Open Transforaminal Lumbar Interbody Fusion Research Articles

Lumbosacral Traumatic Spondylolisthesis L5 to S1-Classification and Surgical Management of a Difficult Presentation.

Lumbosacral traumatic spondylolisthesis L5-S1 is a rare clinical entity that compromises the stability of the L5 vertebra by displacing it anteriorly, laterally, or posteriorly on the S1 vertebral body secondary to osteotendinous and/or articular compromise of this segment due to trauma. This pathology is difficult to classify and manage; although surgical management remains the gold standard, short- and long-term results in the literature are scarce and highly variable. We present the case of a 53-year-old patient with lumbar trauma due to a free fall from a height of 6 meters. The fall resulted in cauda equina syndrome secondary to lumbosacral traumatic spondylolisthesis L5-S1, which required immediate surgical management. For surgical management, we used a posterior approach for L5-S1 transpedicular screw fixation, spinal decompression, bilateral root foraminotomy of L5, and L5-S1 open transforaminal lumbar interbody fusion with open reduction. After the operation, the patient reported immediate improvement of postoperative lower extremities pain and was discharged on the third postoperative day after achieving clinical improvement with physical therapy and bladder rehabilitation exercises. Lumbosacral traumatic spondylolisthesis L5-S1 is an unusual pathology that requires further study as there is currently no standardized classification. Surgical management is the gold standard and includes open reduction with short transpedicular screw fixation in segment L5-S1 and other surgical interventions such as extension to the pelvis with iliac screws, screws to the L4 vertebral body, and use of lumbar interbody fusion cages.

Does indirect decompression by oblique lateral interbody fusion produce similar clinical and radiological outcomes to direct decompression by open transforaminal lumbar interbody fusion.

Open transforaminal lumbar interbody fusion (O-TLIF) remains the most popular and widely practiced lumbar fusion method even today, providing direct decompression. Oblique lateral interbody fusion (OLIF) is a novel retroperitoneal approach that allows placement of a large interbody cage which provides an indirect neural decompression, and screws can be placed minimal invasively or through the Wiltse OLIF (W-OLIF) approach. We aim to find out the short-term efficacy of W-OLIF to O-TLIF in terms of radiological and clinical outcomes in patients of lumbar degenerative diseases. Fifty-two patients were divided equally into two groups (group O-TLIF and group W-OLIF). Several parameters were measured, such as the spinal cord cross-sectional area (SC-CSA), foraminal cross-sectional area (F-CSA), disc height (DH), foraminal height (FH), Schizas grade for stenosis, and Meyerding's grading for olisthesis. Functional scores were measured using the visual analog scale (VAS) for low back pain (LBP) and lower limbs, Oswestry Disability Index. All parameters were repeat measured at 3 months follow-up. Statistical analysis was done using SPSS software. Both groups were similar in composition preoperatively. There was significant improvement in all clinical and radiological parameters post-surgery in either group. However, at 3 months, The DH, FH, FSA, and VAS (LBP) were better in the W-OLIF group than in O-TLIF. Procedure-related complications were seen in both groups (15% in the O-TLIF group and 19% in the W-TLIF group), but only one patient in O-TLIF required revision due to cage migration. Similar improvement occurs in most of the clinical and radiological parameters in the W-OLIF group compared to the O-TLIF group. Few radiological parameters such as the DH, FH, and F-CSA and the VAS (LBP) correction are superior in the W-OLIF group in the short-term follow-up. We conclude that indirect decompression by W-OLIF provides equivalent, if not better, results than the traditional O-TLIF lumbar fusion.

Transforaminal lumbar interbody fusion with an expandable interbody device: Two-year clinical and radiographic outcomes

BackgroundThe use of interbody cages as an adjunct to lumbar spinal fusion remains an important technique to enhance segmental stability, promote solid arthrodesis, maintain neuroforaminal decompression, and preserve/improve segmental lordosis. Appropriate segmental lumbar lordosis and sagittal balance is well-known to be critical for long-term patient outcomes. This study sought to evaluate the radiographic and clinical results of TLIF in patients using an articulating, expandable cage. Primary endpoint was clinical and radiographic outcomes, including complications, at 12 and 24 months. MethodsA total of 37 patients underwent open single-level or 2-level TLIF by a single surgeon using an expandable cage with concomitant bilateral pedicle screws and posterolateral arthrodesis. Clinical outcomes included ODI and VAS for back and legs. Radiographic outcomes included pelvic incidence and tilt, lumbar and segmental lordoses, and disc height at the operative level(s). All outcomes were collected at baseline, 2-weeks, 6-weeks, 3-months, 6-months, 12-months, and 24-months postop. ResultsA total of 28 patients were available for analysis. Nine patients failed to follow-up at 24 months. Mean ODI scores showed significant improvement, from pre-to-postoperative at 24 months (55%; p<.0001). VAS for back and legs was significantly lower at 24 months on average by 72 and 79%, respectively (p<.0001 for both). Both segmental and lumbar lordoses significantly improved by 5.3° and 4.2° (p<.0001 and p=.049), respectively. Average disc height improved by 49% or 6.1 mm (p<.001). No device-related complications nor instances of measured subsidence. One patient had a superficial infection, and another had an intraoperatively repaired incidental durotomy. ConclusionsThe use of an expandable cage contributed to improvement in both segmental and lumbar lordosis with no reported complications at 24-month follow-up. All clinical measures significantly improved as well. The expandable cage design represents an effective and safe option to increase cage size and allow significant segmental lordosis correction.

