"One and a half" minimally invasive transforaminal lumbar interbody fusion: single level transforaminal lumbar interbody fusion with adjacent segment unilateral laminotomy for bilateral decompression for spondylolisthesis with bisegmental stenosis

Expandable cages that expand both height and lordosis provide improved immediate effect on sagittal alignment and short-term clinical outcomes following minimally invasive transforaminal lumbar interbody fusion (MIS TLIF)

Background

Failure to restore lordotic alignment is not an uncommon problem following minimally invasive transforaminal lumbar interbody fusion (MIS TLIF), even with expandable cages that increase disc height. This study aims to investigate the effect of the expandable cage that is specifically designed to expand both height and lordosis. We evaluated the outcomes of MIS TLIF in restoring immediate postoperative sagittal alignment by comparing two different types of expandable cages. One cage is designed to solely increase disc height (Group H), while the other can expand both height and lordosis (Group HL).

Methods

Patients undergoing MIS TLIF using expandable cages were retrospectively reviewed, including 40 cases in Group H and 109 cases in Group HL. Visual analog scores of back and leg pain, and Oswestry disability index were collected. Disc height, disc angle, and sagittal alignment were measured. Complications were recorded, including early subsidence which was evaluated with computed tomography.

Results

Clinical and radiographic outcomes significantly improved in both groups postoperatively. Group HL showed superior improvement in segmental lordosis (4.4°±3.5° vs. 2.1°±4.8°, P=0.01) and disc angle (6.3°±3.8 vs. 2.2°±4.3°, P<0.001) compared to Group H. Overall incidence of early subsidence was 23.3%, predominantly observed during initial cases as part of the learning curve, but decreased to 18% after completion of the first 20 cases.

Conclusions

Expandable cages with a design specifically aimed at increasing lordotic angle can provide favorable outcomes and effectively improve immediate sagittal alignment following MIS TLIF, compared to conventional cages that only increase in height. However, regardless of the type of expandable cage used, it is crucial to avoid applying excessive force to achieve greater disc height or lordosis, as this may contribute to subsidence and a possible reduction in lordotic alignment restoration. Long-term results are needed to evaluate the clinical outcome, fusion rate, and maintenance of the sagittal alignment.

Microsurgical Tubular Resection of Intradural Extramedullary Spinal Tumors With 3-Dimensional-Navigated Localization

BACKGROUND

The safety and efficacy of minimally invasive spine surgical (MISS) approaches have stimulated interest in adapting MISS principles for more complex pathology including intradural extramedullary (IDEM) tumors. No study has characterized a repeatable approach integrating the MISS surgical technique and 3-dimensional intraoperative navigated localization for the treatment of IDEM tumors.

OBJECTIVE

To describe a safe and reproducible technical guide for the navigated MISS technique for the treatment of benign intradural and extradural spinal tumors.

METHODS

Retrospective review of prospectively collected data on 20 patients who underwent navigated microsurgical tubular resection of intradural extramedullary tumors over a 5-year period. We review our approach to patient selection and report demographic and outcomes data for the cohort.

RESULTS

Our experience demonstrates technical feasibility and safety with a 100% rate of gross total resection with no patients demonstrating recurrence during an average follow-up of 20.2 months and no instances of perioperative complications. We demonstrate favorable outcomes regarding blood loss, operative duration, and hospital length of stay.

CONCLUSION

Navigated localization and microsurgical tubular resection of IDEM tumors is safe and effective. Adherence to MISS principles and thoughtful patient selection facilitate successful management of these patients.

Percutaneous Endoscopic Posterior Lumbar Interbody Fusion with Unilateral Laminotomy for Bilateral Decompression Vs. Open Posterior Lumbar Interbody Fusion for the Treatment of Lumbar Spondylolisthesis

Background

Endoscopic lumbar interbody fusion is a new technology that is mostly used for single-segment and unilateral lumbar spine surgery. The purpose of this study is to introduce percutaneous endoscopic posterior lumbar interbody fusion (PE-PLIF) with unilateral laminotomy for bilateral decompression (ULBD) for lumbar spondylolisthesis and evaluate the efficacy by comparing it with open posterior lumbar interbody fusion (PLIF).

Methods

Twenty-eight patients were enrolled in PE-PLIF with the ULBD group and the open PLIF group. The perioperative data of the two groups were compared to evaluate the safety of PE-PLIF with ULBD. The visual analog scale (VAS) back pain, VAS leg pain, and Oswestry Disability Index (ODI) scores of the two groups preoperatively and postoperatively were compared to evaluate clinical efficacy. Preoperative and postoperative imaging data were collected to evaluate the effectiveness of the operation.

Results

No differences in baseline data were found between the two groups (p > 0.05). The operation time in PE-PLIF with the ULBD group (221.2 ± 32.9 min) was significantly longer than that in the PLIF group (138.4 ± 25.7 min) (p < 0.05), and the estimated blood loss and postoperative hospitalization were lower than those of the PLIF group (p < 0.05). The postoperative VAS and ODI scores were significantly improved in both groups (p < 0.05), but the postoperative VAS back pain score in the PE-PLIF group was significantly lower than that in the PLIF group (p < 0.05). The excellent and good rates in both groups were 96.4% according to MacNab’s criteria. The disc height and cross-sectional area of the spinal canal were significantly improved in the two groups after surgery (p < 0.05), with no difference between the groups (p > 0.05). The fusion rates in PE-PLIF with the ULBD group and the PLIF group were 89.3% and 92.9% (p > 0.05), respectively, the cage subsidence rates were 14.3% and 17.9% (p > 0.05), respectively, and the lumbar spondylolisthesis reduction rates were 92.72 ± 6.39% and 93.54 ± 5.21%, respectively (p > 0.05).

