Transforaminal Interbody Fusion Research Articles

Patient-reported outcomes 1 and 2years after transforaminal thoracic interbody fusion (TTIF).

Retrospective Cohort Study with prospectively collected data. Transforaminal interbody fusion was initially designed for the lumbar spine. A similar approach was later introduced for the thoracic spine (TTIF). Here we report the surgical technique and the Core Outcome Measures Index (COMI) at 1-year and 2-year follow-ups, as well as the sagittal radiographic kyphosis correction of TTIF, achieved at 1year and the latest follow-up. All TTIF procedures from 2012 to 2020 were included. COMI scores were collected preoperatively and at 1- and 2-year follow-ups. The sagittal angle between the upper and lower endplates at the segment where TTIF was performed was measured on preoperative, 1-year postoperative, and last available radiographs. Seventy-nine TTIF procedures were performed for 64 patients (36% males; mean age 67.5 (SD 15.3) years). COMI score reduced from a mean value of 8.1 (SD 1.4) preoperatively to 4.7 (SD 2.7) at 1-year follow-up and 4.7 (SD 2.7) at 2-year follow-up. The mean correction of segmental kyphosis was 10.8 (SD 7.3, p < 0.0001) degrees at 1-year follow-up and 9.3 (SD 7.0, p < 0.0001) degrees at the final follow-up 3.4 (SD 1.4) years after the operation. Kaplan-Meier analysis for reoperations showed a 5-year survival of 91% (95% CI 0.795-1) for primary TTIF operations and survival of 77% (95% CI 0.651-0.899) for TTIFs performed after earlier fusion operations. TTIF is a feasible procedure in the thoracic spine. Kyphosis correction of approximately 10° was maintained at 1-year and final follow-up. Over 69% at 1-year and 61% at 2-year follow-up achieved MCID for COMI.

Impact of metabolic syndrome on morbidity and mortality following transforaminal interbody fusion (TLIF)

Study designRetrospective Multi-Institutional Database Study. ObjectiveInvestigate the effect of metabolic syndrome (MetS) on the outcomes of Transforaminal Lumbar Interbody Fusion (TLIF) Summary of background dataTLIF procedures in lumbar spine pathology are common. MetS is a combination of conditions, including medication required hypertension, diabetes mellitus (DM), and body mass index (BMI) of 30 kg/m2s or more. The prevalence of MetS has increased drastically over the past two decades. Our study aimed to understand the effect of MetS on morbidity and mortality of TLIF postoperatively. MethodsOur study used American College of Surgeons National Surgical Quality Improvement (ACS-NSQIP) data from 2006 to 2019 to find all patients who underwent TLIF. Patients with MetS were compared to those without MetS. Fisher's test identified univariate relationships between MetS and preoperative/postoperative variables. Multivariable logistic regression models were utilized to analyze the association between MetS and postoperative morbidity and mortality. Results54,980 patients were identified who received TLIF. 10.7 % had MetS preoperatively. Patients with and without MetS showed statistically significant univariate differences in most preoperative and postoperative variables. After adjusting for preoperative comorbidities, patients with MetS had greater multivariate-adjusted odds of wound infections (aOR = 1.5889, CI 1.1952–2.112, p = 0.00144), pulmonary events (aOR = 1.5517, CI 1.1207–2.1485, p = 0.00813), renal events (aOR = 2.8685, CI 1.5511–5.3045, p = 0.00078), sepsis (aOR = 1.6773, CI 1.1647–2.4155, p = 5.44E-03), and return to OR (aOR = 1.4764, CI 1.2201–1.7866, p = 6.19E-05) ConclusionsPatients with MetS are at elevated risk for various morbidity and mortality markers after TLIF. Surgeons performing TLIFs on these patients should be aware of the increased potential for postoperative events that may complicate the patient's recovery. Level of evidenceLevel III.

Fusion's Location and Quality within the Fixated Segment Following Transforaminal Interbody Fusion (TLIF).