Clinical efficacy of minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) in the treatment of II° lumbar isthmic spondylolisthesis: A retrospective cohort study.

Minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) is not suitable for high-grade isthmic spondylolisthesis, whether MIS-TLIF can treat II° lumbar isthmic spondylolisthesis (IS) is still controversial. This retrospective cohort study compared the clinical efficacy of MIS-TLIF and open transforaminal lumbar interbody fusion (OPEN-TLIF) in the treatment of II° lumbar IS. From January 2017 to January 2023, 101 patients with II° lumbar IS were diagnosed in our hospital and underwent surgical treatment, of which 53 received MIS-TLIF surgery and 48 received OPEN-TLIF surgery. The operation time, blood loss and surgical complications were compared between the 2 groups. The pain, function, reduction rate and fusion rate of the patients were evaluated during follow-up. The amount of intraoperative blood loss, postoperative drainage, and postoperative hospital stay in the MIS-TLIF group were significantly lower than those in the OPEN-TLIF group were (P < .01). In the MIS-TLIF group, there were 1 case of dural sac injury and 3 cases of lower limb paralysis. The complication rate of MIS-TLIF was lower than the OPEN-TLIF group (P = .032). In the visual analog scale score of low back pain, the MIS-TLIF group was lower than the OPEN-TLIF group after operation and at the last follow-up. There were no significant differences in postoperative leg pain score, slippage rate, and fusion rate between the 2 groups. Compared with OPEN-TLIF, MIS-TLIF has the advantages of better low back pain relief, less trauma, less bleeding and faster recovery, and is worthy of clinical promotion.

Comparative Outcome Data Using Different Techniques for Posterior Lumbar Fusion: A Large Single-Center Study.

Retrospective single-center study. This study aims to evaluate perioperative and intermediate-term clinical outcomes of patients undergoing different lumbar fusion techniques. Various open and minimally invasive techniques for lumbar fusion are available, but previous studies comparing lumbar fusion techniques have heterogeneous data, making interpretation challenging. Between 2011 and 2018, data from 447 consecutive patients undergoing one/two-level lumbar fusion were analyzed. Posterior lumbar interbody fusion (PLIF) with bilateral muscle strip or Wiltse approach, open transforaminal lumbar interbody fusion (TLIF) and minimally invasive TLIF, and posterolateral fusion only were among the surgical techniques used. Core outcomes measure index (COMI) questionnaires were distributed before surgery and at 3 months, 1 year, and 2 years postoperatively to establish patient selfreported outcome measures. Demographic data (age, gender, and body mass index [BMI]) for each patient were also collected in addition to surgical indication, previous operative history, perioperative outcomes, and complications, and whether later revision surgery was required. Pearson's chi-square test, Kruskal-Wallis test, repeated measure mixed-effects models, and ordinal logistic regression were used for statistical analysis. Postoperative COMI scores improved across all procedures compared with pre-surgery (p<0.001). There was no significant difference between different postoperative COMI scores. Significant predictors of higher postoperative COMI score included higher pretreatment COMI score (p≤0.001), previous surgery (p≤0.04), younger age (p≤0.05), higher BMI (p≤0.005), and the indications of lytic spondylolisthesis (p=0.02) and degenerative disc disease (p<0.001). Patients undergoing minimally invasive TLIF had a significantly shorter post-surgery stay than patients undergoing open PLIF (Kruskal-Wallis test, p=0.03). At 2 years postoperatively, there was no significant difference in clinical outcomes between open and minimally invasive techniques. These findings suggest that the main determinant of surgical approach should be surgeon preference and training.

Minimally Invasive Transforaminal Lumbar Interbody Fusion (MI-TLIF): A Video Technique Guide.

Minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) has been established as an excellent alternative to the traditional open approach for the treatment of degenerative conditions of the lumbar spine1-3. The procedure is performed with the patient under general anesthesia and on a radiolucent table in order to allow for intraoperative fluoroscopy. The procedure is performed through small incisions made over the vertebral levels of interest, typically utilizing either a fixed or expandable type of tubular dilator, which is eventually seated against the facet joint complex4. A laminectomy and/or facetectomy is performed in order to expose the disc space, and the ipsilateral neural elements are visualized5. The end plates are prepared, and an interbody device is placed after the disc is removed. Pedicle screws and rods are then placed for posterior fixation. Nonoperative alternatives include physical therapy and corticosteroid injections. Other operative techniques include open TLIF or other types of lumbar fusion approaches, such as posterior lumbar interbody fusion (PLIF), anterior lumbar interbody fusion, lateral or extreme lateral interbody fusion, or oblique lumbar interbody fusion. Open TLIF was developed in order to obtain a more lateral approach to the lumbar disc space than was previously possible with PLIF. The goal of this was to minimize the amount of thecal-sac and nerve-root retraction required during PLIF4. Additionally, as the number of patients who required revision after PLIF increased, the need arose for an approach to the lumbar spine that circumvented the posterior midline scarring from previous PLIF surgical sites6. MI-TLIF was introduced to reduce the approach-related paraspinal muscle damage of open TLIF5. Indications for MI-TLIF include most degenerative pathology of the lumbar spine, including disc herniation, low-grade spondylolisthesis, and spinal and foraminal stenosis7. However, MI-TLIF allows for less robust correction of deformity than other minimally invasive approaches; therefore, MI-TLIF may not be as effective in cases of substantial spinal deformity or high-grade spondylolisthesis8. MI-TLIF results in significantly less blood loss, postoperative pain, and hospital length of stay compared with open TLIF1-3. Although some studies have suggested increased operative time for MI-TLIF9,10, meta-analyses have shown comparable operative times between the 2 techniques1-3. It is thought that the discrepancy in reported operative times is the result of a learning curve and that, once that is overcome, the difference in operative time between the 2 techniques becomes minimal11,12. One disadvantage of MI-TLIF that has remained constant in the literature is its increased intraoperative fluoroscopy time compared with open TLIF3,13. The complication rate has largely been found to be equivalent between open and MI-TLIF1-3 or slightly lower with MI-TLIF14, especially in the hands of an experienced surgeon15. Finally, the fusion rate and improvement in patient outcome scores have also been found to be largely equivalent1-3. We suggest placing the ipsilateral pedicle screw after the interbody cage has been inserted.Fully visualize the Kambin triangle16 prior to performing the facetectomy. Protect the exiting and traversing nerve roots by placing small cottonoids around them and retracting delicately.Bone removed during facetectomy can be utilized as autograft for the interbody cage.Avoid removing pedicle bone during decompression.If central stenosis is present, the neural decompression should be extended medial to the epidural fat so that the dura mater can be visualized all of the way to the contralateral pedicle.Perform an adequate end plate preparation prior to interbody insertion while being mindful to avoid injuring the end plate, to minimize the risk of future cage subsidence.Confirm correct placement of the interbody device on intraoperative fluoroscopy.If bone morphogenic protein is utilized, be careful not to pack too much posteriorly as this may cause nerve irritation. TLIF = transforaminal lumbar interbody fusionMI-TLIF = minimally invasive TLIFPLIF = posterior lumbar interbody fusionALIF = anterior lumbar interbody fusionLLIF = lateral lumbar interbody fusionXLIF = extreme lateral interbody fusionOLIF = oblique lumbar interbody fusionDLIF = direct lateral interbody fusionMRI = magnetic resonance imagingA/P = anteroposteriorEMG = electromyographicBMP = bone morphogenic proteinXR = x-ray (radiograph)OTC = over the counterDVT = deep vein thrombosisPE = pulmonary embolismMI = myocardial infarctionMIS = minimally invasive surgeryOR = operating roomLOS = length of stayVAS = visual analog scaleODI = Oswestry Disability IndexM-H = Mantel-HaenszelRR = risk ratioCI = confidence intervalNSAIDs = nonsteroidal anti-inflammatory drugs.

Perspective: Can intraoperative neurophysiological monitoring (IONM) limit errors associated with lumbar pedicle screw fusions/transforaminal lumbar interbody fusions (TLIF)?

We evaluated whether intraoperative neural monitoring (IONM), including somatosensory evoked potential monitoring (SEP), motor evoked potential monitoring (MEP), and electrophysiological monitoring (EMG), could reduce operative errors attributed to lumbar instrumented fusions, including minimally invasive (MI) transforaminal lumbar interbody fusion (TLIF)/open TLIF. Operative errors included retraction/stretch or cauda equina neural/cauda equina injuries that typically occurred during misplacement of interbody devices (IBD) and/or malpositioning of pedicle screws (PS). IONM decreased the incidence of intraoperative errors occurring during instrumented lumbar fusions (MI-TLIF/TLIF). In one series, significant loss of intraoperative SEP in 5 (4.3%) of 115 patients occurred after placing IBD; immediate removal of all IBD left just 2 patients with new neural deficits. In other series, firing of trigger EMG's (t-EMG) detected intraoperative PS malpositioning, prompted the immediate redirection of these screws, and reduced the need for reoperations. One t-EMG study required a reoperation in just 1 of 296 patients, while 6 reoperations were warranted out of 222 unmonitored patients. In another series, t-EMG reduced the pedicle screw breech rate to 7.78% (1723 PS) from a higher 11.25% for 1680 PS placed without t-EMG. A further study confirmed that MEP's picked up new motor deficits in 5 of 275 TLIF. SEP/MEP/EMG intraoperative monitoring appears to reduce the risk of surgical errors when placing interbody devices and PS during the performance of lumbar instrumented fusions (MI-TLIF/TLIF).However, IONM is only effective if spine surgeons use it, and immediately address significant intraoperative changes.

