Transforaminal Lumbar Interbody Fusion Patients Research Articles

What is the early fate of adjacent segmental lordosis compensation at L3-4 and L5-S1 following a lateral versus transforaminal lumbar Interbody Fusion at L4-5?

Degenerative spondylolisthesis causes translational and angular malalignment, resulting in a loss of segmental lordosis. This leads to compensatory adjustments in adjacent levels to maintain balance. Lateral lumbar interbody fusion (LLIF) and transforaminal lumbar interbody fusion (TLIF) are common techniques at L4-5. This study compares compensatory changes at adjacent L3-4 and L5-S1 levels six months post LLIF versus TLIF for grade 1 degenerative spondylolisthesis at L4-5. A retrospective study included patients undergoing L4-5 LLIF or TLIF with posterior pedicle screw instrumentation (no posterior osteotomy) for grade 1 spondylolisthesis. Pre-op and 6-month post-op radiographs measured segmental lordosis (L3-L4, L4-L5, L5-S1), lumbar lordosis (LL), and pelvic incidence (PI), along with PI-LL mismatch. Multiple regressions were used for hypothesis testing. 113 patients (61 LLIF, 52 TLIF) were studied. TLIF showed less change in L4-5 lordosis (mean = 1.04°, SD = 4.34) compared to LLIF (mean = 4.99°, SD = 5.53) (p = 0.003). L4-5 angle changes didn't correlate with L3-4 changes, and no disparity between LLIF and TLIF was found (all p > 0.16). In LLIF, greater L4-5 lordosis change predicted reduced compensatory L5-S1 lordosis (p = 0.04), while no significant relationship was observed in TLIF patients (p = 0.12). LLIF at L4-5 increases lordosis at the operated level, with compensatory decrease at L5-S1 but not L3-4. This reciprocal loss at adjacent L5-S1 may explain inconsistent improvement in lumbar lordosis (PI-LL) post L4-5 fusion.

Does Bone Morphogenetic Protein Use Reduce Pseudarthrosis Rates in Single-Level Transforaminal Lumbar Interbody Fusion Surgeries?

Recombinant human bone morphogenetic protein 2 (rhBMP-2, or BMP for short) is a popular biological product used in spine surgeries to promote fusion and avoid the morbidity associated with iliac crest autograft. BMP's effect on pseudarthrosis in transforaminal lumbar interbody fusion (TLIF) remains unknown. To assess the rates of pseudarthrosis in single-level TLIF with and without concurrent use of BMP. This was a retrospective cohort study conducted at a single academic institution. Adults undergoing primary single-level TLIF with a minimum of 1 year of clinical and radiographic follow-up were included. BMP use was determined by operative notes at index surgery. Non-BMP cases with iliac crest bone graft were excluded. Pseudarthrosis was determined using radiographic and clinical evaluation. Bivariate differences between groups were assessed by independent t test and χ 2 analyses, and perioperative characteristics were analyzed by multiple logistic regression. One hundred forty-eight single-level TLIF patients were included. The mean age was 59.3 years, and 52.0% were women. There were no demographic differences between patients who received BMP and those who did not. Pseudarthrosis rates in patients treated with BMP were 6.2% vs 7.5% in the no BMP group (P = 0.756). There was no difference in reoperation for pseudarthrosis between patients who received BMP (3.7%) vs those who did not receive BMP (7.5%, P = 0.314). Patients who underwent revision surgery for pseudarthrosis more commonly had diabetes with end-organ damage (revised 37.5% vs not revised 1.4%, P < 0.001). Multiple logistic regression analysis demonstrated no reduction in reoperation for pseudarthrosis related to BMP use (OR 0.2, 95% CI 0.1-3.7, P = 0.269). Diabetes with end-organ damage (OR 112.6,95% CI 5.7-2225.8, P = 0.002) increased the risk of reoperation for pseudarthrosis. BMP use did not reduce the rate of pseudarthrosis or the number of reoperations for pseudarthrosis in single-level TLIFs. Diabetes with end-organ damage was a significant risk factor for pseudarthrosis. BMP is frequently used "off-label" in transforaminal lumbar interbody fusion; however, little data exists to demonstrate its safety and efficacy in this procedure.

Comparison of Transforaminal Lumbar Interbody Fusion in the Ambulatory Surgery Center and Traditional Hospital Settings, Part 2: Assessment of Surgical Safety in Medicare Beneficiaries.