Transforaminal interbody fusion (TLIF) has gained increased popularity over recent decades and is being employed as an established surgical treatment for several lumbar spine pathologies, including degenerative spondylosis, spondylolisthesis, infection, tumor and some cases of recurrent disc herniation. Despite the seemingly acceptable fusion rates after TLIF (up to 94%), the literature is still limited regarding the specific location and quality of fusion inside the fixated segment. In this single-institution, retrospective population-based study, we evaluated all post-operative computed tomography (CT) of patients who underwent TLIF surgery at a medium-sized medical center between 2010 and 2020. All CT studies were performed at a minimum of 1 year following the surgery, with a median of 2 years. Each CT study was evaluated for post-operative fusion, specifically in the posterolateral and intervertebral body areas. The fusion's quality was determined and classified in each area according to Lee's criteria, as follows: (1) definitive fusion: definitive bony trabecular bridging across the graft host interface; (2) probable fusion: no definitive bony trabecular crossing but with no gap at the graft host interface; (3) possible arthrosis: no bony trabecular crossing with identifiable gap at the graft host interface; (4) definite pseudarthrosis: no traversing trabecular bone with definitive gap. A total of 48 patients were included in this study. The median age was 55.6 years (SD ± 15.4). The median time from surgery to post-operative CT was 2 years (range: 1-10). Full definitive fusion in both posterolateral and intervertebral areas was observed in 48% of patients, and 92% showed definitive fusion in at least one area (either posterolateral or intervertebral body area). When comparing the posterolateral and the intervertebral area fusion rates, a significantly higher definitive fusion rate was observed in the posterolateral area as compared to the intervertebral body area in the long term follow-up (92% vs. 52%, p < 0.001). In the multivariable analysis, accounting for several confounding factors, including the number of fixated segments and cage size, the results remained statistically significant (p = 0.048). In conclusion, a significantly higher definitive fusion rate at the posterolateral area compared to the intervertebral body area following TLIF surgery was found. Surgeons are encouraged to employ bone augmentation material in the posterolateral area (as the primary site of fusion) when performing TLIF surgery.

Minimally invasive transforaminal lumbar interbody fusion with unilateral pedicle screw fixation (UNILF): outcomes at 7years.

To assess clinical, functional and radiographical results of one-level minimally invasive transforaminal interbody fusion with unilateral pedicle screw fixation (UNILIF) in the treatment of stable lumbar degenerative diseases with a minimum of 5years of follow-up. From January 2012 to December 2016, clinical and radiological data of patients with degenerative lumbar disease managed by UNILIF were prospectively collected. Patients with a follow-up that ended before 5years were excluded. SF-12, Oswestry disability index (ODI) and visual analog scale (VAS) were collected preoperatively, at 2 years and at the last follow-up. A full-spine standing radiograph was performed at each follow-up appointment. Mean operative time was 74.7 (± 19) minutes, mean blood loss was 131.1 (± 207) ml and mean follow-up was 7.5 (± 1.7) years. All functional scores and VAS were significantly improved between the preoperative and the 2 years postoperative. Between the 2 years postoperative and the last follow-up ODI and VAS continued to significantly improved. Fusion rate was 98.6% on radiographic analysis at follow-up. UNILIF method is a safe and effective surgical strategy. It provides a durable improvement in functional score over 7years of follow-up with a stable radiological correction over time.

Postoperative cage migration and subsidence following TLIF surgery is not associated with bony fusion

Pseudarthrosis following transforaminal interbody fusion (TLIF) is not infrequent. Although cage migration and subsidence are commonly regarded as evidence of the absence of solid fusion, there is still no evidence of the influence of cage migration and subsidence on fusion. This study aimed to evaluate cage migration and subsidence using computed tomography (CT) DICOM data following lumbar interbody fusion. The effects of cage migration and subsidence on fusion and clinical outcomes were also assessed. A postoperative CT data set of 67 patients treated with monosegmental TLIF was analyzed in terms of cage position. To assess the effects of cage migration and subsidence on fusion, 12-month postoperative CT scans were used to assess fusion status. Clinical evaluation included the visual analog scale for pain and the Oswestry Disability Index. Postoperative cage migration occurred in 85.1% of all patients, and cage subsidence was observed in 58.2%. Radiological signs of pseudarthrosis was observed in 7.5% of the patients Neither cage migration nor subsidence affected the clinical or radiographic outcomes. No correlation was found between clinical and radiographic outcomes. The incidence of cage migration was considerable. However, as cage migration and subsidence were not associated with bony fusion, their clinical significance was considered limited.

