Transforaminal Lumbar Interbody Fusion Procedure Research Articles

Comparison of clinical and radiographic outcomes in unilateral transforaminal lumbar interbody fusion: a retrospective analysis of three surgical approaches.

The primary objective of this study is to evaluate and compare the clinical and radiographic outcomes of the combined spinous process-splitting approach with a Wiltse (SPSW) approach, the combined conventional approach with a Wiltse (CW) approach, and the conventional open (CO) approach in unilateral transforaminal lumbar interbody fusion (TLIF). The clinical outcomes were assessed, and intraoperative data and complications were collected. Numeric Rating Scale (NRS) scores for low back pain and leg pain, the Japanese Orthopaedic Association Back Pain Evaluation Questionnaire (JOABPEQ) scores for evaluating functions of the lumbar spine and health-related quality of life, and the modified MacNab standard for assessing satisfaction were analyzed. Radiographic outcomes included disc space height, segmental lordosis, interbody fusion assessment, and the rate of muscle atrophy of the multifidus and the erector spinae muscles. Among the three groups, the SPSW group exhibited the shortest operation and drain retention time, lowest intraoperative blood loss, and minimal postoperative blood loss. Notably, the SPSW group displayed the highest level of social life function based on the JOABPEQ, and the highest level of patient satisfaction according to the modified MacNab Criteria, along with the lowest rate of muscle atrophy. All the SPSW, CW, and CO approach TLIF procedures achieved overall satisfactory effects of decompression and fusion for lumbar degenerative diseases. The SPSW approach procedure appears to be associated with the smallest surgical trauma and highest satisfaction because of reducing iatrogenic injury of the paraspinal muscles.

Transforaminal lumbar interbody fusion with or without release of the anterior longitudinal ligament: A single-center, retrospective observational cohort study

Background: Transforaminal anterior release (TFAR) is a technical extension of the transforaminal lumbar interbody fusion (TLIF) procedure with deliberate release of the anterior longitudinal ligament (ALL). Methods: In a retrospective, single-center observational cohort study, consecutive adult patients undergoing TLIF surgery at L4/L5 and/or L5/S1 between 01/2018 – 12/2022 for degenerative disc disease or deformity were considered. The TFAR group (with ALL release) was compared to a standard TLIF group (without ALL release), matched in a 1:3 ratio. Uni- and multivariable logistic regression models were built to estimate the likelihood of any AE, reoperation, and excellent/good clinical outcome at 12 months. Results: Of 438 patients, 18 undergoing TFAR were matched to 53 undergoing standard TLIF. TFAR procedures were frequently part of extensive, anterior-posterior or multilevel fusion procedures with longer surgery time and higher blood loss. The rates of intraoperative surgical AEs were similar (16.7 vs. 11.3%, p=0.789). The rates and severities of surgical AEs, as well as reoperation rates and clinical outcomes were similar at time of discharge, 90 days, and 12 months postoperatively (all p>0.05). TFAR allowed for an increase in total lumbar lordosis of 16.1° and in lumbar lordosis between L4-S1 of 16.3° at discharge, which was maintained during follow-up. In both the uni- and multivariable models, patients undergoing TFAR were as likely as patients undergoing standard TLIF to experience any complication (adjusted OR 0.78, 95% CI 0.21 – 2.94), any reoperation (aOR 0.46, 95% CI 0.11 – 1.90) or excellent/good clinical outcome at 12 months (aOR 2.01, 95% CI 0.52 – 7.74). Conclusions: The TFAR technique has a safety profile which is comparable to the standard TLIF procedure, but it allows for a greater restoration of lumbar lordosis at L4-S1. We suggest considering the TFAR technique in selected patients with sagittal imbalance and mobile segments for restoration of lumbar lordosis.

Closing the Gap: The Incidence of Complications in Minimally Invasive Tubular, Endoscopic, and Robotic-Assisted Transforaminal Lumbar Interbody Fusion Procedures

Background ContextThe aim of the current study was to compare the incidence of postoperative complications between MIS tubular, endoscopic and Robot-assisted TLIF techniques. MethodsConsecutive patients who underwent single or multi-level TLIF between 2020 and 2022. Pre-operative and post-operative patient reported outcomes (VAS Leg and ODI), demographic, and intra-operative variables were recorded. One way ANOVA with Bartlett’s equal-variance and Pearson chi-squared tests were used. ResultsThe current study included a total of 170 TLIF patients: 107 (63%) tubular, 42 (25%) endoscopic, and 21 (12%) robot-assisted. All three TLIF techniques had similar complication rates: tubular 6 (5.6%), endoscopic 2 (4.8%), and robot-assisted 1 (4.8%) all occurring within the first two weeks. Tubular TLIF reported the lowest incidence of new onset neurological symptoms, primarily radiculitis or numbness/tingling, at two weeks postoperatively (p<0.05) with 21 (20%) tubular, 17 (41%) endoscopic, and 9 (43%) robot-assisted patients. There were two revisions in the robot-assisted group, while tubular and endoscopic each had one within one year. There was no statistical difference in pre- or postoperative PROs between the TLIF groups. ConclusionsThe current study demonstrated that tubular, endoscopic, and robot-assisted TLIF procedures had similar complication rates. The tubular MIS TLIF reported less new neurological symptoms compared to endoscopic and robot-assisted TLIF procedures at two weeks postoperative, with all groups declining in symptom persistency at later time intervals. Average VAS scores continuously improved up to one year postoperatively amongst all groups.

