Minimally Invasive Transforaminal Lumbar Interbody Research Articles

Comparison of mMO-TLIF via Midline Incision Versus MIS-TLIF via Wiltse Approach in Lumbar Degenerative Disease

BackgroundTo compare the clinical and radiological outcomes of modified mini-open transforaminal lumbar interbody fusion (mMO-TLIF) via posterior midline incision for "targeted limited dissection" versus minimal invasive transforaminal lumbar interbody fusion (MIS-TLIF) via Wiltse approach in lumbar degenerative diseases.MethodsA total of 60 consecutive patients in our center from January 2019 to March 2020 were enrolled, including 30 patients who were treated with mMO-TLIF via posterior midline incision and 30 treated with MIS-TLIF through the Wiltse approach. Perioperative parameters were recorded. The questionnaires of Oswestry Disability Index (ODI) and Visual Analogue Score (VAS) were conducted before the operation and after the operation (3 days, 1 week, and 2 years). CT and MRI radiological outcomes were evaluated before the operation and at a 2-year follow-up.ResultsThere were no significant differences in the general data, gender, age, and BMI between the two groups. All patients were successfully operated without intraoperative complications. There were significant differences between the two groups in the operation time (p < 0.001) and intraoperative bleeding (p < 0.05). There was no difference in ODI and VAS scores between groups pre- and post-operatively, but they were both significantly improved compared to those before the operation (p < 0.01). At a 2-year follow-up, the paraspinal muscle atrophy and fat infiltration were increased comparing to pre-operation, but the difference was also not statistically significant (p > 0.05). In addition, both the two groups’ fusion rates were more than 90% at a 2-year follow-up, however, no difference was detected between the two groups.ConclusionmMO-TLIF via midline incision for “targeted limited dissection” could achieve similar clinical and radiological outcomes as MIS-TLIF for lumbar degenerative disease.

Risk factors for spinal subdural hematoma after minimally invasive transforaminal lumbar Interbody Fusion (MI-TLIF): a multivariate analysis

BackgroundSpinal subdural hematoma (SSH) is a rare cause of compression of the neutral elements of the spinal cord. However, little is known about the presentation of acute SSH after lumbar spine surgery. The reason for this may be that symptomatic SSH occurs rarely and is not given enough attention by spine surgeons. Currently, the decision to perform MRI postoperatively is more dependent on surgeon preference; therefore, no high-quality studies have been published. Our team reports our experience in the diagnosis and management of SSH after lumbar decompression and fusion surgery.MethodsWe retrospectively studied 215 patients who underwent routine MRI following minimal invasive transforaminal lumbar interbody fusion (MI-TLIF) between 2020-01-01 and 2022-06-30. The patients were divided into SSH group (17 cases) and non-SSH group (198 cases) according to the occurrence of SSH. Univariate analysis and multivariate logistic regression analysis were performed to identify relevant risk factors that increase the risk of SSH postoperatively.ResultsNone of the patients presented with serious neurologic symptoms, such as lower extremity paralysis or cauda equina syndrome that required emergency hematoma debridement. SSH was found in 17 (7.9%) patients and non-SSH in 198 (92.1%). Factors affecting SSH were presence of hypertension, presence of diabetes and postoperative anticoagulant therapy. The significantly independent risk factor of postoperative SSH were diabetes (P = 0.008, OR: 6.988) and postoperative anticoagulant therapy (P = 0.003, OR: 8.808).ConclusionsSSH after MI-TLIF is not a rare condition, with generally no requirement of emergency evacuation. Comprehensive anti-symptomatic treatment could achieve satisfactory results. Diabetes mellitus and postoperative anticoagulant therapy are independent risk factors for SSH. Spine surgeons should hold applicability of the use of anticoagulants after lumbar surgery.

Radiological and Clinical Outcomes comparing 2-level MIS Lateral and MIS Transforaminal Lumbar Interbody Fusion in Degenerative Lumbar Spinal Stenosis.

