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Baker JF, Errico TJ, Kim Y, Razi A. Degenerative spondylolisthesis: contemporary review of the role of interbody fusion. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2016; 27:169-180. [PMID: 27888353 DOI: 10.1007/s00590-016-1885-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/17/2016] [Accepted: 11/11/2016] [Indexed: 01/03/2023]
Abstract
Degenerative spondylolisthesis is a common presentation, yet the best surgical treatment continues to be a matter of debate. Interbody fusion is one of a number of options, but its exact role remains ill defined. The aim of this study was to provide a contemporary review of the literature to help determine the role, if any, of interbody fusion in the surgical treatment of degenerative spondylolisthesis. A systematic review of the literature since 2005 was performed. Details on study size, patient age, surgical treatments, levels of slip, patient reported outcome measures, radiographic outcomes, complications and selected utility measures were recorded. Studies that compared a cohort treated with interbody fusion and at least one other surgical intervention for comparison were included for review. Only studies examining the effect in degenerative spondylolisthesis were included. Two authors independently reviewed the manuscripts and extracted key data. Thirteen studies were included in the final analysis. A total of 565 underwent interbody fusion and 761 underwent other procedures including decompression alone, interspinous stabilisation and posterolateral fusion with or without instrumentation. Most studies were graded Level III evidence. Heterogeneous reporting of outcomes prevented formal statistical analysis. However, in general, studies reviewed concluded no significant clinical or radiographic difference in outcome between interbody fusion and other treatments. Two small studies suggested interbody fusion is a better option in cases of definite instability. Interbody fusion only provided outcomes as good as instrumented posterolateral fusion. However, most studies were Level III, and hence, we remain limited in defining the exact role of interbody fusion-cases with clear instability appear to be most appropriate. Future work should use agreed-upon common outcome measures and definitions.
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Affiliation(s)
- Joseph F Baker
- Department of Spine and Spinal Deformity Surgery, NYU Langone Medical Center Hospital for Joint Diseases, 301 East 17th Street, New York, NY, 10002, USA.
| | - Thomas J Errico
- Department of Spine and Spinal Deformity Surgery, NYU Langone Medical Center Hospital for Joint Diseases, 301 East 17th Street, New York, NY, 10002, USA
| | - Yong Kim
- Department of Spine and Spinal Deformity Surgery, NYU Langone Medical Center Hospital for Joint Diseases, 301 East 17th Street, New York, NY, 10002, USA
| | - Afshin Razi
- Department of Spine and Spinal Deformity Surgery, NYU Langone Medical Center Hospital for Joint Diseases, 301 East 17th Street, New York, NY, 10002, USA
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Applying the Mini-Open Anterolateral Lumbar Interbody Fusion with Self-Anchored Stand-Alone Polyetheretherketone Cage in Lumbar Revision Surgery. BIOMED RESEARCH INTERNATIONAL 2016; 2016:1758352. [PMID: 27885355 PMCID: PMC5112305 DOI: 10.1155/2016/1758352] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/23/2016] [Revised: 09/04/2016] [Accepted: 09/28/2016] [Indexed: 12/15/2022]
Abstract
The author retrospectively studied twenty-two patients who underwent revision lumbar surgeries using ALLIF with a self-anchored stand-alone polyetheretherketone (PEEK) cage. The operation time, blood loss, and perioperative complications were evaluated. Oswestry disability index (ODI) scores and visual analog scale (VAS) scores of leg and back pain were analyzed preoperatively and at each time point of postoperative follow-up. Radiological evaluation including fusion, disc height, foraminal height, and subsidence was assessed. The results showed that the ALLIF with a self-anchored stand-alone PEEK cage is safe and effective in revision lumbar surgery with minor surgical trauma, low access-related complication rates, and satisfactory clinical and radiological results.
