Percutaneous Transforaminal Lumbar Interbody Fusion Research Articles

114 Percutaneous Transforaminal Lumbar Interbody Fusion Is Associated with Reduced Postoperative Opioid Consumption When Compared with Minimally Invasive Transforaminal Lumbar Interbody Fusion

INTRODUCTION: Opioid use and postoperative pain following lumbar interbody fusion is a common problem for patients during rehabilitation. Less invasive surgical techniques techniques such as minimally invasive transforaminal lumbar interbody fusion (miTLIF) and Percutaneous transforaminal lumbar interbody fusion (pTLIF) have been associated with decreased post-operative pain, estimated blood loss, and shorter hospital length of stay. While pTLIF is a newer technique, its utilization has been increasing and preliminary studies have shown a reduction in post-operative pain, blood loss, faster recovery, and shorter LOS in comparison to miTLIF. METHODS: We performed a multi-surgeon, single institution retrospective analysis on consecutive patients undergoing 1 or 2 level percutaneous or minimally invasive TLIF from January 1, 2018- December 31, 2020. We collected data for each patient regarding time spent in the post-anesthesia care unit (PACU), PACU Visual Analogue Scale (VAS), 24-hour postoperative opioid use, hospital LOS, and documented distance ambulated on post-operative day (POD) 1. RESULTS: There were 37 patients who underwent pTLIF and 70 who underwent miTLIF. The average postoperative 24-hour oral morphine equivalent utilizations for pTLIF and miTLIF patients were 90 mg and 149 mg, respectively (p < 0.004). Time spent in the PACU, PACU VAS, distance ambulated on POD1, and LOS were similar between the two groups. CONCLUSION: Percutaneous TLIF was associated with a 40% reduction in 24-hour postoperative oral morphine equivalent utilization. Larger prospective studies maybe helpful in determining the impact of pTLIF on perioperative outcomes.

Robotic-Assisted Trajectory Into Kambin's Triangle During Percutaneous Transforaminal Lumbar Interbody Fusion-Initial Case Series Investigating Safety and Efficacy.

Minimally invasive spine surgery (MISS) has the potential to further advance with the use of robot-assisted (RA) techniques. While RA pedicle screw placement has been extensively investigated, there is a lack of literature on the use of the robot for other tasks, such as accessing Kambin's triangle in percutaneous lumbar interbody fusion (percLIF). To characterize the surgical feasibility and preliminary outcomes of an initial case series of 10 patients receiving percLIF with RA cage placement via Kambin's triangle. We performed a single-center, retrospective review of patients undergoing RA percLIF using robot-guided trajectory to access Kambin's triangle for cage placement. Patients undergoing RA percLIF were eligible for enrollment. Baseline health and demographic information in addition to peri- and postoperative data was collected. The dimensions of each patient's Kambin's triangle were measured. Ten patients and 11 levels with spondylolisthesis were retrospectively reviewed. All patients successfully underwent the planned procedure without perioperative complications. Four patients underwent their procedure with awake anesthesia. The average dimension of Kambin's triangle was 66.3 m2. With the exception of 1 patient who stayed in the hospital for 7 d, the average length of stay was 1.2 d, with 2 patients discharged the day of surgery. No patients suffered postoperative motor or sensory deficits. Spinopelvic parameters and anterior and posterior disc heights were improved with surgery. As MISS continues to evolve, further exploration of robot-guided surgical practice, such as our technique, will lead to creative solutions to challenging anatomical variation and overall improved patient care.

176. Thoracolumbar interfascial plane (TLIP) block and intrathecal fentanyl injection results in an opioid-free peri- and postoperative recovery and early ambulation after percutaneous lumbar spine surgery