Retrospective Cohort Study. To compare early postoperative radiological and clinical outcomes between 2-level minimally invasive (MIS) trans-psoas lateral lumbar interbody fusion (LLIF) and MIS transforaminal lumbar interbody fusion (TLIF) for degenerative lumbar spinal stenosis. Fifty three consecutive patients undergoing 2-level lumbar interbody fusion from L3-L5 for degenerative lumbar spinal stenosis were enrolled. Twenty four patients underwent LLIF and 29 underwent TLIF. Operative time and length of stay were similar between LLIF and TLIF (272.8 ± 82.4 vs 256.1 ± 59.4 minutes; 5.5 ± 2.8 vs 4.7 ± 3.3 days, P > .05), whereas blood loss was lower for LLIF (229.0 ± 125.6 vs 302.4 ± 97.1mls, P = .026). Neurological deficits were more common in LLIF (9 vs 3, P = .025), whereas persistent deficits were rare for both (1 vs 1, P = 1). For both groups, all patient reported outcomes visual analogue scale (VAS back pain, VAS leg pain, ODI, SF-36 physical) improved from preoperative to 2-years postoperative (P < .05), with both groups showing no significant differences in extent of improvement for any outcome. Lateral lumbar interbody fusion demonstrated superior restoration of disc height (L3-L4: 4.1 ± 2.4 vs 1.2 ± 1.9mm, P < .001; L4-L5: 4.6 ± 2.4 vs .8 ± 2.8mm, P < .001), foraminal height (FH) (L3-L4: 3.5 ± 3.6 vs 1.0 ± 3.6mm, P = .014; L4-L5: 3.0 ± 3.5 vs -.1 ± 4.4mm, P = .0080), segmental lordosis (4.1 ± 6.4 vs -2.1 ± 8.1°, P = .005), lumbar lordosis (LL) (4.1 ± 7.0 vs -2.3 ± 12.6°, P = .026) and pelvic incidence-lumbar lordosis (PI-LL) mismatch (-4.1 ± 7.0 vs 2.3 ± 12.6°, P = .019) at 2-years follow-up. The superior radiological outcomes demonstrated by 2-level trans-psoas LLIF did not translate into difference in clinical outcomes compared to 2-level TLIF at the 2-years follow-up, suggesting both approaches are reasonable for 2-level lumbar interbody fusion in degenerative lumbar spinal stenosis.

Comparison of effectiveness between percutaneous coaxial large-channel endoscopic lumbar interbody fusion and minimal invasive transforaminal lumbar interbody fusion in treatment of degenerative lumbar spinal stenosis

To compare the effectiveness of percutaneous coaxial large-channel endoscopic lumbar interbody fusion (PE-LIF) and minimal invasive transforaminal lumbar interbody fusion (MIS-TLIF) in the treatment of degenerative lumbar spinal stenosis. The clinical data of 134 patients with single-segment degenerative lumbar spinal stenosis who met the selection criteria between January 2019 and January 2021 were retrospectively analyzed, including 52 cases in PE-LIF group and 82 cases in MIS-TLIF group. There was no significant difference in general data such as gender, age, disease duration, surgical segment, and preoperative visual analogue scale (VAS) scores of low back pain and lower extremity pain, and Oswestry disability index (ODI) between the two groups ( P>0.05). The operation time, intraoperative blood loss, postoperative drainage, hospitalization stay, and complications were recorded and compared between the two groups. The level of serum creatine kinase (CK) was recorded at 1 day before operation and at 1 and 3 days after operation to evaluate intraoperative muscle damage. The Brantigan criteria was used to evaluate the interbody fusion in the two groups. The VAS scores of low back pain and lower extremity pain at 1 day before operation and at 3 days, 3 months, and 1 year after operation, and the ODI scores at 1 day before operation and at 3 months and 1 year after operation were recorded and compared between the two groups. There was no significant difference in operation time and hospitalization stay between the two groups ( P>0.05). The intraoperative blood loss and postoperative drainage in the PE-LIF group were significantly lower than those in the MIS-TLIF group ( P<0.05). There was no significant difference in serum CK between the two groups before operation ( P>0.05), and the serum CK in the PE-LIF group at 1 and 3 days after operation were significantly lower than those in the MIS-TLIF group ( P<0.05). All patients were followed up regularly for 1 year. The postoperative VAS scores of low back pain and lower extremity pain and ODI score in both groups were significantly lower than those before operation ( P<0.05); there was no significant difference between the two groups ( P>0.05). At 1 year after operation, 48 patients in PE-LIF group had successful interbody fusion, and 77 patients in MIS-TLIF group had successful interbody fusion. There was no significant difference in the interbody fusion distribution between the two groups at 3 months and 1 year after operation ( P>0.05). There were 2 and 3 cases of lower limb numbness, 1 and 3 cases of neuroedema pain, 1 and 1 case of Cage displacement, 1 and 1 case of pedicle screw loosening in the PE-LIF group and MIS-TLIF group, respectively. No infection or dural sac tearing occurred in the two groups. There was no significant difference in the incidence of complications between the two groups (9.6% vs. 9.8%) ( χ 2=0.001, P=0.979). In the treatment of single-segment degenerative lumbar spinal stenosis, PE-LIF can achieve similar effectiveness as MIS-TLIF, and PE-LIF has less intraoperative blood loss and less muscle damage.