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Coe JD, Zucherman JF, Kucharzyk DW, Poelstra KA, Miller LE, Kunwar S. Multiexpandable cage for minimally invasive posterior lumbar interbody fusion. MEDICAL DEVICES-EVIDENCE AND RESEARCH 2016; 9:341-347. [PMID: 27729817 PMCID: PMC5047724 DOI: 10.2147/mder.s112523] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
The increasing adoption of minimally invasive techniques for spine surgery in recent years has led to significant advancements in instrumentation for lumbar interbody fusion. Percutaneous pedicle screw fixation is now a mature technology, but the role of expandable cages is still evolving. The capability to deliver a multiexpandable interbody cage with a large footprint through a narrow surgical cannula represents a significant advancement in spinal surgery technology. The purpose of this report is to describe a multiexpandable lumbar interbody fusion cage, including implant characteristics, intended use, surgical technique, preclinical testing, and early clinical experience. Results to date suggest that the multiexpandable cage allows a less invasive approach to posterior/transforaminal lumbar interbody fusion surgery by minimizing iatrogenic risks associated with static or vertically expanding interbody prostheses while providing immediate vertebral height restoration, restoration of anatomic alignment, and excellent early-term clinical results.
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Affiliation(s)
| | | | | | - Kornelis A Poelstra
- Department of Surgery, Sacred Heart Hospital on the Emerald Coast, Miramar Beach, FL
| | | | - Sandeep Kunwar
- Bell Neuroscience Institute, Washington Hospital Healthcare System, Fremont, CA, USA
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Clinical Outcomes of Posterior Lumbar Interbody Fusion versus Minimally Invasive Transforaminal Lumbar Interbody Fusion in Three-Level Degenerative Lumbar Spinal Stenosis. BIOMED RESEARCH INTERNATIONAL 2016; 2016:9540298. [PMID: 27747244 PMCID: PMC5056235 DOI: 10.1155/2016/9540298] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/09/2016] [Accepted: 09/05/2016] [Indexed: 12/25/2022]
Abstract
The aim of this study was to directly compare the clinical outcomes of posterior lumbar interbody fusion (PLIF) and minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) in three-level lumbar spinal stenosis. This retrospective study involved a total of 60 patients with three-level degenerative lumbar spinal stenosis who underwent MIS-TLIF or PLIF from January 2010 to February 2012. Back and leg visual analog scale (VAS), Oswestry Disability Index (ODI), and Short Form-36 (SF-36) scale were used to assess the pain, disability, and health status before surgery and postoperatively. In addition, the operating time, estimated blood loss, and hospital stay were also recorded. There were no significant differences in back VAS, leg VAS, ODI, SF-36, fusion condition, and complications at 12-month follow-up between the two groups (P > 0.05). However, significantly less blood loss and shorter hospital stay were observed in MIS-TLIF group (P < 0.05). Moreover, patients undergoing MIS-TLIF had significantly lower back VAS than those in PLIF group at 6-month follow-up (P < 0.05). Compared with PLIF, MIS-TLIF might be a prior option because of noninferior efficacy as well as merits of less blood loss and quicker recovery in treating three-level lumbar spinal stenosis.
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Epstein NE. Extreme lateral lumbar interbody fusion: Do the cons outweigh the pros? Surg Neurol Int 2016; 7:S692-S700. [PMID: 27843688 PMCID: PMC5054636 DOI: 10.4103/2152-7806.191079] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2016] [Accepted: 08/02/2016] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Major factors prompted the development of minimally invasive (MIS) extreme lateral interbody fusion (XLIF; NuVasive Inc., San Diego, CA, USE) for the thoracic/lumbar spine. These include providing interbody stabilization and indirect neural decompression while avoiding major visceral/vessel injury as seen with anterior lumbar interbody fusion (ALIF), and to avert trauma to paraspinal muscles/facet joints found with transforaminal lumbar interbody fusion (TLIF), posterior lumbar interbody fusion (PLIF), and posterior-lateral fusion techniques (PLF). Although anticipated pros of MIS XLIF included reduced blood loss, operative time, and length of stay (LOS), they also included, higher fusion, and lower infection rates. Unanticipated cons, however, included increased morbidity/mortality rates. METHODS We assessed the pros and cons (e.g., risks, complications, comparable value/superiority/inferiority, morbidity/mortality) of MIS XLIF vs. ALIF, TLIF, PLIF, and PLF. RESULTS Pros of XLIF included various biomechanical and technical surgical advantages, along with multiple cons vs. ALIF, TLIF, PLIF, and PLF. For example, XLIF correlated with a considerably higher frequency of major neurological deficits vs. other constructs; plexus injuries 13.28%, sensory deficits 0-75% (permanent in 62.5%), motor deficits 0.7-33.6%, and anterior thigh pain 12.5-25%. XLIF also disproportionately contributed to other major morbidity/mortality; sympathectomy, major vascular injuries (some life-ending others life-threatening), bowel perforations, and seromas. Furthermore, multiple studies documented no superiority, and the potential inferiority of XLIF vs. ALIF, TLIF, PLIF, and PLF. CONCLUSION Reviewing the pros of XLIF (e.g. radiographic, technical, biomechanical) vs. the cons (inferiority, increased morbidity/mortality) vs. ALIF, TLIF, PLIF, and PLF, we question whether XLIF should remain part of the lumbar spinal surgical armamentarium.
