Single-level Transforaminal Lumbar Interbody Research Articles

Does Preoperative Modic Changes Influence the Short-term Fusion Rate of Single Level Transforaminal Lumbar Interbody Fusion?-a Matched-pair Case Control Study.

At present, the influence of Modic changes (MCs) on postoperative fusion rate of lumbar interbody fusion (LIF) is mainly focused on the medium- and long-term fusion rate, while the short-term fusion rate has not been reported. The aim of this study was to compare the short-term fusion rate of lumbar degenerative disease patients with and without MCs after single level transforaminal lumbar interbody fusion (TLIF). In this retrospective and matched-pair case control study, we included 100 patients who underwent TLIF from January 2017 to January 2020 and had at least two follow-up visits over a two-year period. Fifty patients with MCs (MCs group) were matched with 50 patients without MCs (non MCs group) for age, sex, surgical level, diagnosis, operative time, and intraoperative blood loss. We collected the X-ray and computed tomography (CT) data of patients from 3 months to 2 years after the operation to assess bony fusion and the cage union ratio. According to the type of cage, the MCs group was further divided into the nano-hydroxyapatite/polyamide 66 (n-HA/PA66) group and polyetheretherketone (PEEK) group, and the fusion performance between the two groups was compared. Finally, age, sex, body mass index (BMI), smoking and cage type were included in the logistic regression model for risk factor analysis. The bony fusion rates in the MCs group at 3 months, 6 months, 1 year and 2 years after surgery were significantly lower than those in the non MCs group (P < 0.05) (23.8% vs 62.5%, 52.6% vs 78.9%, 61.1% vs 83.3%, 74.0% vs 90.0%). The average coronal cage union ratios of the upper and lower endplates in the MCs group were significantly lower than those in the non MCs group (54.3% ± 17.5% vs 75.0% ± 17.2%, P < 0.05; 73.3% ± 12.0% vs 84.9% ± 8.0%, P < 0.05). Similarly, analogous results were obtained by comparing the MCs and non MCs groups' three-dimensional CT sagittal plane images (62.5% ± 16.5% vs 76.1% ± 12.4%, P < 0.05; 67.0% ± 13.9% vs 79.8% ± 11.5%, P < 0.05). Short-term fusion rates were lower in the MCs group than in the non MCs group. The coronal and sagittal cage union ratio in the MCs group was lower than that in the non MCs group. The fusion performance of n-HA/PA66 and PEEK cages in the MCs group was comparable.

Awake spinal fusion: a retrospective analysis of minimal invasive single level transforaminal lumbar interbody fusion done under spinal anaesthesia in 150 cases

&lt;p&gt;&lt;strong&gt;Background&lt;/strong&gt;: Spinal anaesthesia carries the advantage of having rapid onset, lesser blood loss, early recovery and hospital stay as compared to general anaesthesia. The present study evaluated outcomes of awake spinal fusion i.e., minimal invasive single level transforaminal lumbar interbody fusion (MIS-TLIF) under spinal anaesthesia. Current study is a retrospective analysis of prospectively collected data carried to assess patient related outcome benefits for a single level transforaminal lumbar interbody fusion done under spinal anaesthesia.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Methods&lt;/strong&gt;: Patients who fit deemed criteria not responding to 6 weeks of conservative treatment to lumbar degenerative pathologies underwent MIS-TLIF. The demographic data, visual analogue pain scale (VAS), Oswestry disability index (ODI), blood loss, time from entering operation theatre to time of incision, time of bandaging to exit from operation theatre, time of stay in post anaesthesia care unit (PACU), duration of surgery, nausea/vomiting, urinary retention, requirement of analgesics, duration of stay in hospital, peri-operative complications, fusion rate and satisfaction score were compiled and assessed.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Results:&lt;/strong&gt; 150 patients were operated with MISTLIF under spinal anaesthesia. VAS and ODI score improved significantly at final follow up (p&amp;lt;0.05). The mean duration of surgery was 148±18.24 minutes and blood loss were 109.64±110.45 ml. The average time from entering OT to incision and bandaging to exit was respectively 27.32±8.44 and 6.43±3.28 minutes. Mean PACU time was 36.74±6.32 minutes while duration of stay averaged 1.58±0.67 days. Post operative analgesia requirement was in 10.6% patients and radiographic fusion was observed in 96.6% patients. 90.6% patients were fully satisfied with spinal anaesthesia.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Conclusions: &lt;/strong&gt;Awake spinal fusion should be considered as a novel surgical approach with newer minimal invasive surgical techniques and regional anaesthesia to improve patient satisfaction and overall surgical outcome.&lt;/p&gt;