Clinical Outcomes of the Transforaminal Lumbar Interbody Fusion Technique Among Patients With Low Back Pain Showing Type 1 Modic Changes on MRI.

Introduction The unilateral transforaminal lumbar interbody fusion (TLIF) signifies a different surgical method, circumventing both the anterior method and the method via the spinal canal. Due to the shortage of literature available for clinical outcomes and consequences post-TLIF, we undertook the current study to assess the TLIF technique's clinical outcomes among patients with low back pain showing type 1 Modic changes on MRI. Material and methods A cross-sectional study was conducted between January 2019 and March 2021. All patients included in the study had Modic type 1 change and disabling lowback pain as the main complaint and/or leg pain. Data were collected on age, body mass index (BMI), gender, and other risk factors like diabetes mellitus, steroid use, and smoking. Pain intensity was evaluated using a visual analog scale (VAS) before and after surgery. A radiographic evaluation was also performed. Preand post-operative pain scores and differences in disc height were assessed using the Wilcoxon rank sum test. A p-value of less than 0.05 was considered significant. Results The mean length of stay in the hospital was 4.3±1.61. The mean pre-operative lower back pain score was 8.78±0.79. The mean post-operative score was substantially lowered to 0.83±0.7. There was a significant difference between pre- and post-operative lumbar pain (p-value < 0.001). There was a significant increase in mean disc height from pre-operative (7.14 mm) to post-operative (11.02 mm) and also at one year (10.21 mm) with a p-value of <0.001. Of the patients,82.14% did not have any complications, and 3.57% each had either delayed wound healing without any infection or transient post-operative radiculopathy that improved in six weeks. Conclusion TLIF procedure can be considered safeto provide anterior and posterior column support by adopting a unilateral posterior approach. The outcomes were favorable in terms of no prolonged length of stay, less blood loss, no mortality, reduction in the severity of pain, and improvement in disc height. However, the appropriate selection of patients for this technique is pivotal for the success of the procedure.

Surgeon Perceptions of Performing Transforaminal Lumbar Interbody Fusion in an Ambulatory Surgical Center vs Hospital Setting in the Elderly Population: Results of a Surgeon Survey.

There is an increasing acceptance of conducting minimally invasive transforaminal lumbar interbody fusion (TLIF) in ambulatory surgical centers (ASCs). The Centers for Medicare and Medicaid Services (CMS) introduced the Hospitals Without Walls (HWW) program in March 2020. This program granted hospitals regulatory flexibility to offer services and procedures in nontraditional locations, including ASCs. However, implementation hurdles persist. A survey was sent to 235 surgeons regarding the use of ASCs for performing TLIF surgeries on elderly patients. Multiple-choice questions covering various aspects of TLIF practice preferences, including surgical indications, decision factors for choosing ASCs over hospitals, implementation hurdles, reimbursement concerns, staffing issues, and the impact of CMS rules and regulations on TLIF in ASCs, particularly concerning physician ownership and self-referral conflicts governed by the Stark law, were asked. The survey completion rate was 25.8% (Figure 1). The most common surgical indications for TLIF in ASCs were spondylolisthesis (80%), spinal stenosis (62.5%), and low back pain (47.5%). Most surgeons (78%) believed TLIF could be safely performed in ASCs. Streamlined workflow, lower infection rates, and cost-effectiveness were advantages listed by 58.5% of surgeons. Patient's medical history (75.8%), followed by ASC resources and capabilities (61%) and surgeon preference (61%), were relevant factors. Higher efficiencies at ASCs (14.6%), contractual issues (9.8%), and ownership issues (7.3%) were less relevant to surgeons. About 65.9% of surgeons reported lower reimbursement in ASCs, and 43.9% said it was an implementation hurdle. Lower direct costs were reported by 53.7% of surgeons. Other hurdles included a lack of trained staff (24.4%), inadequate staffing (22.0%), cost overruns (26.8%), high Joint Commission or the Accreditation Association for Ambulatory Health Care credentialing costs, and surgeons feeling uncomfortable performing TLIF in ASCs (22.0%). Only 17.1% listed medical problems as a reason their patient was considered unsuitable for the ASC environment. A majority (53.7%) stated that their ASCs complied with strict Stark requirements by disclosing physician ownership interests. However, 22% of surgeons reported self-referrals under the "In-Office Ancillary Services Exception" allowed by the Stark law. Our survey data show that surgeons' perceptions of current CMS rules and regulations may hinder the transition into the ASC setting because they think the reimbursement is too low and the regulatory burden is too high. ASCs have disproportionally higher initial acquisition and ongoing costs related to staff training and maintenance of the TLIF technology that CMS should consider when determining the appropriate financial remuneration for these complex procedures. ASC offers a viable and attractive option for their TLIF procedure with the advantage of same-day discharge and at-home recovery.

