Transforaminal Lumbar Interbody Fusion Surgery Research Articles

The impact of frailty on clinical outcomes of older patients undergoing enhanced recovery after lumbar fusion surgery: A prospective cohort study.

Frailty is recognized as a surrogate for physiological age and has been established as a valid and independent predictor of postoperative morbidity, mortality, and complications. ERAS can enhance surgical safety by minimizing stress responses in frail patients, enabling surgeons to discharge patients earlier. However, the question of whether and to what extent the frailty impacts the post-ERAS outcomes in older patients remains. An evidence-based ERAS program was implemented in our center from January 2019. This is a prospective cohort study of patients aged ≥75 years who underwent open transforaminal lumbar interbody fusion (TLIF) for degenerative spine disease from April 2019 to October 2021. Frailty was assessed with the Fried frailty scale (FP scale), and patients were categorized as non/prefrail (FP 0-2) or frail (FP ≥ 3). The preoperative variables, operative data, postoperative outcomes and follow-up information were compared between the two groups. Univariate and multivariate logistic regression analyses were used to identify risk factors for 90-day major complications and prolonged length of hospital stay (LOS) after surgery. A total of 245 patients (age of 79.8 ± 3.4 yr) who had a preoperative FP score recorded and underwent scheduled TLIF surgery were included in the final analysis. Comparisons between non-frail and prefrail/frail patients revealed no significant difference in age, sex, and surgery-related variables. Even after adjusting for multiple comparisons, the association between Fried frailty and ADL-dependency, IADL-dependency, and malnutrition remained significant. Preoperative frailty was associated with increased rates of postoperative adverse events. A higher CCI grade was an independent predictor for 90-day major complications, while Fried frailty and MNA-SF scores <12 were predictive of poor postoperative recovery. Frail older patients had more adverse post-ERAS outcomes after TLIF compared to non/prefrail older patients. Continued research and multidisciplinary collaboration will be essential to refine and optimize protocols for surgical care in frail older adults.

Association between vertebral endplate defects and patient-reported symptoms: an immunohistochemical study investigating the COX-2/PGE-2/EP-4 axis

Background ContextVertebral endplate defects are often implicated in degenerative disc disorders, yet their connection to patient-reported symptoms remains unclear. COX-2 and PGE-2 are known for their roles in inflammation and pain, with EP-4 receptor involvement in pain signaling. Examining their expression in vertebral endplate tissues may provide insights into pathomechanism of low back pain. PurposeTo investigate the association between endplate defects and patient-reported symptoms and to further clarify the role of the COX-2/PGE-2/EP-4 axis in the pathogenesis of chronic low back pain. Study Design/SettingRetrospective study. Patient SampleA total of 71 patients who had undergone single-level L4/5 or L5/S1 modified laminectomy decompression preserving proximal upper laminae and transforaminal lumbar interbody fusion surgery were included in this study, including 18 patients diagnosed with lumbar disc herniation, 19 with lumbar disc herniation accompanied by degenerative lumbar spinal stenosis, and 34 with degenerative spondylolisthesis. Outcome MeasuresDemographic data, Pfirrmann grade, Modic changes, endplate defect score, visual analog scale (VAS) for back and leg pain, and Oswestry Disability Index (ODI) before surgery, 3-month and 6-month follow-up, and the percentage of immune-positive cells (COX-2, PGE-2, and EP-4) in endplate tissue sections. MethodsPatients were divided into defect and non-defect groups according to endplate morphology on lumbar MR. All intraoperative endplate specimens were immediately fixed in 10% formaldehyde, and then embedded in paraffin 3 days later for tissue sections. The outcome measures were compared between the defect group and non-defect group. Data were analyzed using independent t-tests and χ² tests. Pearson's rank correlation test was used to assess correlations between patient-reported symptoms and the percentage of immune-positive cells in the groups. Multivariable logistic regression models using the forward stepwise likelihood ratio method were used to identify the factors that were independently associated with endplate defects. ResultsThe age of Defect group was significantly higher than that of non-defect group (52.5±7.7 vs. 57.2±9.1. p=.024). There were no significant differences in gender, diagnosis, BMI, comorbidities, or surgical level between the two groups. Modic changes (Type Ⅱ/Type Ⅲ) were more common in patients of Defect group than non-defect group (38.5% vs. 11.1%, p<.001), and so was disc degeneration (Pfirrmann grade Ⅳ/Ⅴ) (69.2% vs. 33.3%, p<.001). Defect group had significantly higher VAS-Back (6.5±2.0 vs. 4.9±1.6, p<.001) and ODI scores (62.9±10.7 vs. 45.2±14.8, p<.001) than non-defect group, while there was no significant differences between the two groups during the 3 and 6-month follow-up after surgery. Histologically, Defect group was characterized by upregulation of COX-2, PGE-2, and EP-4 in endplate tissue sections. Both in defect and non-defect groups, VAS-Back showed moderate positive correlations with the expressions of COX-2 (r=0.643; r=0.558, p both<0.001), PGE-2 (r=0.611; r=0.640, p both<.001), and EP-4 (r=0.643; r=0.563, p both<.001). Multivariate regression analyses reveled that percentage of COX-2-positive cells was associated with endplate defects (OR=1.509, 95%CI [1.048–2.171], p=0.027), as well as percentage of PGE-2-positive (OR=1.291, 95%CI [1.106–1.508], p=.001) and EP-4-positive cells (OR=1.284, 95%CI [1.048∼2.171], p=.003). ConclusionsPatients with endplate defects had worse quality of life, more severe disc degeneration and Modic changes, and up-regulated COX-2/PGE-2/EP-4 axis expression in cartilage endplates in patients with defected endplates. Inflammatory factors may significantly contribute to the onset and progression of chronic low back pain in patients with endplate defects, consequently impacting patient-reported symptoms.

