and replace it with a surgical implant
• MIS TLIF and bone graft material. For additional
stability, a second posterior(from the back)
Least Invasive Techniques
procedure may be performed to insert
• AxiaLIF® support rods or screws.
• AxiaLIF 2L®
• Surgical time ranges from 3 to 8 hours
• Hospital stay ranges from 3 to 5 days
• Typically a 5-inch incision in abdomen
• Some risk of muscle and tissue scarring
• The procedure does not preserve ligaments
and tissues directly supporting the spine
• Risks reported in literature of vascular
injury, nerve injury, incontinence,
impotence, muscle and tissue scarring

13. 24 25
PLIF TLIF
The PLIF procedure takes a posterior Like the PLIF procedure, TLIF begins with a
(from the back) approach to the lumbar posterior (from the back) incision, however
spine through an incision in the patient’s the surgical angle approaches the vertebra
back. The surgeon must detach and move more laterally, or diagonally toward the
muscles attached to the vertebrae, and in patient’s side. The altered approach to the
some cases a portion of vertebral bone spine, compared to PLIF, limits some of the
called the lamina, may be removed for operative trauma to supporting muscle and
better visualization and access to the disc soft-tissue.
space.
To access the disc space, the surgeon may
• Surgical times ranges from 3 to 8 hours remove a portion of the lamina (a bone
• Hospital stay ranges from 3 to 5 days covering the spinal nerves) and all of the
facet joint, which is a major stabilizer of
• Typically a 6-inch incision the spine. The access route, though less
• Dissection of muscle and soft-tissue of invasive than the PLIF procedure, still
the spine can cause post-operative pain involves disruption of muscle, soft-tissue
and slow healing process and nerves and it may pose a risk of post-
• Risks reported in literature of vascular operative pain and complications.
injury, nerve injury, incontinence, • Surgical times range 2 to 4 hours
impotence, muscle and tissue scarring • Hospital stay ranges from 3 to 5 days
• Typically a 4-inch incision
• Risks reported in literature of vascular
injury, nerve injury, incontinence,
impotence, muscle and tissue scarring

14. 26 27
AxiaLIF ®
The Least Invasive
Solution to
Lumbar Fusion
LATERAL APPROACH
The lateral approach is a newer technique
that approaches the spine through a small
incision in the patient’s side. It avoids the
need to cut or remove muscles in the
patient’s back to approach the disc space.
The procedure is less traumatic, and can
offer better recovery time than open spine
procedures; however, the procedure is
effective only in treating vertebrae that are
easily accessed from the side. This excludes
the L5/S1 disc space and frequently L4/L5 in
some patients. These are two disc spaces
which are often the source of a patient’s
back pain and levels that are frequently
operated on.
• Less invasive than open spine
procedures
• Can offer faster patient recovery
• Lateral approach unable to access
the L5/S1 disc space
• Access to L4/L5 disc space may be
limited in some patients
• Risk of transient numbness and
prolonged thigh pain due to nerve
retraction during surgery

15. 28 29
AxiaLIF 360® and AxiaLIF®2L™
The AxiaLIF® procedure is the least invasive
approach to lumbar fusion. Rather than
accessing the spine from the back, through
muscle and supporting soft-tissue, or from
the front, through the abdominal cavity —
AxiaLIF® approaches the spine from below,
through a small 1-inch incision next to the
tailbone.
With this approach, no muscles or blood
vessels are retracted or dissected, and the
nerve roots at the back of the spine are
avoided, thus reducing the potential for
complications.
Access to the disc space is achieved
without compromising the outer supporting
structures of this disc, including the annulus
and major supporting ligaments. This allows
the surgeon to remove the damaged disc
from within, without sacrificing the overall
disc structure.
A strong, titanium rod is used to engage
the vertebral bodies above and below
the disc space. This allows the surgeon to
restore the height of the disc space which
can remove pressure from the nerves.
The AxiaLIF® procedure is the least invasive
approach to L5/S1 fusion and AxiaLIF® 2L™
offers a 2-level fusion with a single one-inch
incision.