Which surgery is better for obese patients with lumbar degenerative diseases: open TLIF or Endo-LIF? A retrospective matched case–control study

ObjectiveThis study aimed to evaluate short-term clinical efficacy of percutaneous endoscopic posterior lumbar interbody fusion (Endo-LIF) in the treatment of obese patients with lumbar degenerative diseases (LDD). MethodsPatients who underwent single-level lumbar fusion surgery from July 2020 to July 2022 were retrospectively analyzed in this study. The main inclusion criterion was a body mass index (BMI) ≥30kg/m2. A matched case-control design was conducted to compare the short-term outcomes between the Endo-LIF and transforaminal lumbar interbody fusion (TLIF) in obese patients. Cases were defined as those who underwent Endo-LIF, and controls were matched from those patients with open TLIF according to corresponding matched criteria. Surgeon satisfaction was evaluated by questionnaires at the end of each surgery, patient satisfaction and their willingness to undergo the same surgery again were collected. ResultsTwo groups of patients were successfully completed surgery. In comparison with the open TLIF group, the Endo-LIF group had significantly less blood loss, less time to postoperative ambulation, less postoperative complications and shorter hospitalization days, but longer operation time and x-ray exposure times. The satisfaction of surgeons and patients in Endo-LIF group significantly were superior to open TLIF group. ConclusionEndo-LIF is a safe and effective surgery in the treatment of obese patients. Although this procedure needs longer operation time and x-ray exposure times, it still maybe a promising option for obese patients with LDD.

Postoperative Lumbar Spondylodiscitis Following Transforaminal Endoscopy and Outcomes of Transforaminal Lumbar Interbody Fusion

Objective: To describe the presentation spectrum of postoperative spondylodiscitis (POS&lt;i&gt;e&lt;/i&gt;) following transforaminal endoscopic lumbar discectomy and to report the outcomes of transforaminal lumbar interbody fusion (TLIF).Methods: This study analyzed all patients with the classic features of POS&lt;i&gt;e&lt;/i&gt; who underwent index surgery elsewhere and presented to us. They had not responded to conservative care for 3 weeks and were operated further with open TLIF. The treatment response was judged by the declining values of inflammatory markers, improvements in mobility, and decreases in pain. Patients’ outcomes were analyzed using a visual analogue scale (VAS), the Oswestry Disability Index (ODI), and the occurrence of complications. Radiological outcomes were assessed by fusion and implant stability. The spectrum of the demographic presentation was analyzed. PubMed was searched to find the incidence of POS&lt;i&gt;e&lt;/i&gt; and the spectrum of organisms involved.Results: Fifteen patients were operated primarily by interventionalists and four by surgeons among 19 POS&lt;i&gt;e&lt;/i&gt; patients who finally underwent TLIF at Stavya Spine Hospital &amp; Research Institute. Organism culture positivity was found in 10 and no culture results were present in 9 cases. All TLIF cases had a follow-up of 52.94 ± 13.66 months (range, 28–71 months). The preoperative back pain VAS improved from 9.47 ± 0.61 (8–10) to 0.42 ± 0.50 (0–1). The leg pain VAS improved from 5.78 ± 4.19 (6–10) to 0.52 ± 0.61 (0–1). The preoperative ODI improved from 87.01 ± 7.70 (73.33–97.79) to 7.36 ± 8.14 (0–26.67). No major complications occurred. Cure of infection and stable reconstruction with fusion were achieved in all patients.Conclusion: POS&lt;i&gt;e&lt;/i&gt; has a very low reported incidence. Standardization of training and sterilization would further reduce its incidence. However, aggressive early TLIF in patients with nonresponding POS&lt;i&gt;e&lt;/i&gt; produces beneficial results.

A novel mini-open transforaminal lumbar interbody fusion for lumbar degenerative diseases: technical note and preliminary results