(1) Background: The clinical benefits and procedural efficiencies of performing minimally invasive fusion procedures, such as transforaminal lumbar interbody fusion (TLIF), in the ambulatory surgery center (ASC) are becoming increasingly well established. Currently, Medicare does not provide reimbursement for its beneficiaries eligible for TLIF in the ASC due to a lack of evidence regarding procedural safety. However, the initiation of the Hospital Without Walls program allowed for traditional hospital procedures to be relocated to other facilities such as ASCs, providing a unique opportunity to evaluate the utility of TLIF in the ASC in Medicare-age patients. (2) Methods: This single-center, retrospective study compared baseline characteristics, intraoperative variables, and 30-day postoperative safety outcomes between 48 Medicare-age patients undergoing TLIF in the ASC and 48 patients having the same procedure as hospital in-patients. All patients had a one-level TLIF using the VariLift®-LX expandable lumbar interbody fusion device. (3) Results: There were similar patient characteristics, procedural efficiency, and occurrence of clinical 30-day safety events between the two study groups. However, there was a marked and statistically significant difference in the median length of stay favoring TLIF patients treated in the ASC (23.9 h vs. 1.6 h, p = 0.001). All ASC-treated patients were discharged on the day of surgery. Postoperative visits to address adverse events were rare in either group. (4) Conclusions: These findings provide evidence that minimally invasive TLIF can be performed safely and efficiently in the ASC in Medicare-age patients. With same-day discharge, fusion procedures performed in the ASC offer a similar safety and more attractive cost-benefit profile for older patients than the same surgery undertaken in the traditional hospital setting. The Centers for Medicare and Medicaid Services should strongly consider extending the appropriate reimbursement codes (CPT ® 22630, 22633) for minimally invasive TLIF and PLIF to the ASC Covered Procedure List so that Medicare-age patients can realize the clinical benefits of surgeries performed in this setting.

Periprocedural Polypharmacy in Lumbar Fusions Performed Under Spinal Anesthesia Compared With General Anesthesia.

Spinal anesthesia (SA) is a safe and effective alternative to general endotracheal anesthesia (GEA) for lumbar surgery. Foremost among the reasons to avoid GEA is the desire to minimize postoperative cognitive dysfunction (POCD). Although POCD is a complex and multifactorial entity, the risk of its development has been associated with anesthetic modality and perioperative polypharmacy, among others. To determine whether SA reduced polypharmacy compared with GEA in patients undergoing transforaminal lumbar interbody fusion (TLIF). Demographic and procedural data of 424 consecutive TLIF patients were extracted retrospectively. Patients undergoing single-level TLIF through GEA (n = 186) or SA (n = 238) were enrolled into our database. Perioperative medications, excluding antibiotic prophylaxis and local anesthetics, were classified into various categories. Patients in the SA cohort received a mean of 4.5 medications vs a mean of 10.5 medications in the GEA cohort ( P < .0001). This reduction in perioperative medications remained significant after a multivariate analysis to control for confounders ( P < .001 for all variables). The use of vasopressors was significantly reduced in the SA cohort ( P < .001), which coincided with a significant reduction in hypotensive episodes ( P < .001). Patients undergoing TLIF through GEA had 3.6 times greater odds of experiencing a hypotensive episode intraoperatively (odds ratio = 3.62, 95% CI [2.38-5.49]). Spinal anesthesia is associated with a significant decrease in perioperative medications and may confer superior intraoperative hemodynamic stability, which lowers pressor requirements. The decrease of perioperative medications may be an important contribution in reducing the incidence of POCD in patients undergoing TLIFs, although this requires further study.

Transforaminal lumbar interbody fusion with a silicon nitride cage demonstrates early radiographic fusion.

Degeneration of the lumbar spine is common in aging adults and reflects a significant morbidity burden in this population. In selected patients that prove unresponsive to non-surgical treatment, posterior lumbar fusion (PLF) surgery, with or without adjunctive transforaminal lumbar interbody fusion (TLIF) can relieve pain and improve function. We describe here the radiographic fusion rates for PLF versus TLIF, using an intervertebral spinal cage made of silicon nitride ceramic (chemical formula Si3N4). This retrospective cohort analysis enrolled 99 patients from August 2013 to January 2017; 17 had undergone PLF at 24 levels, while 82 had undergone TLIF at 104 levels. All operations were performed by a single surgeon at one institution. Radiographic and clinical outcomes were compared between PLF and TLIF at 2 and 6 weeks and then at 3, 6, 12, and 24 months. TLIF patients fused at higher rates compared to PLF at the 3-month (38.5% vs. 8.3%, P=0.006), 6-month (78.7% vs. 35.0%, P<0.001) and 12-month time periods (97.9% vs. 81.3%, P=0.018), with no difference at 24 months (100% vs. 94.4%, P=0.102). Index level segmental motion was significantly less and intervertebral disc height was improved in TLIF over PLF at all follow up intervals. Foraminal height was only greater in early follow up periods (2 weeks, 6 weeks and 3 months). TLIF patients experienced lover rates of PI-LL mismatch which was maintained across long term follow-up. Pelvic tilt was lower following TLIF compared to PLF, with no differences in complication rates between study groups. Our retrospective series demonstrated that TLIF performed with silicon nitride interbody cages led to earlier radiographic fusion, greater restoration of disc and foraminal height, increased segmental rigidity and improved sagittal alignment when compared to PLF alone.

Multicenter assessment of outcomes and complications associated with transforaminal versus anterior lumbar interbody fusion for fractional curve correction.