Necessity of fusion following decompression surgery in patients with single-level lumbar stenosis: study protocol for an open-label multicentre non-inferiority randomized controlled clinical trial

BackgroundThe necessity of spinal segment fusion after decompression is one of the most controversial and unresolved issues in single-level lumbar spinal stenosis surgery. To date, only one trial carried out 15 years ago focused on this problem. The key purpose of the current trial is to compare the long-term clinical results of the two surgical methods (decompression vs. decompression and fusion) in patients with single-level lumbar stenosis.MethodsThis study is focused on the non-inferior clinical results of decompression compared with the standard fusion procedure. In the decompression group, the spinous process, the interspinous and supraspinous ligaments, part of the facet joints, and corresponding parts of the vertebral arch are to be preserved intact. In the fusion group, decompression is to be supplemented with transforaminal interbody fusion. Participants meeting the inclusion criteria will be randomly divided into two equal groups (1:1), depending on the surgical method. The final analysis will include 86 patients (43 per group). The primary endpoint is Oswestry Disability Index dynamics at the end of the 24-month follow-up compared to the baseline level. Secondary outcomes included those estimated using the SF-36 scale, EQ-5D-5L, and psychological scales. Additional parameters will include sagittal balance of the spine, fusion results, total cost of surgery, and hospital stay followed by two-year treatment. Follow-up examinations will be performed at 3, 6, 12, and 24 monthsDiscussionAuthors suggest that this study will improve the evidence for application of various surgical techniques for lumbar spine stenosis surgery and verify the existing protocol for surgical management.Trial registrationClinicalTrials.gov NCT05273879. Registered on March 10, 2022.

INVESTIGATION OF BACTERIAL AND VIRAL SLOW INTERVERTEBRAL DISC INFECTIONS

Objective. Currently, few publications have been available regarding an effect of level, type of intrusion, and viral infections on spinal disc degeneration. The study was aimed to evaluate an incidence of indolent bacterial and viral intervertebral disc infections in unstratified group of patients operated on for spinal degenerative pathologies.&#x0D; Material and methods. For the study, intraoperative disc samples were collected from patients who underwent discectomy and total spinal fusion surgery for degenerative pathologies between the years December, 2018 to January, 2020. 447 samples were examined obtained from 392 patients (189 women and 203 men) with a mean age of 58.1 years.&#x0D; The following epidemiological and clinical data were collected: gender, age, spinal segments affected, type of surgical approach, preoperative C-reactive protein (CRP; reference range 0.00.5 mg/dL), and preoperative as well as 6-month postoperative ODI and NDI, both expressed as a percentage. The incidence of postoperative infections within six months after surgery as well as MI for each operated segment was assessed. Only patients with ventral cervical or dorsal thoracic access were enrolled in the study. In the lumbar region, the ventral assess was chosen for anterior lumbar interbody fusion, the lateral approach for oblique or extreme lateral interbody fusion, and the dorsal approach in case of standard microdiscectomy of posterior transforaminal interbody fusion or transforaminal interbody fusion.&#x0D; A logistic regression analysis was performed to model a risk of positive microbiological culture and a risk of emerging modal changes by using a set of independent variables selected in a stepwise manner by using the Akaike information criterion as a measure of quality of select procedure.&#x0D; Results. MRI for modal analysis was available for all 447 segments. MRI revealed 45 type 1 SCs (10.07% of all segments), 118 type 2 SCs (26.4%), and 5 type 3 SCs (1.12%). Microbiological culture was available in 410 segments. In these 410 segments, 39 type 1 MCs, 113 type 2 MCs, and 5 type 3 MCs were found. A statistically significant relationship was found between SC type 2 and a positive microbiological result (p = 0.0127). In contrast, there were no statistically significant associations for type 1 and type 3 SCs (p=0.3052 and p=0.0767, respectively).&#x0D; Conclusion. A relation between disc degeneration and infections seems unlikely. Histopathological evidence of inflammation in degenerated discs is rare and unrelated to microbiological findings.