Conclusion

The results from this study indicate that ULBD can be successfully performed during PE-PLIF, and the combined procedure is a safe and reliable treatment method for lumbar spondylolisthesis.

Oblique Lateral Interbody Fusion versus Transforaminal Lumbar Interbody Fusion in Degenerative Lumbar Spondylolisthesis: A Single-Center Retrospective Comparative Study

Objective

To compare the efficacy of oblique lateral interbody fusion (OLIF) and transforaminal lumbar interbody fusion (TLIF) in single-level degenerative lumbar spondylolisthesis (DLS).

Methods

A retrospective analysis of patients who underwent single-level DLS surgery in our department from 2015 to 2018 was performed. According to the surgical method, the enrolled patients were divided into two groups, namely, the OLIF group who underwent OLIF combined with percutaneous pedicle screw fixation (PPSF) and the TLIF group. Clinical outcomes included operation time, operation blood loss, postoperative drainage, hospital stay, visual analog scale (VAS) score, Oswestry disability index (ODI), and complications, and imaging outcomes included upper vertebral slip, intervertebral space height (ISH), intervertebral foramen height (IFH), intervertebral space angle (ISA), lumbar lordosis (LL), and bone fusion rate. All outcomes were recorded and analyzed.

Results

A total of 65 patients were finally included, and there were 28 patients and 37 patients in the OLIF group and the TLIF group, respectively. The OLIF group showed shorter operation time, less blood loss, less postoperative drainage, and shorter hospital stay than the TLIF group (P < 0.05). The ISH, IFH, ISA, and LL were all larger in the OLIF group at postoperative and last follow-up (P < 0.05), but the degree of upper vertebral slip was found no difference between the two groups (P > 0.05). The bone graft fusion rate of OLIF group and TLIF group at 3 months, 6 months, and last follow-up was 78.57%, 92.86%, and 100% and 70.27%, 86.49%, and 97.30%, respectively, and no significant differences were found (P > 0.05). Compared with the TLIF group, the OLIF group showed a superior improvement in VAS and ODI at 1 month, 3 months, and 6 months postoperative (P < 0.05), but no differences were found at 12 months postoperative and the last follow-up (P > 0.05). There was no significant difference in complications between the two groups, with 4 patients and 6 patients in the OLIF group and TLIF group, respectively (P > 0.05).

Conclusions

Compared with TLIF, OLIF showed the advantages of less surgical invasion, better decompression effect, and faster postoperative recovery in single-level DLS surgery.

Minimally invasive tubular laminectomies in multilevel spine surgery-an illustrative case-based review of techniques and combined approaches

Minimally invasive techniques have become part of the spine surgeons' armamentarium and are currently utilized to treat many conditions involving the cervical, thoracic, lumbar and sacral spine. Surgical treatment of severe degenerative conditions such as multilevel spinal stenosis, tandem stenosis, combination of stenosis or disk herniation and spondylolisthesis at adjacent spinal levels, as well as extensive infections or hematomas, may require a multilevel tailored approach with all the challenges that such surgical planning entails. Although the use of minimally invasive tubular decompressive procedures has gained widespread popularity in the recent years, the adoption of such techniques during multilevel spine surgery can be at times challenging. A careful tailored selection of the surgical approach that better fits needs and expectations of the patient is therefore consequential to achieve good clinical and radiological outcome without compromising efficiency and results. Many surgical techniques have been described in literature but very few reports on the use of combined tubular approached are currently present. We therefore present an illustrative review of techniques for tubular laminectomies and combined approaches that can be utilized in the surgical treatment of multilevel spinal conditions. Illustrative cases documenting common and less common indications for the use of minimally invasive laminectomies are also presented.

Tailored minimally invasive tubular laminectomies for the urgent treatment of rare holocord spinal epidural abscess: case report and review of technique

Spinal abscesses that involve the full length of the spine, from the cervical to the sacral regions, are rare and account for approximately 1% of spinal epidural infections. Urgent surgical decompression combined with antibiotics treatment is usually recommended in these patients and selection of the most suitable surgical approach is tailored on the extent and location of the fluid collection. We present a rare case of holocord spinal epidural abscess treated with cervico-thoracic-lumbar tandem tubular decompressive laminectomies with alternating incisions, which were tailored on the preoperative sagittal and axial extension of the abscess. This minimally invasive procedure allowed for the successful drainage and decompression of the epidural space in an adult patient presenting with acute worsening tetraparesis. After the surgery the patient's neurological examination improved and follow up radiological studies confirmed the successful decompression of the epidural space. Tailoring not only the level but also the laterality of the tandem tubular approach, may be beneficial in minimizing soft tissues trauma, blood loss, operative time and need for more extensive surgical exposure, while successfully treating rare holospinal epidural infections. Minimally invasive tailored decompression of holocord spinal epidural abscesses should be considered as a surgical option in selected patients presenting with acute neurological symptoms.