ANALYSIS OF COMPLICATIONS IN PATIENTS UNDERGOING TRANSFORAMINAL LUMBAR INTERBODY FUSION: A CRITICAL EXAMINATION OF SURGICAL INTERVENTIONS FOR LUMBAR CANAL STENOSIS

Objective: The lumbar spine undergoes degenerative changes with age, leading to lumbar canal stenosis (LCS). Surgical interventions, including transforaminal lumbar interbody fusion (TLIF), become essential when conservative measures fail. Understanding complications associated with TLIF is crucial for informed decision-making and improved patient outcomes.&#x0D; Methods: A study involving 40 LCS patients undergoing TLIF was conducted at Indira Gandhi Medical College, Shimla. Records were retrospectively evaluated for 15 patients (pre-May 2016) and prospectively for 25 patients (May 2016-May 2017). Surgical indications, inclusion/exclusion criteria, preoperative preparation, and TLIF procedures were outlined. Postoperative care and follow-up assessments were detailed. Statistical analysis utilized SPSS 17.0 with a significance level of 0.05.&#x0D; Results: Age and sex distribution demonstrated a significant association (p=0.0049), with a male predominance (57.5%). Occupation analysis revealed 32.5% farmers, 15% laborers, 5% drivers, and 47.5% 'others.' Neurological deficits were present in 75% of cases, while facet joint arthropathy affected 67.5% of patients. Preoperative Oswestry Disability Index indicated severe disability in 62.5% of cases.&#x0D; Conclusion: This study provides critical insights into TLIF complications for LCS, emphasizing male predominance, occupation-related considerations, and significant preoperative disability. Findings contribute to refining surgical protocols, minimizing risks, and optimizing patient safety in TLIF for LCS, essential for advancing spinal surgery standards.

Spinal Anesthesia Reduces Perioperative Polypharmacy and Opioid Burden in Patients Over 65 Who Undergo Transforaminal Lumbar Interbody Fusion

Polypharmacy and opioid administration are thought to increase the risk of postoperative cognitive dysfunction and delirium in elderly patients. Spinal anesthesia (SA) holds potential to reduce perioperative polypharmacy in spine surgery. As more geriatric patients undergo spine surgery, understanding how SA can reduce polypharmacy and opioid administration is warranted. We aim to compare the perioperative polypharmacy and dose of administered opioids in patients ≥65 years who undergo transforaminal lumbar interbody fusion (TLIF) under SA versus general anesthesia (GA). A retrospective analysis of 200 patients receiving a single-surgeon TLIF procedure at a single academic center (2014-2021) was performed. Patients underwent the procedure with SA (n=120) or GA (n= 80). Demographic, procedural, and medication data were extracted from the medical record. Opioid consumption was quantified as morphine milligram equivalents (MME). Statistical analyses included χ2 or Student's t-test. Patients receiving SA were administered 7.45 medications on average versus 12.7 for GA patients (P < 0.001). Average perioperative opioid consumption was 5.17 MME and 20.2 MME in SA and GA patients, respectively (P < 0.001). The number of patients receiving antiemetics and opioids remained comparable postoperatively, with a mean of 32.2 MME in the GA group versus 27.5 MME in the SA group (P= 0.14). Antiemetics were administered less often as a prophylactic in the SA group (32%) versus 86% in the GA group (P < 0.001). SA reduces perioperative polypharmacy in patients ≥65 years undergoing TLIF procedures. Further research is necessary to determine if this reduction correlates to a decrease the incidence of postoperative cognitive dysfunction and delirium.

Hybrid cortical bone trajectory and modified cortical bone trajectory techniques in transforaminal lumbar interbody fusion at L4-L5 segment: A finite element analysis