Minimally invasive LLIF surgery to decrease the occurrence of adjacent-segment disease compared to conventional open TLIF.

Lateral lumbar interbody fusion with percutaneous pedicle screw fixation (Mis-LLIF) can establish indirect decompression by lifting the vertebra with a large intervertebral cage, which causes less damage to the posterior elements. Thus, Mis-LLIF is expected to reduce the incidence of adjacent segment disease (ASD). The aim of the study was to compare the occurrence of ASD between Mis-LLIF and conventional open transforaminal interbody fusion (TLIF). A total of 156 patients (TLIF group = 88, Mis-LLIF group = 68) who underwent single-level lumbar interbody fusion (L2/3, L3/4, or L4/5) at a single institution between 2003 and 2018 with minimum 2-year follow-up were retrospectively reviewed. The incidence of symptomatic ASD requiring reoperation (S-ASD) and radiological adjacent segment degeneration (R-ASD) 2years postoperatively were investigated between 51 paired patients from both groups who were propensity score (PS) matched by demographic and baseline clinical data. The effect of characteristics arising from differences in surgical methods between Mis-LLIF and TLIF, such as the amount of distraction of the index fused level (∆H), on S-ASD and R-ASD was also examined. There were no significant differences in the incidence of S-ASD between the Mis-LLIF and TLIF groups (adjusted OR 1.3; 95% CI 0.41-3.9). There was no significant difference in the incidence of R-ASD between the Mis-LLIF and TLIF groups both at the cranial (adjusted OR 1.0; 95% CI 0.22-4.5) and caudal level (adjusted OR 1.5; 95% CI 0.44-5.3). On the other hand, ∆H was significantly higher in the Mis-LLIF group than in the TLIF group (3.6mm vs. 1.7mm, respectively, P < 0.0001), and was extracted as a significant independent risk factor for S-ASD (adjusted HR 2.7; 95% CI 1.1-6.3) and R-ASD at the cranial side (adjusted HR 6.4; 95% CI 1.7-24) in multivariable analysis with PS adjustment. The incidence of R-ASD or S-ASD was not significantly reduced in the Mis-LLIF group compared to the TLIF group, with greater ∆H potentially being a contributing factor. Using a thin cage in both TLIF and Mis-LLIF may decrease the occurrence of ASD.

Minimally Invasive Decompression With Noninstrumented Facet Fusion Versus Minimally Invasive Transforaminal Lumbar Interbody Fusion for Stenosis Associated With Grade 1 Lumbar Degenerative Spondylolisthesis.

Retrospective matched cohort study. With a growing interest in minimally invasive spine surgery (MIS), the question of which technique is the most advantageous for patients with low-grade degenerative lumbar spondylolisthesis (DLS) still remains unclear. To compare patient-reported outcomes, perioperative morbidity, and rates of reoperation between MIS decompression with either unilateral noninstrumented facet fusion (MIS-F) or with transforaminal interbody fusion (MIS-T) for grade 1 DLS. Twenty patients who underwent MIS-T and 20 patients with MIS-F were matched based on age, sex, and preoperative ODI, VAS back, and VAS leg. All patients had DLS with at least 4 millimeters of translation on standing radiographs. Exclusion criteria included prior level surgery, multilevel instability, disk impinging on the exiting nerve root, spondylolisthesis from significant facet arthropathy, or foraminal compromise from disk collapse. ODI, VAS back, VAS leg, and patient satisfaction measured by the North American Spine Society questionnaire were tracked at 3, 6, 12, and 24 months postoperatively. Minimum clinically important differences and substantial clinical benefits were calculated. MIS-F and MIS-T resulted in decreased ODI at 3, 6, and 12 months following the index procedure. Sixty percent of MIS-F and 83% of MIS-T patients reached minimum clinically important difference at 1 year postoperatively; however, using the threshold of 30% ODI reduction from baseline, 67% of MIS-F and 83% MIS-T ( P = 0.25) achieved this goal. Forty-three percent of MIS-F and 59% of MIS-T patients met substantial clinical benefits. Satisfaction at 1 year, measured by a score of 1 or 2 on the North American Spine Society questionnaire, was 64% for MIS-F and 83% for MIS-T. MIS-F and MIS-T are effective treatment options for spinal stenosis associated with low-grade DLS. Both techniques result in comparable patient-reported outcomes and satisfaction up to 2 years and have similar long-term reoperation rates. More evidence is required to delineate optimal selection characteristics for MIS-F versus MIS-T.