Few studies have compared fractional curve correction after long fusion between transforaminal lumbar interbody fusion (TLIF) and anterior lumbar interbody fusion (ALIF) for adult symptomatic thoracolumbar/lumbar scoliosis (ASLS). The objective of this study was to compare fractional correction, health-related quality of life (HRQL), and complications associated with L4-S1 TLIF versus those of ALIF as an operative treatment of ASLS. The authors retrospectively analyzed a prospective multicenter adult spinal deformity database. Inclusion required a fractional curve ≥ 10°, a thoracolumbar/lumbar curve ≥ 30°, index TLIF or ALIF performed at L4-5 and/or L5-S1, and a minimum 2-year follow-up. TLIF and ALIF patients were propensity matched according to the number and type of interbody fusion at L4-S1. Of 135 potentially eligible consecutive patients, 106 (78.5%) achieved the minimum 2-year follow-up (mean ± SD age 60.6 ± 9.3 years, 85% women, 44.3% underwent TLIF, and 55.7% underwent ALIF). Index operations had mean ± SD 12.2 ± 3.6 posterior levels, 86.6% of patients underwent iliac fixation, 67.0% underwent TLIF/ALIF at L4-5, and 84.0% underwent TLIF/ALIF at L5-S1. Compared with TLIF patients, ALIF patients had greater cage height (10.9 ± 2.1 mm for TLIF patients vs 14.5 ± 3.0 mm for ALIF patients, p = 0.001) and lordosis (6.3° ± 1.6° for TLIF patients vs 17.0° ± 9.9° for ALIF patients, p = 0.001) and longer operative duration (6.7 ± 1.5 hours for TLIF patients vs 8.9 ± 2.5 hours for ALIF patients, p < 0.001). In all patients, final alignment improved significantly in terms of the fractional curve (20.2° ± 7.0° to 6.9° ± 5.2°), maximum coronal Cobb angle (55.0° ± 14.8° to 23.9° ± 14.3°), C7 sagittal vertical axis (5.1 ± 6.2 cm to 2.3 ± 5.4 cm), pelvic tilt (24.6° ± 8.1° to 22.7° ± 9.5°), and lumbar lordosis (32.3° ± 18.8° to 51.4° ± 14.1°) (all p < 0.05). Matched analysis demonstrated comparable fractional correction (-13.6° ± 6.7° for TLIF patients vs -13.6° ± 8.1° for ALIF patients, p = 0.982). In all patients, final HRQL improved significantly in terms of Oswestry Disability Index (ODI) score (42.4 ± 16.3 to 24.2 ± 19.9), physical component summary (PCS) score of the 36-item Short-Form Health Survey (32.6 ± 9.3 to 41.3 ± 11.7), and Scoliosis Research Society-22r score (2.9 ± 0.6 to 3.7 ± 0.7) (all p < 0.05). Matched analysis demonstrated worse ODI (30.9 ± 21.1 for TLIF patients vs 17.9 ± 17.1 for ALIF patients, p = 0.017) and PCS (38.3 ± 12.0 for TLIF patients vs 45.3 ± 10.1 for ALIF patients, p = 0.020) scores for TLIF patients at the last follow-up (despite no differences in these parameters at baseline). The rates of total complications were similar (76.6% for TLIF patients vs 71.2% for ALIF patients, p = 0.530), but significantly more TLIF patients had rod fracture (28.6% of TLIF patients vs 7.1% of ALIF patients, p = 0.036). Multiple regression analysis demonstrated that a 1-mm increase in L4-5 TLIF cage height led to a 2.2° reduction in L4 coronal tilt (p = 0.011), and a 1° increase in L5-S1 ALIF cage lordosis led to a 0.4° increase in L5-S1 segmental lordosis (p = 0.045). Operative treatment of ASLS with L4-S1 TLIF versus ALIF demonstrated comparable mean fractional curve correction (66.7% vs 64.8%), despite use of significantly larger, more lordotic ALIF cages. TLIF cage height had a significant impact on leveling L4 coronal tilt, whereas ALIF cage lordosis had a significant impact on restoration of lumbosacral lordosis. The advantages of TLIF may include reduced operative duration and hospitalization; however, associated HRQL was inferior and more rod fractures were detected in the TLIF patients included in this study.