BACKGROUND CONTEXT Open lumbar spine fusion surgery usually requires opioid analgesia for several weeks during the postoperative recovery period. Recently, a facet-sparing, full percutaneous transforaminal lumbar interbody fusion (TLIF) has been introduced that uses an endoscopic cannula for placement of an interbody cage in combination with percutaneous transpedicular screws and rods. The Thoraco-Lumbar Interfascial Plain (TLIP) block is a novel, ultrasound-guided local anesthesia technique that targets the sensory component of the dorsal rami of the thoracolumbar nerves. PURPOSE We aim to evaluate the efficacy in avoiding post-operative opioid analgesics and allowing early patient ambulation of a novel inter-disciplinary, spine surgery protocol that combines a perioperative TLIP block, intrathecal fentanyl injection and percutaneous TLIF spine surgery. STUDY DESIGN/SETTING Prospective, nonrandomized sequential case series study. PATIENT SAMPLE A total of 15 consecutive patients underwent TLIP combined with percutaneous TLIF spine surgery between 2018 and 2019. Indication for spine surgery was degenerative disk disease of the lumbar spine with or without spondylolisthesis up to grade 2 and foraminal stenosis. OUTCOME MEASURES Pre- and postoperative visual analogic scale (VAS) for lumbar back and leg pain were quantitatively assessed (range 0 to 10) immediately, at 6 and at 12 hours after surgery and at time of hospital discharge. Oswestry Disability Index (ODI) scores (range 0 to 50) were assessed preoperatively and at time of hospital discharge. The time of first post-operative patient ambulation was registered. Significance between pre- and postoperative scores were analyzed with student's paired t-test. METHODS Intrathecal fentanyl 25 mcgr was administered to the patient in sitting position and ultrasound-guided bilateral TLIP was performed in prone position with bupivacaine 0.25% and dexamethasone 8mgrs (20ml each side) by the anesthesia team. All patients were operated on under general anesthesia (protocol: propofol 2.0-3.0 mcg/ml (TCI) following BIS, ketamine 0.15 mg/Kg/h, rocuronium 0.4 mg/Kg). Percutaneous TLIF was performed by inserting an expandable interbody implant using the facet-sparing, trans-Kambin approach with an endoscopic cannula and complemented with a percutaneous posterior fixation consisting of transpedicular screws and rods. Postoperative analgesia included NSAIDs, acetaminophen and a manually patient-controlled oral sublingual 15 mcgr sufentanil microtablet analgesic system (Zalviso®), while its use was monitored. RESULTS Fifteen patients with a mean age of 64.1 years (range, 34 to 82 years) were evaluated. A median of two levels (range, 1 to 4 levels) per patient were instrumented and a median of one interbody cage (range, 1 to 2 cages) was placed in the lumbar spine. No intravenous fentanyl administration was necessary during surgery. The median time of surgery was 3.5 hours. Mean preoperative VAS scores for lumbar back and leg pain were 6.3 and 5.8, respectively. Mean postoperative VAS back scores at 0h, 6h, 12h and at discharge improved to 1.2, 1.8, 2.4 and 2.7 (P CONCLUSIONS The combination of perioperative TLIP, intrathecal fentanyl injection and percutaneous TLIF surgery prevents peri- and postoperative opioid administration and improves the quality of peri- and postoperative analgesia, allowing early patient ambulation and fast hospital discharge. This interdisciplinary analgesia protocol is a promising solution to avoid opioid analgesia in spine surgery and could be particularly interesting in the context of an outpatient spine surgery setting. FDA DEVICE/DRUG STATUS Fentanyl (Approved for this indication), Zalviso (Approved for this indication), Bupivacaine (Approved for this indication), Globus RISE (Approved for this indication)

Awake percutaneous transforaminal lumbar interbody fusion with expandable cage and robotic-assisted navigation and instrumentation: Case report and review of literature

Awake surgeries are commonly performed in many specialties through the use of local or regional anesthesia. These methods avoid the risks associated with general endotracheal anesthesia and allow faster recovery times. In neurosurgery, awake surgeries are typically reserved for craniotomies involving tumor or lesion resection near eloquent tissue. Only recently has awake spine fusion surgery been performed, and only in very limited capacity. Here, we describe the first reported case of awake percutaneous transforaminal lumbar interbody fusion with robotic navigation and instrumentation under spinal anesthesia.

Full Percutaneous Transforaminal Lumbar Interbody Fusion Using the Facet-sparing, Trans-Kambin Approach.