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.

A Propensity Score-Matched Cohort Study Comparing 3 Different Spine Pedicle Screw Fixation Methods: Freehand, Fluoroscopy-Guided, and Robot-Assisted Techniques.

This study aimed to compare the accuracy of robotic spine surgery and conventional pedicle screw fixation in lumbar degenerative disease. We evaluated clinical and radiological outcomes to demonstrate the noninferiority of robotic surgery. This study employed propensity score matching and included 3 groups: robot-assisted mini-open posterior lumbar interbody fusion (PLIF) (robotic surgery, RS), c-arm guided minimally invasive surgery transforaminal lumbar interbody fusion (C-arm guidance, CG), and freehand open PLIF (free of guidance, FG) (54 patients each). The mean follow-up period was 2.2 years. The preoperative spine condition was considered. Accuracy was evaluated using the Gertzbein-Robbins scale (GRS score) and Babu classification (Babu score). Radiological outcomes included adjacent segmental disease (ASD) and mechanical failure. Clinical outcomes were assessed based on the visual analogue scale, Oswestry Disability Index, 36-item Short Form health survey, and clinical ASD rate. Accuracy was higher in the RS group (p < 0.01) than in other groups. The GRS score was lower in the CG group, whereas the Babu score was lower in the FG group compared with the RS group. No significant differences were observed in radiological and clinical outcomes among the 3 groups. Regression analysis identified preoperative facet degeneration, GRS and Babu scores as significant variables for radiological and clinical ASD. Mechanical failure was influenced by the GRS score and patients' age. This study showed the superior accuracy of robotic spine surgery compared with conventional techniques. When combined with minimally invasive surgery, robotic surgery is advantageous with reduced ligament and muscle damage associated with traditional open procedures.

Does Epidural Corticosteroid Application During Spinal Surgery Reduce Postoperative Pain?: An Adjunct to Multimodal Analgesia.