Efficiency of Spinal Anesthesia versus General Anesthesia for Minimal Invasive Single Level Transforaminal Lumbar Interbody Fusion: A Retrospective Analysis of 178 Patients

Objective: To evaluate the efficacy of spinal anesthesia in patients undergoing minimal invasive single level transforaminal lumbar interbody fusion surgery (MIS TLIF) and to compare the results with that of general anesthesia.Method: 178 patients were included in the study, 86 were in general anesthesia and 92 were in spinal anesthesia. Patients aged between 20 to 70 years who had undergone MIS-TLIF not responding to 6 weeks of conservative treatment were included. The routine steps of anesthesia for both general and spinal anesthesia were adhered. The VAS, blood loss, duration of surgery, time from entering operation theatre to time of incision, time of bandaging to exit from operation theatre, time of stay in Post Anesthesia Care Unit (PACU), nausea/vomiting, urinary retention, duration of stay in hospital, peri-operative complications were compiled and assessed. Appropriate statistical analysis was applied.Results: The mean time for entering the operation theatre to the incision; mean time from bandaging to the exit; mean PACU time and the mean hospital stay were significantly lower in the spinal anesthesia group (p&lt;0.05). The other parameters are comparable except, urinary retention which was significantly higher in spinal anesthesia group (p&lt;0.05). Conclusion: Spinal anesthesia offers efficient operating room functioning with decreasing overall operation theatre time. It is very efficient alternative technique to general anesthesia which can be considered for elective lumbar surgeries with a lower late of adverse events especially at lower lumbar levels.

PEEK Versus Titanium Static Interbody Cages: A Comparison of 1-Year Clinical and Radiographic Outcomes for 1-Level TLIFs.

This was a retrospective cohort study. This study evaluates the patient-reported Health Related Quality of Life outcomes and radiographic parameters of patients who underwent a single level transforaminal lumbar interbody fusion with either a polyetheretherketone (PEEK) or titanium interbody cage. Spinal stenosis with instability is a common diagnosis that is often treated with interbody fusion, in particular transforaminal lumbar interbody fusion. Titanium and PEEK interbody cage properties have been extensively studied to understand their effect on fusion rates and subsidence. A retrospective cohort study was conducted from a single, high volume, academic hospital. Health Related Quality of Life outcomes were obtained from Outcomes Based Electronic Research Database and electronic medical record chart review. Subsidence was defined as a loss of 2 mm or more in the anterior or posterior disk height. Spinopelvic alignment parameters measured were sacral slope, pelvic tilt, pelvic incidence, lumbar lordosis, segmental lordosis, and pelvic incidence-lumbar lordosis mismatch. Fusion rates were assessed by the Brantigan-Steffee criteria. The study included a total of 137 patients (108 PEEK, 29 titanium). Overall, no significant changes were noted between the 2 groups at 3 month or 1-year follow-up. Perioperatively, patients did report improvement in all outcome parameters within the PEEK and titanium groups. No significant difference was noted in subsidence rate between the 2 groups. Segmental lordosis significantly increased within the PEEK (+4.8 degrees; P<0.001) and titanium (+4.6 degrees; P=0.003) cage groups, however no difference was noted between groups. No significant difference was noted in fusion between the PEEK and titanium cage cohorts (92.6% vs. 86.2%; P=0.36). Overall, while PEEK and titanium cages exhibit unique biomaterial properties, our study shows that there were no significant differences with respect to patient-reported outcomes or radiographic outcomes between the 2 groups at the 1-year follow-up time point. Level III.