This was a prospective, multicenter, consecutive case series' study. The objective of this study was to evaluate a novel facet-sparing, percutaneous transforaminal lumbar interbody fusion (pTLIF) technique consisting of percutaneous insertion of an expandable interbody cage through an endoscopic cannula with the trans-Kambin approach and complemented with percutaneous transpedicular screws and rods. Lumbar interbody fusion by open or minimally invasive surgery is the usual treatment for degenerative disk disease but requires a relatively long recovery period. The transforaminal trans-Kambin approach is a standard in endoscopic spine surgery for safe intradiscal access without facet resection. Preoperative and postoperative Visual Analogue Scale (VAS) and Oswestry Disability Index scores were quantitatively assessed at 1, 3, 6, and 12 months after surgery and then every 12 months for patients treated with pTLIF between 2009 and 2018 in 2 health care centers. An immediate postoperative control computed tomography scan was performed, whereas conventional postoperative x-ray controls were performed at 1 month and 1 year. Statistical evaluation was performed with the Student t test. A total of 51 patients (mean age, 59.3 y) were evaluated. The overall mean VAS score for axial lumbar pain improved from 6.6 to 1.8 (P<0.01), mean VAS score for leg pain from 5.5 to 1.2 (P<0.01), and mean Oswestry Disability Index scores from 30.3 to 11.8 (P<0.01) postoperatively with a mean follow-up of 27.9 months (range, 1-77.8 mo). Median estimated blood loss was 103.6 mL. Postoperative complications included 12 (22%) cases with transitory ipsilateral dysesthesia, 2 (4%) cases with transitory ipsilateral muscle weakness, and 3 (6%) clinically asymptomatic cases with radiologic cage subsidence. Median hospital stay was 1.4 days (range, 1-3.2 d). Postoperative scores for pTLIF significantly improved with minimal blood loss and no long-term complications. On the basis of this experience, the facet-sparing pTLIF is a reliable and safe technique with early hospital discharge, opening the way to outpatient instrumented spine surgery. Level III.

Feasibility of Full Percutaneous Segmental Stabilization of the Lumbar Spine With a Combination of an Expandable Interbody Cage and an Interspinous Spacer: Preliminary Results.

We evaluated the feasibility of a full percutaneous approach with an expandable interbody cage and an interspinous spacer for a segmental stabilization of the anterior and posterior columns of the lumbar spine, respectively, with local anesthesia. Patients were prospectively included between 2012 and 2018 in this single-center, feasibility case series. An expandable interbody cage was inserted with endoscopy-based, facet-sparing percutaneous transforaminal lumbar interbody fusion (pTLIF). An interspinous spacer was percutaneously placed through the same skin incision. Pre- and postoperative Visual Analog Scale (VAS) and Oswestry Disability Index (ODI) outcomes at 1, 3, 6, 12, and 24 months were obtained and evaluated with the Student t test. Postoperative outcome was classified according to modified Macnab criteria. A total of 16 patients were included, presenting mean preoperative scores for VAS back of 6.9 ± 2.5, VAS leg 7.9 ± 1.2, and ODI 30.1 ± 4.5. Postoperative mean scores for VAS back of 1.9 ± 2.1, VAS leg 2.1 ± 3.4, and ODI 14.8 ± 13.0 significantly (P < .001) decreased with a mean follow-up of 18.1 ± 16.6 months (range 1-65.2). Postoperative outcome was excellent and good for 13 (81%) cases, fair for 2 (13%), and poor for 1 (6%) case with a preoperative spondylolisthesis, which required revision surgery due to persisting instability. Postoperative complications included 3 cases with transitory, ipsilateral dysesthesia and 2 cases with radiologic cage subsidence but no clinical symptoms. Median postoperative time until hospital discharge was 16 hours. Our preliminary results for this full percutaneous technique show a similar outcome compared to conventional surgery with a fast patient recovery and early postoperative hospital discharge, opening the way to instrumented, outpatient surgery.

Wednesday, September 26, 2018 7:35 AM–9:00 AM ePosters: P129. True percutaneous transforaminal lumbar interbody fusion (pTLIF) with an expandable interbody cage using the endoscopic posterolateral approach: a long-term follow-up report of 50 cases