Depressed patients with greater symptom duration before MIS-TLIF do not report inferior outcomes.

Patients with preoperative depressive symptoms may demonstrate inferior patient-reported outcomes (PROs). The effect of preoperative symptom duration (SD) on PROs in this population has not been well-studied. We aim to assess the influence of preoperative SD on PROs in patients with low mental health scores prior to minimally invasive transforaminal interbody fusion (MIS-TLIF). Patients who had undergone elective, primary MIS-TLIF with preoperative SF-12 MCS score below 45.6, a previously established threshold for depression, were selected. Patients were divided into matched lesser duration (LD; SD<365 days) and greater duration (GD; SD≥365 days) cohorts. PROs were collected preoperatively and at 6-week/12-week/6-month/1-year postoperative periods. PROs included PROMIS-PF/ODI/VAS back/VAS leg/SF-12 MCS. PROs were compared within and between groups. Rates of achievement of minimal clinically important difference (MCID) were compared between groups. One hundred twenty-two patients were included after matching cohorts. Patients in the LD cohort demonstrated improvement in PROMIS-PF at 12-weeks/6-month/1-year, and ODI/VAS back/VAS leg/SF-12 MCS at all postoperative periods (p≤0.024, all). Patients in the GD cohort demonstrated improvement in PROMIS-PF at 12-weeks/6-month/1-year, and ODI/VAS back/VAS leg/SF-12 MCS at all postoperative periods (p≤0.013, all). There were no differences in PROs or MCID achievement between cohorts at any period. Patients with preoperative depressive symptoms undergoing MIS-TLIF, regardless of duration of preoperative symptoms, demonstrated improvements in physical function, disability, pain, and mental health domains. Patients with greater duration of preoperative symptoms did not report inferior outcomes at any period. Rates of clinically important improvements in all domains were favorable and similar between cohorts.

499 Prospective, Randomized and Controlled Multicenter Study of Posterior Lumbar Facet Arthroplasty for the Treatment of Spondylolisthesis

INTRODUCTION: Prospective, Randomized and Controlled Multicenter Study of Posterior Lumbar Facet Arthroplasty for the Treatment of Spondylolisthesis. METHODS: The study was a prospective, randomized, controlled Food and Drug Administration (FDA) Investigational Device Exemption (IDE) trial evaluating the investigational TOPS device to the control, transforaminal interbody fusion (TLIF) and pedicle screw fixation. Follow-up duration was a minimum twenty-four months. RESULTS: A total of 249 patients were evaluated comparing the investigational TOPS group (n = 170) to the control TLIF group (n = 79. There were no statistically significant differences between implanted levels (L4-5 TOPS 95%; L4-5 TLIF 95%) or blood loss. The overall composite measure for clinical success was statistically significantly higher in the TOPS group, 85%, compared to the fusion group, 64% (p = 0.0138). The percentage of subjects reporting minimum 15-point improvement in ODI showed a statistically significant difference (p-value = 0.037) favoring TOPS (94.0%) over TLIF (79.4%). CONCLUSIONS: This study demonstrates that posterior lumbar decompression and dynamic stabilization with the TOPS device is safe and efficacious in the treatment of lumbar stenosis with degenerative spondylolisthesis. Additionally, decompression and dynamic stabilization with the TOPS device maintains segmental motion.