Expandable cages increase the risk of intraoperative subsidence but do not improve perioperative outcomes in single level transforaminal lumbar interbody fusion

Expandable cages (EXP) are being more frequently utilized in transforaminal lumbar interbody fusions (TLIF). EXP were designed to reduce complications related to neurological retraction, enable better lordosis restoration, and improve ease of insertion, particularly in the advent of minimally invasive surgical (MIS) techniques, however they are exponentially more expensive than the nonexpandable (NE) alternative. To investigate the clinical results of expandable cages in single level TLIF. Retrospective review at a single institution. Two hundred and fifty-two single level TLIFs from 2012 to 2018 were included. Clinical characteristics, perioperative and neurologic complication rates, and radiographic measures. Patients ≥18 years of age who underwent single level TLIF with minimum 1 year follow-up were included. clinical characteristics, perioperative and neurologic complications. Radiographic analysis included pelvic incidence-lumbar lordosis (PI-LL) mismatch, segmental lumbar lordosis (LL) mismatch, disc height restoration, and subsidence ≥2 mm. Statistical analysis included independent t tests and chi-square analysis. For nonparametric variables, Mann-Whitney U test and Spearman partial correlation were utilized. Multivariate regression was performed to assess relationships between surgical variables and recorded outcomes. For univariate analysis significance was set at p<.05. Due to the multiple comparisons being made, significance for regressions was set at p<.025 utilizing Bonferroni correction. Two hundred and fifty-two TLIFs between 2012 and 2018 were included, with 152 NE (54.6% female, mean age 59.28±14.19, mean body mass index (BMI) 28.65±5.38, mean Charlson Comorbidity Index (CCI) 2.20±1.89) and 100 EXP (48% female, mean age 58.81±11.70, mean BMI 28.68±6.06, mean CCI 1.99±1.66) with no significant differences in demographics. Patients instrumented with EXP cages had a shorter length of stay (3.11±2.06 days EXP vs. 4.01±2.64 days NE; Z=-4.189, p<.001) and a lower estimated blood loss (201.31±189.41 mL EXP vs. 377.82±364.06 mL NE; Z=-6.449, p<.001). There were significantly more MIS-TLIF cases and bone morphogenic protein (BMP) use in the EXP group (88% MIS, p<.001 and 60% BMP, p<.001) as illustrated in Table 1. There were no significant differences between the EXP and NE groups in rates of radiculitis and neuropraxia. In multivariate regression analysis, EXP were not associated with a difference in perioperative outcomes or complications. Radiographic analyses demonstrated that the EXP group had a lower PI-LL mismatch than the NE cage group at baseline (3.75±13.81° EXP vs. 12.75±15.81° NE; p=.001) and at 1 year follow-up (3.81±12.84° EXP vs. 8.23±12.73° NE; p=.046), but change in regional and segmental alignment was not significantly different between groups. Multivariate regression demonstrated that EXP use was a risk factor for intraoperative subsidence (2.729[1.185-6.281]; p=.018). Once technique was controlled for, TLIFs utilizing EXP do not have significantly improved neurologic or radiographic outcomes compared with NE. EXP increase risk of intraoperative subsidence. These results question the value of the EXP given the higher cost.