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Affiliation(s)
- Nancy E. Epstein
- Chief of Neurosurgical Spine and Education, Department of Neurosurgery, Winthrop University Hospital, Mineola, New York – 11501, USA
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Neurological Complications after Lateral Transpsoas Approach to Anterior Interbody Fusion with a Novel Flat-Blade Spine-Fixed Retractor. BIOMED RESEARCH INTERNATIONAL 2016; 2016:8450712. [PMID: 27294140 PMCID: PMC4880715 DOI: 10.1155/2016/8450712] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/22/2016] [Revised: 04/13/2016] [Accepted: 04/19/2016] [Indexed: 11/24/2022]
Abstract
Introduction. The lateral lumbar interbody fusion (LLIF) surgical approach has potential advantages over other approaches but is associated with some unique neurologic risks due to the proximity of the lumbosacral plexus. The present study analyzed complications following LLIF surgical approach using a novel single flat-blade retractor system. Methods. A retrospective data collection of patients receiving LLIF using a novel single flat-blade retractor system at two institutions in the US. Inclusion criteria were all patients receiving an LLIF procedure with the RAVINE® Lateral Access System (K2M, Inc., Leesburg, VA, USA). There was no restriction on preoperative diagnosis or number of levels treated. Approach-related neurologic complications were collected and analyzed postoperatively through a minimum of one year. Results. Analysis included 253 patients with one to four treated lateral levels. Immediate postoperative neurologic complications were present in 11.1% (28/253) of patients. At one-year follow-up the approach-related neurologic complications resolved in all except 5 patients (2.0%). Conclusion. We observed an 11.1% neurologic complication rate in LLIF procedures. There was resolution of symptoms for most patients by 12-month follow-up, with only 2% of patients with residual symptoms. This supports the hypothesis that the vast majority of approach-related neurologic symptoms are transient.
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Choi MK, Kim SB, Park BJ, Park CK, Kim SM. Do Trunk Muscles Affect the Lumbar Interbody Fusion Rate?: Correlation of Trunk Muscle Cross Sectional Area and Fusion Rates after Posterior Lumbar Interbody Fusion Using Stand-Alone Cage. J Korean Neurosurg Soc 2016; 59:276-81. [PMID: 27226860 PMCID: PMC4877551 DOI: 10.3340/jkns.2016.59.3.276] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2015] [Revised: 10/06/2015] [Accepted: 10/14/2015] [Indexed: 11/27/2022] Open
Abstract
Objective Although trunk muscles in the lumbar spine preserve spinal stability and motility, little is known about the relationship between trunk muscles and spinal fusion rate. The aim of the present study is to evaluate the correlation between trunk muscles cross sectional area (MCSA) and fusion rate after posterior lumbar interbody fusion (PLIF) using stand-alone cages. Methods A total of 89 adult patients with degenerative lumbar disease who were performed PLIF using stand-alone cages at L4–5 were included in this study. The cross-sectional area of the psoas major (PS), erector spinae (ES), and multifidus (MF) muscles were quantitatively evaluated by preoperative lumbar magnetic resonance imaging at the L3–4, L4–5, and L5–S1 segments, and bone union was evaluated by dynamic lumbar X-rays. Results Of the 89 patients, 68 had bone union and 21 did not. The MCSAs at all segments in both groups were significantly different (p<0.05) for the PS muscle, those at L3–4 and L4–5 segments between groups were significantly different (p=0.048, 0.021) for the ES and MF muscles. In the multivariate analysis, differences in the PS MCSA at the L4–5 and L5–S1 segments remained significant (p=0.048, 0.043 and odds ratio=1.098, 1.169). In comparison analysis between male and female patients, most MCSAs of male patients were larger than female's. Fusion rates of male patients (80.7%) were higher than female's (68.8%), too. Conclusion For PLIF surgery, PS muscle function appears to be an important factor for bone union and preventing back muscle injury is essential for better fusion rate.