BackgroundTransforaminal lumbar interbody fusion (TLIF) is an effective and popular surgical procedure for the management of various spinal pathologies, especially degenerative diseases. Surgeons have been pursuing minimally invasive technology as soon as TLIF was appeared. Currently, TLIF can be performed with transforaminal approaches by open surgery, minimally invasive surgery or percutaneous endoscope. We provide a detailed description of a new modified open TLIF with percutaneous pedicle screws, which we refer to as mini-open TLIF. The objective of this study was to present feasibility of this procedure and the preliminary results.MethodsThe study is a prospective study. From January 2021 to March 2022, 96 patients (43 males and 53 females) with neurological symptoms due to degenerative lumbar spine diseases were enrolled. Operation time, blood loss, ambulatory time, hematocrit and complications were recorded during perioperative period. Clinical symptoms were evaluated 1 week, 3 months and 12 months after surgery. Visual analogue scale (VAS) scores for lower back pain and leg pain and Oswestry disability index (ODI) were assessed. Magnetic resonance imaging was performed preoperatively and 12 months postoperatively to emulate cross-sectional area of paraspinal muscles. The lumbar interbody fusion rate was evaluated by CT scanning.ResultsThe mean operation time of single level was 112.6 min, and the mean operation time of multilevel was 140.1 min. Intraoperative blood loss of single level was 64.5 ml and was 116.3 ml of multilevel. The VAS and ODI scores before and after surgery were significantly different (P < 0.0001) and reached minimal clinically important difference. Atrophy rate of paraspinal muscles was 2.5% for symptomatic side and 1.2% for asymptomatic side. The cross-sectional area before and after the operation and atrophy rate had no statistically significant difference (P > 0.05).ConclusionMini-open TLIF is effective and feasible for the treatment of lumbar degenerative diseases especially in multilevel disease, with minor damage to muscle and shorter operation time.Trial registration: This study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the Ethics Committee of the Second Affiliated Hospital of Soochow University (No. JD-LK2023045-I01).

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.

Utility of Expandable Interbody Cages in Open Transforaminal Interbody Fusions: A Comparison With Static Cages.

Background Expandable interbody cages, while popular in minimally invasive fusions due to their slim profile and increased ease of insertion, have not been widely explored in open surgery. The benefits of expandable cages may also extend to open fusions through their potential to achieve a greater restoration of lumbar lordosis while minimizing intraoperative complications. To highlight these benefits, we present a case series of adult spinal deformity (ASD) patients treated with an open transforaminal lumbar interbody fusion (TLIF) using expandable cages and compare outcomes to those of patients treated with static cages from the literature. Methods A retrospective cohort study of patients who underwent a deformity correction procedure and TLIF with expandable interbody cages at Brigham and Women's Hospital between 2018 and 2022 was conducted. Patient demographics, complications, and pre- and postoperative radiographic parameters of spinopelvic alignment were collected. A literature search was completed to identify studies employing static cages. T-tests were performed to compare postoperative changes in radiographic parameters by cage type. Results Forty-five patients (mean age of 62.6 years) with an average of 2.1 cages placed met the inclusion criteria. Patients experienced five intraoperative complications and 23 neurologic deficits (from minor to major), while nine patients required a revision operation. Lumbar lordosis increased by 9.8° ± 14.5° (p < 0.0001), the sagittal vertical axis (SVA) decreased by 25.5 mm ± 56.7 mm (p = 0.0048), and pelvic incidence-lumbar lordosis mismatch decreased by 13.3° ± 17.5° (p < 0.0001) with the use of expandable cages. Expandable cages yielded similar changes in lumbar lordosis to 15° and 8° cagesbut improved the lumbar lordosis generated from rectangular and 4° cages. When compared to static cages, expandable cages mildly reduced intraoperative complications. Conclusions Expandable interbody cages are an effective means of restoring spinopelvic alignment in ASD that have the potential to improve patient outcomes in open fusions compared to standard static cages. Especially when compared to rectangular and 4° static cages, expandable cages provide a clear benefit in the correction of lumbar lordosis. The impact of open spinal fusions with expandable cages on outcomes should continue to be explored in other cohorts.

Association between early ambulation exercise and short-term postoperative recovery after open transforaminal lumbar interbody fusion: a single center retrospective analysis

BackgroundEarly ambulation in patients undergoing transforaminal lumbar interbody fusion (TLIF) surgery is recommended, however, the precise time interval after open surgery has never been specified. Current retrospective analysis was conducted aiming to clarify an accurate time interval.MethodsA retrospective analysis of eligible patients was conducted using the databases of the Bone Surgery Department, Third Affiliated Hospital of Sun Yat-sen University from 2016 to 2021. Data pertaining to postoperative hospital stay length, expenses, incidence of complications were extracted and compared using Pearson’s χ2 or Student’s t-tests. A multivariate linear regression model was conducted to identify the relationship between length of hospital stay (LOS) and other outcomes of interest. A propensity analysis was conducted to minimize bias and to evaluate the reliability of results.ResultsA total of 303 patients met the criteria and were included for the data analysis. Multivariate linear regression results demonstrated that a high ASA grade (p = 0.016), increased blood loss (p = 0.003), cardiac disease (p < 0.001), occurrence of postoperative complications(p < 0.001) and longer ambulatory interval (p < 0.001) was significantly associated with an increased LOS. The cut-off analysis manifested that patients should start mobilization within 3 days after open TLIF surgery (B = 2.843, [1.395–4.292], p = 0.0001). Further comparative analysis indicated that patients who start ambulatory exercise within 3 days have shorter LOS (8.52 ± 3.28d vs 12.24 ± 5.88d, p < 0.001), total expenses ( 9398.12 ± 2790.82vs 10701.03 ± 2994.03 [USD], p = 0.002). Propensity analysis revealed such superiority was stable along with lower incidence of postoperative complications (2/61 vs 8/61, p = 0.0048).ConclusionsThe current analysis suggested that ambulatory exercise within 3 days for patients who underwent open TLIF surgery was significantly associated with reduced LOS, total hospital expenses, and postoperative complications. Further causal relationship would be confirmed by future randomized controlled trials.