BackgroundThe academia has increasingly acknowledged the superior biomechanical performance of the hybrid fixation technique in recent years. However, there is a lack of research on the hybrid fixation technique using BCS (Bilateral Cortical Screws) and BMCS (Bilateral Modified Cortical Screws). This study aims to investigate the biomechanical performance of the BCS and BMCS hybrid fixation technique in transforaminal lumbar interbody fusion (TLIF) at the L4-L5 segment in a complete lumbar-sacral finite element model. MethodsThree cadaver specimens are used to construct three lumbar-sacral finite element models. The biomechanical properties of various fixation technologies (BCS-BCS, BMCS-BMCS, BMCS-BCS, and BCS-BMCS) are evaluated at the L4-5 segment with a TLIF procedure conducted, including the range of motion (ROM) of the L4-5 segment, as well as the stress experienced by the cage, screws, and rods. The testing is conducted under specific loading conditions, including a compressive load of 400 N and a torque of 7.5Nm, subjecting the model to simulate flexion, extension, lateral bending, and rotation. ResultsNo significant variations are seen in the ROM at the L4-5 segment when comparing the four fixation procedures during flexion and extension. However, when it comes to lateral bending and rotation, the ROM is ordered in descending order as BCS-BCS, BCS-BMCS, BMCS-BMCS, and BMCS-BCS. The maximum stress experienced by the cage is observed to be highest within the BMCS-BCS technique during movements including flexion, extension, and lateral bending. Conversely, the BMCS-BMCS technique exhibits the highest cage stress levels during rotational movements. The stress applies to the screws and rods order the sequence of BCS-BCS, BCS-BMCS, BMCS-BCS, and BMCS-BMCS throughout all four working conditions. ConclusionThe BMCS-BCS technique shows better biomechanical performance with less ROM and lower stress on the internal fixation system compared to other fixation techniques. BMCS-BMCS technology has similar mechanical performance to BMCS-BCS but has more contact area between screws and cortical bone, making it better for patients with severe osteoporosis.

Biomechanical evaluation of modified and traditional cortical bone trajectory technique on adjacent segment degeneration in transforaminal lumbar interbody fusion—finite element analysis

ObjectivesModified cortical bone trajectory (MCBT) technique was proposed by our team in previous studies, but its biomechanical properties at adjacent segments have not been discussed yet. Therefore, the purpose of this study is to investigate the biomechanical properties of modified cortical bone trajectory (MCBT) technique on adjacent segment degeneration (ASD) in transforaminal intradiscal lumbar disc fusion (TLIF) compare to traditional bone trajectory (TT) technique and cortical bone trajectory (CBT) technique.MethodsThe four human cadaveric lumbar specimens were provided by the anatomy teaching and research department of Xinjiang Medical University and four intact finite element models of the L1-S1 segment were generated. For each of these, three transforaminal lumbar interbody fusion procedures with three different fixation techniques were reconstructed at the L4-L5 segment, as follows: TT-TT (TT at both L4 and L5 segments), CBT-CBT (CBT at both L4 and L5 segments), MCBT-MCBT (MCBT at both L4 and L5 segments). The range of motion and von Mises stress of the intervertebral disc of the L3-L4 and L5-S1 segments were recorded with a 400N compressive load and 7.5 Nm moments in flexion, extension, left–right bending, and left–right rotation.ResultsThe peak ROM of the L3-L4 segment in the MCBT-MCBT group was reduced by 10.5%, 6.1%, 12.2%, 4.1%, and 1.5% in flexion, extension, left–right bending, and left rotation compared to the TT-TT group and reduced by 1.8%, 5.5%, 10.0%, 12.8%, and 8.8% in flexion, left–right bending, and left–right rotation compared to the CBT-CBT group, respectively. The MCBT-MCBT group has the lowest peak ROM of the L3-L4 segment in flexion, left bending, and right rotation, the lowest peak ROM of the L5-S1 segment in extension and right rotation, and the lowest peak von Mises stress of the intervertebral disc at the L5-S1 segment in right rotation compared to the TT-TT and CBT-CBT group. In addition, the peak von Mises stress at the L3-L4 segment was lowest and more dispersed in all motions, the MCBT-MCBT group exhibited lower peak ROM of the L5-S1 segment in flexion, extension, and right rotation, and showed lower peak von Mises stress of the disc at the L5-S1 segment in flexion, extension, and right rotation compared with the TT-TT group.ConclusionThe modified cortical bone trajectory technique may have a beneficial effect on reducing the incidence of ASD in the L4-L5 TLIF model compared to the traditional bone trajectory technique and cortical bone trajectory technique.

Adhesive surface electrodes versus needle-based neuromonitoring in lumbar spinal surgery.

The relative safety and more widespread utility of an adhesive surface electrode-based neuromonitoring (ABM) system may reduce the time and cost of traditional needle-based neuromonitoring (NBM). This retrospective cohort review included one- and two-level transforaminal lumbar interbody fusion procedures (2019-2023). The primary variables studied included were time (in minutes) from patient entry into the operating room (OR) to incision, time from patient entry into the OR to closure, and time from incision to closure. Univariate and bivariate analyses were performed to compare the outcomes between the ABM (31 patients) and NBM (51 patients) modalities. We found no significant differences in the time from patient entry into the OR to incision (ABM: 71.8, NBM: 70.3, P = 0.70), time from patient entry into the OR to closure (ABM: 284.2, NBM: 301.7, P = 0.27), or time from incision to closure (ABM: 212.4, NBM: 231.4, P = 0.17) between the two groups. Further, no patients from either group required reoperation for mal-positioned instrumentation, and none sustained a new postoperative neurological deficit. The ABM approach did, however, allow for a reduction in neurophysiologist-workforce and neuromonitoring costs. The introduction of the ABM system did not lower surgical time but did demonstrate similar efficacy and clinical outcomes, with reduced clinical invasiveness, neurophysiologist-associated workforce, and overall neuromonitoring cost compared to NBM.

