Comparison of minimally invasive fusion and instrumentation versus open surgery for severe stenotic spondylolisthesis with high-grade facet joint osteoarthritis. Eur Spine J. 2013;22:1731-1740. [PMID: 23479028 DOI: 10.1007/s00586-013-2732-6]

Impact of iatrogenic alterations on adjacent segment degeneration after lumbar fusion surgery: a systematic review

PURPOSE

Adjacent segment degeneration (ASDeg) and disease (ASDis) remain significant challenges following lumbar spinal fusion surgery, with reported incidences of 36% for ASDeg and 11% for ASDis within two to seven years post-operation. However, the mechanisms leading to the development of ASDeg are still poorly understood. This comprehensive review aims to elucidate the multifactorial etiology of ASDeg by examining important iatrogenic alterations associated with spinal fusion.

METHODS

A systematic review following PRISMA guidelines was conducted to identify clinical studies quantifying the occurrence of ASDeg and ASDis after lumbar fusion surgery. An EMBASE and citation search up to April 2023 yielded 378 articles. Data extracted encompassed study design, fusion type, sample size, patient age, and incidence of ASDeg and ASDis. A total of 87 publications were analyzed in the context of iatrogenic alterations caused by surgical access (muscle damage, ligament damage, facet joint damage) and instrumentation (fusion angle, immobilization).

RESULTS

Ligament damage emerged as the most impactful iatrogenic factor promoting ASDeg and ASDis development. Similarly, muscle damage had a significant impact on long-term musculoskeletal health, with muscle-sparing approaches potentially reducing ASDis rates. Immobilization led to compensatory increased motion at adjacent segments; however, the causal link to degeneration remains inconclusive. Fusion angle showed low evidence for a strong impact due to inconsistent findings across studies. Facet joint violations were likely contributing factors but not primary initiators of ASDeg.

CONCLUSION

Based on the analyzed literature, ligament and muscle damage are the most impactful iatrogenic factors contributing to ASDeg and ASDis development. Minimally invasive techniques, careful retractor placement, and ligament-preserving decompression may help mitigate these effects by reducing undue muscle and ligament trauma. Although it is not possible to definitively advocate for one or more techniques, the principle of selecting the most tissue-sparing approach needs to be scaled across surgical planning and execution. Further research is necessary to fully elucidate these mechanisms and inform surgical practices to mitigate ASDeg risk.

Long-Term Outcomes of Minimally Invasive vs. Traditional Open Spinal Fusion: A Comparative Analysis

Spinal fusion is a widely performed surgical intervention for managing degenerative spinal conditions, instability, and deformities. Traditionally, open spinal fusion has been the standard approach, offering direct visualization and access to spinal structures. However, advancements in surgical techniques have led to the development of minimally invasive spinal fusion (MISF) as an alternative, aiming to achieve comparable clinical outcomes while reducing surgical trauma, postoperative pain, and recovery time. Despite these advantages, concerns remain regarding the long-term effectiveness of MISF, particularly in terms of fusion rates, complication risks, and adjacent segment disease (ASD). This review critically examines the long-term outcomes of MISF compared to traditional open fusion, focusing on key factors such as perioperative outcomes, pain relief, functional recovery, fusion success rates, and cost-effectiveness. Perioperative data indicate that MISF is associated with reduced blood loss, shorter hospital stays, and lower infection rates but may involve longer surgical times and a steeper learning curve. Long-term clinical outcomes appear comparable between MISF and open fusion, with both techniques achieving high fusion rates and significant improvements in pain and function. However, the impact of MISF on adjacent segment disease remains inconclusive, with conflicting evidence regarding its potential biomechanical advantages. Cost-effectiveness analyses suggest that MISF may offer financial advantages in the long term by reducing hospitalization and rehabilitation expenses, despite higher initial surgical costs. Nonetheless, limitations in current research, including variability in study methodologies, patient selection, and surgeon expertise, necessitate further high-quality, long-term randomized controlled trials. This review synthesizes the current literature on MISF and traditional open fusion, identifies existing research gaps, and outlines future directions for optimizing surgical decision-making and improving patient outcomes.

Less Is More: Evaluating the Benefits of Minimally Invasive Spinal Surgery

This review aims to explore the evolution, techniques, and outcomes of minimally invasive spine surgery (MISS) within the field of neurosurgery. We sought to address the increasing burden of spine degeneration in a rapidly aging population and the need for optimizing surgical management. This review explores various techniques in MISS, drawing upon evidence from retrospective studies, case series, systematic reviews, and technological advancements in neurosurgical spine treatment. Various approaches, including endonasal cervical, transoral cervical, transcervical, mini-open/percutaneous, tubular, and endoscopic techniques, provide alternatives for current approaches to a range of spinal pathologies. The main findings of this review highlight potential advantages of MISS over traditional open surgery, including reduced complications, shorter hospital stays, and improved patient outcomes. Our research underscores the importance of adopting MISS techniques to optimize patient care in neurosurgical spine treatment.

Comparison of midline lumbar interbody fusion and minimally invasive transforaminal lumbar interbody fusion for treatment of lumbar degeneration disease

Midline lumbar interbody fusion (MIDLIF) and minimally invasive transforaminal interbody fusion (MIS-TLIF) are two minimally invasive lumbar fusion methods that have gained popularity in the past two decades. MIDLIF involves the use of cortical bone trajectory screws, whereas MIS-TLIF uses traditional pedicle screws. However, there is a significant lack of research directly examining the clinical efficacy of these two methods in treating single-segment lumbar degenerative diseases. Hence, the objective of our retrospective study is to assess and contrast the surgical and clinical results of MIDLIF and MIS-TLIF. The study population comprised 133 patients diagnosed with single-segment lumbar degenerative disease that received treatment using either MIDLIF (n = 65) or MIS-TLIF (n = 68) in our department from January 2017 to January 2019. The fusion rates for MIDLIF were consistently lower than MID-TLIF at all post-operative time periods of follow-up, however, the differences between the two groups were not statistically significant. The 1-year fusion rates were 81.5% (MIDLIF) and 83.8% (MIS-TLIF) (P = 0.728), and the 2-year fusion rates were 87.7% (MIDLIF) and 91.2% (MIS-TLIF) (P = 0.513). The final follow-up fusion rates were 93.8% (MIDLIF) and 95.6% (MIS-TLIF) (P = 0.653). MIDLIF had several advantages over MIS-TLIF, including a shorter operative time (135.2 ± 15.70 vs. 160.1 ± 17.2 min, P < 0.001), decreased intraoperative blood loss (147.9 ± 36.4 vs. 169.5 ± 24.7 mL, P < 0.001), and a shorter length of hospital stay (10.8 ± 3.1 vs. 12.4 ± 4.1d; P = 0.014). No significant differences were seen between the groups in terms of the postoperative day of ambulation, Oswestry dysfunction index (ODI) scores, and visual analog scale (VAS) scores for leg and lower back pain (P > 0.05). Although not significant (P = 0.707), MIDLIF (13.8%) had fewer overall complications than MIS-TLIF (16.2%). Therefore, compared to MIS-TLIF, MIDLIF provides perioperative benefits while achieving the same outcomes as MIS-TLIF in terms of fusion rate, pain relief, functional improvement, and complication rate.

Different lumbar fusion techniques for lumbar spinal stenosis: a Bayesian network meta-analysis

OBJECTIVE

To comprehensively compare and assess the effects of different lumbar fusion techniques in patients with lumbar spinal stenosis (LSS).

METHODS

PubMed, Embase, Cochrane Library, and Web of Science databases were systematically searched up to December 24, 2022 in this network meta-analysis. Outcomes were pain (pain, low back pain, and leg pain), Japanese Orthopaedic Association (JOA), Oswestry Disability Index (ODI), complications, reoperation, and fusion. Network plots illustrated the direct and indirect comparisons of different fusion techniques for the outcomes. League tables showed the comparisons of any two fusion techniques, based on both direct and indirect evidence. The efficacy of each fusion technique for LSS was ranked by rank probabilities.

RESULTS

Totally 29 studies involving 2,379 patients were eligible. For pain, percutaneous endoscopic transforaminal lumbar interbody fusion (Endo-TLIF) was most likely to be the best technique, followed by minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF), extreme lateral interbody fusion (XLIF), and transforaminal lumbar interbody fusion (TLIF). Percutaneous endoscopic posterior lumbar interbody fusion (Endo-PLIF) had the greatest likelihood to be the optimal technique for low back pain, followed sequentially by MIS-TLIF, minimally invasive posterior lumbar interbody fusion (MIS-PLIF), XLIF, Endo-TLIF, TLIF, oblique lumbar interbody fusion (OLIF), posterior lumbar interbody fusion (PLIF), and posterolateral lumbar fusion (PLF). MIS-PLIF was ranked the most effective technique concerning leg pain, followed by Endo-TLIF, MIS-TLIF, TLIF, Endo-PLIF, PLIF, OLIF, PLF, and XLIF. As regards JOA scores, Endo-TLIF had the maximum probability to be the best technique, followed by MIS-TLIF and TLIF. Endo-PLIF had the greatest likelihood to be the optimum technique for complications, followed by TLIF, MIS-TLIF, Endo-TLIF, OLIF, and XLIF.

CONCLUSION

Minimally invasive fusion techniques may be effective in the treatment of LSS, compared with traditional techniques. Minimally invasive techniques were likely non-inferior with regards to postoperative complications.

Management of Spinal Metastasis by Minimally Invasive Surgical Techniques: Surgical Principles and Indications-A Literature Review

BACKGROUND

Spinal metastasis is becoming more frequent. This raises the topics of pain and neurological complications, which worsen the functional and survival prognosis of oncological population patients. Surgical treatment must be as complete as possible in order to decompress and stabilize without delaying the management of the oncological disease. Minimally invasive spine surgical techniques inflict less damage on the musculocutaneous plan than opened ones.

METHODS

Different minimally invasive techniques are proposed in this paper for the management of spinal metastasis. We used our experience, developed degenerative and traumatic pathologies, and referred to many authors, establishing a narrative review of our local practice.