139. Segmental lordosis restoration using ALIF vs TLIF in adults with flatback deformity

139. Segmental lordosis restoration using ALIF vs TLIF in adults with flatback deformity

A Prospective Randomized Study of the Safety and Efficacy of Transforaminal Lumbar Interbody Fusion Versus Posterior Lumbar Interbody Fusion in the Treatment of Lumbar Spondylolisthesis: A Cost utility from a Lower-middle-income Country Perspective and Review of Literature

BACKGROUND: The safety and efficacy of transforaminal lumbar interbody fusion (TLIF) and posterior lumbar interbody fusion (PLIF) in lumbar spondylolisthesis have not been validated in many prospective randomized trials. AIM: We aimed to validate the safety and efficacy of TLIF and PLIF surgery in lumbar spondylolisthesis using the clinical, radiographic, and cost-utility outcomes. METHODS: The data of surgically treated single-level spondylolisthesis patients were randomized prospectively into two groups. The groups were compared regarding demographics, perioperative complications, hospital stay, total expenditure, fusion rate, and clinical outcomes (visual analog scale, Oswestry disability index, Zurich claudication scale, and Odom’s criteria). A review of literature was done to compare the outcomes with the ones from higher-income nations. RESULTS: Thirty-three patients underwent prospective randomization. The improvement in the clinical outcomes at 12-month follow-up showed improvement in the TLIF group more than the PLIF group but with no significant difference. The mean operative time was significantly longer in the PLIF (p &lt; 0.05), also, the blood loss was significantly less in the TLIF (p &lt; 0.001). The complications frequency did not show any statistical significance between both groups and no significant difference in the patient’s post-operative patient satisfaction (p = 0.6). The mean hospital stay was non-significantly longer in the PLIF (p = 0.7). At 12-month follow-up, 93.3% of the TLIF patients were fused versus 86.7% of the PLIF (p = 0.5). The total cost of the TLIF was significantly less (p &lt; 0.001). CONCLUSION: Both PLIF and TLIF could achieve similar fusion rates and clinical satisfaction in the management of lumbar spondylolisthesis. The TLIF group was significantly better in terms of financial burden, operative time, and blood loss.

A retrospective comparison of radiographic and clinical outcomes in single-level degenerative lumbar disease undergoing anterior versus transforaminal lumbar interbody fusion.

Single-level lumbar degenerative disc disease (DDD) remains a significant cause of morbidity in adulthood. Anterior lumbar interbody fusion (ALIF) and Transforaminal lumbar interbody fusion (TLIF) are surgical techniques developed to treat this condition. With limited studies on intermediate term outcomes in a single cohort, we compare radiographic and clinical outcomes in patients undergoing ALIF and TLIF. A retrospective chart review was performed on 164 patients (111 TLIF; 53 ALIF) over a 60-month period. X-ray radiographs obtained pre-operatively, prior to discharge, and at one year were utilized for radiographic assessment. Segmental lordosis, lumbar lordosis and HRQOL scores were measured preoperatively and at one-year timepoints. Changes in lumbar lordosis and segmental lordosis were significantly greater after ALIF (4.6° vs. -0.6°, P=0.05; 4.7° vs. -0.7°, P<0.05) at one year (mean time, 366±20 days). At one year or greater, there was a greater reduction in mean VAS-leg score in TLIF patients (3.4 vs. 0.6, P<0.05) and ODI score (16.2 vs. 5.4, P<0.05). Similar outcomes were seen for VAS-back, SF-12 Physical Health, and SRS-30 Function/Activity. SF-12 Mental Health scores were found to be lower in patients undergoing TLIF (-3.5 vs. 2.7, P<0.05). ALIF demonstrated a superior method of increasing lumbar and segmental lordosis. TLIF was utilized more in patients with higher pre-operative VAS-leg pain scores and therefore, showed a greater magnitude of VAS-leg pain improvement. TLIF also demonstrated a greater improvement in ODI scores despite similar baseline scores, suggesting a possible enhanced functional outcome.

A novel lumbar total joint replacement may be an improvement over fusion for degenerative lumbar conditions: a comparative analysis of patient-reported outcomes at one year