The efficacy and safety of tranexamic acid in transforaminal lumbar interbody fusion: a systematic review and meta-analysis.

This meta-analysis aimed to assess the efficacy and safety of tranexamic acid (TXA) in transforaminal lumbar interbody fusion (TLIF), focusing on its impact on intraoperative blood loss and related outcomes. The review process was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched the PubMed, EMBASE, Medline, and Cochrane Library databases to identify all literature related with TXA and TLIF. Finally, five trials ultimately meeting the inclusion criteria. Continuous variables were analyzed using mean difference and categorical variables were analyzed using Peto odds ratio, via random effects models. The meta-analysis revealed a significant reduction in intraoperative blood loss associated with TXA use during TLIF, as confirmed by the RCTs. However, the impact of TXA on other outcomes, such as postoperative drainage volume, total blood loss, and length of hospital stay, remains inconclusive due to limited data. No severe complications related to TXA use were reported, providing preliminary evidence of its safety in TLIF. TXA appears to effectively reduce intraoperative blood loss in TLIF, based on the available RCT evidence. However, further research is needed to provide a comprehensive assessment of TXA's overall impact on various outcomes in this context. This meta-analysis underscores the importance of ongoing investigation to establish the full potential and safety profile of TXA in TLIF procedures.

Bone Grafting Options for Single-Level TLIF: So Many Options, What Is the Evidence?

This review seeks to investigate the clinically relevant bone graft materials in single-level transforaminal lumbar interbody fusion (TLIF) procedures as defined by (1) primary outcomes (ie, fusion rates and complication rates) and (2) patient-reported outcomes (ie, visual analog scale [VAS] and Oswestry disability index [ODI]). Because of the advantages in stimulating bone growth, autologous bone grafts such as the iliac crest bone graft (ICBG) have been the gold standard. Numerous alternatives to ICBG have been introduced. Understanding the risks and benefits of bone graft options is vital to optimizing patient care. A PubMed search was performed for all clinical studies published between January 2008 and March 2023 that referenced the single-level TLIF procedure as well as one of the following grafts: autograft, allograft, bone morphogenetic protein (BMP), demineralized bone matrix, or mesenchymal stem cells (MSCs). Case studies and reports were excluded. Twenty-eight studies met the inclusion criteria. Studies from the PubMed search demonstrated similarly high fusion rates across nearly all graft materials, the lone exception being MSCs, which showed lower fusion rates. ICBG grafts experienced higher rates of postoperative graft site pain. The BMP graft material had high rates of radiculitis, heterogeneous ossification, and vertebral osteolysis. Patients saw an overall improvement in VAS and ODI scores with all graft materials. Local autografts and ICBG have been the most studied. Fusion rates during single-level TLIF were similar across all graft materials except MSCs. Patient-reported pain levels improved after TLIF surgery regardless of the type of grafts used. While BMP implants have shown promising benefits, they have introduced a new array of complications not normally seen in ICBG implants. The study is limited by the lack of evidence of certain graft materials as well as nonuniformity in metrics evaluating the efficacy of graft materials.

Comparison of Intraoperative Endplate Injury between Mini-Open Lateral Lumbar Interbody Fusion (LLIF) and Transforaminal Lumbar Interbody Fusion (TLIF) and Analysis of Risk Factors: A Retrospective Study

Objective The study aimed to compare the incidence of intraoperative endplate injury in patients who underwent Transforaminal interbody fusion (TLIF) and mini-open lumbar interbody fusion (LLIF) surgery. The independent risk factors related to endplate injury in LLIF procedure were analyzed. Methods A total of 199 patients who underwent LLIF (n = 106) or TLIF (n = 93) surgery from June 2019 to September 2021 were reviewed. The endplate injury was assessed by postoperative sagittal CT scan. A binary logistic analysis model were used to identify independent risk factors related to LLIF endplate injury based on univariate analysis. Results There was an obvious difference in the occurrence of intraoperative endplate injury between LLIF (42/106, 39.6%) and TLIF group (26/93, 28%), although it did not reach the significant level. L1 CT value (OR = 0.985, 95% CI = 0.972–0.998), cage position (OR = 3.881, 95% CI = 1.398–10.771) and height variance (OR = 1.263, 95% CI = 1.013–1.575) were independent risk factors for endplate injury in LLIF procedure. According to the cage settlement patterns, there 5 types of A to E. The severity of the facet joint degeneration was positively related to the occurrence of endplate injury. Conclusions The incidence of intraoperative endplate injury is higher in LLIF than in TLIF procedures. Low bone quantity, cage posterior position and larger height variance are risk factors to induce endplate injury in LLIF surgery. The facet joint degeneration may be related to severe endplate injuries and even fractures.