RESULTS

Forty-eight articles were selected, and these allowed us to describe the different techniques: percutaneous methods such as vertebro/kyphoplasty, osteosynthesis, mini-open surgery, or that through a posterior or anterior approach. Also, some studies detail the contribution of new technologies, such as intraoperative CT scan and robotic assistance.

CONCLUSIONS

It seems essential to offer a lasting solution to a spinal problem, such as in the form of pain relief, stabilization, and decompression. Our department has embraced a multidisciplinary and multidimensional approach to MISS, incorporating cutting-edge technologies and evidence-based practices.

Latest Developments in Minimally Invasive Spinal Treatment in Slovakia and Its Comparison with an Open Approach for the Treatment of Lumbar Degenerative Diseases

The study describes the benefits of MIS-TLIF (minimally invasive transforaminal lumbar interbody fusion) and compares them with OTLIF (open transforaminal lumbar interbody fusion). It compares blood loss, length of hospitalization stays (LOS), operation time, and return of the patient to the environment. A total of 250 adults (109 males and 141 females), mean age 59.5 ± 12.6, who underwent MIS-TLIF in the Neurosurgery Clinic (NSC) Ruzomberok, Slovakia, because of lumbar degenerative diseases (LDD), participated in this retrospective study. Data were obtained from the patients' medical records and from the standardized Oswestry Disability Index (ODI) index questionnaire. To compare ODI in our study sample, we used the Student's Paired Sample Test. To compare the MIS-TLIF and OTLIF approaches, a meta-analysis was conducted. Confidence intervals were 95% CI. The test of homogeneity (Chi-square (Q)) and the degree of heterogeneity (I² test) among the included studies were used. Statistical analyses were two-sided (α = 0.05). All monitored parameters were significantly better in MIS-TLIF group: blood loss (p < 0.001), operation time (p < 0.001), and ODI changes (p < 0.001). LOS (p < 0.042) were close to the significance level. ODI in the study sample decreased by 33.44% points after MIS-TLIF, and it significantly increased as well (p < 0.001). The percentage of patients who were satisfied with the surgery they underwent was 84.8%. The study confirmed that the MIS-TLIF method is in general gentler for the patient and allows the faster regeneration of patient's health status compared to OTLIF.

How to predict the culprit segment in percutaneous transforaminal endoscopic surgery under local anesthesia for surgical treatment of lumbar degenerative diseases? Radiologic images or clinical symptoms

Objective

Percutaneous transforaminal endoscopic surgery (PTES) is a novel, minimally invasive technique used to treat lumbar degenerative diseases (LDDs). PTES under local anesthesia was performed to treat the culprit segment of LDDs predicted by radiologic images or clinical symptoms, and the efficacy, security, and feasibility were evaluated.

Methods

Eighty-seven cases of LDDs with nerve root symptoms, which were not consistent with lumbar degenerative levels and degrees on MRI and CT, were treated with PTES under local anesthesia in a day surgery ward from January 2015 to December 2019. Forty-two patients, whose culprit segments were predicted by radiologic images, were included in group A. The other 45 patients, whose culprit segments were predicted by clinical symptoms, were included in group B. Leg pain VAS and ODI scores before and after PTES were recorded. The outcome was defined according to the MacNab grade at the 2-year follow-up. Postoperative complications were recorded.

Results

In group A, 2 patients underwent PTES for one segment, 37 patients underwent PTES for two segments, and 3 patients underwent PTES for three segments. One of the one-segment PTES patients had no relief from symptoms and underwent another PTES for other culprit segments 3 months after surgery. In group B, 44 of 45 patients were treated using PTES for one segment and 1 patient was treated for two segments. Group B showed significantly less operative duration, less blood loss, and less fluoroscopy frequency than group A (p < 0.001). The leg pain VAS score and the ODI score significantly decreased after the operation in both groups (p < 0.001), and the excellent and good rates were 97.6% (41/42) in group A and 100% (45/45) in group B at the 2-year follow-up. The leg pain VAS score of group B was significantly lower than that of group A immediately and 1 week, 1 month, 2 months, and 3 months after surgery (p < 0.001). There was no statistical difference in ODI scores and the excellent and good rates between the two groups. No complications, such as wound infection or permanent nerve injury, were observed.

Conclusion

It is much more accurate to predict the culprit segment according to clinical symptoms than radiologic images in PTES under local anesthesia for surgical treatment of LDDs.

Minimally invasive versus open transforaminal lumbar interbody fusion for grade I lumbar spondylolisthesis: 5-year follow-up from the prospective multicenter Quality Outcomes Database registry

OBJECTIVE

Minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) has been used to treat degenerative lumbar spondylolisthesis and is associated with expedited recovery, reduced operative blood loss, and shorter hospitalizations compared to those with traditional open TLIF. However, the impact of MI-TLIF on long-term patient-reported outcomes (PROs) is less clear. Here, the authors compare the outcomes of MI-TLIF to those of traditional open TLIF for grade I degenerative lumbar spondylolisthesis at 60 months postoperatively.

METHODS

The authors utilized the prospective Quality Outcomes Database registry and queried for patients with grade I degenerative lumbar spondylolisthesis who had undergone single-segment surgery via an MI or open TLIF method. PROs were compared 60 months postoperatively. The primary outcome was the Oswestry Disability Index (ODI). The secondary outcomes included the numeric rating scale (NRS) for back pain (NRS-BP), NRS for leg pain (NRS-LP), EQ-5D, North American Spine Society (NASS) satisfaction, and cumulative reoperation rate. Multivariable models were constructed to assess the impact of MI-TLIF on PROs, adjusting for variables reaching p < 0.20 on univariable analyses and respective baseline PRO values.

RESULTS

The study included 297 patients, 72 (24.2%) of whom had undergone MI-TLIF and 225 (75.8%) of whom had undergone open TLIF. The 60-month follow-up rates were similar for the two cohorts (86.1% vs 75.6%, respectively; p = 0.06). Patients did not differ significantly at baseline for ODI, NRS-BP, NRS-LP, or EQ-5D (p > 0.05 for all). Perioperatively, MI-TLIF was associated with less blood loss (108.8 ± 85.6 vs 299.6 ± 242.2 ml, p < 0.001) and longer operations (228.2 ± 111.5 vs 189.6 ± 66.5 minutes, p < 0.001) but had similar lengths of hospitalizations (MI-TLIF 2.9 ± 1.8 vs open TLIF 3.3 ± 1.6 days, p = 0.08). Discharge disposition to home or home health was similar (MI-TLIF 93.1% vs open TLIF 91.1%, p = 0.60). Both cohorts improved significantly from baseline for the 60-month ODI, NRS-BP, NRS-LP, and EQ-5D (p < 0.001 for all comparisons). In adjusted analyses, MI-TLIF, compared to open TLIF, was associated with similar 60-month ODI, ODI change, odds of reaching ODI minimum clinically important difference, NRS-BP, NRS-BP change, NRS-LP, NRS-LP change, EQ-5D, EQ-5D change, and NASS satisfaction (adjusted p > 0.05 for all). The 60-month reoperation rates did not differ significantly (MI-TLIF 5.6% vs open TLIF 11.6%, p = 0.14).

CONCLUSIONS

For symptomatic, single-level grade I degenerative lumbar spondylolisthesis, MI-TLIF was associated with decreased blood loss perioperatively, but there was no difference in 60-month outcomes for disability, back pain, leg pain, quality of life, or satisfaction between MI and open TLIF. There was no difference in cumulative reoperation rates between the two procedures. These results suggest that in appropriately selected patients, either procedure may be employed depending on patient and surgeon preferences.

One-level open vs. minimally invasive transforaminal lumbar interbody fusion: a systematic review and advanced meta-analytic assessment of prospective studies with at least two years follow-up

PURPOSE

To determine whether the open or the minimally invasive transforaminal lumbar interbody fusion (O-TLIF, MI-TLIF) is the favored treatment, we provide first meta-analyses using prospective studies with at least two years follow-up only and present the clinical relevance of statistical results for the first time.

METHODS

After a systematic review of six databases, we conducted 10 meta-analyses of randomized controlled trials (RCTs) and 10 meta-analyses of eligible prospective studies (EPSs) to compare fusion rate, patient-reported outcome measures (back pain (B-VAS), leg pain, Oswestry Disability Index (ODI)), for the first time safety outcome measures as operative and postoperative complications per case, and the perioperative outcome measures estimated blood loss (EBL), operation time and length of hospital stay (LOS). The clinical relevance was assessed by overall effect sizes (OESs) of statistically significant meta-analytic results.

RESULTS

In our meta-analyses of RCTs, MI-TLIF is statistically significantly superior in ODI, EBL and LOS, with clinically meaningful OESs only in EBL and LOS. In meta-analyses of EPSs, MI-TLIF is statistically significantly superior in B-VAS, postoperative complications per case, EBL and LOS, all with clinically meaningful OESs except for B-VAS. The meta-analyses of remaining outcome measures present statistically nonsignificant results. In a descriptive analysis of complications, postoperative wound infections predominate in O-TLIF and hardware malposition in MI-TLIF.

CONCLUSION

After at least two years, O-TLIF and MI-TLIF can be considered equally efficacious, which simplifies surgeons' decision between both treatments, however, with the safety outcome measure postoperative complications per case and the perioperative outcome measures EBL and LOS in favor of MI-TLIF. LEVEL OF EVIDENCE I: Well conducted meta-analyses, systematic reviews, or RCTs with a low risk of bias.

Long-term clinical outcome of minimally invasive versus open single-level transforaminal lumbar interbody fusion for degenerative lumbar diseases: a meta-analysis

BACKGROUND CONTEXT

Minimally invasive surgical transforaminal lumbar interbody fusion (MIS-TLIF) was developed in addition to open-TLIF to minimize iatrogenic soft-tissue damage. A potential disadvantage of MIS-TLIF is inadequate visualization, which may lead to incomplete neural decompression and a less robust arthrodesis. This may cause long-term problems and result in decreased patient satisfaction.