“Satellite pedicle screws” - A novel technique of pedicle screw insertion in obese patients undergoing lumbar fusion

The presence of thick sub-cutaneous fat and bulky paraspinal musculature mandates extensive surgical dissection in obese patients undergoing open Transforaminal lumbar interbody fusion surgery. Securing a ‘converging’ pedicle screw trajectory becomes difficult by the counterforces of the erector spinae muscles and thick sub-cutaneous fat in obese patients, especially at the L5-S1 level. We describe the use of a limited standard posterior midline exposure and a separate, far lateral ‘satellite’ incision to insert pedicle screws in an optimal trajectory in obese patients. Through proper pre-operative planning of the axial and sagittal MRI, the appropriate entry site is determined which is executed intra-operatively to insert pedicle screws freehand. Through a single 1.5 cm incision, both L5-S1 screws were inserted. Fourteen obese patients (mean BMI was 30.5 ± 1.1) received 56 satellite pedicle screws for TLIF at L5-S1 level. The mean age was 48.3 ± 9.7 years. The mean blood loss was 244.8 ± 114 ml and the mean operative time was 126.7 ± 82.8 min. In all patients, the screws were inserted as per pre-operative planning without any difficulties. All wounds healed well without wound complications. There were no screw related complications, and in the antero-posterior and lateral radiographs, there were no screw breaches. Satellite free-hand pedicle screws are safe and easily reproducible. They enable limited dissection of the main surgical wound and well-medialised converging pedicle screws in obese patients.

Biplanar Expandable Cages for Transforaminal Lumbar Interbody Fusion Are Safe and Achieve Good 1-Year Clinical and Radiological Outcomes in an Asian Population.

This study investigated 1-year clinical and radiological outcomes of biplanar expandable (BE) cages following transforaminal lumbar interbody fusion (TLIF) in an Asian population. A retrospective review was conducted of all consecutive patients who underwent TLIF with BE cages performed by 2 fellowship-trained spine surgeons from 2020 to 2021. Inclusion criteria included open or minimally invasive (MIS) TLIF, of up to 3 spinal segments, performed for treatment of degenerative disc disease, spondylolisthesis, or spinal stenosis. Patient-reported outcomes, including visual analog score (VAS) for back and lower limb pain, Oswestry Disability Index (ODI) and North American Spine Society neurogenic symptom score (NSS), and various radiographic parameters, were evaluated. A total of 23 patients underwent TLIF with BE cages with a follow-up duration of 1.25 years. Of those patients, 7 (30%) underwent 1-level TLIF, 12 (52%) underwent 2-level TLIF, and 4 (18%) underwent 3-level TLIF, with a total of 43 spinal segments fused. Four patients (17%) underwent MIS TLIF while 19 patients (83%) underwent open TLIF. VAS for back pain scores improved by 4.8 ± 3.4 (P < 0.001) from 6.5 ± 2.6 to 1.7 ± 2.2; VAS for lower limb pain scores improved by 5.2 ± 3.8 (P < 0.001) from 5.7 ± 3.4 to 0.5 ± 1.6; ODI scores improved by 29.0 ± 18.1 (P < 0.001) from 49.4 ± 15.1 to 20.4 ± 14.2; and NSS scores improved by 36.8 ± 22.1 (P < 0.001) from 53.3 ± 21.1 to 16.5 ± 19.8. Significant improvements in radiological parameters included increase in anterior disc height, posterior disc height, foraminal height, segmental lordosis, and lumbar lordosis. There were no implant-related complications, cage subsidence, cage migration, or revision surgery at 1 year. TLIF performed with BE cages led to significantly improved patient-reported outcomes and radiographic parameters at 1 year and is safe for use in Asians. The results of this study support the effectiveness and safety of TLIF with biplanar expandable cages.