The effect of ketorolac on posterior minimally invasive transforaminal lumbar interbody fusion: an interim analysis from a randomized, double-blinded, placebo-controlled trial

BACKGROUND CONTEXTPostoperative pain control following posterior lumbar fusion continues to be challenging and often requires high doses of opioids for pain relief. The use of ketorolac in spinal fusion is limited due to the risk of pseudarthrosis. However, recent literature suggests it may not affect fusion rates with short-term use and low doses. PURPOSEWe sought to demonstrate noninferiority regarding fusion rates in patients who received ketorolac after undergoing minimally invasive (MIS) posterior lumbar interbody fusion. Additionally, we sought to demonstrate ketorolac's opioid-sparing effect on analgesia in the immediate postoperative period. STUDY DESIGN/SETTINGThis is a prospective, randomized, double-blinded, placebo-controlled trial. We are reporting our interim analysis. PATIENT SAMPLEAdults with degenerative spinal conditions eligible to undergo a one to three-level MIS transforaminal lumbar interbody fusion (TLIF). OUTCOME MEASURESSix-month and 1-year radiographic fusion as determined by Suk criteria, postoperative opioid consumption as measured by intravenous milligram morphine equivalent, length of stay, and drug-related complications. Self-reported and functional measures include validated visual analog scale, short-form 12, and Oswestry Disability Index. METHODSA double-blinded, randomized placebo-controlled, noninferiority trial of patients undergoing 1- to 3-level MIS TLIF was performed with bone morphogenetic protein (BMP). Patients were randomized to receive a 48-hour scheduled treatment of either intravenous ketorolac (15 mg every 6 hours) or saline in addition to a standardized pain regimen. The primary outcome was fusion. Secondary outcomes included 48-hour and total postoperative opioid use demonstrated as milligram morphine equivalence, pain scores, length of stay (LOS), and quality-of-life outcomes. Univariate analyses were performed. The present study provides results from a planned interim analysis. RESULTSTwo hundred and forty-six patients were analyzed per protocol. Patient characteristics were comparable between the groups. There was no significant difference in 1-year fusion rates between the two treatments (p=.53). The difference in proportion of solid fusion between the ketorolac and placebo groups did not reach inferiority (p=.072, 95% confidence interval, -.07 to .21). There was a significant reduction in total/48-hour mean opioid consumption (p<.001) and LOS (p=.001) for the ketorolac group while demonstrating equivalent mean pain scores in 48 hours postoperative (p=.20). There was no significant difference in rates of perioperative complications. CONCLUSIONSShort-term use of low-dose ketorolac in patients who have undergone MIS TLIF with BMP demonstrated noninferior fusion rates. Ketorolac safely demonstrated a significant reduction in postoperative opioid use and LOS while maintaining equivalent postoperative pain control.

Use of Intraoperative Computed Tomography Improves Outcome of Minimally Invasive Transforaminal Lumbar Interbody Fusion: A Single-Center Retrospective Cohort Study

To provide data about surgical workflow, accuracy, complications, radiation exposure, and learning curve effect in patients who underwent minimally invasive (MIS) transforaminal lumbar interbody fusion with navigation coupled with mobile intraoperative computed tomography. A retrospective analysis was performed of data from consecutive patients who underwent single- or double-level MIS transforaminal lumbar interbody fusion at a single institution; mobile intraoperative computed tomography combined with a navigation system was used as the sole intraoperative imaging method to place pedicular screws; decompression and interbody fusion were performed through a 22-mm tubular retractor. Clinical data, perioperative complications, accuracy of pedicular screw placement, and radiation exposure were analyzed. A learning curve effect on surgical time and accuracy was assessed. A total of 408 screws in 100 patients were analyzed. In all cases, spinal navigation allowed for identification of pedicular trajectories and greatly facilitated nerve root decompression through the MIS approach. Overall accuracy according to Heary classification was 95.3%. Nineteen screws (4.7%) presented a minor lateral breach (<2 mm), not clinically significant. Surgical time, blood loss, and patient radiation exposure compared favorably with reported values from other series using three-dimensional navigation. A learning curve effect on surgical time, but not on screw accuracy, was identified. MIS transforaminal lumbar interbody fusion can now be performed without any radiation exposure to the surgeon and operating room staff, with almost absolute accuracy during screw positioning and tubular decompression. A learning curve effect on surgical time, but not on overall screw accuracy, may be expected.