PURPOSE

To evaluate the long-term clinical outcome, measured by patient-reported outcomes (PROMs), of patients with degenerative lumbar diseases treated with single-level TLIF (open vs. minimally invasive) with a minimum follow-up of 2-years.

STUDY DESIGN

Meta-analysis.

METHODS

The systematic review was conducted according to the PRISMA guidelines. Relevant studies were identified from Pubmed, MEDLINE, EMBASE, Scopus, Web of Science, and CENTRAL from the date of inception to August 2019. The inclusion criteria were (1) longitudinal comparative studies of MIS-TLIF versus open-TLIF approach for degenerative spine disease (2) outcomes reported as PROMs, (3) minimum follow-up of 2-years.

RESULTS

Sixteen studies were included in the analysis. In total, 1,321 patients were included (660 MIS-TLIF& 661 open-TLIF). The following PROMS were analyzed: EQ-5D, SF, ODI, and VAS. Both techniques resulted in significant improvement in PROM, which remained significant at 2-years follow-up. However, no significant differences were found in all PROMs at 2-years follow-up. Both treatments resulted in a high rate of spinal fusion (80.5% vs. 91.1%; p=.29) and low rate of reoperation (3.0% vs. 2.4%; p=.50) or adjacent segment disease (12.6% vs. 12.40%; p=.50).

CONCLUSIONS

MIS-TLIF and open-TLIF have comparable long-term clinical outscomes. Both operations can significantly reduce pain and positively improve PROMs. No significant differences were found between both treatments in clinical outcomes at a follow-up of minimal 2-years. Therefore, MIS-TLIF seems to be an effective and safe alternative to traditional open-TLIF in the long-term.

Management of degenerative spondylolisthesis: development of appropriate use criteria

BACKGROUND CONTEXT

Outcomes of treatment in care of patients with spinal disorders are directly related to patient selection and treatment indications. However, for many disorders, there is absence of consensus for precise indications. With the increasing emphasis on quality and value in spine care, it is essential that treatment recommendations and decisions are optimized.

PURPOSE

The purpose of the North American Spine Society Appropriate Use Criteria was to determine the appropriate (ie reasonable) multidisciplinary treatment recommendations for patients with degenerative spondylolisthesis across a spectrum of more common clinical scenarios.

STUDY DESIGN

A Modified Delphi process was used.

METHODS

The methodology was based on the Appropriate Use Criteria development process established by the Research AND Development Corporation. The topic of degenerative spondylolisthesis was selected by the committee, key modifiers determined, and consensus reached on standard definitions. A literature search and evidence analysis were completed by one work group simultaneously as scenarios were written, reviewed, and finalized by another work group. A separate multidisciplinary rating group was assembled. Based on the literature, provider experience, and group discussion, each scenario was scored on a nine-point scale on two separate occasions, once without discussion and then a second time following discussion based on the initial responses. The median rating for each scenario was then used to determine if indications were rarely appropriate (1 - 3), uncertain (4-6), or appropriate (7-9). Consensus was not mandatory.

RESULTS

There were 131 discrete scenarios. These addressed questions on bone grafting, imaging, mechanical instability, radiculopathy with or without neurological deficits, obesity, and yellow flags consisting of psychosocial and medical comorbidities. For most of these, appropriateness was established for physical therapy, injections, and various forms of surgical intervention. The diagnosis of spondylolisthesis should be determined by an upright x-ray. Scenarios pertaining to bone grafting suggested that patients should quit smoking prior to surgery, and that use of BMP should be reserved for patients who had risk factors for non-union. Across all clinical scenarios, physical therapy (PT) had an adjusted mean of 7.66, epidural steroid injections 5.76, and surgery 4.52. Physical therapy was appropriate in most scenarios, and most appropriate in patients with back pain and no neurological deficits. Epidural steroid injections were most appropriate in patients with radiculopathy. Surgery was generally more appropriate for patients with neurological deficits, higher disability scores, and dynamic spondylolisthesis. Mechanical back pain and presence of yellow flags tended to be less appropriate, and obesity in general had relatively little influence on decision making. Decompression alone was more strongly considered in the presence of static versus dynamic spondylolisthesis. On average, posterior fusion with or without interbody fusion was similarly appropriate, and generally more appropriate than stand-alone interbody fusion which was in turn more appropriate than interspinous spacers.

CONCLUSIONS

Multidisciplinary appropriate treatment criteria were generated based on the Research AND Development methodology. While there were consistent and significant differences between surgeons and non-surgeons, these differences were generally very small. This document provides comprehensive evidence-based recommendations for evaluation and treatment of degenerative spondylolisthesis. The document in its entirety will be found on the North American Spine Society website (https://www.spine.org/Research-Clinical-Care/Quality-Improvement/Appropriate-Use-Criteria).

Retrospective Comparison of Minimally Invasive and Open Monosegmental Lumbar Fusion, and Impact of Virtual Reality on Surgical Planning and Strategy

BACKGROUND AND STUDY AIMS

 Spinal fusion for symptomatic lumbar spondylolisthesis can be accomplished using an open or minimally invasive surgical (MIS) technique. Evaluation of segmental spondylolisthesis and instabilities and review of their therapies are inseparably connected with lumbar tomographic imaging. We analyzed a cohort of patients who underwent MIS or open monosegmental dorsal fusion and compared surgical outcomes along with complication rates. We furthermore evaluated the influence of virtual reality (VR) visualization on surgical planning in lumbar fusion.

MATERIAL AND METHODS

 Patient files were retrospectively analyzed regarding patient- and disease-related data, operative performance, surgical outcomes, and perioperative surgical complications. Preoperative computed tomography (CT) and magnetic resonance imaging (MRI) scans were retrospectively visualized via VR software. A questionnaire evaluated the influence of three-dimensional (3D) VR images versus two-dimensional CT and MRI scans on therapy planning, fusion method, and surgical technique and procedure.

RESULTS

 Overall, 171 patients were included (MIS/open: 90/81). MIS was associated with less blood loss, shorter surgery time and hospital stay, lower complication rates, equivalent long-term patient-reported outcomes, but lower fusion rates and higher late reoperation rates than open surgery. Image presentation using VR significantly influenced the recommended surgical therapies (decompression only/decompression and fusion; p = 0.02), had no significant influence on the recommended fusion method (rigid/dynamic/stand-alone; p = 0.77), and, in cases of rigid fusion, a significant influence on the recommended technique (MIS/open; p = 0.03) and fusion procedure (p = 0.02).

CONCLUSION

 In patients with monosegmental degenerative or isthmic spondylolisthesis, MIS fusion was advantageous concerning perioperative complication rates and perioperative surgical outcomes, but disadvantageous regarding fusion and reoperation rates compared to open fusion. 3D-VR-based analysis of sectional images significantly influenced the recommended surgical planning.

Outcomes of Minimally Invasive versus Open Surgery for Intermediate to High-grade Spondylolisthesis: A 10-Year Retrospective, Multicenter Experience

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

The primary objective of our study was to evaluate the surgical outcomes and complications of minimally invasive surgery (MIS) versus open surgery in the management of intermediate to high grade spondylolisthesis, and secondarily to compare the outcomes following MIS in-situ fusion versus MIS reduction and open in-situ fusion versus open reduction subgroups.

SUMMARY OF BACKGROUND DATA

High-grade spondylolisthesis is a relatively rare spine pathology with unknown prevalence. The optimal management and long-term prognosis of high-grade spondylolisthesis remain controversial.

METHODS

A multicenter, retrospective cohort study of adult patients who were surgically treated for grade II or higher lumbar or lumbosacral spondylolisthesis from January 2008 until February 2019, was conducted.

RESULTS

A total of 57 patients were included in this study. Forty cases were treated with open surgery and 17 with MIS. Specifically, seven patients underwent MIS in-situ fusion, 11 patients open in-situ fusion, an additional 10 patients underwent MIS reduction, and 29 had open reduction. Patients who underwent open surgery had significantly better pain relief at short-term follow-up with no statistically significant difference in the rate of complications (25% vs. 35.2%, P = 0.44), as compared with MIS. The most common complications were related to instrumentation (17.7%), followed by neurological complications (14.5%), wound infection/dehiscence (6.5%), and post laminectomy syndrome (1.6%). The average follow-up time was 9.1 ± 6.2 months. In a subgroup comparison, the complication rate in the open in-situ fusion (36.3%) versus open reduction (20.6%) subgroup was non-significant (P = 0.42). However, complication rate in the MIS reduction group (55%) was significantly higher than MIS in-situ fusion (P = 0.03).

CONCLUSION

MIS reduction is associated with a higher rate of complications in the management of grade II or higher lumbar or lumbosacral spondylolisthesis. The management of this complex pathology may be better addressed via traditional open surgery.

LEVEL OF EVIDENCE

3.

Overview of Minimally Invasive Spine Surgery

Minimally invasive spine surgery (MISS) has continued to evolve over the past few decades, with significant advancements in technology and technical skills. From endonasal cervical approaches to extreme lateral lumbar interbody fusions, MISS has showcased its usefulness across all practice areas of the spine, with unique points of access to avoid pertinent neurovascular structures. Adult spine deformity has also recognized the importance of minimally invasive techniques in its ability to limit complications and to provide adequate sagittal alignment correction and improvements in patients' functional status. Although MISS has continued to make significant progress clinically, consideration must also be given to its economic impact and the learning curve surgeons experience in adding these procedures to their armamentarium. This review examines current innovations in MISS, as well as the economic impact and future directions of the field.

Minimally Invasive Transforaminal Lumbar Interbody Fusion for the Surgical Management of Post-Discectomy Syndrome

STUDY DESIGN

This was a prospective case series of 30 patients with post-discectomy syndrome with an average of 18 months of follow-up (level IV).

PURPOSE

The efficacy of post-discectomy syndrome managed by minimally invasive surgery transforaminal lumbar interbody fusion (MIS-TLIF) was evaluated.