490 Beyond Placement of Pedicle Screws - New Applications for Robotics in Spine Surgery: A Multi-Surgeon, Single-Institution Experience

INTRODUCTION: Interest in robotic-assisted spine surgery has grown as surgeon comfort and technology have evolved to maximize the benefits of time-saving and precision. However, the Food and Drug Administration (FDA) has currently only approved robotics to assist in determining the ideal trajectory for pedicle screw placement after extensive research supporting its efficacy and efficiency. To be considered a durable and effective option, robotics need to expand beyond the indication of just placing pedicle screws. METHODS: We will explore accessing Kambin’s Triangle in percutaneous transforaminal interbody fusion (percLIF), iliac fixation in metastatic cancer, and sacroiliac (SI) fusions. Each of these topics will be covered in-depth with associated background information and subsequent discussion. RESULTS: Without the need for laminectomies or facetectomies, minimal tissue disruption was attained by using RA instrumentation finely tuned to each patient’s unique spinal landscape for percLIF. In the cases of iliac fixation, the use of S2AI screws was precluded by the extensive damage to the sacrum. Therefore, a modified iliac screw entry point was utilized with an entry point slightly more medial than the traditional method, with a pre-planned trajectory of the screws using robot assistance. For SI joint fusion, we review our group at Duke University's published case series displaying the “off-label” use of the robot, which is the first reported case series of its kind in the literature. CONCLUSIONS: We show that with a proper understanding of its limitations, robots can help surgeons perform difficult surgeries in a safe manner.

Marker Screw Utilization for Minimally Invasive Transforaminal Lumbar Interbody Fusion (MS-MIS TLIF): Promises and Advantages.

Background and Objective: Minimally Invasive Transforaminal Lumbar Interbody Fusion (MIS-TLIF) has been investigated and shown excellent short- and long-term outcomes. In this paper, we describe a new MIS-TLIF technique and pedicle screw insertion using a marker screw as a guidance method. Moreover, we report perioperative, postoperative, and patient-related outcomes. In addition, this paper outlines major differences in radiation exposure, cost effectiveness and accuracy of Marker Screw Minimally Invasive Transforaminal Interbody Fusion (MS-MIS TLIF) compared to other techniques. We report our technique to share our knowledge and experience with the aim of achieving a better MIS-TLIF that would help both surgeons and patients. Materials and Methods: A prospective case series was conducted between October 2018 and February 2021. Patients undergoing MS-MIS TLIF with marker screws were consecutively included. The surgery did not exceed two levels. The patients' medical records were reviewed, and the included patients were asked to complete two outcome-questionnaires before surgery and at the six-month visit. The surgical technique is described in this paper. Results: A total of 37 patients were recruited. The mean age was 57.35 ± 12.8 years, and more than half of the patients were females. The most common indications for surgery were degenerative disc disease and spondylolisthesis, with the typical level at L4-5. The operative time was 3.02 ± 0.83 h, while the estimated blood loss was 127.7 ± 71.1 mL. The average time for ambulation and hospitalization was 1 ± 1.1 and 2.84 ± 1.4 days, respectively. The patients described significant improvement in both questionnaires. No screw-related complications or screw revisions were needed up to two years of follow-up. Conclusions: The use of marker screws for pedicle screw placement through a minimally invasive fashion is shown to be a promising technique that can overcome many drawbacks, including cost, operative time, and radiation exposure. Performing MS-MIS TLIF can achieve a 360- degree fusion compared to percutaneous MIS-TLIF.

Predictors of Subsidence and Its Clinical Impact Following Expandable Cage Insertion in Minimally Invasive Transforaminal Interbody Fusion.

Retrospective review of prospectively collected multi-surgeon data. Examine the rate, clinical impact, predictors of subsidence after expandable MI-TLIF cage. Expandable cage technology has been adopted in minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) to reduce the risks and optimize outcomes. Although subsidence is of particular concern when using expandable technology as force required to expand the cage can weaken the endplates, its rates, predictors, and outcomes lack evidence. Patients who underwent 1 or 2 level MI-TLIF using expandable cages for degenerative lumbar conditions and had a follow-up of>1 year were included. Preop and immediate, early, and late postoperative radiographs were reviewed. Subsidence was determined if the average anterior/posterior disc height decreased by>25% compared to the immediate postoperative value. Patient reported outcomes were collected and analyzed for differences at the early (<6mo) and late (>6mo) timepoints. Fusion was assessed by 1-year postop CT. 148 patients were included (mean age 61y, 86% 1-level, 14% 2-level). 22 (14.9%) demonstrated subsidence. Although statistically not significant, patients with subsidence were older, lower bone mineral density, and had higher BMI and comorbidity burden. Operative time was significantly higher (P=0.02) and implant width was lower (P<0.01) for subsided patients. VAS-Leg was significantly lower for subsided patients compared to non-subsided patients at a>6m time point. Long-term (>6m) patient acceptable symptom state (PASS) achievement rate was lower for subsided patients (53% vs. 77%), although statistically not significant (P=0.065). No differences existed in complication, reoperation, or fusion rates. 14.9% of patients experienced subsidence predicted by narrower implants. Although subsidence did not have a significant impact on most PROMs and complication, reoperation, or fusion rates, patients had lower VAS-Leg and PASS achievement rate at the>6-month timepoint. 4.