16. 30 31
AxiaLIF Step-by-Step
®
Step 1 Step 4
Degenerative disc and improper disc height Bone growth material is inserted in place
before the AxiaLIF ® procedure. of the diseased disc
Step 2 Step 5
Access to the diseased disc is obtained Lost disc height is restored and the spine
is stabilized
Step 3
Center of the diseased disc is removed

17. 32 33
AxiaLIF®
A soft-tissue sparring Patient Testimonials
approach to fusion
• Return to work in as little as 2 weeks
unlike open procedures which may
require as many as 30 or more days
• Not an open procedure - percutaneous
approach means the entire procedure is “I feel very fortunate, that I got
done through a small tube referred to this physician who was
using the TranS1 approach.”
• Visually guided under flourscopy – a
live x-ray guides the surgeon during
the procedure, rather than using a large
incision for a direct view
• Small 1 inch incisions
• Surgical time typically less
than 2 hours “All around it’s just a better procedure.”
• Hospital stay typically ranges from
1 to 2 days
• Posterior fixation can be completed
in a single surgical setting
• Less likelihood of post-operative
complications
“It has changed my life . . . immediately.”
• No disruption of spine supporting
muscles or tissue which allows for
faster recovery
“After the surgery, I’m driving around
in my big truck and I’m crying. I’m
crying because I’ve got my life back.”

18. 34 35
What to Expect from
the AxiaLIF Procedure* ®
To help you understand what to expect What kind of follow-up can I expect?
from the AxiaLIF ® surgery, we have listed Follow-up varies from surgeon to surgeon.
the more common questions that patients However, your first follow-up visit will
ask. If you have further questions, please probably be within a few weeks of surgery,
consult your doctor. Your doctor is the then every few months for the first year.
best source of information regarding After the first year, you should be checked
your healthcare. annually.
What is the goal of surgery How do I rehabilitate after surgery?
of the AxiaLIF ® surgery? Every surgeon follows a slightly different
The primary goal of surgery is to relieve program. Your doctor will advise you
your pain. This will be acheived by accordingly.
stabilizing and fusing the vertebra(e).
As with any back surgery, relief of pain will When can I return to work?
vary from patient to patient. Typically, AxiaLIF ® patients can return
to work in 2 weeks.
How long will my surgery last?
Surgery time will vary from surgeon to What complications are
surgeon and patient to patient. On average, associated with the procedure?
AxiaLIF® surgery will take 1.5 to 2.5 hours. The most serious risk associated with
procedure is the risk of bowel perforation.
When can I go home from the hospital? Thankfully, this is treatable, non-permanent
Usually, a patient can leave the hospital and the occurence has been reported in
in one or two days. Typically you can be only 1/2 of 1% of all AxiaLIF ® procedures.
released once you have adjusted to oral You may be asked to do a bowel preparation
pain medications and you and your doctor prior to surgery to reduce the likelyhood of
are comfortable with your ability to get up any injury.
and move about without problems.
*Individual results may vary
When should I start feeling relief
from my back and/or leg pain?
Apart from the pain of surgery, which
may take days to recover from, you
may feel relief of back and leg pain
symptoms almost immediately
post-operatively.

19. 36 37
Glossary of Terms
Allograft – obtained from a bone bank, this Cauda Equina – a bundle of nerve roots
human bone graft material is placed between from the lumbar and sacral spinal nerves
vertebrae to develop fusion
Cervical Spine – the uppermost portion
Annulus – the outer casing of a vertebral disc of the spine; the neck
Anterior Lumbar Interbody Fusion (ALIF) Coccyx – the tailbone
– an operation where the lumbar spine is
approached from the front through an incision Contraindication – a factor that renders
in the abdomen the administration of a drug or device or
the carrying out of a medical procedure
Arthritis – inflammation of a joint, usually inadvisable
accompanied by pain, swelling, and changes
in structure Cortical Bone – the dense, hard outer
layer of bone material
Autograft – a bone graft taken from the
patient’s body that is placed between Degenerative Disc Disease – a slow
vertebrae to develop fusion deterioration of discs located between
vertebrae
Axial Lumbar Interbody Fusion (AxiaLIF ®)
the least invasive lumbar fusion technique Disc Degeneration – the deterioration of
where the spine is approached through a small a disc and possible loss of disc height
incision near the tailbone
Discectomy – removal of a portion of a
Bone Graft – bone taken from the patient herniated or degenerative intervertebral disc
during surgery or a bone substitute that is
used to take the place of removed bone or Dura Mater – a protective membrane
to fill a bony defect covering the spinal cord and brain
Bone Spurs – bony projections formed along Facet Joint – There is one facet joint on
joints that can limit motion and can cause pain each side of a vertebra, together these
(also called osteophytes) joints allow movement between two
vertebrae and provide stability
Cancellous Bone – open, latticed, or porous
inner bone structure