Outpatient Minimally Invasive Lumbar Fusion Using Multimodal Analgesic Management in the Ambulatory Surgery Setting.

The transition of minimally invasive (MIS) spine surgery from the inpatient to outpatient setting has been aided by advances in multimodal analgesic (MMA) protocols. This clinical case series of patients demonstrates the feasibility of ambulatory MIS transforaminal lumbar interbody fusion (TLIF) and lateral lumbar interbody fusion (LLIF) procedures while using an enhanced MMA protocol. Consecutive MIS TLIF or LLIF procedures with percutaneous pedicle screw fixation and direct decompression in the ambulatory setting were reviewed. The procedures were performed using an MMA protocol. The ambulatory surgery center (ASC) did not allow for observation of patients for periods of time greater than 23 hours. We recorded patient demographics, perioperative, and postoperative characteristics. Fifty consecutive patients were identified from September 2016 to July 2019. Forty-one patients (82%) underwent MIS TLIF, and 9 patients underwent MIS LLIF (18.0%). All patients were discharged on the same day of surgery. The mean length of stay was 4.5 hours and 3.8 hours for the TLIF and LLIF cohorts, respectively. Our review of medical records revealed no postoperative complications following either the TLIF or the LLIF procedures. The present study of 50 consecutive patients is the largest clinical series of ASC patients undergoing lumbar fusion procedures in a stand-alone facility with no extended postoperative observation capability. While using MMA protocol within the ASC, no postoperative complications were observed for either MIS TLIF or LLIF procedures. All patients were discharged from the ambulatory surgical center on the day of surgery with well-controlled postoperative pain. 4. The MMA protocol is an essential aspect in transitioning minimally invasive lumbar spine surgery to the ASC. Our findings indicate that MIS lumbar fusion spine surgery with an enhanced MMA protocol can lead to safe and timely ASC discharge while minimizing hospital admission.

Awake minimally invasive transforaminal lumbar interbody fusion with a pedicle-based retraction system

ObjectiveRecently there has been increasing interest in the use of regional anesthesia for minimally-invasive transforaminal lumbar interbody fusion (TLIF) and laminectomy, with the goal of reducing the side effects and risks associated with general anesthesia and also to improve patient satisfaction. The goal of this technical note is to describe important perioperative aspects to safely perform an awake spine surgery and to describe a novel technique to preform minimally-invasive TLIF using a pedicle-based retraction system. MethodsWe report our patient selection criteria, perioperative anesthesia protocol and surgical technique for awake TLIF with the Maximum Access Surgery (MAS) TLIF Retraction System. We describe an illustrative case of a 66-year-old female that presented with leg pain, lumbar MRI revealed a grade one spondylolisthesis at L4−5 with severe canal stenosis. She underwent a L4−5 Awake MIS TLIF using the MAS TLIF Retraction System. ResultsThe first 10 awake TLIF we performed with the MAS TLIF Retraction System had a mean procedure time of 117.3 min with a standard deviation (SD) of 13, and a mean total OR time of 151 min, SD 14.5. No surgery was converted under general anesthesia. No intraoperative complications were reported. Average length of stay was 1.3 ± 0.46 days. ConclusionAwake MAS TLIF is a safe and effective technique, with the advantage of reducing the risk and side effect of general anesthesia and the approach-associated damage to soft tissues and morbidity. The pedicle-based distraction allows easier access to the intervertebral disc space for both disc preparation and cage placement.