A prospective, randomized, placebo-controlled, double-blinded study. To examine the effect of intraoperative epidural administration of Depo-Medrol on postoperative back pain and radiculitis symptoms in patients undergoing Transforaminal Lumbar Interbody Fusion (TLIF). Postoperative pain is commonly experienced by patients undergoing spinal fusion surgery. Adequate management of intense pain is necessary to encourage early ambulation, increase patient satisfaction, and limit opioid consumption. Intraoperative steroid application has been shown to improve postoperative pain in patients undergoing lumbar decompression surgeries. There have been no studies examining the effect of epidural steroids on both back pain and radicular pain in patients undergoing TLIF. In all, 151 patients underwent TLIF surgery using rh-BMP2 with 3 surgeons at a single institution. Of those, 116 remained in the study and were included in the final analysis. Based on a 1:1 randomization, a collagen sponge saturated with either Saline (1cc) or Depo-Medrol (40mg/1cc) was placed at the annulotomy site on the TLIF level. Follow-up occurred on postoperative days 1, 2, 3, 7, and postoperative months 1, 2, and 3. Lumbar radiculopathy was measured by a modified symptom- and laterality-specific Visual Analog Scale (VAS) regarding the severity of back pain and common radiculopathy symptoms. The patients who received Depo-Medrol, compared with those who received saline, experienced significantly less back pain on postoperative days 1, 2, 3, and 7 (P<0.05). There was no significant difference in back pain beyond day 7. Radiculopathy-related symptoms such as leg pain, numbness, tingling, stiffness, and weakness tended to be reduced in the steroid group at most time points. This study provides Level 1 evidence that intraoperative application of Depo-Medrol during a TLIF surgery with rh-BMP2 significantly reduces back pain for the first week after TLIF surgery. The use of epidural Depo-Medrol may be a useful adjunct to multimodal analgesia for pain relief in the postoperative period.

Impact of Obesity on Outcomes of Minimally Invasive Transforaminal Lumbar Interbody Fusion Surgeries: A Systematic Review and Meta-Analysis

To evaluate the impact of obesity on various outcomes in patients undergoing minimally invasive transforaminal lumbar interbody fusion (TLIF) surgeries. PubMed, Scopus, Embase, and Cochrane Library databases were screened for studies reporting outcomes in obese and nonobese patients undergoing TLIF surgeries. Studies reporting operative time, estimated blood loss, length of hospital stay, incidence of pseudoarthrosis, Oswestry Disability Index (ODI) scores, pain scores (Visual Analog Scale, VAS), and PROMIS PF scores were included. A qualitative and quantitative analysis was performed to calculate mean differences or odds ratios (ORs) using random-effects models. Fourteen good-quality studies were included in this review, with a combined sample size of 4,889 participants. The analysis revealed that patients with obesity had slightly longer operative times compared to patients with normal weight, with a mean difference of 14.87minutes, though not significant. Similarly, morbidly obese patients had a mean difference of 21.44minutes in operative time. Estimated blood loss was comparable in both groups. However, morbidly obese patients had longer hospital stays, with a mean difference of 8.18days and obese patients have 20% higher odds of experiencing complications compared to nonobese patients. The incidence of pseudoarthrosis, ODI scores, or pain scores (VAS back and leg) were similar in obese and normal weight patients. Obesity, particularly morbid obesity, may have an impact on certain outcomes in patients undergoing minimally invasive TLIF surgeries. Morbidly obese patients tend to have significantly longer operative times with significantly longer hospital stays than nonobese patients.

Development of End-to-End Artificial Intelligence Models for Surgical Planning in Transforaminal Lumbar Interbody Fusion.

Transforaminal lumbar interbody fusion (TLIF) is a commonly used technique for treating lumbar degenerative diseases. In this study, we developed a fully computer-supported pipeline to predict both the cage height and the degree of lumbar lordosis subtraction from the pelvic incidence (PI-LL) after TLIF surgery, utilizing preoperative X-ray images. The automated pipeline comprised two primary stages. First, the pretrained BiLuNet deep learning model was employed to extract essential features from X-ray images. Subsequently, five machine learning algorithms were trained using a five-fold cross-validation technique on a dataset of 311 patients to identify the optimal models to predict interbody cage height and postoperative PI-LL. LASSO regression and support vector regression demonstrated superior performance in predicting interbody cage height and postoperative PI-LL, respectively. For cage height prediction, the root mean square error (RMSE) was calculated as 1.01, and the model achieved the highest accuracy at a height of 12 mm, with exact prediction achieved in 54.43% (43/79) of cases. In most of the remaining cases, the prediction error of the model was within 1 mm. Additionally, the model demonstrated satisfactory performance in predicting PI-LL, with an RMSE of 5.19 and an accuracy of 0.81 for PI-LL stratification. In conclusion, our results indicate that machine learning models can reliably predict interbody cage height and postoperative PI-LL.