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.

Residual motion of cortical versus pedicle screw constructs after decompression, interbody fusion and cross-link augmentation

PurposeTo compare the residual range of motion (ROM) of cortical screw (CS) versus pedicle screw (PS) instrumented lumbar segments and the additional effect of transforaminal interbody fusion (TLIF) and cross-link (CL) augmentation.MethodsROM of thirty-five human cadaver lumbar segments in flexion/extension (FE), lateral bending (LB), lateral shear (LS), anterior shear (AS), axial rotation (AR), and axial compression (AC) was recorded. After instrumenting the segments with PS (n = 17) and CS (n = 18), ROM in relation to the uninstrumented segments was evaluated without and with CL augmentation before and after decompression and TLIF.ResultsCS and PS instrumentations both significantly reduced ROM in all loading directions, except AC. In undecompressed segments, a significantly lower relative (and absolute) reduction of motion in LB was found with CS 61% (absolute 3.3°) as compared to PS 71% (4.0°; p = 0.048). FE, AR, AS, LS, and AC values were similar between CS and PS instrumented segments without interbody fusion. After decompression and TLIF insertion, no difference between CS and PS was found in LB and neither in any other loading direction. CL augmentation did not diminish differences in LB between CS and PS in the undecompressed state but led to an additional small AR reduction of 11% (0.15°) in CS and 7% (0.05°) in PS instrumentation.ConclusionSimilar residual motion is found with CS and PS instrumentation, except of slightly, but significantly inferior reduction of ROM in LB with CS. Differences between CS and PS in diminish with TLIF but not with CL augmentation.

Commentary: Multilevel Endoscopic Transforaminal Interbody Fusion for Severe Discitis, Osteomyelitis, and Kyphotic Deformity in the Lumbar Spine: 2-Dimensional Operative Video.

Commentary: Multilevel Endoscopic Transforaminal Interbody Fusion for Severe Discitis, Osteomyelitis, and Kyphotic Deformity in the Lumbar Spine: 2-Dimensional Operative Video.

Transforaminal Interbody Fusion Using the Unilateral Biportal Endoscopic Technique Compared With Transforaminal Lumbar Interbody Fusion for the Treatment of Lumbar Spine Diseases: Analysis of Clinical and Radiological Outcomes.

There has been a widespread application of minimally invasive spinal surgery techniques in the past few years. Unilateral biportal endoscopic has been successfully used in a variety of lumbar spine diseases, but there are few studies on lumbar fusion assisted by unilateral biportal endoscopy. To compare the clinical and radiological outcomes of transforaminal interbody fusion using the unilateral biportal endoscopic technique (UBEIF) and transforaminal lumbar interbody fusion (TLIF) in patients with lumbar disease. We studied 128 patients, 58 in the UBEIF group and 70 in the TLIF group. The Oswestry disability index, creatine kinase, visual analog score (VAS) for leg and back pain were used to assess clinical outcomes. Radiographic outcomes were assessed using the fusion rate, internal fixation loosening, and adjacent segment degeneration. Back and leg pain VAS scores in both groups were significantly lower 3, 6, and 12 months after surgery ( P < .05). A significant reduction in Oswestry disability index in both groups was observed 6 and 12 months after surgery ( P < .05). Compared with the TLIF group at 1 week after surgery, UBEIF patients' VAS score for back pain significantly improved ( P < .05). There was no difference in fusion rate between the 2 groups (98.27% vs 98.57%). UBEIF and TLIF have similar clinical and radiographic outcomes in the treatment of single-segment lumbar disease with lumbar instability, including improved back and leg pain, improved disability, and high fusion rates. Furthermore, with UBEIF, less blood is lost, there is better relief of early back pain, and hospital stays are shorter.