37. Outpatient minimally invasive lumbar fusion using multimodal analgesic management in the ambulatory surgery setting

BACKGROUND CONTEXT The transition of minimally invasive (MIS) spine surgery from the inpatient to outpatient setting has been aided by advances in multimodal analgesic (MMA) protocols. This clinical case series of patients demonstrates the feasibility of ambulatory MIS transforaminal lumbar interbody fusion (TLIF) and a lateral lumbar interbody fusion (LLIF) procedures while using an enhanced MMA protocol. PURPOSE To present a clinical case series of patients who underwent either a MIS transforaminal lumbar interbody fusion (TLIF) or a lateral lumbar interbody fusion (LLIF) in the ambulatory surgery setting while using an enhanced MMA protocol. STUDY DESIGN/SETTING Retrospective. PATIENT SAMPLE A total of 50 patients who underwent MIS TLIF or LLIF with percutaneous pedicle screw fixation with direct decompression. OUTCOME MEASURES Postoperative pain, postoperative narcotics, postoperative complications. METHODS Consecutive patients who underwent outpatient MIS TLIF or LLIF procedures with percutaneous pedicle screw fixation and direct decompression in the ambulatory setting were reviewed. The procedures were performed using an MMA protocol. The senior surgeon performing the cases had extensive experience, operating in an ambulatory surgical center. Patient demographics and baseline characteristics were recorded, including age, sex, smoking status, Charlson Comorbidity Index (CCI), and body mass index (BMI). Perioperative characteristics, postoperative pain scores and narcotics administered to patients prior to discharge from the ASC were recorded including any complications. RESULTS A total of 50 consecutive patients were identified from September 2016 to July 2019, of which 41 patients (82%) underwent MIS TLIF, and 9 patients underwent MIS LLIF (18.0%). The LLIF procedures involved percutaneous posterior pedicle screw instrumentation and direct tubular posterior decompression. All patients in our study population were discharged home on the day of surgery from the surgical center. The mean length of stay was 4.5±1.6 hours and 3.8±1.6 hours for the TLIF and LLIF cohorts respectively. There was an outlier of 8.8 hours following a TLIF procedure. This patient reported a high VAS pain score of 9 immediately following surgery that needed to be adequately controlled prior to discharge. Our review of medical records revealed no postoperative complications following either the TLIF or LLIF procedures. CONCLUSIONS To our knowledge, the present study of 50 consecutive patients is the largest clinical series of patients who underwent outpatient lumbar fusion procedures in a stand-alone ambulatory surgery setting with no extended postoperative observation capability. Our study of patients who underwent outpatient MIS TLIF or LLIF procedures in the ambulatory surgery setting while using a well-developed multimodal analgesia protocol demonstrated no postoperative complications. Postoperative pain was adequately controlled and all patients were discharged from the ambulatory surgical center on the day of surgery approximately 4.5 (TLIF) and 3.8 (LLIF) hours after the procedure. The findings suggest that with proper preoperative patient selection, an enhanced MMA protocol can lead to discharge of patients from a surgical center and minimize admission to a hospital. Preventing these complications may help increase the likelihood of timely discharge facilitating the performance of lumbar fusion procedures in the ambulatory setting. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Postoperative Anemia Predicts Length of Stay for Geriatric Patients Undergoing Minimally Invasive Lumbar Spine Fusion Surgery.

Introduction:We hypothesize that postoperative anemia will predict length of stay (LOS) for geriatric patients undergoing minimally invasive (MIS) lumbar spine fusions.Materials and Methods:Patients who underwent MIS lateral and transforaminal lumbar interbody fusion between January 2017 and March 2018 at an academic tertiary care referral center were selected. Eighty-one patients were included. The primary outcome variable was LOS, measured in days. The predictors studied were preoperative hemoglobin (Hgb), postoperative day 1 Hgb, postoperative nadir Hgb, intraoperative Hgb decrement (preoperative Hgb-postoperative day 1 Hgb), perioperative Hgb decrement (preoperative Hgb-postoperative nadir Hgb), age, American Society of Anesthesiologists–Physical Status (ASA-PS) score, volume of perioperative intravenous (IV) fluids (IVFs), and number of levels fused. Simple linear regression and analysis of variance were used for statistical analysis.Results:In the present study, preoperative anemia was not associated with longer LOS (P = .15). Postoperative anemia was associated with longer LOS as both postoperative day 1 Hgb (P = .05*) and postoperative nadir Hgb (P < .0001*) predicted longer LOS. Greater intraoperative Hgb decrement did not predict longer LOS (P = .36); however, greater perioperative Hgb decrement predicted longer LOS (P < .0001*). Older age (P = .01*) and greater number of levels fused (P = .03*) predicted longer LOS; however, a greater ASA-PS classification did not predict longer LOS. Greater IVF administration was associated with longer LOS (P < .0001*).Discussion:Postoperative nadir Hgb (P < .0001*) was more predictive of longer LOS than postoperative day 1 Hgb (P = .05*). There is a perioperative Hgb decrement associated with longer LOS (P < .0001*). Geriatric patients may be more susceptible to the potential contributors to Hgb decrement, including occult bleeding post-op and hemodilution from IVF administration.Conclusion:Postoperative anemia, perioperative decrement in Hgb, older age, greater number of levels fused, and greater total IVFs administered predict longer LOS. Understanding the impact of these factors on LOS is critical as these procedures increasingly move to the outpatient setting.