The Clinical Outcome of Transforaminal Lumbar Interbody Fusion and Laminectomy for Single-Level Lumbar Canal Stenosis with Grade 1 and 2 Spondylolisthesis

Background: Lower back pain is a common cause of disability that affects mobility and quality of life (QOL) in both adult and elderly patients. Initial management of lower back pain includes anti-inflammatory drugs, analgesics, physiotherapy, and epidural steroid infiltration. Despite multiple attempts of conservative management, if a patient develops refractory radicular pain with or without neurologic deficit and claudication, surgery is indicated. The two main approaches to surgical intervention include decompression (laminectomy only) and decompression with fusion [transforaminal lumbar interbody fusion (TLIF)].&#x0D; Methods: The study was done between May 2019 and November 2022. In this randomized study, we compared the clinical outcome of TLIF and laminectomy for single-level lumbar canal stenosis with grade 1 and 2 spondylolisthesis. Forty patients with single-level lumbar canal stenosis with grade 1 and 2 spondylolisthesis were randomly divided into two equal groups. Patients in both groups were followed up for 2 years.&#x0D; Results: In this study, we also noted estimated amount of blood loss, procedure time, time taken for ambulation, length of hospitalization, and demography. The Oswestry Disability Index (ODI) scores improved significantly postoperatively. The modified MacNab criteria suggest the outcomes rated as excellent/good rate of 90% in TLIF and 85% in laminectomy.&#x0D; Conclusion: We evaluated that TLIF procedures were associated with slightly more significant improvement in clinical outcomes in all of the scoring systems that were applied; TLIF provides early ambulation but a higher cost of treatment and longer hospital stay compared to laminectomy. Laminectomy procedures are associated with lesser economic burden, hospital stay, and blood loss, as well as shorter surgical duration compared to TLIF.

The Effects of Interbody Device Design and Placement on Lumbar Lordosis and Disc Height in Transforaminal Lumbar Interbody Fusion

There are a wide variety of interbody devices available for use in transforaminal lumbar interbody fusion (TLIF). While traditionally these interbodies are bullet-shaped, crescent-shaped cages have become increasingly common. There is a paucity of literature comparing the effect of cage geometry with substratification for surgical approach (minimally invasive (MIS) vs. open). The aim of this study was to determine the effect of implant geometry, positioning, and surgical approach on the correction of different spinal alignment parameters in patients undergoing TLIF. A retrospective chart and imaging review was performed on 103 patients with a total of 131 instrumented segments performed by a single surgeon. Preoperative, initial postoperative, and final postoperative standing lateral lumbar radiographs were evaluated for lumbar lordosis (LL), segmental lordosis (SL), anterior disc height (ADH), and posterior disc height (PDH). Anterior-posterior implant positioning was recorded for initial and final postoperative radiographs. These measurements were compared among four groups: open bullet (OB), MIS bullet (MB), open crescent (OC), and MIS crescent (MC). SL increased in all groups by a mean of 2.9° at initial imaging and 2.2° at final imaging. The OC group had greater initial improvement in SL compared to the MB group (p = 0.02), though this effect was lost at final follow-up (p = 0.11). The OB and OC groups conferred greater initial improvement in ADH (p = 0.02; p = 0.04), while the OC group had greater final improvement in ADH compared to the MB and MC groups (p = 0.01; p = 0.01). The OC group had less initial improvement in PDH compared with the other groups (p = 0.03, p = 0.02, p &lt; 0.01). The MB group provided greater final improvement in PDH compared with the MC and OC groups (p = 0.04, p = 0.01). Cage geometry, surgical approach, and implant position all demonstrated a statistically significant but clinically minor impact on segmental alignment for TLIF procedures.

Promotion of higher rates of early fusion using activated titanium versus polyetheretherketone cages in adults undergoing 1- and 2-level transforaminal lumbar interbody fusion procedures: a randomized controlled trial.