Comparison of the total and hidden blood loss in patients undergoing single-level open and unilateral biportal endoscopic transforaminal lumbar interbody fusion: a retrospective case control study

PurposeThis study aimed to compare total blood loss (TBL) and hidden blood loss (HBL) in patients undergoing single-level open transforaminal lumbar interbody fusion (O-TLIF) and unilateral biportal endoscopic transforaminal lumbar interbody fusion (ULIF).MethodsA total of 53 patients who underwent ULIF and 53 patients who underwent O-TLIF from March 2020 to July 2022 were retrospectively reviewed. The Nadler’s formula was employed to estimate the patient’s blood volume (PBV), Gross’s formula to estimate TBL, and Sehat’s formula to estimate HBL. The obtained data were then analyzed with independent t test, chi-squared test, and analysis of covariance.ResultsTBL and measured blood loss (MBL) in ULIF group (326.86 ± 223.45 ml, 99.00 ± 72.81 ml) was significantly lower than O-TLIF group (427.97 ± 280.52 ml, 270.66 ± 102.34 ml). Nevertheless, the HBL in ULIF group was higher than that in O-TLIF group (227.86 ± 221.75 ml vs 157.31 ± 268.08 ml), however this was not statistically significant (p = 0.143). The HBL was 69.71 ± 23.72% of TBL in ULIF group and 36.76 ± 18.79% of TBL in O-TLIF group. Patients in ULIF group had lower TBL and MBL, shorter duration of drainage, lower postoperative anemia, and shorter postoperative hospital stay compared to those in O-TLIF group.ConclusionsPerioperative HBL should not be neglected in patients undergoing ULIF or O-TILF, as it accounts for a large percentage of TBL in both groups. ULIF is associated with lower TBL and MBL, postoperative anemia, shorter postoperative hospital stays compared with O-TLIF.

Minimally Invasive Transforaminal Lumbar Interbody Fusion with Expandable Cages.

Minimally invasive surgical transforaminal lumbar interbody fusion (MIS-TLIF) is an increasingly common procedure for the treatment of lumbar degenerative pathologies. The MIS-TLIF technique often results in less soft-tissue injury compared with the open TLIF technique, reducing postoperative pain and recovery time1-3. However, the narrow surgical aperture of this minimally invasive technique has increased the difficulty of interbody cage placement. Expandable cages were designed to improve ease of insertion, improve visualization around the cage on insertion, reduce neurological retraction and injury by passing the nerve root with the implant in a collapsed state, and enable better disc-height and lordosis restoration on expansion4. This procedure is performed with the patient under general anesthesia and in a prone position. The appropriate spinal level is identified with use of fluoroscopy, and bilateral paramidline approaches are made utilizing the Wiltse intermuscular approach. Pedicle screws are placed bilaterally. A pedicle-based retractor or tubular retractor is passed along the Wiltse plane, and bilateral inferior facetectomies are performed. A foraminotomy is performed, including a superior facetectomy on the side with compression of the exiting nerve root. A thorough discectomy with end-plate preparation is performed. The disc space is sized with use of trial components. The cage is then implanted with a pre-expansion height less than the trialed height and is expanded under fluoroscopy. After expansion, the cage is backfilled with allograft and local autograft. Finally, the rods are contoured and reduced bilaterally, followed by closure in a multilayered approach. Nonoperative alternatives to the minimally invasive TLIF technique include physical therapy or epidural corticosteroid injections. When surgical intervention is indicated, there are several approaches that can be utilized during lumbar interbody fusion, including the posterior, direct lateral, anterior, or oblique approaches5. Expandable cages are designed to be inserted in a collapsed configuration and expanded once placed into the interbody space. This design offers numerous potential advantages over static alternatives. The low-profile, expandable cages require less impaction during placement, minimizing iatrogenic end-plate damage. Additionally, expandable cages require less thecal and nerve-root retraction and provide a larger surface footprint once expanded. The MIS-TLIF technique has been shown to significantly reduce back pain, leg pain, and disability, and to significantly increase function, with most improvements observed after 12 months postoperatively. Patients may experience a 51% and 39% reduction in visual analogue pain scores and Oswestry Disability Index scores, respectively6. The results for expandable cages compared with traditional static cages in TLIF surgery require further study. The technique utilized during insertion and placement of interbody cages plays an important role in cage subsidence. To reduce the risk of cage subsidence, cages should be placed level with the end plate and in contact with the apophyseal ring anteriorly. Additionally, caution should be taken when expanding the cage to ensure that the cage is not overexpanded, which may also increase the risk of mechanical failure and intraoperative subsidence.It is critical to understand the flexibility of the disc space and the osseous quality of the patient in order to know how much expansion may be applied through the cage without subsidence.If bullet-type cages are utilized, the tip of the cage should cross midline of the vertebral body to avoid generating iatrogenic scoliosis.Spine bone density should be investigated preoperatively in at-risk patients in order to identify osteoporotic patients, who are at greater risk for subsidence and instrumentation failure.Although advances in device technology are welcomed, surgeons should maintain a strong focus on technique to reduce complications and improve clinical outcomes when utilizing expandable cages. TLIF = transforaminal lumbar interbody fusionMIS = minimally invasive surgeryALIF = anterior lumbar interbody fusionMRI = magnetic resonance imagingCT = computed tomographyPEEK = polyetheretherketoneAP = anterioposteriorEMG = electromyographyDVT = deep vein thrombosisPE = pulmonary embolusODI = Oswestry Disability IndexEXP = expandable.