Development and external validation of a nomogram for predicting postoperative adverse events in elderly patients undergoing lumbar fusion surgery: comparison of three predictive models

BackgroundThe burden of lumbar degenerative diseases (LDD) has increased substantially with the unprecedented aging population. Identifying elderly patients with high risk of postoperative adverse events (AEs) and establishing individualized perioperative management is critical to mitigate added costs and optimize cost-effectiveness to the healthcare system. We aimed to develop a predictive tool for AEs in elderly patients with transforaminal lumbar interbody fusion (TLIF), utilizing multivariate logistic regression, single classification and regression tree (hereafter, “classification tree”), and random forest machine learning algorithms.MethodsThis study was a retrospective review of a prospective Geriatric Lumbar Disease Database (age ≥ 65). Our outcome measure was postoperative AEs, including prolonged hospital stays, postoperative complications, readmission, and reoperation within 90 days. Patients were grouped as either having at least one adverse event (AEs group) or not (No-AEs group). Three models for predicting postoperative AEs were developed using training dataset and internal validation using testing dataset. Finally, online tool was developed to assess its validity in the clinical setting (external validation).ResultsThe development set included 1025 patients (mean [SD] age, 72.8 [5.6] years; 632 [61.7%] female), and the external validation set included 175 patients (73.2 [5.9] years; 97 [55.4%] female). The predictive ability of our three models was comparable, with no significant differences in AUC (0.73 vs. 0.72 vs. 0.70, respectively). The logistic regression model had a higher net benefit for clinical intervention than the other models. A nomogram based on logistic regression was developed, and the C-index of external validation for AEs was 0.69 (95% CI 0.65–0.76).ConclusionThe predictive ability of our three models was comparable. Logistic regression model had a higher net benefit for clinical intervention than the other models. Our nomogram and online tool (https://xuanwumodel.shinyapps.io/Model_for_AEs/) could inform physicians about elderly patients with a high risk of AEs within the 90 days after TLIF surgery.

Intradural lumbar disc herniation at the L3–L4 level: A case report and literature review

Abstract Only 0.26% of all disc herniations are caused by intradural disc herniation (IDH), making it a rare pathology. We present the case of a 44-year-old man who suffered from right radicular low back pain and motor impairments. At the level of L3–L4, magnetic resonance imaging (MRI) revealed an intradural, extra-axial spinal mass. This individual had several specific MRI imaging characteristics. Laminectomy, durotomy, and transforaminal lumbar interbody fusion surgery was performed, and the disc was completely removed. At the 6-month follow-up, the patient showed full recovery. The diagnosis of IDH is very challenging and every spine surgeon must be aware. The best treatment for this pathology is surgical intervention.

A comparative study of perioperative pain, blood loss, and hospital stay in an Indian population undergoing mini-open oblique lumbar interbody fusion versus open transforaminal lumbar interbody fusion.