Comparison of Transforaminal Lumbar Interbody Fusion in the Ambulatory Surgery Center and Traditional Hospital Settings, Part 1: Multi-Center Assessment of Surgical Safety

(1) Background: The technological advances achieved with minimally-invasive surgery have enabled procedures to be undertaken in outpatient settings, and there has been growing acceptance of performing minimally-invasive transforaminal interbody fusion (TLIF) in the ambulatory surgery center (ASC). The purposeof this study was to determine the comparative 30 day safety profile for patients treated with TLIF in the ASC versus the hospital setting. (2) Methods: This multi-center study retrospectively collected baseline characteristics, perioperative variables, and 30 day postoperative safety outcomes for patients having a TLIF using the VariLift®-LX expandable lumbar interbody fusion device. Outcomes were compared between patients undergoing TLIF in the ASC (n = 53) versus in the hospital (n = 114). (3) Results: Patients treated in-hospital were significantly older, frailer and more likely to have had previous spinal surgery than ASC patients. Preoperative back and leg pain scores were similar between study groups (median, 7). ASC patients had almost exclusively one-level procedures (98%) vs. 20% of hospital procedures involving two-levels (p = 0.004). Most procedures (>90%) employed a stand-alone device. The median length of stay for hospital patients was five times greater than for ASC patients (1.4 days vs. 0.3 days, p = 0.001). Emergency department visits, re-admissions and reoperations were rare whether the patients were managed in the traditional hospital setting or the ASC. (4) Conclusions: There were equivalent 30 day postoperative safety profiles for patients undergoing a minimally-invasive TLIF irrespective of surgical setting. For appropriately selected surgical candidates, the ASC offers a viable and attractive option for their TLIF procedure with the advantage of same-day discharge and at-home recovery.

Comparative Clinical Analysis of Oblique Lateral Interbody Fusion at L5/S1 versus Minimally Invasive Transforaminal Interbody Fusion (MIS-TLIF) for Degenerative Lumbosacral Disorders.

Since 2015, we have performed minimally invasive oblique lateral interbody fusion (OLIF) at L5/S1 for various lumbosacral spine disorders using percutaneous pedicle screws. This study evaluated the clinical and radiologic results between OLIF at L5/S1 and minimally invasive transforaminal interbody fusion (MIS-TLIF) for single to multilevel degenerative lumbosacral disorders. A total of 124 patients underwent either OLIF (62 cases) or MIS-TLIF (62 cases). The applied disorders were L5 isthmic spondylolisthesis, foraminal stenosis, pseudarthrosis, adjacent segment degeneration, a combination of L4/5 and L5/S1 pathology, and others. We performed OLIF with posterior percutaneous fixation in the same lateral position. MIS-TLIF was performed with modified cortical bone trajectory screws. The operation time (OT), estimated blood loss (EBL), JOABPEQ effectiveness rate (%),Visual Analog Scale (VAS), fusion rate, radiologic segmental alignment, and complications were evaluated. The average follow-up periods were 51 and 69 months (24-95) in the OLIF and MIS-TLIF groups, respectively. Furthermore, the average fused segments were 1.6 and 1.5 in each group, respectively. The OT and EBL per segment were 130 min and 56 mL and 100 min and 64 mL, respectively. The JOABPEQ effectiveness rate in the OLIF group demonstrated a statistically higher value in the domains of pain, low-back function, and gait than the MIS-TLIF group (P<0.01). The follow-up VAS of low-back pain (LBP) and lower extremity numbness had lower values in the OLIF group (P<0.05). The fusion rates were 98% and 90%, respectively. Segmental lordosis at L5/S1 was significantly larger in the OLIF group (15° vs. 11°, P<0.01). The OLIF group demonstrated less pain as well as better low-back and gait functions at follow-up. The minimally invasive anterolateral fusion employing OLIF at L5/S1 using percutaneous screws serves as a viable and effective procedure with less residual LBP and high fusion rate.