BACKGROUND CONTEXT Interbody fusion by open discectomy is the usual treatment for degenerative disc disease but requires a relatively long recovery period. The transforaminal posterolateral approach is a well-known standard in endoscopic spine surgery that allows direct access to the disk with progressive tissue dilation, avoiding tissue and bone dissection. PURPOSE The aim of this study was to assess the efficacy and safety of percutaneous transforaminal interbody fusion (pTLIF) for lumbar spinal fusion. pTLIF consists of percutaneous insertion of an expandable implant with the endoscopic posterolateral approach through an endoscopic cannula with progressive tissue dilatation. The anterior cage placement is complemented with a percutaneous posterior fixation. STUDY DESIGN/SETTING Prospective, nonrandomized, single-arm, single-center, single surgeon sequential case series study. PATIENT SAMPLE Between 2009 and 2017, the pTLIF procedure was performed in one center for 50 patients with an expandable interbody cage. OUTCOME MEASURES Patient outcome was scored pre- and post-operatively with visual analogic scale (VAS), Oswestry disability index (ODI) and modified Macnab criteria. Scores were performed preoperatively and at 1 month, 3 months, 6 months, 1 year and at least 2yearspost-operatively. A CT scan was performed immediately after surgery. Conventional X-ray controls were performed at 1 month and 1 year post-operatively. METHODS Indication for surgery was degenerative disc disease of the lumbar spine with or without spondylolisthesis up to grade 2, and for revision surgery. Percutaneous transforaminal interbody fusion was performed by inserting an expandable implant with the endoscopic posterolateral approach through an endoscopic cannula with progressive tissue dilatation. Percutaneous posterior fixation comprised transpedicular screws and rods, interspinous spacer and transfacet screws depending on each case. Significance between pre- and postoperative scores was analyzed with Student's paired t-test. RESULTS The mean follow-up period was 33.1 (SD 20.4) months. The outcome was excellent in 28 (56%), good in 17 (34%), fair in 3 (6%) and poor in 2 (4%) cases according to Macnab criteria. The latter two cases were lost before 6 months of follow-up and consequently classified as poor. Significant differences (p CONCLUSIONS The pTLIF technique shows 90% of Excellent and Good postoperative results and no major complications for a long-term mean follow-up of 33 months, proving the efficacy and safety of the pTLIF procedure for primary and revision surgery cases. Percutaneous transforaminal interbody fusion allows bypassing posterior scar tissue from previous operations in revision surgery cases hereby reducing the risk of dural tear and nerve injury. Postoperative median time until walking (6 hours) and until hospital discharge was faster compared to standard open TLIF (25hours vs. 5 days), probably due to the less invasive handling of the soft and bony tissues with the endoscopic posterolateral approach. The pTLIF technique has disruptive potential as it opens the way to ambulatory fusion surgery in an outpatient clinical setting.

Percutaneous Transforaminal Lumbar Interbody Fusion (pTLIF) with a Posterolateral Approach for the Treatment of Denegerative Disk Disease: Feasibility and Preliminary Results.

Interbody fusion by open discectomy is the usual treatment for degenerative disk disease but requires a relatively long recovery period. The transforaminal posterolateral approach is a well-known standard in endoscopic spine surgery that allows direct access to the disk with progressive tissue dilation. The aim of this study was to assess the feasibility of percutaneous transforaminal interbody fusion (pTLIF) with insertion of an expandable or a standard rigid interbody implant for patients with degenerative disk disease with or without spondylolisthesis and for revision surgery. Between 2009 and 2014, the pTLIF procedure was performed in 30 patients. Ten patients underwent insertion of a rigid implant (group A) and the remaining 20 underwent insertion of an expandable titanium interbody implant as the initial procedure (n = 10) (group B) or after failed back surgery (n = 10) (group C). Patient outcomes were scored with visual analogic scale (VAS), Oswestry disability index (ODI) and modified Macnab criteria. The mean follow-up period was 38 (17) (range 11 to 67) months. The outcome was excellent in 18, good in 10 and fair in 2. No poor results and no major complications were reported. No differences in VAS and ODI scores according to the study group were found. Median postoperative time until hospital discharge was 26 hours (20 to 68 hours). Postoperative values for VAS and ODI scores improved significantly (p<0.05) compared to preoperative data in all study groups. These preliminary results have shown the feasibility and efficacy of the pTLIF procedure using a posterolateral approach for the treatment of degenerative disk disease with or without spondylolisthesis up to grade 2 and in revision surgery. No significant differences in outcome were observed between an expandable and a rigid cage. Median postoperative time until hospital discharge was faster compared to standard TLIF (26 hours vs. 9.3 days).