Background contextEffective alternatives to lumbar fusion for degenerative conditions have remained elusive. Anterior total disc replacement does not address facet pathology or central/recess stenosis, resulting in limited indications. A posterior-based motion-preserving option that allows for neural decompression, facetectomy, and reconstruction of the disc and facets may have a role. PurposeThe purpose was to compare one-year patient-reported outcomes for a novel, all-posterior, lumbar total joint replacement (LTJR – replacing both the disc and facet joints) against transforaminal lumbar interbody fusion (TLIF) for degenerative lumbar conditions warranting fusion (degenerative spondylolisthesis, recurrent disc herniation, severe foraminal stenosis requiring facet removal, and adjacent segment degeneration). Study design/settingA retrospective analysis of prospectively collected data comparing outcomes for LTJR patients to TLIF patients at an academic teaching hospital. Patient sampleAnalysis was conducted on 156 adult TLIF patients who were propensity matched to the 52 LTJR patients for a total sample of 208. Outcome measuresSelf-reported Oswestry Disability Index (ODI) and Numeric Rating Scale (NRS) for back and leg pain were compared preoperatively, 3 months and 1 year after surgery. MethodsThe implant is a motion-preserving lumbar reconstruction that replaces the function of both the disc and facets and is implanted using a bilateral transforaminal approach with complete facetectomies. Adult patients with degenerative lumbar pathology undergoing either LTJR or open TLIF were analyzed. These degenerative conditions included: grade 1 degenerative spondylolisthesis, recurrent disc herniation, adjacent segment disease, disc degeneration with severe foraminal stenosis). Trauma, tumor, grade 2 or higher spondylolisthesis, spinal deformity, and infection cases were excluded. Propensity score matching was performed to ensure parity between the cohorts. Multivariable regression analyses were done to compare the 1-year results as measured by 3 different standards to assess procedure success. ResultsAt 3 months, both the LTJR and TLIF cohorts showed significant and similar improvements in ODI and NRS back and leg pain. At 1 year, the LTJR cohort showed continued improvement in ODI and NRS back pain, while the TLIF group showed a plateau for ODI, back and leg pain. In a series of three multivariable logistic regressions, LTJR was shown to provide 3.3 times greater odds of achieving the minimal clinical symptom state in disability and pain (ODI <20%, NRS back and leg pain <2) and 2.4 and 4.1 times greater odds of achieving substantial clinical benefit (18% reduction in ODI) and minimal clinically important difference (30% reduction in ODI) as compared to TLIF. ConclusionsHere we present a comparative analysis for the first 52 patients undergoing a novel, posterior-based LTJR for the lumbar spine versus TLIF for degenerative pathology. The approach for the LTJR allows for wide neural decompression, facetectomy, and complete discectomy, with the implant working to replace the function of the disc and facets to preserve motion. At 1 year, the LTJR cohort showed significant improvement in ODI and NRS back and leg pain as compared to TLIF. These results suggest that wide neural decompression combined with motion preservation using this novel LTJR may represent a viable alternative to TLIF for treating certain degenerative conditions. A prospective controlled trial is under development to further evaluate the efficacy, safety, and durability of this procedure.

Biologics and Minimally Invasive Approach to TLIFs: What Is the Risk of Radiculitis?

Bone morphogenetic protein (BMP) and allograft containing mesenchymal stem cells (live cell) are popular biologic substitutes for iliac crest autograft used in transforaminal lumbar interbody fusion (TLIF). Use of these agents in the pathogenesis of postoperative radiculitis remains controversial. Recent studies have independently linked minimally invasive (MIS) TLIF with increased radiculitis risk compared to open TLIF. The purpose of this study was to assess the rate of postoperative radiculitis in open and MIS TLIF patients along with its relationship to concurrent biologic adjuvant use. Patients ≥18 years undergoing single-level TLIF from June 2012 to December 2018 with minimum 1-year follow-up were included. Outcome measures were rate of radiculitis, intra- and postoperative complications, revision surgery; length of stay (LOS), and estimated blood loss (EBL). There were 397 patients: 223 with open TLIFs, 174 with MIS TLIFs. One hundred and fifty-nine surgeries used bone morphogenetic protein (BMP), 26 live cell, 212 neither. Open TLIF: higher mean EBL, LOS, and Charlson Comorbidity Index (CCI) than MIS. Postoperative radiculitis in 37 patients (9.32% overall): 16 cases MIS BMP (15.69% of their cohort), 6 MIS without BMP (8.33%), 5 open BMP (8.77%), 10 open without BMP (6.02%). MIS TLIF versus open TLIF: no differences in 1-year reoperation rates, infection/wound complication, pseudarthrosis, or postoperative complication rate. BMP versus non-BMP: no differences in reoperation rates, infection/wound complication, pseudarthrosis, or postoperative complication rate. Multivariate logistic regression found that neither BMP (P = .109) nor MIS (P = .314) was an independent predictor for postoperative radiculitis when controlled for age, gender, body mass index, and CCI. Using paired open and MIS groups (N = 168 each) with propensity score matching, these variables were still not independently associated with radiculitis (P = .174 BMP, P = .398 MIS). However, the combination of MIS with BMP was associated with increased radiculitis risk in both the entire patient cohort (odds ratio [OR]: 2.259 [1.117-4.569], P = .023, N = 397) and PSM cohorts (OR: 2.196 [1.045-4.616], P = .038, N = 336) compared to other combinations of surgical approach and biologic use. Neither the MIS approach nor BMP use is an independent risk factor for post-TLIF radiculitis. However, risk of radiculitis significantly increases when they are used in tandem. This should be considered when selecting biological adjuvants for MIS TLIF. 3.

P133. Does bone morphogenic protein (BMP) use reduce pseudoarthrosis rates in single-level TLIF surgeries?