There are several approaches for lumbar fusion, although there is yet to be a consensus on which approach is the best. This study aimed to evaluate the intraoperative blood loss and acute postoperative pain in single-level mini-open oblique lumbar interbody fusion (OLIF) versus open transforaminal lumbar interbody fusion (TLIF) surgeries for the degenerative spine. Thirty-two patients were assigned by the surgeon to OLIF or TLIF groups - 16 in mini-open OLIF and 16 in open TLIF groups. The intraoperative blood loss and postoperative hemoglobin, numerical rating scale (NRS) at proposed time intervals for 24 h postoperative, and rescue analgesics used were compared among the groups. The operative duration and hospital stay in both groups were also compared. The OLIF group showed significantly higher postoperative hemoglobin (11.5 vs. 10.5 g %, P = 0.04), lower 24-h postoperative pain scores on movement, (NRS 4 vs. 5.5, P = 0.0001), and shorter hospital stay (4.5 vs. 7 days, P = 0.003) than TLIF group. However, the surgery duration was significantly longer in OLIF than in TLIF (190 vs. 150 min, P = 0.005). Intraoperative hemodynamics, other postoperative pain scores at variable time points, and rescue analgesics given were comparable among groups (P > 0.05). Intraoperative blood loss was lower in OLIF than TLIF (275 vs. 500 mL) but was not statistically significant (P > 0.05). Mini-open OLIF has favorable perioperative outcomes compared to open TLIF. Patients have higher postoperative hemoglobin and lesser pain on movement on the first postoperative day, leading to earlier mobilization and a shorter hospital stay.

Does platelet-rich plasma enhance fusion in transforaminal lumbar interbody fusion? A prospective clinico-radiological comparative study

Abstract Background: Several animal studies have shown that platelet-rich plasma (PRP) is effective in enhancing bone fusion. However, the role and efficacy of PRP in spinal fusion surgery remain uncertain. The objective was to evaluate the efficacy of PRP in bone fusion and to compare the clinical and radiological outcomes of transforaminal lumbar interbody fusion (TLIF) with and without PRP. Materials and Methods: This prospective study was done on 50 patients who underwent TLIF surgery for various spinal pathologies. Patients were divided into the control group (underwent TLIF with interbody cage and local bone grafts alone) and the study group (underwent TLIF with interbody cage, local bone grafts, and PRP). Functional outcome was evaluated using visual analog score (VAS) and Oswestry disability index (ODI). Radiological outcome was assessed by Bridwell’s grading system for fusion on computed tomography scan at the end of 2 years. Results: The average bone fusion rate was significantly higher in the PRP group compared to the control group; however, the average duration of fusion was not statistically significant. There was no difference in VAS and ODI at 1 and 2 years. There was also no significant difference in lower back pain, leg pain, and numbness in both groups at the end of 1 year. Conclusion: Although there is no statistically significant difference in functional outcome between both groups, local application of PRP along with autologous bone grafts increases bone fusion rates with good clinical and radiological outcomes.

Postoperative lordosis distribution index, patient reported outcome measures, and revision surgery following transforaminal lumbar interbody fusion

ObjectiveLordosis Distribution Index (LDI) is a new radiographic parameter associated with postoperative residual symptoms in patients undergoing Transforaminal Lumbar Interbody Fusion (TLIF). Recently, it has been applied on patients undergoing instrumented spine surgery, however not correlated to Patient Related Outcome Measures (PROMs). This study investigates whether the obtained the postoperative LDI after TLIF surgery correlates with the clinical outcome measured with PROMs. MethodsThis study was based on prospectively obtained data in patients undergoing TLIF throughout 2017 at a Danish university hospital. Medical records and the DaneSpine Database were accessed to obtain preoperative, operative and follow-up data. Primary outcome was Oswestry Disability Index (ODI) 12 months postoperatively. Secondary outcomes included revision rate and additional PROMs. Results126 patients were included. 70 patients were classified with normolordosis (56 %), 42 hypolordosis (33 %) and 14 hyperlordosis (11 %). All groups experienced significant radiological changes undergoing surgery. Average reduction in ODI at 12 months postoperatively was −15.3 (±20.0). Minimally clinical important difference was achieved in 68 patients (54.0 %). No significant difference in PROMs between LDI-groups was observed in unadjusted or adjusted analyses. Revision surgery was performed in 8 patients with normolordosis (11.4 %), 7 hypolordosis (16.7 %) and 4 hyperlordosis (28.6 %). ConclusionsWe found no significant correlation between postoperative LDI subgroups of normolordotic, hypo- or hyperlordotic patients and the clinical outcome of posterolateral fusion and TLIF surgery. A trend towards lower rate of revision surgery in the normolordotic group compared to the hypo- and hyperlordotic group was observed.