The Influence of Body Mass Index on Functional Outcomes, Satisfaction, and Return to Work After Single-level Minimally-invasive Transforaminal Lumbar Interbody Fusion: A Five-year Follow-up Study.

Retrospective study using prospectively collected registry data. To evaluate the effect of obesity on patient-reported outcome measures of pain, disability, quality of life, satisfaction, and return to work after single-level minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF). MIS-TLIF is an appealing alternative for obese patients with potentially lower complication risk. However, there is limited data investigating the influence of obesity on outcomes 5 years after MIS-TLIF. Prospectively collected registry data of 296 patients who underwent single-level MIS-TLIF at a single institution were reviewed. Patients had complete 2- and 5-year follow-up data. Patients were stratified into control (<25.0 kg/m), overweight (25.0-29.9 kg/m), and obese (≥30.0 kg/m) groups. Outcomes assessed were visual analogue scale for back pain, leg pain, Oswestry Disability Index, Short-form 36, North American Spine Society score for neurogenic symptoms, return to work (RTW), return to function (RTF), satisfaction, and expectation fulfilment. Length of operation, length of stay, and comorbidities were recorded. Among the patients, 156 (52.7%) had normal weight, 108 (36.5%) were overweight, and 32 (10.8%) were obese. There was no difference in length of operation or hospitalization (P > 0.05). All three groups had comparable preoperative scores at baseline (P > 0.05). At 5 years, the control group had significantly higher PCS compared with the overweight (P = 0.043) and obese groups (P = 0.007), although the change in scores was similar (P > 0.05). The rate of MCID attainment, RTW, RTF, expectation fulfilment, and satisfaction was comparable. Nonobese patients had better physical well-being in the mid-term, although obese patients experienced a comparable improvement in clinical scores. Obesity had no impact on patients' ability to RTW or RTF. Equivalent proportions of patients were satisfied and had their expectations fulfilled up to 5 years after MIS-TLIF. 3.

Comparative Prospective Study Reporting Intraoperative Parameters, Pedicle Screw Perforation, and Radiation Exposure in Navigation-Guided versus Non-navigated Fluoroscopy-Assisted Minimal Invasive Transforaminal Lumbar Interbody Fusion.

Study DesignProspective cohort study.PurposeTo compare intraoperative parameters, radiation exposure, and pedicle screw perforation rate in navigation-guided versus non-navigated fluoroscopy-assisted minimal invasive transforaminal lumbar interbody fusion (MIS TLIF).Overview of LiteratureThe poor reliability of fluoroscopy-guided instrumentation and growing concerns about radiation exposure have led to the development of navigation-guided instrumentation techniques in MIS TLIF. The literature evaluating the efficacy of navigation-guided MIS TLIF is scant.MethodsEighty-seven patients underwent navigation- or fluoroscopy-guided MIS TLIF for symptomatic lumbar/lumbosacral spondylolisthesis. Demographics, intraoperative parameters (surgical time, blood loss), and radiation exposure (sec/mGy/Gy.cm2 noted from C-arm for comparison only) were recorded. Computed tomography was performed in patients in the navigation and non-navigation groups at postoperative 12 months and reviewed by an independent observer to assess the accuracy of screw placement, perforation incidence, location, grade (Mirza), and critical versus non-critical neurological implications.ResultsTwenty-seven patients (male/female, 11/16; L4–L5/L5–S1, 9/18) were operated with navigation-guided MIS TLIF, whereas 60 (male/female, 25/35; L4–L5/L5–S1, 26/34) with conventional fluoroscopy-guided MIS TILF. The use of navigation resulted in reduced fluoroscopy usage (dose area product, 0.47 Gy.cm2 versus 2.93 Gy.cm2), radiation exposure (1.68 mGy versus 10.97 mGy), and fluoroscopy time (46.5 seconds versus 119.08 seconds), with p-values of <0.001. Furthermore, 96.29% (104/108) of pedicle screws in the navigation group were accurately placed (grade 0) (4 breaches, all grade I) compared with 91.67% (220/240) in the non-navigation group (20 breaches, 16 grade I+4 grade II; p=0.114). None of the breaches resulted in a corresponding neurological deficit or required revision.ConclusionsNavigation guidance in MIS TLIF reduced radiation exposure, but the perforation status was not statistically different than that for the fluoroscopy-based technique. Thus, navigation in nondeformity cases is useful for significantly reducing the radiation exposure, but its ability to reduce pedicle screw perforation in nondeformity cases remains to be proven.