BACKGROUND CONTEXT Recombinant human bone morphogenetic protein 2 (rhBMP-2) is a popular biologic product used in transforaminal lumbar interbody fusion (TLIF) surgeries to promote fusion and avoid the morbidity associated with iliac crest autograft. However, use of rhBMP-2 and its effect on pseudarthrosis rates in TLIFs remains unknown. PURPOSE To assess the rates of pseudarthrosis in open and MIS TLIF patients, with and without concurrent rhBMP-2 use. STUDY DESIGN/SETTING Retrospective cohort study at a single academic institution. PATIENT SAMPLE Included: 317 single level TLIF patients. Consisting of 157 open TLIF (OTLIF), 115 bilateral Wiltse MIS TLIF (WTLIF), and 45 hybrid midline MIS with percutaneous pedicle or cortical screws (MTLIF). OUTCOME MEASURES Clinical characteristics, perioperative and postoperative outcomes, surgical procedure, rates of pseudarthrosis diagnosis, and revision for pseudarthrosis. METHODS Patients ≥18 years old undergoing 1-level TLIF with minimum 1-year of clinical and radiographic follow up were included. Pseudarthrosis was determined using both radiographic and clinical evaluations. Differences between groups were assessed by ANOVA and chi squared analyses. Demographic and perioperative characteristics were analyzed by multivariate logistic regression. RESULTS The cohort included 317 patients (mean age 59.68±13.29, F 52.7%). There was no significant difference in gender, BMI, or smoking status among groups (all p>.05). WTLIF had the lowest EBL (ml) (192.16±177.11mL vs 302.73±246.51 vs 363.85±370.49, respectively p= CONCLUSIONS MP use did not reduce the rate of pseudarthrosis or the number of reoperations for pseudarthrosis in this cohort. No difference in pseudarthrosis rates between the three TLIF approaches was noted. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Protocolization of Post-Transforaminal Lumbar Interbody Fusion Pain Control with Elimination of Benzodiazepines and Long-Acting Opioids.

The opioid epidemic continues to worsen with a concomitant increase in opioid-related mortality. In response, the Department of Defense and Veterans Health Agency recommended against the use of long-acting opioids (LAOs) and concurrent use of opioids with benzodiazepines. Subsequently, we eliminated benzodiazepines and LAOs from our postoperative pain control regimen. To evaluate the impact of removing benzodiazepines and LAOs on postoperative pain in single-level transforaminal lumbar interbody fusion (TLIF) patients. A retrospective cohort study of single-level TLIF patients from February 2016-March 2018 was performed. Postoperative pain control in the+benzodiazepine cohort included scheduled diazepam with or without LAOs. These medications were replaced with nonbenzodiazepine, opioid-sparing adjuncts in the -benzodiazepine cohort. Pain scores, length of hospitalization, trigger medication use, and opioid use and duration were compared. Among 77 patients, there was no difference between inpatient pain scores, but the -benzodiazepine cohort experienced a faster rate of morphine equivalent reduction (-18.7%, 95% CI [-1.22%, -36.10%]), used less trigger medications (-1.55, 95% CI [-0.43, -2.67]), and discharged earlier (0.6 d; 95% CI [0.01, 1.11 d]). As outpatients, the -benzodiazepine cohort was less likely to receive opioid refills at 2 wk (29.2% vs 55.8%, P=.021) and 6 mo postoperatively (0% vs 13.2%, P=.039), and was less likely to be using opioids by 3 mo postoperatively (13.3% vs 34.2%, P=.048). Replacement of benzodiazepines and LAOs in the pain control regimen for single-level TLIFs did not affect pain scores and was associated with decreased opioid use, a reduction in trigger medications, and shorter hospitalizations.

Clinical experience with the use of a spherical bioactive glass putty for cervical and lumbar interbody fusion.

A retrospective clinical case series study was conducted to evaluate the use of a novel, spherical bioactive glass bone graft (BioSphere Putty) as a graft material for cervical and lumbar interbody fusion. Data was collected from a single surgeon using BioSphere Putty along with standardized hardware in anterior cervical decompression and fusion (ACDF), transforaminal lumbar interbody fusion (TLIF), and anterior lumbar interbody fusion (ALIF) surgical procedures. BioSphere Putty was used in combination with cancellous allograft (ACDF and ALIF) or in combination with autograft (TLIF). Clinical outcomes were assessed at 1- and 2-year using radiographic imaging and the visual analog pain scale (VAS). VAS scores at the 1- and 2-year follow-up periods were statistically compared to pre-operative scoring. Successful clinical outcomes were determined by a combination of the presence of a complete radiographic fusion and a decrease in VAS at 1-year and 1- and 2-year follow-up periods. The retrospective review of the patient data identified 248 cases that had either 1- or 1- & 2-year follow-up. This consisted of 115 ACDF procedures and 133 lumbar fusion procedures. Lumbar fusion cases were further sub-grouped with 103 patients undergoing TLIF procedures and 30 patients undergoing ALIF procedures. The global results for the series as a whole showed clinical outcomes comparative to other advanced biologic bone grafts. Radiographically all patients demonstrated fusion (100% fusion rate) and there were no clinical adverse events, infections, or graft-related complications in any of the patients in the series. One-year VAS scores were consistent with historical norms and demonstrated significant decreases in pre-operative pain for both ACDF patients (78% decrease) and lumbar patients (66% decrease TLIF/ALIF) (t test, P<0.05). By 2 years, VAS scores continued to drop with significant decreases for the ACDF patients (96%), TLIF patients (82%), and ALIF patients (80%) (t test, P<0.05). VAS scores were also assessed for each individual patient. The data showed a VAS score decrease from pre-operative levels in 93% of the ACDF patients and 89% of the lumbar patients. Combined with the 100% radiographic fusion rate in all patients, this resulted in a in a clinical success rate of 93% for the ACDF patients and 89% for the lumbar patients. The results of this clinical case series demonstrated that BioSphere Putty is a clinically effective and versatile synthetic bone graft material in the spine.