Safety and benefit of ambulation within 24 hours in elderly patients undergoing lumbar fusion: propensity score matching study of 882 patients

BACKGROUND CONTEXTElderly patients are less likely to recover from lumbar spine fusion (LSF) as rapidly compared with younger patients. However, there is still a lack of research on the effect of early ambulation on elderly patients undergoing LSF surgery for lumbar degenerative disorders. PURPOSETo evaluate the safety and benefit of ambulation within 24 hours in elderly patients who underwent LSF. STUDY DESIGNA retrospective study. PATIENT SAMPLEConsecutive patients (aged 65 and older) who underwent elective transforaminal lumbar interbody fusion surgery for degenerative disorders from January 2019 to October 2022. OUTCOME MEASURESOutcome measures included postoperative complications, postoperative drainage (mL), laboratory test data, length of hospital stay (LOS), readmission and reoperation within 3 months. METHODSEarly ambulation patients (ambulation within 24 hours after surgery) were propensity-score matched 1:1 to a delayed ambulation patients (ambulation at a minimum of 48 hours postoperatively) based on age, intraoperative blood loss, and number of fused segments. The incidence of postoperative adverse events (AEs, including rates of complications, readmission, and prolonged LOS) and the average LOS were used to assess the safety and benefit of early ambulation, respectively. Multivariable regression analysis was performed to assess the association between early ambulation and postoperative AEs. The risk factors for delayed ambulation were also determined using multivariable logistic analyses. RESULTSA total of 998 patients with LSF surgery were reviewed in this study. After excluding 116 patients for various reasons, 882 patients (<24 hours: N=350, 24–48 hours: N=230, and >48 hours: N= 302) were included in the final analysis. After matching, sex, BMI, preoperative comorbidities, laboratory test data and surgery-related variables were comparable between the groups. The incidence of postoperative AEs was significantly lower in the EA group (44.3% vs 64.0%, p<.001). The average postoperative LOS of the EA group was 2 days shorter than the DA group (6.5 days vs 8.5 days, p<.001). Patients in the EA group had a significantly lower rate of prolonged LOS compared with the DA group (35.1% vs 55.3%, p<.001). There was no significant difference in postoperative drainage volumes between the two groups. Multivariable analysis identified older age (odds ratio [OR] 1.07, p<.001), increased intraoperative EBL (OR 1.002, p=.001), and higher international normalization ratio (OR 10.57, p=.032) as significant independent risk factors for delayed ambulation. CONCLUSIONSAmbulation within 24 hours after LSF surgery is independently associated fewer AEs and shorter hospital stays in elderly patients. Implementing the goal of ambulation within 24 hours after LSF surgery into enhanced recovery after surgery protocols for elderly patients seems appropriate. Older age, increased intraoperative blood loss and worse coagulation function are associated with delayed ambulation.

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.

Compare the outcomes of minimally invasive versus opentransforaminal lumbar interbody fusion in treatment lumbar spinal stenosis

Background: Minimally invasive-transforaminal lumbar interbody fusion has become an effective method to treat lumbar spinal stenosis and is widely used. This article compares the effectiveness of minimally invasive and open transforaminal lumbar interbody fusion surgery in treating lumbar spinal stenosis. Methods: From 9/2018 to 10/2022, 104 patients with lumbar spinal stenosis were treated with transforaminal lumbar interbody fusion, including 52 cases in the minimally invasive surgery group and 52 cases in the open surgery group. Parameters such as surgery time, blood loss, postoperative time, hospital stay, and complications were recorded. The Visual Analog Scale (VAS) was used to assess low back and leg pain, and the Oswestry Disability Index (ODI) was used to assess pain and functional outcome in preoperation, three months, and six months after surgery. Follow-up plain X ray were taken to evaluate the fusion after 2 years. Results: The two groups found no significant differences in age, sex ratio, and percentage of cause spinal stenosis data. Compared with the open surgery group, the minimally invasive surgery group had less intraoperative blood loss (127.50 ± 27.99 mL vs 25.12 ± 62.05 mL, P &lt; 0.001), bed immobilization time shorter (1.21 ± 0.41 days versus 2.40 ± 0.60 days, P &lt; 0.001) and shorter postoperative hospital stay (4.42 ± 0.94 days versus 6.77 ± 1.13 days, P &lt; 0.001). VAS scores of low back pain and leg pain and ODI scores of the two groups decreased statistically significantly compared to before surgery, but there was no difference between the two groups after six months. X-ray showed no significant difference in fusion of the two groups. Conclusion: Our study showed that minimally invasive transforaminal lumbar interbody fusion is a safe and effective option in treating lumbar spinal stenosis and has the advantage of less blood loss and less hospital stay compared to open surgery. Key words: Transforaminal lumbar interbody fusion (TLIF), minimally invasive spine surgery, open spine surgery, spinal stenosis.