Endoscopic Lumbar Interbody Fusion, Minimally Invasive Transforaminal Lumbar Interbody Fusion, and Open Transforaminal Lumbar Interbody Fusion for the Treatment of Lumbar Degenerative Diseases: A Systematic Review and Network Meta-Analysis.

network meta-analysis. To compare the clinical efficacy and safety of endoscopic lumbar interbody fusion (Endo-LIF), minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF), and open transforaminal lumbar interbody fusion (OTLIF) in the treatment of lumbar degenerative diseases (LDDs). A literature search was conducted in the PubMed, Embase, and Cochrane Library databases. Studies comparing Endo-LIF, MIS-TLIF and OTLIF published from September 2017 to September 2022 for the treatment of LDD were retrieved. Data were extracted from preset clinical outcome measures, including operation time, estimated intraoperative estimated blood loss (EBL), length of hospital stay (LOS), complications, visual analog scale (VAS) score, Oswestry disability index (ODI) score, etc. Thirty-one studies with 3467 patients were included in this study. Network meta-analysis showed that in the comparison of the 3 procedures, Endo-LIF was superior to MIS-TLIF and OTLIF in terms of reducing EBL, LOS, time to ambulation, and VAS score of back pain. MIS-TLIF was superior to Endo-LIF in terms of ODI improvement, and OTLIF required the shortest intraoperative fluoroscopy time. There was no significant difference in operative time, complication rate, fusion rate, VAS score of leg pain, or JOA score among the 3 procedures. Endo-LIF, MIS-TLIF and OTLIF each have their own advantages and disadvantages and show similar results in many respects, except for better early outcomes achieved with the more minimally invasive procedure.

Reoperation Rates Due to ASD following Primary 1-2 level MIS vs. Open TLIF.

Retrospective analysis of prospectively collected data. To investigate the effect of the approach of the TLIF (open vs. MIS) on reoperation rates due to ASD at 2 - 4 year follow up. Adjacent segment degeneration (ASDeg) is a complication of lumbar fusion surgery which may progress to adjacent segment disease (ASD) and cause debilitating postoperative pain potentially requiring additional operative management for relief. Minimally invasive (MIS) transforaminal lumbar interbody fusion surgery (TLIF) has been introduced to minimize this complication but the impact on ASD incidence is unclear. For a cohort of patients undergoing 1- or 2-level primary TLIF between 2013 and 2019, patient demographics and follow-up outcomes were collected and compared between patients who underwent open versus MIS TLIF using Mann Whitney U test, Fischer's exact test, and binary logistic regression. 238 patients met inclusion criteria. There was a significant difference in revision rates due to ASD between MIS and open TLIFs at 2 (5.8% vs. 15.4%, P=0.021) and 3 (8% vs. 23.2%, P=0.03) year follow up, with open TLIFs demonstrating significantly higher revision rates. Surgical approach was the only independent predictor of reoperation rates at both 2 and 3 year follow ups (2-year P=0.009; 3-year P=0.011). Open TLIF was found to have a significantly higher rate of reoperation due to ASD compared to the MIS approach. Additionally, surgical approach (MIS vs. Open) appears to be an independent predictor of reoperation rates.

Patient Frailty Influences Outcome After Open, But Not Minimally Invasive, Transforaminal Interbody Fusion: A Case Series of 115 Patients With Lumbar Degenerative Disease.

For transforaminal lumbar interbody fusion (TLIF), there are equally good open and minimally invasive surgery (MIS) options. To determine if frailty has a differential effect on outcome for open vs MIS TLIF. We performed a retrospective review of 115 TLIF surgeries (1-3 levels) for lumbar degenerative disease performed at a single center; 44 MIS transforaminal interbody fusions and 71 open TLIFs were included. All patients had at least a 2-year follow up, and any revision surgery during that time was recorded. The Adult Spinal Deformity Frailty Index (ASD-FI) was used to separate patients into nonfrail (ASD-FI < 0.3) and frail (ASD-FI > 0.3) cohorts. The primary outcome variables were revision surgery and discharge disposition. Univariate analyses were performed to reveal associations in demographic, radiographic, and surgical data with the outcome variables. Multivariate logistic regression was used to assess independent predictors of outcome. Frailty uniquely predicted both reoperation (odds ratio 8.1, 95% CI 2.5-26.1, P = .0005) and discharge to a location other than home (odds ratio 3.9, 95% CI 1.2-12.7, P = .0239). Post hoc analysis indicated that frail patients undergoing open TLIF had a higher revision surgery rate (51.72%) compared with frail patients undergoing MIS-TLIF (16.7%). Nonfrail patients undergoing open and MIS TLIF had a revision surgery rate of 7.5% and 7.7%, respectively. Frailty was associated with increased revision rate and increased probability to discharge to a location other than home after open transforaminal interbody fusions, but not MIS transforaminal interbody fusions. These data suggest that patients with high frailty scores may benefit from MIS-TLIF procedures.