Comparison of Technical Outcomes in Instrumented Posterolateral Fusion (PLF) with and without Transforaminal Lumbar Interbody Fusion (TLIF) performed using Silicon Nitride cages

Background: Posterior lumbar fusion is performed for lumbar degeneration that leads to spinal stenosis and spondylolisthesis. Two common approaches include PLF and TLIF, with a current lack of consensus as to the superior approach. The objective of this study is to compare fusion rates, spinal parameters and complications for both surgical approaches using the silicon nitride cage (Si3N4). Our hypothesis is TLIF with a Si3N4 cage will have higher fusion rates, improved technical outcomes and fewer complications when compared to PLF alone. The Si3N4 cage has advantageous surface properties compared to other interbody cages, promoting theoretically higher fusion rates for TLIF procedures.&#x0D; Methods: A retrospective chart review of 102 spinal fusion patients (PLF=17, TLIF=85) was performed. One spine surgeon performed the fusions and reviewed pre-operative and post-operative radiographs. Measurable outcomes included fusion rates, surgical complications and pelvic/spinal radiographic parameters. Radiographic parameters included restoration of lumbar lordosis (LL), segmental lordosis (SL), pelvic incidence (PI), pelvic tilt (PT), disc height (DH) and foraminal height (FH). Patients who had ≥1 year follow up radiographs were included in analysis (PLF=16, TLIF=48).&#x0D; Results: TLIF patients with a Si3N4 cage had improved fusion rates (PLF=81.8%, TLIF=100% p=0.003), lumbar lordosis (PLF=-4.38o TLIF=3.15o p=0.001), disc height (PLF=0.55mm, TLIF=4.61mm p=&lt;0.001), foraminal height (PLF=-0.05mm, TLIF=2.41mm p=0.036) and a lower incidence of PI-LL mismatch (PLF=46.15%, TLIF=7.5% p=0.004). No statistically significant difference was found for surgical complications (PLF=11.1%, TLIF=17.6%) or segmental lordosis (PLF=-1.00mm, TLIF=1.17mm). An age difference of statistical significance was also found between the two patient populations (PLF=61.9, TLIF=54.1 p=0.018).&#x0D; Conclusion: Despite the difference in age between the procedure groups, TLIF with a Si3N4 cage proved to be superior in fusion rates, lumbar lordosis, PI-LL mismatch, disc height and foraminal height restoration.&#x0D;

Does transforaminal lumbar interbody fusion produce leg pain?-Results from a RCT.

Transforaminal lumbar interbody fusion (TLIF) is presently the most used method to achieve lumbar interbody fusion worldwide. The special preparation and cage insertion imply a risk of an undesirable side effect in the form of residual neurogenic pain. This issue has not been investigated prior in a randomized clinical trial (RCT) set up. To test whether TLIFs had a higher incidence of leg pain in comparison to a common instrumented posterolateral fusion (PLF) and to test whether a higher occurrence of leg pain on the ipsilateral side in the TLIF group was present. One hundred patients included in a RCT comparing TLIF and PLF fulfilled pain drawings and numeric rating scale (NRS) scale from 0 to 10 preoperatively, after 1 year, and after 2 years. Difference in pain appearance, type, localization, and intensity was compared between groups. A slightly higher number of patients in the TLIF group reported leg pain at 2 years follow-up: no leg pain, 47% (PLF) and 37% (TLIF); unilateral leg pain, 31% (PLF) and 25% (TLIF); bilateral leg pain, 22% (PLF) and 37% (TLIF), p = 0.270. Numbness and pins and needles on the anterior aspect of the lower leg were marked by 10% and 12% of TLIF patients compared to 6% and 4% in PLF patients p = 0.498/0.197. The ipsilateral side of cage insertion in the TLIF group was not a place for new leg pain compared to the contralateral side. The special surgical preparation used in TLIFs does not result in the development of new ipsilateral leg pain. However, a higher percentage of the patients in the TLIF group had new leg pain in comparison to PLF after 2 years.