OVERVIEW OF LITERATURE

In post-discectomy syndrome wherein conservative treatment had failed, the best surgical treatment modality still remains controversial.

METHODS

Patients were functionally assessed using the Visual Analog Scale (VAS) for low back pain (LBP) and leg pain (LP) and Oswestry Disability Index (ODI). Radiological fusion was confirmed with plain X-rays and when indicated with computed tomography scan at 12 months postoperatively. A total of 30 patients with 37 operated at lumbar levels with failed discectomy surgery who met our inclusion criteria were treated with MIS-TLIF.

RESULTS

The ODI of all patients showed significant improvement from a mean of 73.78% preoperatively to 16.67% at 1 month and 14.13% at 12 months postoperatively. The preoperative LBP VAS score (mean, 4.37) showed a significant decrease (p <0.001) to 1.90 at 1 month and 1.10 at 12 months. Preoperative LP VAS score of limb pain averaged 7.53 and showed a significant (p <0.001) decrease to 3.47 at 1 month and 1.10 at 12 months. All patients attained radiological fusion at 12 months.

CONCLUSIONS

MIS-TILF constitutes a valid and effective treatment option for patients with post-discectomy syndrome.

Comparison of O-arm navigation and microscope-assisted minimally invasive transforaminal lumbar interbody fusion and conventional transforaminal lumbar interbody fusion for the treatment of lumbar isthmic spondylolisthesis

Objective

The objective of this study is to compare the clinical efficacy of O-arm navigation and microscope-assisted minimally invasive transforaminal lumbar interbody fusion (modified MIS-TLIF) versus conventional TLIF in the lumbar isthmic spondylolisthesis.

Materials and methods

Forty patients with 1-level lumbar isthmic spondylolisthesis were enrolled in the study. Perioperative indexes including operation time, intraoperative bleeding, bed rest time, time of hospitalisation stay and the accuracy rate of screw placement were analysed. Preoperative and postoperative visual analogue scale (VAS) and Oswestry disability index (ODI) were assessed.

Results

The operation time in the modified MIS-TLIF group was longer than the conventional TLIF group (p ​< ​0.05). However, intraoperative blood loss in the modified MIS-TLIF group was less than the comparative group (p ​< ​0.05). The average bed rest time and hospitalisation stay in the modified MIS-TLIF group was shorter than conventional TLIF group (p ​< ​0.05). The screw placement in the modified MIS-TLIF group was more precisely than that in the conventional TLIF group (p ​< ​0.05). Meanwhile, the improvement of VAS and ODI in the modified MIS-TLIF group were lower than that in the conventional TLIF group 1 and 6 months after operation (p ​< ​0.05). There was no difference in the VAS and ODI score between the two group at the last follow-up (p ​> ​0.05).

Conclusion

Navigation and microscope-assisted MIS-TLIF is safe and reliable for treatment of lumbar isthmic spondylolisthesis (Meyerding degree I or II) with potential advantages including less injury, less blood loss, higher screw accuracy and faster recovery after operation.

The translational potential of this article

Compared with conventional transforaminal lumbar interbody fusion, O-arm navigation and microscope-assisted minimally invasive transforaminal lumbar interbody fusion has a huge advantage in surgery treatment of lumbar isthmic spondylolisthesis. Hence, this article provided a better surgery method to deal with lumbar isthmic spondylolisthesis, and robot-assisted minimally invasive transforaminal lumbar interbody fusion will be adopted in the future.

Minimally invasive spine surgery in the treatment of pyogenic spondylodiscitis: an initial retrospective series study

Introduction

Pyogenic spondylodiscitis is a bacterial infection affecting the intervertebral disc and its adjacent vertebrae. Although relatively rare, it is a challenging medical disease with a poor prognosis that requires immediate diagnosis and treatment with suitable antibiotics.

Aim

To evaluate the clinical outcome of minimally invasive spine surgery (MIS) for pyogenic spondylodiscitis.

Material and methods

The retrospective study cohort consisted of 10 consecutive patients who had undergone MIS decompression and/or discectomy for thoracic or lumbar pyogenic spondylodiscitis in our hospital. Data including patient characteristics, symptoms, visual analog scale (VAS) score, surgical approach and postoperative outcomes were obtained for retrospective analysis.

Results

Between January 2005 and December 2013, 10 patients underwent MIS decompression in the Department of Orthopedics in our medical university. Seven of these patients had lumbar infections and 3 had thoracic infections. All 10 patients had improved VAS scores immediately after surgery and after discharge. The VAS score (respectively on postoperative day 1 and day 7) suggested that the patients in this study had significantly less pain than preoperatively (day 1: 5 vs. 9, p < 0.001; day 7: 2.9 vs. 9, p < 0.001). The organism was obtained in 10 (100%) patients by the operative cultures. All patients achieved an excellent clinical recovery without the need for further spine surgery. All patients underwent postoperative imaging during follow-up and showed complete resolution or dramatically improved magnetic resonance imaging changes.

Conclusions

Minimally invasive spine surgery is a safe and effective surgical approach for pyogenic spondylodiscitis.

Enhanced recovery after spine surgery: review of the literature

The concept of Enhanced Recovery After Surgery (ERAS) entails recovery facilitation of patients who undergo surgery through the implementation of a multidisciplinary and multimodal perioperative care approach. By its application, ERAS improves the overall functional outcome after surgery while maintaining high standards of care. A review of the essential aspects of ERAS in spine surgery was undertaken. Special consideration was given to the risks and benefits for patients and caregivers, as well as the medical and economical aspects of this concept. ABBREVIATIONS EBL = estimated blood loss; ERAS = Enhanced Recovery After Surgery; MISS = minimally invasive spine surgery; TLIF = transforaminal lumbar interbody fusion.

Lumbar Interbody Fusions for Degenerative Spondylolisthesis: Review of Techniques, Indications, and Outcomes

STUDY DESIGN

Broad narrative review.

OBJECTIVES

To review and summarize the current literature on the outcomes, techniques, and indications of lumbar interbody fusion in degenerative spondylolisthesis.

METHODS

A thorough review of peer-reviewed literature was performed on the outcomes, techniques, and indications of lumbar interbody fusions in degenerative spondylolisthesis.

RESULTS

A number of studies have found similar results between interbody fusions and posterolateral fusion in the setting of degenerative spondylolisthesis. There is some evidence that suggests that interbody fusion may be a useful adjunct in the setting of unstable degenerative spondylolisthesis. The number of options for interbody fusions has quickly expanded. Initially, interbody fusions were accomplished via an anterior approach. Posterior and transforaminal interbody fusions are 2 options that accomplish an interbody fusion without the morbidity of an anterior approach. Over the past decade, minimally invasive options including extreme lateral, oblique, and minimally invasive transforaminal interbody fusions have gained popularity.

CONCLUSIONS

Lumbar interbody fusion can be a useful tool in the setting of unstable degenerative spondylolisthesis. A number of technique options, both open and minimally invasive, are available to accomplish an interbody fusion. The literature to this date does not support a clear benefit of one technique over others in the setting of degenerative spondylolisthesis.

Comparison of Minimally Invasive and Open Transforaminal Lumbar Interbody Fusion for Lumbar Disc Herniation: A Retrospective Cohort Study

Background

This cohort study compared the efficacy and safety of minimally invasive versus open transforaminal lumbar interbody fusion (Mis-TLIF versus Open-TLIF) for lumbar disc herniation with radiculopathy.

Material/Methods

From July 2016 to September 2017, we recruited 37 patients suffering from lumbar disc herniation with radiculopathy. Seventeen patients underwent Mis-TLIF (Mis group) and 20 patients underwent Open-TLIF (Open group). Baseline characteristics were similar between the 2 groups before surgery. We compared postoperative clinical and radiological outcomes between the 2 groups.

Results

Compared to patients in the Open group, patients in the Mis group has significantly less intraoperative hemorrhage, drainage fluid, time to go, and hospital stay after surgery, but had longer operation times (P<0.05). These 2 groups had similar postoperative hemoglobin reduction and drain removal time. In addition, the postoperative back and leg pain and intervertebral height reduction at 3 months after surgery in the Mis group were remarkably lower than those in the Open group. There was no significant difference in postoperative Oswestry disability index (ODI) or intervertebral height change immediately after surgery and at 1 month postoperatively between the 2 groups.

Conclusions

Mis-TLIF shows some benefits in lumbar disc herniation compared to Open-TLIF in terms of intraoperative hemorrhage, drainage fluid, time to go, hospital stay after surgery, and postoperative back and leg pain.

Minimally Invasive Versus Traditional Open Transforaminal Lumbar Interbody Fusion for the Treatment of Single-Level Spondylolisthesis Grades 1 and 2: A Systematic Review and Meta-Analysis

OBJECTIVE

To compare the clinical efficacy and safety between minimally invasive and traditional open transforaminal lumbar interbody fusion in the treatment of single-level spondylolisthesis grades 1 and 2.

METHODS

This was a systematic review and meta-analysis. A comprehensive literature retrieval was performed in 3 electronic databases (PubMed, Embase, and Cochrane library). Randomized or nonrandomized controlled studies published from January 2000 to April 2018 that compared minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) with traditional open transforaminal lumbar interbody fusion (TO-TLIF) for treating single-level spondylolisthesis grades 1 and 2 were retrieved. Quality of included studies were evaluated by the modified Jadad scale. Data were extracted according to the predefined clinical outcome measures, including preoperative and postoperative back pain visual analogue scale and Oswestry Disability Index score; operation time and estimated intraoperative blood loss; length of hospitalization; and the complications, reoperation, and fusion rate.

RESULTS

Six studies (n = 394 patients) were finally included. Two were randomized controlled trials and the remaining 4 were prospective or retrospective cohort studies. The pooled data revealed that both techniques had similar preoperative and last follow-up back pain visual analogue scale scores, complication rate, reoperation rate, and fusion rate. However, with the exception of more operation time, MIS-TLIF was associated with less intraoperative blood loss, shorter hospital stay, and better long-term functional outcome when compared with TO-TLIF.