P75. Pathway analysis in spine surgery: a model for evaluating length of stay

BACKGROUND CONTEXT Spine surgeries utilize significant hospital resources, with length of stay (LOS) being a major cost driver. Predicting inpatient hospitalization is essential for the operational success of a hospital. Previous studies identifying pertinent factors that impact LOS in spine surgery are limited. PURPOSE To identify pre-, intra-, and post-operative factors associated with LOS in patients undergoing spine surgery. STUDY DESIGN/SETTING Retrospective review of spine surgery patients at a Canadian tertiary academic teaching hospital. PATIENT SAMPLE A total of 415 spine surgery patients. OUTCOME MEASURES LOS (calculated from the date of surgery to the date of discharge, with no accommodation for partial days). METHODS Institutional research ethics board (IRB) approval was obtained. Patients undergoing surgery by two orthopedic spine surgeons between October 2014 to October 2016 were identified using billing codes. Chart data were extracted on 16 surgical and nonsurgical factors by two independent reviewers. Factors collected included age, sex, BMI, ASA class, insurance claim, transfusion, preop medication use (antidepressant, neuroleptic and narcotic), surgical procedure (sub-grouped into 10 categories: single level transforaminal lumbar interbody fusion (TLIF), 2-level TLIF, discectomy, laminectomy, posterior c-spine, minimally-invasive stabilization, anterior lumbar interbody fusion (ALIF), anterior cervical decompression and fusion (ACDF), major deformity, and other (hematoma, removal of hardware, incision and drainage), Charlson Comorbidity Index, preop hemoglobin, surgical time, initial versus revision surgery, intraop analgesic dose, and LOS. Multiple quasi-poisson regression was used to identify factors associated with LOS. RESULTS There were 378 patients with full data included in the final analysis. Average age of the cohort was 52 years (16.3 sd, range 16-88) and 51% were female. Thirty percent (n=123) of the procedures were 1-level TLIF, while 6% (n=25) were 2-level TLIF. Other prominent procedures included discectomy (18%), laminectomy (15%) and posterior c-spine (7%). The average LOS for the entire cohort was 5.9 ±11.0 days and was right skewed: 58 subjects (14%) had 0 days in hospital and 59 subjects (14%) stayed longer than 1 week. A poisson model was built to predict LOS with surgical procedure while controlling for the other study variables. Compared to patients undergoing one- or two-level laminectomy, those that had single level or two-level discectomy stayed less than half as long (IRR=0.44, 95% CI: [0.24, 0.80]). Posterior c-spine patients (IRR=4.92, 95% CI: [2.92, 8.28]), major deformities (IRR=3.07, 95% CI: [1.85, 5.10]), ACDFs (IRR=2.24, 95% CI: [1.21, 4.15]), and 1-level TLIFs (IRR=1.50, 95%CI: [1.03, 2.16]) all had significantly longer hospital stays. Amongst the other study variables, ASA class 4 patients had a significantly longer stay (IRR=4.3), and patients that received a transfusion also stayed longer (IRR=2.7). All other factors evaluated were not found to be independently predictive of LOS. CONCLUSIONS The LOS within this cohort is strongly correlated with the procedure performed. Medical comorbidities and other factors did not significantly impact LOS except in very ill patients. Future pathway improvement should focus on procedure-specific, post-operative rehabilitation protocols and appropriate pre-operative optimization of severe medical illness. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Comparing Radiographic Parameters for Single-Level L5-S1 Interbody Fusion: Anterior Lumbar (ALIF) Versus Transforaminal Lumbar Interbody Fusion (TLIF)

Abstract INTRODUCTION The lumbosacral junction acts as a transition point between the mobile lumbar spine and the rigid pelvis. It is thereby susceptible to degenerative changes necessitating fusion at L5-S1. In this study, we compared radiographic outcomes observed from single-level anterior lumbar interbody fusion (ALIF) and transforaminal lumbar interbody fusion (TLIF) at this level. METHODS Retrospective review of single-level ALIF and TLIF with up to one level PSF at L5-S1 between May 2007 and October 2018 was undertaken. X-ray measurements were gathered for lumbar lordosis, segmental lordosis, pelvic tilt, sacral slope, pelvic incidence, pelvic incidence-lumbar lordosis mismatch, anterior/posterior disc height, and sagittal vertical axis. Computed tomography /magnetic resonance imaging was used to determine central canal area, sagittal diameter, foraminal height, and foraminal area. RESULTS A total of 47 ALIF patients and 50 TLIF patients were included. Patients averaged 53.7 ± 10.1 yr of age for ALIF and 49.4 ± 14.7 yr old for TLIF (P = .094) with significant differences (P = .0017) seen with gender as ALIF had 60.4% males and TLIF 70.0% females. Single-level ALIF led to significantly (P = .0010) more segmental lordosis (+5.75° ± 7.31°) than TLIF (+0.25° ± 6.55°), though differences in lumbar lordosis were not statistically significant (P = .52). ALIF significantly increased both anterior (+10.4 ± 4.32 mm vs +4.30 ± 3.55 mm; P &lt; .0001) and posterior disc height (+4.33 ± 3.32 mm vs + 2.98 ± 2.07 mm; P = .043) than TLIF. Changes in sagittal vertical axis also significantly differed (P = .030) with ALIF decreasing sagittal vertical axis by 17.8 ± 26.4 mm from +60.3 mm to + 42.5 mm, and TLIF increasing by 0.95 ± 25.8 mm from 39.9 mm to 40.9 mm. Pelvic tilt, sacral slope, pelvic incidence, pelvic incidence-lumbar lordosis mismatch had no significant differences. No statistically significant differences were observed with central canal area, sagittal diameter, foraminal height or foraminal area between ALIF and TLIF. CONCLUSION At L5-S1, the ALIF approach leads to increased segmental lordosis, disc height, while also decreasing sagittal vertical axis to a significant degree than TLIF. However, these two approaches were no different with regards to pelvic parameters and measures of central canal and foraminal decompression.