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Affiliation(s)
- Man Kyu Choi
- Department of Medicine, Graduate School, Kyung Hee University, Seoul, Korea
| | - Sung Bum Kim
- Department of Neurosurgery, Kyung Hee University Hospital, Kyung Hee University School of Medicine, Seoul, Korea
| | - Bong Jin Park
- Department of Neurosurgery, Kyung Hee University Hospital, Kyung Hee University School of Medicine, Seoul, Korea
| | - Chang Kyu Park
- Department of Neurosurgery, Kyung Hee University Hospital, Kyung Hee University School of Medicine, Seoul, Korea
| | - Sung Min Kim
- Department of Neurosurgery, Kyung Hee University Hospital at Gangdong, Kyung Hee University School of Medicine, Seoul, Korea
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Lateral Lumbar Interbody Fusion in Ambulatory Surgery Centers: Patient Selection and Outcome Measures Compared With an Inhospital Cohort. Spine (Phila Pa 1976) 2016; 41:686-92. [PMID: 27064334 DOI: 10.1097/brs.0000000000001285] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Comparative analysis. OBJECTIVE To evaluate the safety and outcomes of moving lateral lumbar interbody fusion (LLIF) surgeries to an outpatient setting. SUMMARY OF BACKGROUND DATA LLIF has been popularized as a less invasive lumbar fusion surgery as an alternative approach to anterior lumbar interbody fusions, posterior lateral interbody fusion, and transforaminal lateral interbody fusion (TLIF). Lumbar fusions have been traditionally performed in a hospital setting because of the potential blood loss, length of surgery, and need for longer recovery. There is a movement to transition spine surgeries to outpatient settings with many benefits afforded by less invasive techniques and technologies. METHODS The medical records of 70 consecutive patients with prospectively collected data were retrospectively reviewed. Two cohort groups, inpatients (40 patients) and outpatients (30 patients), were created. Patient demographics, risk factors, and body mass index (BMI) were evaluated to determine inclusion criteria for study. RESULT A total of 34 males and 36 females, age range (31-71) average 59.3 ± 2.3 years. Average BMI was 29.6 ± 1.1 kg/m. The most common level operated on being L3-L4 in both groups (63%). Mean preoperative inpatient Oswestry Disability Index (ODI) increased from 48.5 ± 3.0 to 55.5 ± 3.2 compared with outpatient preoperative ODI means reduced from 45.2 ± 5.1 to 39.1 ± 4.6. There was no statistically significant change in VAS scores between groups. There was however significant improvement in outpatient preoperative VAS scores from 7.3 ± 0.5 to 4.1 ± 0.5, P = 0.045. CONCLUSION The outcomes of the present study have shown that patients who had LLIF performed in the outpatient setting had statistically significant improvement in ODI scores compared with the inpatient setting (P = 0.013). Fusion was achieved in all patients and there was no evidence of implant failure or subsidence. Complications were transient in both settings. We conclude that outpatient LLIF improves patients' outcomes with similar safety profile as the hospital setting. LEVEL OF EVIDENCE 3.
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Epstein NE. More nerve root injuries occur with minimally invasive lumbar surgery, especially extreme lateral interbody fusion: A review. Surg Neurol Int 2016; 7:S83-95. [PMID: 26904372 PMCID: PMC4743267 DOI: 10.4103/2152-7806.174895] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2015] [Accepted: 11/02/2015] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND In the lumbar spine, do more nerve root injuries occur utilizing minimally invasive surgery (MIS) techniques versus open lumbar procedures? To answer this question, we compared the frequency of nerve root injuries for multiple open versus MIS operations including diskectomy, laminectomy with/without fusion addressing degenerative disc disease, stenosis, and/or degenerative spondylolisthesis. METHODS Several of Desai et al. large Spine Patient Outcomes Research Trial studies showed the frequency for nerve root injury following an open diskectomy ranged from 0.13% to 0.25%, for open laminectomy/stenosis with/without fusion it was 0%, and for open laminectomy/stenosis/degenerative spondylolisthesis with/without fusion it was 2%. RESULTS Alternatively, one study compared the incidence of root injuries utilizing MIS transforaminal lumbar interbody fusion (TLIF) versus posterior lumbar interbody fusion (PLIF) techniques; 7.8% of PLIF versus 2% of TLIF patients sustained root injuries. Furthermore, even higher frequencies of radiculitis and nerve root injuries occurred during anterior lumbar interbody fusions (ALIFs) versus extreme lateral interbody fusions (XLIFs). These high frequencies were far from acceptable; 15.8% following ALIF experienced postoperative radiculitis, while 23.8% undergoing XLIF sustained root/plexus deficits. CONCLUSIONS This review indicates that MIS (TLIF/PLIF/ALIF/XLIF) lumbar surgery resulted in a higher incidence of root injuries, radiculitis, or plexopathy versus open lumbar surgical techniques. Furthermore, even a cursory look at the XLIF data demonstrated the greater danger posed to neural tissue by this newest addition to the MIS lumbar surgical armamentariu. The latter should prompt us as spine surgeons to question why the XLIF procedure is still being offered to our patients?