CONCLUSIONS

Based on the available evidence, MIS-TLIF appears to be a more efficacious and safe technique with reduced tissue trauma, quicker postoperative recovery, and better long-term functional outcome for the treatment of single-level spondylolisthesis grades 1 and 2.

Does minimally invasive fusion technique influence surgical outcomes in isthmic spondylolisthesis?

OBJECTIVE

To compare the clinical and radiographic results between open transforaminal interbody fusion (TLIF-O) and minimally invasive TLIF (TLIF-M) for single-level low grade isthmic spondylolisthesis (IS).

METHODS

This study enrolled 45 patients who underwent single-level TLIF with low grade IS. The patients were divided into two groups according to operative method: TLIF-M (20 patients) and TLIF-O (25 patients). TLIF-O group was matched with TLIF-M.

RESULTS

At one-year postoperatively, there were no significant differences in any radiologic parameters between the two groups. Perioperative results such as blood loss, operation time, and hospital stay were superior in TLIF-M than in TLIF-O. Fusion was achieved in 17 of 20 patients (85.0%) in TLIF-M and 23 of 25 (92.0%) patients in TLIF-O. Back Visual Analog Scale (VAS) and Oswestry Disability Index (ODI) scores of TLIF-O were significantly lower than TLIF-M at one (back VAS, ODI) and six months (ODI) postoperatively.

CONCLUSIONS

TLIF-M and TLIF-O produced similar clinical and radiological outcomes, including reduction of spondylolisthesis and disc space height restoration at one-year follow-up for single-level low grade IS. However, considering perioperative outcomes, back pain, and quality of life, TLIF-M might be a better option for single-level low grade IS compared to TLIF-O.

Minimally invasive guidewireless, navigated pedicle screw placement: a technical report and case series

OBJECTIVE Percutaneous pedicle screw insertion (PPSI) is a mainstay of minimally invasive spinal surgery. Traditionally, PPSI is a fluoroscopy-guided, multistep process involving traversing the pedicle with a Jamshidi needle, placement of a Kirschner wire (K-wire), placement of a soft-tissue dilator, pedicle tract tapping, and screw insertion over the K-wire. This study evaluates the accuracy and safety of PPSI with a simplified 2-step process using a navigated awl-tap followed by navigated screw insertion without use of a K-wire or fluoroscopy. METHODS Patients undergoing PPSI utilizing the K-wire-less technique were identified. Data were extracted from the electronic medical record. Complications associated with screw placement were recorded. Postoperative radiographs as well as CT were evaluated for accuracy of pedicle screw placement. RESULTS Thirty-six patients (18 male and 18 female) were included. The patients' mean age was 60.4 years (range 23.8-78.4 years), and their mean body mass index was 28.5 kg/m² (range 20.8-40.1 kg/m²). A total of 238 pedicle screws were placed. A mean of 6.6 pedicle screws (range 4-14) were placed over a mean of 2.61 levels (range 1-7). No pedicle breaches were identified on review of postoperative radiographs. In a subgroup analysis of the 25 cases (69%) in which CT scans were performed, 173 screws were assessed; 170 (98.3%) were found to be completely within the pedicle, and 3 (1.7%) demonstrated medial breaches of less than 2 mm (Grade B). There were no complications related to PPSI in this cohort. CONCLUSIONS This streamlined 2-step K-wire-less, navigated PPSI appears safe and accurate and avoids the need for radiation exposure to surgeon and staff.

Transforaminal Lumbar Interbody Fusion: Traditional Open Versus Minimally Invasive Techniques

Recently, minimally invasive spine arthrodesis has gained popularity among spine surgeons. Minimally invasive techniques have advantages and disadvantages compared with traditional open techniques. Comparisons between short-term outcomes of minimally invasive transforaminal interbody fusion and open transforaminal interbody fusion in terms of estimated blood loss, postoperative pain, and hospital length of stay have been well documented and generally favor the minimally invasive technique. However, the advantages of minimally invasive transforaminal interbody fusion must be evaluated in the context of long-term results, such as patient-reported outcomes and the success of arthrodesis. Because the literature is equivocal in identifying the superior technique for successful long-term outcomes, more study is needed. Patient safety, the risk of complications, and the cost of these techniques also must be considered.

Effectiveness of a Decision-Making Protocol for the Surgical Treatment of Lumbar Stenosis with Grade 1 Degenerative Spondylolisthesis

BACKGROUND

Addition of fusion to decompression for stenosis with grade 1 degenerative spondylolisthesis is a controversial topic, and the question remains if fusion provides any benefit to the patient that warrants the increased health care utilization and perioperative morbidity. There is no consensus on indications for use of fusion over decompression alone.

METHODS

Patients received fusion or decompression according to a decision-making protocol based on their pattern of complaints, location of the compression, and facet angles and effusion as proven predictors of postoperative instability. Propensity score matching of patients was done for baseline data.

RESULTS

The study comprised 102 patients in 2 equally sized groups. No intergroup differences in numeric rating scale and Oswestry Disability Index were detected at any follow-up point (all P > 0.05). Duration of surgery, length of stay, estimated blood loss, and radiation doses were higher in the fusion group (all P < 0.001). Cumulative reoperation rate was similar with 6% for fusion and 8% for decompression (P > 0.05), as was the complication rate (8% vs. 6%, P > 0.05). Postoperative iatrogenic progression of spondylolisthesis requiring fusion surgery was seen in only 2% in the decompression group.

CONCLUSIONS

Use of a decision-making protocol led to a low rate of iatrogenically increased spondylolisthesis after decompression, while retaining outcomes. These data suggest that a decision-making protocol based on clinical history, location of nerve root compression, and proven radiologic predictors of postoperative instability assigns patients to fusion or decompression in a safe and effective manner.

Clinical and radiographic outcomes of bilateral decompression via a unilateral approach with transforaminal lumbar interbody fusion for degenerative lumbar spondylolisthesis with stenosis

BACKGROUND CONTEXT

Laminectomy with posterior lumbar interbody fusion (PLIF) has been shown to achieve satisfactory clinical outcomes, but it leads to potential adverse consequences associated with extensive disruption of posterior bony and soft tissue structures.

PURPOSE

This study aimed to compare the clinical and radiographic outcomes of bilateral decompression via a unilateral approach (BDUA) with transforaminal lumbar interbody fusion (TLIF) and laminectomy with PLIF in the treatment of degenerative lumbar spondylolisthesis (DLS) with stenosis.

STUDY DESIGN

This is a prospective cohort study.

PATIENT SAMPLE

This study compared 43 patients undergoing BDUA+TLIF and 40 patients undergoing laminectomy+PLIF.

OUTCOME MEASURES

Visual analog scale (VAS) for low back pain and leg pain, Oswestry Disability Index (ODI), and Zurich Claudication Questionnaire (ZCQ) score.

METHODS

The clinical outcomes were assessed, and intraoperative data and complications were collected. Radiographic outcomes included slippage of the vertebra, disc space height, segmental lordosis, and final fusion rate. This study was supported by a grant from The National Natural Science Foundation of China (81572168).

RESULTS

There were significant improvements in clinical and radiographic outcomes from before surgery to 3 months and 2 years after surgery within each group. Analysis of leg pain VAS and ZCQ scores showed no significant differences in improvement between groups at either follow-up. The mean improvements in low back pain VAS and ODI scores were significantly greater in the BDUA+TLIF group than in the laminectomy+PLIF group. No significant difference was found in the final fusion rate at 2-year follow-up. The BDUA+TLIF group had significantly less blood loss, shorter length of postoperative hospital stay, and lower complication rate compared with the laminectomy+PLIF group.

CONCLUSIONS

When compared with the conventional laminectomy+PLIF procedure, the BDUA+TLIF procedure achieves similar and satisfactory effects of decompression and fusion for DLS with stenosis. The BDUA+TLIF procedure appears to be associated with less postoperative low back discomfort and quicker recovery.

Minimally invasive versus open fusion for Grade I degenerative lumbar spondylolisthesis: analysis of the Quality Outcomes Database

OBJECTIVE

Lumbar spondylolisthesis is a degenerative condition that can be surgically treated with either open or minimally invasive decompression and instrumented fusion. Minimally invasive surgery (MIS) approaches may shorten recovery, reduce blood loss, and minimize soft-tissue damage with resultant reduced postoperative pain and disability.

METHODS

The authors queried the national, multicenter Quality Outcomes Database (QOD) registry for patients undergoing posterior lumbar fusion between July 2014 and December 2015 for Grade I degenerative spondylolisthesis. The authors recorded baseline and 12-month patient-reported outcomes (PROs), including Oswestry Disability Index (ODI), EQ-5D, numeric rating scale (NRS)–back pain (NRS-BP), NRS–leg pain (NRS-LP), and satisfaction (North American Spine Society satisfaction questionnaire). Multivariable regression models were fitted for hospital length of stay (LOS), 12-month PROs, and 90-day return to work, after adjusting for an array of preoperative and surgical variables.

RESULTS

A total of 345 patients (open surgery, n = 254; MIS, n = 91) from 11 participating sites were identified in the QOD. The follow-up rate at 12 months was 84% (83.5% [open surgery]; 85% [MIS]). Overall, baseline patient demographics, comorbidities, and clinical characteristics were similarly distributed between the cohorts. Two hundred fifty seven patients underwent 1-level fusion (open surgery, n = 181; MIS, n = 76), and 88 patients underwent 2-level fusion (open surgery, n = 73; MIS, n = 15). Patients in both groups reported significant improvement in all primary outcomes (all p < 0.001). MIS was associated with a significantly lower mean intraoperative estimated blood loss and slightly longer operative times in both 1- and 2-level fusion subgroups. Although the LOS was shorter for MIS 1-level cases, this was not significantly different. No difference was detected with regard to the 12-month PROs between the 1-level MIS versus the 1-level open surgical groups. However, change in functional outcome scores for patients undergoing 2-level fusion was notably larger in the MIS cohort for ODI (−27 vs −16, p = 0.1), EQ-5D (0.27 vs 0.15, p = 0.08), and NRS-BP (−3.5 vs −2.7, p = 0.41); statistical significance was shown only for changes in NRS-LP scores (−4.9 vs −2.8, p = 0.02). On risk-adjusted analysis for 1-level fusion, open versus minimally invasive approach was not significant for 12-month PROs, LOS, and 90-day return to work.