Does Minimally Invasive Spine Surgery Minimize Surgical Site Infections?

Study DesignRetrospective review of prospectively collected data.PurposeTo evaluate the incidence of surgical site infections (SSIs) in minimally invasive spine surgery (MISS) in a cohort of patients and compare with available historical data on SSI in open spinal surgery cohorts, and to evaluate additional direct costs incurred due to SSI.Overview of LiteratureSSI can lead to prolonged antibiotic therapy, extended hospitalization, repeated operations, and implant removal. Small incisions and minimal dissection intrinsic to MISS may minimize the risk of postoperative infections. However, there is a dearth of literature on infections after MISS and their additional direct financial implications.MethodsAll patients from January 2007 to January 2015 undergoing posterior spinal surgery with tubular retractor system and microscope in our institution were included. The procedures performed included tubular discectomies, tubular decompressions for spinal stenosis and minimal invasive transforaminal lumbar interbody fusion (TLIF). The incidence of postoperative SSI was calculated and compared to the range of cited SSI rates from published studies. Direct costs were calculated from medical billing for index cases and for patients with SSI.ResultsA total of 1,043 patients underwent 763 noninstrumented surgeries (discectomies, decompressions) and 280 instrumented (TLIF) procedures. The mean age was 52.2 years with male:female ratio of 1.08:1. Three infections were encountered with fusion surgeries (mean detection time, 7 days). All three required wound wash and debridement with one patient requiring unilateral implant removal. Additional direct cost due to infection was $2,678 per 100 MISS-TLIF. SSI increased hospital expenditure per patient 1.5-fold after instrumented MISS.ConclusionsOverall infection rate after MISS was 0.29%, with SSI rate of 0% in non-instrumented MISS and 1.07% with instrumented MISS. MISS can markedly reduce the SSI rate and can be an effective tool to minimize hospital costs.

Post-market surveillance study of FLXfit™TLIF interbody fusion device: protocol for a prospective case series study

Background: Minimally invasive (MIS) lumbar fusion is a frequently utilized treatment for lumbar degenerative pathology. Interbody cages have been the preferred fusion construct in these procedures due to their ability to facilitate fusion and provide structural stability. However, due to the anatomic small access corridor of minimally invasive lumbar fusion procedures, the interbody cages used in these techniques are often limited in size, increasing the risk for pseudarthrosis and subsidence. Expandable interbody cages have been developed to overcome these risks in limitations. However, few clinical studies have been developed and initiated to describe the fusion rates, clinical outcomes, and complication rates in patients receiving these expandable cages. Methods/Design: A prospective case series of 30 patients receiving the FLXFit expandable interbody cage device is currently underway. Patients to undergo MIS transforaminal lumbar interbody fusion (TLIF) for degenerative pathology will be recruited based on their meeting of inclusion criteria and eligibility to receive the expandable cage device. Patient follow-up will occur at 6 weeks, 3 months, 6 months, 1 year, and 2 years. The primary outcome will be fusion status at 1-year, as measured by computed tomography (CT) scan. Patient reported outcomes and radiographic measurements will be obtained preoperatively and at all postoperative time points. All complications, reoperations, and hospital readmissions occurring during follow up will also be recorded. Discussion: This protocol is designed to better describe the outcomes and complications following the utilization of the FLXFit expandable interbody cage device following MIS TLIF. The present manuscript provides the process for patient selection, intervention, and follow-up. Trial registration: ClinicalTrials.gov identifier NCT02805985; registered on June 15, 2016. Ethics: The study protocol has been approved by the Rush University Institutional Review Board (IRB), and will be performed under the ethical standards of the IRB. Informed consent: Signed informed consent will be obtained from each patient.