There is ongoing debate on the relative benefits and drawbacks of polyetheretherketone (PEEK) versus titanium (Ti) in generating a bone-to-implant surface microenvironment conducive to osseointegration. Micro- and nanoscale internal and topographic cage modifications have recently been posited to facilitate osseointegration and fusion, but human in vivo confirmation remains lacking. The authors of this study sought to directly compare early radiological outcomes in adults undergoing 1- and 2-level transforaminal lumbar interbody fusion (TLIF) procedures using either PEEK or nano-etched Ti interbody cages with an incorporated microlattice structure. Patients were enrolled in a single academic center using a single-blind randomized controlled superiority design. Screening was undertaken from a pool of consecutive patients eligible for TLIF to undergo placement in a 1:1 ratio of either lordotic PEEK or activated Ti cages at each level of 1- or 2-level procedures. An a priori power analysis was performed and a preplanned interim analysis was undertaken once 50 of 70 patients were enrolled. Patient study data were collected perioperatively and uploaded to a Research Electronic Data Capture (REDCap) registry. Interbody fusion was assessed based on 6-month postoperative lumbar dual-energy CT (DECT) studies using the method of Brantigan and Steffee, as modified to describe the Fraser definition of locked pseudarthrosis (Brantigan-Steffee-Fraser [BSF] scale). In the final cohort of 50 patients, 40 interbody levels implanted with PEEK cages were compared with 34 interbody levels with activated Ti cages. The trial was stopped early given the results of an interim analysis with respect to the primary outcome. Surgical parameters including number of levels treated, average cage height, and position were not different between groups. For the PEEK and activated Ti groups, 20.6% versus 84.0% demonstrated BSF grade 3 fusion on 6-month postoperative DECT imaging (p < 0.001). Subsidence at 6 months on DECT was identified in 12 (41.4%) of PEEK levels versus 5 (20.8%) of activated Ti levels (p < 0.001). BSF-3 grading was predictive of segmental stability and numeric rating scale (NRS) leg pain improvement at 1 year postoperatively. Oswestry Disability Index and NRS back and leg pain scores all improved similarly in both cohorts at 1 year postoperatively. Activated Ti interbody cages mediate early fusion at significantly higher rates with lower rates of subsidence as compared with PEEK cages. These findings support the idea that interbody cage microscale properties, including surface topography, may play a primary role in facilitating osseointegration and fusion.

Surgeon Experience Matters: An Exact Matched Analysis of TLIF Outcomes Demonstrates No Difference in Surgical Outcomes Between Experienced Neurosurgeons and Orthopedic Surgeons.

Retrospective cohort study. To compare surgical and medical complications profile between neurosurgeons and orthopedic surgeons after transforaminal lumbar interbody fusion (TLIF) procedures. Studies comparing the impact of spine surgeon specialty (neurosurgery vs. orthopedic spine) on TLIF outcomes have been inconclusive and failed to control for operative learning curves and surgical maturity. Orthopedic spine surgeons perform fewer spine procedures in residency, although these differences may be attenuated by mandatory fellowship before starting practice. Any observed differences are likely attenuated with increasing surgeon experience. Using an all-payer claims database, PearlDiver Mariner, 120 million patient records were analyzed between 2010 and 2022, to identify individuals with lumbar stenosis or spondylolisthesis who underwent index one- to three-level TLIF procedures. International Classification of Diseases-Ninth Edition (ICD-9), International Classification of Diseases-10th Edition (ICD-10) and Current Procedural Terminology (CPT) codes were used to query the database. Only Neurosurgeons and Orthopedic spine surgeons who had performed at least 250 procedures were included in the study. Patients undergoing surgery for tumor, trauma, or infection were excluded. 1:1 exact matching was performed using demographic factors, medical comorbidities, and surgical factors which were significantly associated with all-cause surgical or medical complications in a linear regression model. 1:1 exact matching created two equal groups of 18,195 patients without baseline differences who underwent TLIF procedures by neurosurgeons or orthopedic surgeons. There was no difference in all-cause surgical complications between neurosurgeons and orthopedic spine surgeons (relative risk=1.008, 95% CI: 0.850-1.195, P =0.965). All-cause medical complication rate was higher in the neurosurgery cohort (relative risk=1.144, 95% CI: 1.042-1.258, P =0.005). The results of this study suggest that after accounting for surgical maturity, neurosurgeons and orthopedic spine surgeons have similar surgical outcomes. However, neurosurgeons have higher all-cause medical complication rates compared with orthopedic spine surgeons. Further research is warranted to validate this relationship in other spine procedures and for other outcomes.

TLIF is Associated with Lower Rates of Adjacent Segment Disease and Complications Compared to ALIF: A Matched-Cohort Analysis.