CONCLUSIONS

Significant improvement was found in terms of all functional outcomes in patients undergoing open or MIS fusion for lumbar spondylolisthesis. No difference was detected between the 2 techniques for 1-level fusion in terms of patient-reported outcomes, LOS, and 90-day return to work. However, patients undergoing 2-level MIS fusion reported significantly better improvement in NRS-LP at 12 months than patients undergoing 2-level open surgery. Longer follow-up is needed to provide further insight into the comparative effectiveness of the 2 procedures.

Clinical Efficacy and Its Prognostic Factor of Percutaneous Endoscopic Lumbar Annuloplasty and Nucleoplasty for the Treatment of Patients with Discogenic Low Back Pain

OBJECTIVE

The choice of appropriate treatment of discogenic low back pain (DLBP) frequently is difficult. This study sought to identify the clinical efficacy of percutaneous endoscopic lumbar annuloplasty and nucleoplasty (PELAN) to treat patients with DLBP and to investigate prognostic clinical or radiologic variables.

METHODS

Eighty-nine patients with a diagnosis of DLBP who underwent PELAN were included. Numeric Rating Scale (NRS) for back pain, Oswestry Disability Index % (ODI%), and modified Macnab criteria were measured at short-term (3-4 weeks) and long-term follow-up period (at least 12 months) to investigate clinical efficacy of PELAN. The subjects were defined as successful group in case of 50% or more reduction of NRS, 40% or more reduction of ODI%, and good or excellent response of Macnab criteria. Clinical and radiologic variables were compared between successful and unsuccessful outcomes group to determine prognostic variables.

RESULTS

NRS and ODI% were significantly reduced at short- and long-term follow-up after PELAN. Sixty-two (69.7%) and 68 (76.4%) obtained successful NRS reduction and 59 (66.3%) and 68 (76.4%) accomplished successful ODI% reduction at short-term and long-term follow-up, respectively. Successful Mcnab response was found in 61% at short term and 65.2% at long term. Pain during waist flexion among clinical variables was significantly related to good clinical outcomes and Modic change among radiologic variables was significantly related to poor clinical outcomes.

CONCLUSIONS

PELAN provided favorable outcomes in patients with DLBP who were refractory to conservative treatments. Flexion pain was good prognostic, and Modic change was a poor prognostic variable.

Revisions for screw malposition and clinical outcomes after robot-guided lumbar fusion for spondylolisthesis

OBJECTIVE

The accuracy of robot-guided pedicle screw placement has been proven to be high, but little is known about the impact of such guidance on clinical outcomes such as the rate of revision surgeries for screw malposition. In addition, there are very few data about the impact of robot-guided fusion on patient-reported outcomes (PROs). Thus, the clinical benefit for the patient is unclear. In this study, the authors analyzed revision rates for screw malposition and changes in PROs following minimally invasive robot-guided pedicle screw fixation.

METHODS

A retrospective cohort study of patients who had undergone minimally invasive posterior lumbar interbody fusion (MI-PLIF) or minimally invasive transforaminal lumbar interbody fusion was performed. Patients were followed up clinically at 6 weeks, 12 months, and 24 months after treatment and by mailed questionnaire in March 2016 as a final follow-up. Visual analog scale (VAS) scores for back and leg pain severity, Oswestry Disability Index (ODI), screw revisions, and socio-demographic factors were analyzed. A literature review was performed, comparing the incidence of intraoperative screw revisions and revision surgery for screw malposition in robot-guided, navigated, and freehand fusion procedures.

RESULTS

Seventy-two patients fit the study inclusion criteria and had a mean follow up of 32 ± 17 months. No screws had to be revised intraoperatively, and no revision surgery for screw malposition was needed. In the literature review, the authors found a higher rate of intraoperative screw revisions in the navigated pool than in the robot-guided pool (p < 0.001, OR 9.7). Additionally, a higher incidence of revision surgery for screw malposition was observed for freehand procedures than for the robot-guided procedures (p < 0.001, OR 8.1). The VAS score for back pain improved significantly from 66.9 ± 25.0 preoperatively to 30.1 ± 26.8 at the final follow-up, as did the VAS score for leg pain (from 70.6 ± 22.8 to 24.3 ± 28.3) and ODI (from 43.4 ± 18.3 to 16.2 ± 16.7; all p < 0.001). Undergoing PLIF, a high body mass index, smoking status, and a preoperative ability to work were identified as predictors of a reduction in back pain. Length of hospital stay was 2.4 ± 1.1 days and operating time was 161 ± 50 minutes. Ability to work increased from 38.9% to 78.2% of patients (p < 0.001) at the final follow-up, and 89.1% of patients indicated they would choose to undergo the same treatment again.

CONCLUSIONS

In adults with low-grade spondylolisthesis, the data demonstrated a benefit in using robotic guidance to reduce the rate of revision surgery for screw malposition as compared with other techniques of pedicle screw insertion described in peer-reviewed publications. Larger comparative studies are required to assess differences in PROs following a minimally invasive approach in spinal fusion surgeries compared with other techniques.

Comparison of the Minimally Invasive and Conventional Open Surgery Approach in the Treatment of Lumbar Stenosis: A Systematic Review and a Meta-Analysis

Introduction: Minimally invasive surgery (MIS) is increasingly used in the treatment of lumbar stenosis. However, it is still not clear if the employment of minimally invasive surgical techniques can achieve superior clinical outcomes compared to standard open laminectomy. Materials and Methods: An extensive literature review regarding the clinical outcome, safety, and efficiency of MIS and standard open surgery (OS) in the treatment of lumbar stenosis was conducted on Medline, Cochrane, EMBASE, and Google Scholar databases up to 19 August 2016. Results: Sixteen studies that enrolled a total of 1580 patients with surgically-indicated lumbar stenosis were identified; 793 patients underwent MIS and 787 patients underwent conventional OS. No significant difference was found in the improvement of Oswestry Disability Index (ODI) (P = 0.718) and operation time (P = 0.322) between patients from different treatment groups. MIS was associated with better visual analogue scale (VAS) for back pain (P = 0.01), shorter length of hospital stay (P <0.001), and lower blood loss (P <0.001). Conclusion: Our findings indicate that both MIS and standard OS can effectively manage patients with lumbar stenosis and lead to comparable clinical outcomes. Further studies are necessary to evaluate MIS with different types of conventional surgery for lumbar stenosis. Key words: Back pain, Laminectomy

Spontaneous Pyogenic Spondylodiscitis in the Thoracic or Lumbar Spine: A Retrospective Cohort Study Comparing the Safety and Efficacy of Minimally Invasive and Open Surgery Over a Nine-Year Period

PURPOSE

Pyogenic spondylodiscitis is a rare disease, but its incidence is increasing. Over the last decade, spinal surgery has been modified to become minimally invasive. In degenerative spinal disorders, such minimally invasive surgery (MIS) reduces blood loss, muscular trauma, and the hospital stay. However, it is not known whether MIS also confers these benefits to patients with pyogenic spondylodiscitis. This retrospective cohort study compared the safety and efficacy of MIS and the conventional open surgical procedure in patients with pyogenic spondylodiscitis.

METHODS

The study cohort consisted of all consecutive patients who underwent surgery for thoracic or lumbar pyogenic spondylodiscitis that was not caused by previous surgery or tuberculosis in our tertiary-care institution between January 2003 and December 2011.

RESULTS

Of the 148 eligible patients, 75 and 73 underwent MIS and open surgery, respectively. The 2 groups did not differ in terms of age, body mass index, American Society of Anaesthesiologists score, comorbidities, septic disease, or preoperative neurologic deficit. The 2 methods were associated with similar postoperative stays in the intensive care unit, overall hospital stays, complication rates, and postoperative survival. However, MIS was associated with a significantly shorter operating time, a lower perioperative need for blood products, and, as expected, an increased intraoperative fluoroscopy duration.

CONCLUSIONS

Our 9-year experience suggests that MIS is safe and effective for spontaneous pyogenic thoracic and lumbar spondylodiscitis.

Comparison between Minimally Invasive Transforaminal Lumbar Interbody Fusion and Conventional Open Transforaminal Lumbar Interbody Fusion: An Updated Meta-analysis

Background:

The previous studies agree that minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) has better function outcomes, less blood loss, and shorter hospital stay, when compared to open-TLIF. However, there are no significance differences on operative time, complication, and reoperation rate between the two procedures. This could be from less relative literatures and lower grade evidence. The further meta-analysis is needed with more and higher grade evidences to compare the above two TLIF procedures.

Methods:

Prospective and retrospective studies that compared open-TLIF and MIS-TLIF were identified by searching the Medline, Embase, Web of Science, China National Knowledge Infrastructure, Wanfang, and VIP database (the literature search comprised Medical Subject Heading terms and key words or Emtree term). The retrieval time ranged from the date when the database was founded to January 2015. Pooled risk ratios (RRs) and weighted mean differences (WMDs) with 95% confidence intervals were calculated for the clinical outcomes and perioperative data.

Results:

Twenty-four studies (n = 1967 patients) were included in this review (n = 951, open-TLIF, n = 1016, MIS-TLIF). MIS-TLIF was associated with a significant decrease in the visual analog score (VAS)-back pain score (WMD = −0.44; P = 0.001), Oswestry Disabilities Index (WMD = −1.57; P = 0.005), early ambulation (WMD = −1.77; P = 0.0001), less blood loss (WMD = −265.59; P < 0.00001), and a shorter hospital stay (WMD = −1.89; P < 0.0001). However, there were no significant differences in the fusion rate (RR = 0.99; P = 0.34), VAS-leg pain (WMD = −0.10; P = 0.26), complication rate (RR = 0.84; P = 0.35), operation time (WMD = −5.23; P = 0.82), or reoperation rate (RR = 0.73; P = 0.32).