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

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). 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. 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. 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.

Comparative Study of Unilateral Minimal Invasive Transforaminal Lumbar Interbody Fusion and Mini-Open Posterior Lumbar Interbody Fusion for the Treatment of Single-Level Degenerative Lumbar Spine Diseases: Retrospective Matched Analysis of Clinical and Radiologic Results in Minimum Two-Year Follow-Up

A minimally invasive TLIF (MIS-TLIF) technique has recently been introduced with the aim of smaller wounds and faster recovery and proved its safety and effectiveness in treating degenerative lumbar spine diseases. On the other hand, the mini-open PLIF (mini-PLIF) procedure, in which pedicle screws are inserted via percutaneous technique after midline decompression, have also become popular based on the premise that a smaller, less traumatic incision should afford better recovery and outcomes.

Laparoscopic ureteral repair for iatrogenic ureteral injury following lumbar disc surgery

Summary Iatrogenic ureteral injury is a rare yet severe complication in lumbar disc surgery. In our hospital we encountered only one such incident in 1946 prior to this case. We hereby present a novel approach in which laparoscopic end-to-end ureteral anastomosis was adopted for the repair of ureteral injury after lumbar disc surgery. A 60-year-old female underwent minimal invasive transforaminal lumbar interbody fusion (TLIF) for spondylolisthesis of the L4–5 level in 2012. Two days after the surgery, the patient complained of progressive right flank pain and a persistent lack of stool passage. An abdominal computer tomography showed right retroperitoneal urinoma and injury to the proximal ureter, which was revealed by contrast extravasation. Retrograde ureteroscopy confirmed complete avulsion of the ureter. Using a double-J catheter as the stent, we laparoscopically repaired the severed ureter, using the end-to-end anastomosis method. Although the operation lasted for 180 minutes, the estimated blood loss was only approximately 50 mL. The double-J catheter was removed 1 month after the surgery. Commonly encountered urological complications, such as obstructive uropathy, loss of renal function, or the subjective flank pain did not occur in the 6-month follow-up. Although the probability of occurrence is low, however, TLIF surgery is potentially capable of causing ureteral injury. The key to the successful execution of safe spinal surgery with a significant risk of ureteral damage would be the careful use of a curette instead of a rongeur. However, in the unforeseen situation where the ureteral damage has occurred, laparoscopic ureteral repair would be an option that could result in a good surgical outcome.

Minimal Invasive Unilateral Transforaminal Lumbar Interbody Fusion by Sublaminar Decompression - Comparison to Bilateral Approach -

Purpose: This is a comparison of the unilateral and bilateral approaches for minimal invasive transforaminal lumbar interbody fusion (TLIF), and we did so by measuring the clinical and radiological results. Materials and Methods: This study examined a consecutive series of 47 patients who underwent one-level TLIF (26 cases of the unilateral approach and 21 cases of the bilateral approach to the lumbar spine) and the follow-up data was compared with a minimum 1-year follow-up. Sublaminar decompression and contralateral foraminectomy were done in all the case of using the unilateral approach. The age of each patient, the amount of intraoperative blood loss, the postoperative drainage, the transfusion requirement and the surgery time were investigated. The clinical outcomes were analyzed using the visual analogue scale, the SF-36 Physical Composite Score (PCS) and the Oswestry disability index (ODI). The preoperative, postoperative & last follow-up changes in the height and angles of the disc in the fused segments and the lumbar lordotic angles were radiologically analyzed. Results: There was no statistical difference between the two groups in terms of the clinical and radiographic results at the last follow-up. But the unilateral approach-group was found to have a less blood loss, less postoperative drainage, a lesser requirement for transfusion and a shorter surgery time. Conclusion: This study confirms that the unilateral approach can be the better way if the technical problems are solved.

P28. Minimal invasive transforaminal lumbar interbody fusion (TLIF) successful clinical and radiographic outcomes at two year follow up

P28. Minimal invasive transforaminal lumbar interbody fusion (TLIF) successful clinical and radiographic outcomes at two year follow up