Postoperative Sclerotic Modic Changes After Transforaminal Lumbar Interbody Fusion: The Prevalence, Risk Factors, and Impact on Fusion.

A retrospective cohort study. This study aimed to assess postoperative sclerotic modic changes (MCs) following transforaminal lumbar interbody fusion for lumbar degenerative disc disease, investigating their prevalence, risk factors, and association with clinical outcomes. Sclerotic MCs may occur in patients with lumbar degenerative disc disease after lumbar interbody fusion. The incidence and characteristics of postoperative sclerotic MCs, as well as their clinical impact, are unknown. The study included 467 patients (510 levels) who underwent single or two-level transforaminal lumbar interbody fusion surgery, divided into a postoperative sclerotic MC group (60 patients, 66 levels) and a non-MC group (407 patients, 444 levels). The time of development and location of postoperative sclerotic MCs, fusion rate, cage subsidence, bilateral process decompression, and cross-link usage were recorded. Preoperative, postoperative, and follow-up visual analogue scale and Oswestry disability index scores were collected. Multivariable logistic regression was used to evaluate factors associated with the development of postoperative sclerotic MCs. The prevalence of postoperative sclerotic MCs was 12.8%. The postoperative sclerotic MC group had a higher body mass index (BMI). The postoperative sclerotic MC group demonstrated a fusion rate of 47%, significantly lower than that of the non-MC group (71%) at six months post-operation. At final follow-up, the fusion rate in the postoperative sclerotic MC group was 62%, significantly lower than that of the non-MC group (86%). Postoperative visual analogue scale and Oswestry disability index scores were significantly higher in the group with postoperative sclerotic MCs. BMI and osteoporosis were significantly associated with the development of postoperative sclerotic MCs. Postoperative sclerotic MCs generally appear within the first year after surgery, with a prevalence of 12.8%. The presence of postoperative sclerotic MCs can adversely impact postoperative outcomes. To prevent postoperative sclerotic MCs, the authors postulate extending the immobilization period with external bracing and improving the management of BMI and osteoporosis in the perioperative time window.

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.

Comparison of screw placement guided by O-arm navigation and ultrasound volume navigation in minimally invasive transforaminal lumbar interbody fusion