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

Symptomatic lumbar spondylolisthesis is commonly accompanied by spinal stenosis in multiple segments. These pathologies are routinely treated by multilevel decompression and instrumented fusion. However, it was hypothesized that a minimally invasive surgery (MIS) fusion in the unstable segment combined with a unilateral laminotomy for bilateral decompression (ULBD) in the adjacent stenotic segment is a biomechanically feasible alternative to a two-level fusion and superior to open laminectomy adjacent to a fused segment. This concept has demonstrated success in a recently published biomechanical cadaver study performed by our group. The present article offers a detailed step by step technical description for an MIS-TLIF (transforaminal lumbar interbody fusion) with adjacent ULBD.

Thursday, September 27, 2018 1:05 PM–2:05 PM Lumbar Spine Surgery: What You Need to Know: 114. No difference in reoperation rates or outcomes for a two-level posterolateral fusion augmented with single- versus two-level transforaminal lumbar interbody fusion

BACKGROUND CONTEXT Interbody devices (IBD) are being increasingly utilized during lumbar fusions with reported benefits, when compared to posterolateral fusion (PLF) alone, including increased fusion rates, increased neuroforaminal height, and the potential for improved sagittal alignment. Moreover, use of IBD has been shown to reduce reoperation rates compared to PLF alone. Although excellent outcomes have been demonstrated for single level transforaminal lumbar interbody fusion (TLIF), outcomes for single level TLIF in the setting of multiple level PLF are unknown. Some have suggested that a single level TLIF in the setting of a two level PLF may lead to increased pseudarthrosis at the level without an IBD, perhaps secondary to differences in stiffness at those levels in the setting of a developing fusion. PURPOSE We aim to determine whether there are differences in reoperation rate and outcomes for patients undergoing two level PLF augmented by a TLIF at only one of the levels vs at both levels. STUDY DESIGN/SETTING Retrospective, single institution, multi-surgeon patient cohort. PATIENT SAMPLE From September 2012 through September 2017, 416 patients were identified who underwent two level PLF with a TLIF at either one of those levels (n=183) or at both (n=233) with greater than one year follow-up. The two level TLIF group was significantly younger than the single level TLIF group (60.2 vs. 63.7, p=0.001), had a significantly lower Charleston Comorbidity Index (0.32 vs. 1.21, p OUTCOME MEASURES Primary outcome was reoperation rate with secondary outcomes including surgical parameters (estimated blood loss [EBL], OR time, length of stay [LOS]) and patient reported outcome measures (ODI, SF-12). METHODS T-tests were used to compare the cohorts for continuous variables and Chi square tests were used to compare the groups on categorical variables. RESULTS The one level and two level TLIF groups underwent 24 reoperations for 25 complication types and 24 reoperations for 27 complication types, respectively. Although the number of overall reoperations was not significantly different (p>0.05), among the reoperation types, there were significantly more reoperations for adjacent segment disease in the two level group compared to the one level group (19 vs. 12, p=0.04). There was no difference in reoperation for pseudarthrosis between the groups (p>0.05). Although the two level group had a higher EBL (p=0.002), they had an overall shorter LOS (p=0.003) (likely because they were younger and healthier to start). Although both groups experienced significant improvements in ODI (p CONCLUSIONS For patients undergoing two level PLF in the setting of a TLIF, using a TLIF at one vs both levels does not seem to influence reoperation rates or outcomes. However, reoperation rates for adjacent segment disease are increased in the setting of a two level PLF augmented by two TLIFs. FDA DEVICE/DRUG STATUS All devices were FDA approved and used as instructed.

Commentary: An evolving perception of the risk of rhBMP-2 use for anterior spinal interbody fusions

COMMENTARY ON: Carragee EJ, Mitsunaga KA, Hurwitz EL, Scuderi GJ. Retrograde ejaculation after anterior lumbar interbody fusion using rhBMP-2: a cohort controlled study. Spine J 2011;11:511–6 ( in this issue ).

P44. Predictors of Impaired Work Status Following Single Level Transforaminal Lumbar Interbody Fusion: A Clinical Study Comparing Patients with and without Work Compensation Claims

BACKGROUND CONTEXT: Prior research has focused on identifying independent predictors of long-term disability in workers with back injuries. Early opioid use and radiculopathy have both been found to be counterproductive to recovery in this cohort. Our study evaluates these factors in patients covered by worker's compensation compared to a control group.