Conclusions:

MIS-TLIF resulted in a similar fusion rate with better functional outcome, less blood loss, shorter ambulation, and hospital stay; furthermore, it did not increase the complication or reoperation rate based on the existing evidence.

Minimally invasive procedure reduces adjacent segment degeneration and disease: New benefit-based global meta-analysis

Objective

Adjacent segment pathology (ASP) is a common complication presenting in patients with axial pain and dysfunction, requiring treatment or follow-up surgery. However, whether minimally invasive surgery (MIS), including MIS transforaminal / posterior lumbar interbody fusion (MIS-TLIF/PLIF) decreases the incidence rate of ASP remains unknown. The aim of this meta-analysis was to compare the incidence rate of ASP in patients undergoing MIS versus open procedures.

Methods

This systematic review was undertaken by following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Statement. We searched electronic databases, including PubMed, EMBASE, SinoMed, and the Cochrane Library, without language restrictions, to identify clinical trials comparing MIS to open procedures. The results retrieved were last updated on June 15, 2016.

Results

Overall, 9 trials comprising 770 patients were included in the study; the quality of the studies included 4 moderate and 5 low-quality studies. The pooled data analysis demonstrated low heterogeneity between the trials and a significantly lower ASP incidence rate in patients who underwent MIS procedure, compared with those who underwent open procedure (p = 0.0001). Single-level lumbar interbody fusion was performed in 6 trials of 408 patients and we found a lower ASP incidence rate in MIS group, compared with those who underwent open surgery (p = 0.002). Moreover, the pooled data analysis showed a significant reduction in the incidence rate of adjacent segment disease (ASDis) (p = 0.0003) and adjacent segment degeneration (ASDeg) (p = 0.0002) for both procedures, favoring MIS procedure. Subgroup analyses showed no difference in follow-up durations between the procedures (p = 0.93).

Conclusion

Therefore, we conclude that MIS-TLIF/PLIF can reduce the incidence rate of ASDis and ASDeg, compared with open surgery. Although the subgroup analysis did not indicate a difference in follow-up duration between the two procedures, larger-scale, well-designed clinical trials with extensive follow-up are needed to confirm and update the findings of this analysis.

Minimally Invasive Surgery Versus Open Surgery Spinal Fusion for Spondylolisthesis: A Systematic Review and Meta-analysis

STUDY DESIGN

Systematic review and meta-analysis.

OBJECTIVE

Compare minimally invasive surgery (MIS) and open surgery (OS) spinal fusion outcomes for the treatment of spondylolisthesis.

SUMMARY OF BACKGROUND DATA

OS spinal fusion is an interventional option for patients with spinal disease who have failed conservative therapy. During the past decade, MIS approaches have increasingly been used, with potential benefits of reduced surgical trauma, postoperative pain, and length of hospital stay. However, current literature consists of single-center, low-quality studies with no review of approaches specific to spondylolisthesis only.

METHODS

This first systematic review of the literature regarding MIS and OS spinal fusion for spondylolisthesis treatment was performed using the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines for article identification, screening, eligibility, and inclusion. Electronic literature search of Medline/PubMed, Cochrane, EMBASE, and Scopus databases yielded 2489 articles. These articles were screened against established criteria for inclusion into this study.

RESULTS

A total of five retrospective and five prospective articles with a total of 602 patients were found. Reported spondylolisthesis grades were I and II only. Overall, MIS was associated with less intraoperative blood loss (mean difference [MD], -331.04 mL; 95% confidence interval [CI], -490.48 to -171.59; P < 0.0001) and shorter length of hospital stay (MD, -1.74 days; 95% CI, -3.04 to -0.45; P = 0.008). There was no significant difference overall between MIS and OS in terms of functional or pain outcomes. Subgroup analysis of prospective studies revealed MIS had greater operative time (MD, 19.00 minutes; 95% CI, 0.90 to 37.10; P = 0.04) and lower final functional scores (weighted MD, -1.84; 95% CI, -3.61 to -0.07; P = 0.04) compared with OS.

CONCLUSION

Current data suggests spinal fusion by MIS is a safe and effective approach to treat grade I and grade II spondylolisthesis. Moreover, although prospective trials associate MIS with better functional outcomes, longer-term and randomized trials are warranted to validate any association found in this study.

LEVEL OF EVIDENCE

2.

A novel minimally invasive, dorsolateral, tubular partial odontoidectomy and autologous bone augmentation to treat dens pseudarthrosis: cadaveric, 3D virtual simulation study and technical report

OBJECTIVE

The goal of this study was to demonstrate the clinical and technical nuances of a minimally invasive, dorsolateral, tubular approach for partial odontoidectomy, autologous bone augmentation, and temporary C1–2 fixation to treat dens pseudarthrosis.

METHODS

A cadaveric feasibility study, a 3D virtual reality reconstruction study, and the subsequent application of this approach in 2 clinical cases are reported. Eight procedures were completed in 4 human cadavers. A minimally invasive, dorsolateral, tubular approach for odontoidectomy was performed with the aid of a tubular retraction system, using a posterolateral incision and an oblique approach angle. Fluoroscopy and postprocedural CT, using 3D volumetric averaging software, were used to evaluate the degree of bone removal of C1–2 lateral masses and the C-2 pars interarticularis. Two clinical cases were treated using the approach: a 23-year-old patient with an odontoid fracture and pseudarthrosis, and a 35-year-old patient with a history of failed conservative treatment for odontoid fracture.

RESULTS

At 8 cadaveric levels, the mean volumetric bone removal of the C1–2 lateral masses on 1 side was 3% ± 1%, and the mean resection of the pars interarticularis on 1 side was 2% ± 1%. The median angulation of the trajectory was 50°, and the median distance from the midline of the incision entry point on the skin surface was 67 mm. The authors measured the diameter of the working channel in relation to head positioning and assessed a greater working corridor of 12 ± 4 mm in 20° inclination, 15° contralateral rotation, and 5° lateral flexion to the contralateral side. There were no violations of the dura. The reliability of C-2 pedicle screws and C-1 lateral mass screws was 94% (15 of 16 screws) with a single lateral breach. The patients treated experienced excellent clinical outcomes.

CONCLUSIONS

A minimally invasive, dorsolateral, tubular odontoidectomy and autologous bone augmentation combined with C1–2 instrumentation has the ability to provide excellent 1-stage management of an odontoid pseudarthrosis. The procedure can be completed safely and successfully with minimal blood loss and little associated morbidity. This approach has the potential to provide not only a less invasive approach but also a function-preserving option to treat complex C1–2 anterior disease.

The Outcomes of Minimally Invasive versus Open Posterior Approach Spinal Fusion in Treatment of Lumbar Spondylolisthesis: The Current Evidence from Prospective Comparative Studies

Purpose. To investigate the evidence of minimally invasive (MI) versus open (OP) posterior lumbar fusion in treatment of lumbar spondylolisthesis from current prospective literatures. Methods. The electronic literature database of Pubmed, Embase, and Cochrane library was searched at April 2016. The data of operative time, estimated blood loss and length of hospital stay, visual analog scale (VAS) of both lower back pain and leg pain, Oswestry disability index (ODI), SF-36 PCS (physical component scores) and SF-36 MCS (mental component scores), complications, fusion rate, and secondary surgery were extracted and analyzed by STATA 12.0 software. Results. Five nonrandom prospective comparative studies were included in this meta-analysis. The meta-analysis showed that the MI group had a significantly longer operative time than OP group, less blood loss, and shorter hospital stay. No significant difference was found in back pain, leg pain, ODI, SF-36 PCS, SF-36 MCS, complications, fusion rate, and secondary surgery between MI and OP groups. Conclusion. The prospective evidence suggested that MI posterior fusion for spondylolisthesis had less EBL and hospital stay than OP fusion; however it took more operative time. Both MI and OP fusion had similar results in pain and functional outcomes, complication, fusion rate, and secondary surgery.

Lumbar degenerative spondylolisthesis epidemiology: A systematic review with a focus on gender-specific and age-specific prevalence

The epidemiology of lumbar degenerative spondylolisthesis (DS) remains controversial. We performed a systematic review with the aim of gaining a better understanding of the prevalence of DS in the general population. The results showed that the prevalence of DS is very gender- and age-specific. Few women and men develop DS before they are 50 years old. After 50 years of age, both women and men begin to develop DS, with women having a faster rate of development than men. For elderly Chinese (≥ 65 years, mean age: 72.5 years), large population-based studies MsOS (Hong Kong, females: n = 2000) and MrOS (Hong Kong, males: n = 2000) showed DS prevalence was 25.0% in women and 19.1% in men. The female:male (F:M) prevalence ratio was 1.3:1. The published data for MsOS (USA) and MrOS (USA) studies seem to show that elderly Caucasian Americans have a higher DS prevalence, being approximately 60-70% higher than elderly Chinese; however, the F:M prevalence ratio was similar to the elderly Chinese population. Patient data showed that female patients more often received surgical treatment than male and preliminary data showed the ratio of female to male patients receiving surgical treatment did not differ between Northeast Asians (Chinese, Japanese, and Korean), Europeans, and American Caucasians, being around 2:1 in the elderly population. The existing data also suggest that menopause may be a contributing factor for the accelerated development of DS in postmenopausal women. The translational potential of this article: A better understanding of epidemiology of lumbar degenerative spondylolisthesis can support patient consultation and treatment planning.

Minimally invasive versus open transforaminal lumbar fusion: a systematic review of complications

PURPOSE

The aim of this study is to compare mTLIF vs. oTLIF with regard to peri-operative complications, operative time, estimated blood loss, fluoroscopic time, and the length of hospital stay.

METHODS

The PubMed and EMBASE databases were searched for relevant articles reporting patients undergoing TLIF, and a comparison between mTILF and oTLIF was performed. The database included patient demographic information, complications, operative time, fluoroscopic time, and the length of hospital stay.