To compare the effectiveness of O-arm navigation and ultrasound volume navigation (UVN) in guiding screw placement during minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) surgery. Sixty patients who underwent MIS-TLIF surgery for lumbar disc herniation between June 2022 and June 2023 and met the selection criteria were included in the study. They were randomly assigned to group A (screw placement guided by UVN during MIS-TLIF) or group B (screw placement guided by O-arm navigation during MIS-TLIF), with 30 cases in each group. There was no significant difference in baseline data, including gender, age, body mass index, and surgical segment, between the two groups ( P>0.05). Intraoperative data, including average single screw placement time, total radiation dose, and average single screw effective radiation dose, were recorded and calculated. Postoperatively, X-ray film and CT scans were performed at 10 days to evaluate screw placement accuracy and assess facet joint violation. Pearson correlation and Spearman correlation analyses were used to observe the relationship between the studied parameters (average single screw placement time and screw placement accuracy grading) and BMI. The average single screw placement time in group B was significantly shorter than that in group A, and the total radiation dose of single segment and multi-segment and the average single screw effective radiation dose in group B were significantly higher than those in group A ( P<0.05). There was no significant difference in the total radiation dose between single segment and multiple segments in group B ( P>0.05), while the total radiation dose of multiple segments was significantly higher than that of single segment in group A ( P<0.05). No significant difference was found in the accuracy of screw implantation between the two groups ( P>0.05). In both groups, the grade 1 and grade 2 screws broke through the outer wall of the pedicle, and no screw broke through the inner wall of the pedicle. There was no significant difference in the rate of facet joint violation between the two groups ( P>0.05). In group A, both the average single screw placement time and screw placement accuracy grading were positively correlated with BMI ( r=0.677, P<0.001; r=0.222, P=0.012), while in group B, neither of them was correlated with BMI ( r=0.224, P=0.233; r=0.034, P=0.697). UVN-guided screw placement in MIS-TLIF surgery demonstrates comparable efficiency, visualization, and accuracy to O-arm navigation, while significantly reducing radiation exposure. However, it may be influenced by factors such as obesity, which poses certain limitations.

Evaluating the Efficacy of Water-Soluble Bone Wax (Tableau Wax) in Reducing Blood Loss in Spinal Fusion Surgery: A Randomized, Controlled, Pilot Study.

Background and Objectives: Lumbar decompression with fusion surgery is an effective treatment for spinal stenosis, but critical postoperative hematoma is a concern. Bone wax has been widely used to control bone bleeding but it has some drawbacks. This study aimed to evaluate the efficacy of Tableau wax, a bioabsorbable hemostatic material, in patients undergoing spinal fusion surgery through a pilot study design. Materials and Methods: A total of 31 patients were enrolled in this single-surgeon, single-institution study. The participants underwent transforaminal lumbar interbody fusion surgery and were randomly assigned to the control group (Bone wax) or test group (Tableau wax). Demographic data, pre- and post-operative hemoglobin levels, blood loss volume, surgical time, Oswestry Disability Index, and EQ-5D scores were recorded. Results: The study showed no significant difference in preoperative and postoperative hemoglobin levels, Oswestry Disability Index, and EQ-5D scores between the groups. However, the Tableau wax group had a significantly lower reduction in hemoglobin levels (1.3 ± 1.0 g/dL) and blood loss (438.2 mL) compared to the Bone wax group (2.2 ± 0.9 g/dL and 663.1 mL, respectively; p = 0.018 and p = 0.022).

Establishment and validation of a nomogram model for postoperative surgical site infection after transforaminal lumbar interbody fusion: A retrospective observational study

BackgroundSurgical site infection is one of the serious complications of transforaminal lumbar interbody fusion surgery, and many factors affect its occurrence. MethodsA total of 1,277 patients who underwent transforaminal lumbar interbody fusion between 2018 and 2021 were enrolled in this study. Subsequently, 1,277 patients were randomly assigned to a training cohort (N = 958) and a validation cohort (N = 319) in a 3:1 ratio. We developed a nomogram according to the results of binary logistic regression analysis in the training cohort. The nomogram's predictive accuracy and discriminative ability were evaluated by calibration curve and receiver operating characteristic analysis. Decision curve analysis was performed to estimate the clinical value of our nomogram. ResultsIn univariate and multivariate analysis, smoking, diabetes, intraoperative blood loss, American Society of Anesthesiologists class ≥III, serum calcium, albumin, and serum glucose were identified as significant independent predictors. The nomogram was developed using these independent predictors, which showed good diagnostic accuracy for surgical site infection of the training and validation cohorts. The calibration curves for the 2 cohorts showed optimal agreement between nomogram prediction and actual observation. The decision curve analysis of the nomogram model showed the great clinical use of the nomogram. ConclusionThe nomogram based on smoking, diabetes, intraoperative blood loss, American Society of Anesthesiologists class, serum calcium, albumin, and serum glucose has the potential as a clinically useful predictive tool of surgical site infection after transforaminal lumbar interbody fusion surgery. It is helpful to visualize the risk factors of surgical site infection.