P16. A retrospective review of transforaminal lumbar interbody fusion patients treated with expandable and static spacers

BACKGROUND CONTEXT Interbody spacers for transforaminal lumbar interbody fusion (TLIF) offer favorable clinical results. Expandable devices allow in situ expansion to optimize fit and mitigate iatrogenic endplate damage occurring during trialing/impaction seen in static devices. PURPOSE To compare patient outcomes of treatment with a static or an expandable TLIF interbody spacer STUDY DESIGN/SETTING Retrospective chart review PATIENT SAMPLE A total of 99 patients undergoing TLIF using one of two interbody spacers, 48 patients received a static peek interbody spacer and 51 received an expandable titanium interbody spacer. OUTCOME MEASURES Blood loss, length of postoperative hospital stay, operative time, Oswestry Disability Index (ODI), Visual Analog Scale (VAS), complication rates. METHODS A retrospective chart review from a single site was performed and surgical data, ODI, and VAS scores were collected. Radiographs were collected/measured when available. Comparisons between groups were performed using independent samples t-tests. Complications were compared using Fisher's exact test. RESULTS Patients treated with expandable spacers had significantly (p 24 months, compared to 12 of 48 (25%) static patients. CONCLUSIONS Patients treated with expandable interbody fusion spacers used in a transforaminal approach demonstrated significantly less blood loss, shorter stays, lower ODI scores, and significantly fewer complications at final follow-up than static spacer patients. 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.

Evaluation of Heterotopic Ossification After Using Recombinant Human Bone Morphogenetic Protein-2 in Transforaminal Lumbar Interbody Fusion: A Computed Tomography Review of 996 Disc Levels.

Study Design:Retrospective cohort study.Objectives:Reported incidences and complications of heterotopic ossification (HO) after using recombinant human bone morphogenetic protein–2 (rhBMP-2) in transforaminal lumbar interbody fusion (TLIF) have been inconclusive. This study was designed to evaluate both incidences of radiologic and symptomatic HO in a large series of TLIFs using rhBMP-2.Methods:A total of 996 disc levels in 927 consecutive TLIF patients were retrospectively evaluated at 6-month postoperative follow-up in a single surgical practice. Subjects were separated into the BMP group and the control group. Operative reports, pre- and postoperative medical records were reviewed. Computed tomography (CT) scans were analyzed and graded independently for ossification at each disc level of TLIF.Results:A total of 933 disc levels were in the BMP group, and 63 were in the control group. Six-month fusion rate of interbody was 92.5% in the BMP group, which was significantly higher in contrast to 71.4% in the control group (P < .001). The incidence of radiologic HO in the BMP group was 13.5%, which was significantly higher than 1.6% in the control group (P = .006). After controlling for basic demographics and comorbidities, the presence of radiologic HO was significantly associated with the use of rhBMP-2 (P = .026). However, only one case in the BMP group (0.11%) developed a symptomatic HO (mild-medium left buttock pain, treated nonsurgically) involving left foramen of L5-S1.Conclusions:rhBMP-2 can be safely used in TLIF with regard to HO. There was a low rate of radiologic HO and minimal symptomatic HO, with high fusion rates at 6 months postoperative.

Comparison of Stand-Alone, Transpsoas Lateral Interbody Fusion at L3-4 and Cranial vs Transforaminal Interbody Fusion at L3-4 and L4-5 for the Treatment of Lumbar Adjacent Segment Disease

Retrospective cohort study. To compare outcomes and complications of stand-alone minimally invasive lateral interbody fusion (LIF) vs revision posterior surgery for the treatment of lumbar adjacent segment disease. Adults who underwent LIF or transforaminal lumbar interbody fusion (TLIF) for adjacent segment disease were compared. Exclusion criteria: >grade 1 spondylolisthesis, posterior approach after LIF, and L5/S1 surgery. Patient demographics, estimated blood loss, hospital length of stay, complications, reoperations, health-related quality of life measures, and radiographs were examined. Data were analyzed with the χ2, Wilcoxon signed rank, and Mann-Whitney U tests. A total of 17 LIF and 16 TLIF patients were included. Demographics were similar. Follow up was similar (LIF: 22.9 ± 11.8 months vs TLIF: 22.0 ± 4.6 months; P = .86). The LIF patients had significantly less blood loss (LIF: 36 ± 16 mL vs TLIF: 700 ± 767 mL; P < .001) and shorter length of stay (LIF: 2.6 ± 2.9 days vs TLIF: 3.3 ± 0.9 days; P = .001). There were no intraoperative complications. Revision rate was 4 of 17 in LIF and 3 of 16 in TLIF (P = .73). Baseline health-related quality of life and radiographic measurements were similar. In both groups, back and leg pain scores significantly improved, and in LIF, the Owestry Disability Index, and EuroQol-5D significantly improved. The LIF had a significant increase in intervertebral height (LIF: 4.8 ± 2.9 mm, P < .001, TLIF: 1.3 ± 3.4 mm, P = .37), which was significantly greater for LIF than TLIF (P = .002). Similarly, LIF had a significant increase in segmental lordosis (LIF: 5.6° ± 4.9°, P < .001, TLIF: 3.6° ± 8.6°, P = .16), which was not significantly different between groups. Patients with adjacent segment disease may receive significant benefit from stand-alone LIF or TLIF. The LIF offers advantages of less blood loss and a shorter hospital stay. 3.