20. 38 39
Fluoroscope – a portable x-ray machine Minimally Invasive – a surgical procedure
used in surgery where a small incision is made and
instrumentation is used through this incision
Foramen – the small openings in the spine
which nerve roots pass through Nucleus Pulposus – center of the
intervertebral disc
Fusion - the joining together of two or
more vertebra Oswestry Disability Index (ODI) – a low back
pain disability questionnaire used to measure
Herniated Disc – a bulge in a disc that a patient’s permanent functional disability
can press on nerves and cause pain
Pedicle – strong portion of the spinal
Intervertebral Disc – a flat, round “cushion” vertebral bone that connects the front
that acts as a shock absorber between of the spine to the back of the spine
vertebrae
Pelvis – the bony structure formed by
Kyphosis – abnormal rearward curvature of the hip bones, sacrum, and coccyx
the spine, resulting in protuberance of the
upper back (hunchback) Posterior Lumbar Interbody Fusion -
(PLIF) – a spine fusion operation where
Lamina – a part of the vertebra located the patient’s lumbar spine is approached
in the back of the vertebral body through an incision in the lower back
Laminectomy – when part or all of the Radiculopathy – pain originating from a
lamina is removed pinched, compressed or irritated nerve root
that may extend into the extremities
Lordosis – abnormal forward curvature
of the spine in the lumbar region Sacroiliac Joints – joints that connect
the sacrum to the pelvis
Lumbar Spine – lower portion of the spine
between the thoracic spine and the sacrum. Sacrum – The sacrum consists of five
The lumbar spine consists of five bones vertebrae labeled S1-S5. The vertebrae are
(vertebrae) labeled L1-L5. normally fused, but in some patients may
not all be fused due to natural anatomic
variance.

21. 40 41
Sciatica – pressure on the sciatic nerve,
causing pain which radiates from the back
to the lower extremities
Spinous Process – bony portion opposite
the body of the vertebra
Spondylolisthesis – forward displacement of
one of the lumbar vertebrae over the vertebrae
below it
Learn more about AxiaLIF ® online
Spondylolysis – A crack in one or both sides
Our informative patient website includes
of the facet joint
patient testimonial videos, procedure
animations and additional resources
Spinal Stenosis – the narrowing of the spinal
to help answer your questions.
canal. Often results in compression putting
pressure on the nerve resulting in pain.
Please visit www.smallincisionsbigresults.com
Thoracic Spine – middle portion of the spine
below the cervical spine (neck) and above the
lumbar spine. This area consists of your upper
body and ribs.
Transforaminal Lumbar Interbody Fusion -
(TLIF) – an operation where the lumbar spine
is approached from the side
Transverse Processes – small, bony bumps
where back muscles attach to vertebrae
Related Journal Articles
• Perez-Cruet MJ, Khoo LT, Fessler RG: An Anatomic Approach to Minimally
Vertebra - (plural: vertebrae) – any one of the Invasive Spine Surgery: “Percutaneous Axial Lumbar Spine Surgery,
Surgical Techniques, St Louis: Quality Medical Publishing, Inc., 2006.
33 bony segments of the spinal column Copyright © 2006 Quality Medical Publishing, Inc.
• Marotta N, Cosar M, Pimenta L, Khoo LT: A Novel Minimally Invasive
Presacral Approach and Instrumentation Technique for Anterior L5-S1
Intervertebral Discectomy and Fusion, Neurosurgical Focus, January 2006.
Visual Analog Scale - A tool used to help a Copyright © 2006 The American Association of Neurological Surgeons.
person rate the intensity of certain sensations • Yuan P, Day T, Albert T, Morrison W, Pimenta L, Cragg A, Weinstein M: Anatomy
of the Percutaneous Presacral Space for a Novel Fusion Technique, Journal of
and feelings, such as pain. Spinal Disorders & Techniques, 2006 June; 19 (4):237-241.

22. USA
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Customer Service Tel: 866.256.1206 Fax: 910.332.1701
customerservice@TranS1inc.com
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Medpass International Limited, Windsor House, Barnett Way
Barnwood, Gloucester GL4 3RT, UK
Tel/Fax: +44 (0)1 452 619 2227
www.TranS1.com
© Copyright TranS1® 2004-2008. All Rights Reserved.
This product and its implantation are covered by one or more of the following U.S. and EP
Patents:
U.S. 6,575,979; U.S. 7,087,058; U.S. 6,558,386; U.S. 6,740,090; U.S. 6,790,210; U.S. 6,558,390;
U.S. 7,014,633; U.S. 6,899,716; U.S. 6,921,403; U.S. 7,309,338; EP 1257217 and EP 1578315
Additional U.S. and International Patents applied for. 45-0038 Rev. E 9-10-08