RESULTS

Fourteen studies were included in this systematic review. The total number of subjects included was 901, of which 455 underwent mTLIF (50 %) and 446 underwent oTLIF (50 %). The operating time for the mTLIF was ranged from 116 to 390 minutes, compared with 102 to 365 minutes for oTLIF, the operating time tended to be longer in the mTLIF group than the oTLIF group. The estimated blood loss was lower in the mTLIF group, ranging from 51 to 578 ml in mTLIF and 225 to 961 ml in oTLIF, respectively. Length of hospital stay was short for the mTLIF with a 2.3 to 10.6 days hospitalization compared to 2.9 to 14.6 days for oTLIF. However the fluoroscopic time was consistently higher in the mTLIF group with a 49 to 106 seconds of fluoroscopy compared to 16.4 to 44 seconds for oTLIF. The complications divided into technical complications and infection complications. The main technical and infection complications included dural tears, screw malposition, and wound infection. Systemic complications included pneumonia, urinary tract infection, and DVT. The numbers of patients with complication was 54 out of 455 (11.87 %) in the mTLIF, and 64 out of 446 (14.35 %) in the oTLIF.

CONCLUSION

The review shows mTLIF offers several potential advantages in reducing blood loss and the length of hospital stay, especially lowering the complication rates for patients compared with oTLIF. However, it required much more operative time and radiation exposure. Class I evidence and high-quality randomized controlled trials are needed for further study.

Perioperative outcomes in minimally invasive lumbar spine surgery: A systematic review

AIM

To compare minimally invasive (MIS) and open techniques for MIS lumbar laminectomy, direct lateral and transforaminal lumbar interbody fusion (TLIF) surgeries with respect to length of surgery, estimated blood loss (EBL), neurologic complications, perioperative transfusion, postoperative pain, postoperative narcotic use, and length of stay (LOS).

METHODS

A systematic review of previously published studies accessible through PubMed was performed. Only articles in English journals or published with English language translations were included. Level of evidence of the selected articles was assessed. Statistical data was calculated with analysis of variance with P < 0.05 considered statistically significant.

RESULTS

A total of 11 pertinent laminectomy studies, 20 direct lateral studies, and 27 TLIF studies were found. For laminectomy, MIS techniques resulted in a significantly longer length of surgery (177.5 min vs 129.0 min, P = 0.04), shorter LOS (4.3 d vs 5.3 d, P = 0.01) and less perioperative pain (visual analog scale: 16 ± 17 vs 34 ± 31, P = 0.04). There is evidence of decreased narcotic use for MIS patients (postoperative intravenous morphine use: 9.3 mg vs 42.8 mg), however this difference is of unknown significance. Direct lateral approaches have insufficient comparative data to establish relative perioperative outcomes. MIS TLIF had superior EBL (352 mL vs 580 mL, P < 0.0001) and LOS (7.7 d vs 10.4 d, P < 0.0001) and limited data to suggest lower perioperative pain.

CONCLUSION

Based on perioperative outcomes data, MIS approach is superior to open approach for TLIF. For laminectomy, MIS and open approaches can be chosen based on surgeon preference. For lateral approaches, there is insufficient evidence to find non-inferior perioperative outcomes at this time.

Hemothorax caused by the trocar tip of the rod inserter after minimally invasive transforaminal lumbar interbody fusion: case report

Minimally invasive surgery (MIS) for transforaminal lumbar interbody fusion (MIS-TLIF) is widely used for lumbar degenerative diseases. In the paper the authors report a unique case of a hemothorax caused by the trocar tip of the rod inserter after MIS-TLIF. A 61-year-old woman presented with thigh pain and gait disturbance due to weakness in her lower right extremity. She was diagnosed with a lumbar disc herniation at L1-2 and the MIS-TLIF procedure was performed. Immediately after surgery, the patient's thigh pain resolved and she remained stable with normal vital signs. The next day after surgery, she developed severe anemia and her hemoglobin level decreased to 7.6 g/dl, which required blood transfusions. A chest radiograph revealed a hemothorax. A CT scan confirmed a hematoma of the left paravertebral muscle. A chest tube was placed to treat the hemothorax. After 3 days of drainage, there was no active bleeding. The patient was discharged 14 days after surgery without leg pain or any respiratory problems. This complication may have occurred due to injury of the intercostal artery by the trocar tip of the rod inserter. A hemothorax after spine surgery is a rare complication, especially in the posterior approach. The rod should be caudally inserted in the setting of the thoracolumbar spine.

Minimally invasive posterior transforaminal lumbar interbody fusion: One-year postoperative morbidity, clinical and radiological results of a prospective multicenter study of 182 cases

INTRODUCTION

Interbody fusion is the gold standard treatment for the management of numerous diseases of the spine. Minimally invasive techniques may be more beneficial than conventional techniques. The main goal of this study was to report the one-year postoperative results of a series of posterior lumbar interbody fusions by a minimally invasive technique in relation to improvement in functional outcome, interbody fusion and morbidity.

MATERIALS AND METHODS

Between January 2012 and May 2013, 182 patients treated by minimally invasive posterior transforaminal lumbar interbody fusion (TLIF) were included in this prospective multicenter study. Clinical assessment was based on a comparison of the preoperative and one-year postoperative Oswestry (ODI), SF-12 and Quebec Scores and the Visual Analog Scale (VAS). Surgical and postoperative follow-up data were evaluated. Radiological assessment was based preoperative and one-year postoperative full spine teleradiographs. Interbody fusion at one-year was systematically evaluated by CT scan.

RESULTS

One hundred and eighty-two patients were included, mean age 58.9 years old. Surgery lasted a mean 101 minutes, mean preoperative bleeding was 143 mL, and mean radiation exposure was 247.4 cGy/cm(2). The rate of postoperative complications was 7.7%. The ODI, the Quebec Score, the SF-12 and the VAS were all significantly improved at one-year (P<0.0001). The rate of fusion was 72.6% at the final follow-up. There was no significant difference in functional outcome between patients with and without fusion.

DISCUSSION

The one-year postoperative radiological results and functional outcome of minimally invasive posterior lumbar fusion are satisfactory. The benefits of this minimally invasive approach are mainly found in the first 6 postoperative months. Successful radiological interbody fusion was not correlated to functional outcome at the final follow-up.

Cost-utility of minimally invasive versus open transforaminal lumbar interbody fusion: systematic review and economic evaluation

PURPOSE

To assess the cost-utility and perioperative costs of minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) versus open-TLIF for degenerative lumbar pathologies.

METHODS

Relevant articles were identified from six electronic databases. Predefined end points were extracted and meta-analysis conducted from the identified studies.

RESULTS

For each study, the direct hospital cost for MI-TLIF was found to be less than that of open-TLIF. When these outcomes were pooled, direct hospital costs were found to be significantly lower in the MI-TLIF group [weighted mean difference (WMD), -$2820; I (2) = 61 %; P < 0.00001]. MI-TLIF was also associated with shorter hospitalization (WMD, 0.99; 95 % CI -1.81, -0.17; I (2) = 96 %; P = 0.02), trend toward reduced complications (relative risk 0.53; 95 % CI 0.23, 1.06; I (2) = 0 %; P = 0.07), and reduced blood loss (WMD, -246.40 mL; I (2) = 98 %; P = 0.003), but was not associated with a significant difference in operation time (WMD, -67.05; 95 % CI -169.44, 35.35; I (2) = 100 %; P = 0.20).

CONCLUSIONS

From the limited evidence, the available data suggest a trend of significantly reduced perioperative costs, length of stay, and blood loss for minimally invasive compared with open surgical approaches for TLIF. MI-TLIF may represent an opportunity for optimal utilization and allocation of health-care resources from both a hospital and societal perspective.

Intraoperative and perioperative complications in minimally invasive transforaminal lumbar interbody fusion: a review of 513 patients

OBJECT

Transforaminal lumbar interbody fusion (TLIF) has become one of the preferred procedures for circumferential fusion in the lumbar spine. Over the last decade, advances in surgical techniques have enabled surgeons to perform the TLIF procedure through a minimally invasive approach (MI-TLIF). There are a few studies reported in the medical literature in which perioperative complication rates of MI-TLIF were evaluated; here, the authors present the largest cohort series to date. They analyzed intraoperative and perioperative complications in 513 consecutive MI-TLIF–treated patients with lumbar degenerative disc disease.

METHODS

The authors performed a retrospective review of prospectively collected data on 513 consecutive patients treated over a 10-year period for lumbar degenerative disc disease using MI-TLIF. All patients undergoing either a first-time or revision 1- or 2-level MI-TLIF procedure were included in the study. Demographic, intraoperative, and perioperative data were collected and analyzed using bivariate analyses (Student t-test, analysis of variance, odds ratio, chi-square test) and multivariate analyses (logistic regression).

RESULTS

A total of 513 patients underwent an MI-TLIF procedure, and the perioperative complication rate was 15.6%. The incidence of durotomy was 5.1%, and the medical and surgical infection rates were 1.4% and 0.2%, respectively. A statistically significant increase in the infection rate was seen in revision MI-TLIF cases, and the same was found for the perioperative complication rate in multilevel MI-TLIF cases. Instrumentation failure occurred in 2.3% of the cases. After analysis, no statistically significant difference was seen in the rates of durotomy during revision and multilevel surgeries. There was no significant difference between the complication rates when stratified according to presenting diagnosis.

CONCLUSIONS

To the authors' knowledge, this is the largest study of perioperative complications in MI-TLIF in the literature. A total of 513 patients underwent MI-TLIF (perioperative complication rate 15.6%). The most common complication was a durotomy (5.1%), and there was only 1 surgical wound infection (0.2%). There were significantly more perioperative infections in revision MI-TLIF cases and more perioperative complications in multilevel MI-TLIF cases. The results of this study suggest that MI-TLIF has a similar or better perioperative complication profile than those documented in the literature for open-TLIF treatment of degenerative lumbar spine disease.