Retrospective cohort. To compare the rate of adjacent segment disease (ASD) in patients undergoing anterior lumbar interbody fusion (ALIF) versus transforaminal lumbar interbody fusion (TLIF) for treatment of degenerative stenosis and spondylolisthesis. ALIF and TLIF are frequently used to treat Lumbar stenosis and spondylolisthesis. While both approaches have distinct advantages, it is unclear whether there are any differences in rates of ASD and postoperative complications. A retrospective cohort study of patients who underwent index 1-3 levels ALIF or TLIF between 2010-2022, using the PearlDiver Mariner Database, an all-claims insurance database (120 million patients). Patients with a history of prior lumbar surgery and those undergoing surgery for cancer, trauma, or infection were excluded. Exact 1:1 matching was performed using demographic factors, medical comorbidities, and surgical factors found to be significantly associated with ASD in a linear regression model. The primary outcome was a new diagnosis of ASD within 36 months of index surgery and secondary outcomes were all-cause medical and surgical complications. Exact 1:1 matching resulted in two equal groups of 106,451 patients undergoing TLIF and ALIF. The TLIF approach was associated with a lower risk of ASD (RR 0.58, 95% CI 0.56-0.59, P < 0.001), and all-cause medical complications (RR 0.94, 95% CI 0.91-0.98, P=0.002). All-cause surgical complications were not significantly different between both groups. After 1:1 exact matching to control for confounding variables, this study suggests that for patients with symptomatic degenerative stenosis and spondylolisthesis, a TLIF procedure (compared to ALIF) is associated with a decreased risk of developing ASD within 36 months of index surgery. Future prospective studies are needed to corroborate these findings. III.

Validation of Impaction Grafting for Single-Level Transforaminal Lumbar Interbody Fusion-Technical Pearls and MicroCT Analysis.

Cadaveric study. Transforaminal lumbar interbody fusion (TLIF) represents a well-documented operative surgical technique utilized in the management of lumbar pathology requiring interbody arthrodesis. The microstructural properties of impaction grafting (IG) after TLIF has yet to be reported. The current study was designed first, to quantify the degree, to which IG augmentation would increase intrabody final bone volume and bone graft surface contact area with the endplates; secondly to quantify the volumes of locally harvested bone and bone needed for maximal impaction. Three cadaveric lumbosacral spine specimens were dissected into L1-L2, L3-L4, and L5-S1 motion segments for a total of 9 functional spinal units. Each interbody unit underwent a TLIF procedure with the implantation of an interbody spacer containing autogenous morselized bone. Microcomputed tomography scans were then performed to evaluate the final bone volume and bone surface contact area (BSCA). Subsequently, IG augmented TLIF procedure was carried and microcomputed tomography scans were repeated. IG augmentation of TLIF exhibited a 346% increase in final bone volume (TLIF: 0.30 ± 0.07 cm 3 ; IG-TLIF: 1.34 ± 0.42 cm 3 ; P < 0.05) and a 152% increase in BSCA (TLIF: 45.06 ± 15.47%; IG-TLIF: 68.28 ± 6.85%; P < 0.05) when compared with the nonimpacted TLIF treatment. In addition, the average amount of autogenous bone collected was 8.21±2.08 cm 3 , which sufficiently fulfilled the requirements for bone grafting (TLIF: 1.23 ± 0.40 cm 3 ; IG-TLIF 6.42 ± 1.20 cm 3 ). IG augmentation of TLIF significantly improved final bone volume in the disc space and BSCA with vertebral endplates in vitro. Greater BSCA and final volume of bone graft reflect promisingly on their potential to increase fusion rates. Clinical studies will be needed to corroborate these findings.

A Comparison Between Cortical Bone Trajectory Screws And Traditional Pedicle Screws in Patients With Single-Level Lumbar Degenerative Spondylolisthesis: Five-Year Results.

A retrospective observational study. This study investigated the clinical and radiological results of using cortical bone trajectory (CBT) screws versus traditional pedicle (TP) screws in transforaminal lumbar interbody fusion (TLIF) during a five-year follow-up of patients with single-level lumbar degenerative spondylolisthesis. Few studies have compared five-year follow-up outcomes between CBT screws and TP screws in TLIF. We reviewed outcome data of patients with single-level lumbar degenerative spondylolisthesis who underwent TLIF procedures with CBT screws (131 patients) or TP screws (80 patients) between 2011 and 2015. Patient-reported clinical outcome data included Oswestry disability index scores and visual analog scale (VAS) scores for back and leg pain at baseline, six months, and one year, two years, and five years postoperatively. The radiographic fusion rate and prevalence of secondary surgery for adjacent segment disease were also measured. During the follow-up over five years, the CBT group had significantly lower VAS scores for back pain ( P <0.0001, respectively). At two years after surgery, the CBT group had significantly higher VAS scores for leg pain ( P =0.007). At five years postoperatively, no significant differences existed in the VAS score for leg pain or in the Oswestry disability index score between the two groups. Radiographic fusion rates (CBT vs. TP: 95.5% vs. 95.9%; P =0.881) and adverse events during the five years after surgery were not significantly different. At two years postoperatively, the prevalence of secondary surgery to treat adjacent segment disease was significantly different between the two groups (CBT vs . TP: 13.7% vs. 5.0%; P =0.044). Our results suggest that, during a five-year followup, CBT screws for TLIF were an effective treatment compared to TP screws in the setting of single-level lumbar degenerative spondylolisthesis. However, when using CBT screws for TLIF, surgeons should consider the higher rate of secondary procedures to treat symptomatic adjacent segment disease.