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Affiliation(s)
- Nancy E Epstein
- Department of Neurousrgery, Winthrop Neuroscience, Winthrop University Hospital, Mineola, New York, USA
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Quillo-Olvera J, Soriano-Solis S, Ortiz-Leyva RU, Gutiérrez-Partida CF, Rodríguez-García M, Soriano-Sánchez JA. MICROSURGICAL LANDMARKS IN MINIMALLY INVASIVE TRANSFORAMINAL LUMBAR INTERBODY FUSION. COLUNA/COLUMNA 2015. [DOI: 10.1590/s1808-185120151404152838] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
Microsurgical landmarks of the facet joint complex were defined to provide guidance and security within the tubular retractor during transforaminal surgery. A retrospective observational study was performed in segments L4-L5 by the left side approach. Microsurgical relevant photos, anatomical models and drawing were used to expose the suggested landmarks. The MI-TLIF technique has advantages compared with conventional open TLIF technique, however minimally invasive technique implies lack of security for the surgeon due to the lack of defined microanatomical landmarks compared to open spine surgery, and disorientation within the tubular retractor, the reason why to have precise microsurgical references and its recognition within the surgical field provide speed and safety when performing minimally invasive technique.
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Liu J, Deng H, Long X, Chen X, Xu R, Liu Z. A comparative study of perioperative complications between transforaminal versus posterior lumbar interbody fusion in degenerative lumbar spondylolisthesis. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2015; 25:1575-1580. [PMID: 26126415 DOI: 10.1007/s00586-015-4086-8] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/30/2015] [Revised: 06/18/2015] [Accepted: 06/18/2015] [Indexed: 11/25/2022]
Abstract
BACKGROUND Both posterior lumbar interbody fusion (PLIF) and transforaminal lumbar interbody fusion (TLIF) are accepted surgical techniques for the treatment of degenerative lumbar spondylolisthesis (DLS). However, it is still unclear one technique offers distinct advantages over the other. OBJECTIVE A retrospective study was performed to compare perioperative complications and functional outcomes of patients undergoing TLIF versus PLIF for DLS. METHODS A total of 226 consecutive patients who underwent surgery for treatment of DLS at three institutions were evaluated from January 2012 to December 2014. In this series, 125 patients underwent PLIF and 101 received TLIF. The operative time, blood loss, allogeneic blood transfusion rate and perioperative complications (including re-operative rate, nerve root injury, dural tear, wound infection) were compared between the two groups. Pain (VAS) and functional outcomes of patients (Kirkaldy-Willis criteria) were quantified before surgery and 1 week after surgery. RESULTS Patients involved in the two groups had similar baseline demographic, clinical and radiographic characteristics. The PLIF group was associated with a higher incidence of post-operative iatrogenic nerve root dysfunction [12 cases (9.6 %) versus 2 cases (1.9 %), P = 0.018] and dural tears [15 cases (12 %) versus 4 cases (3.9 %), P = 0.030]. The re-operation rate was significantly higher in patients undergoing PLIF [13 cases (10.4 %) versus 2 cases (1.9 %), P = 0.011]. In addition, intra-operative blood loss, operative times, and allogeneic blood transfusion rates were higher in the PLIF group when compared to the TLIF group (P < 0.05). The wound infection rate of the PLIF group was similar to that of the TLIF group (7.2 versus 5.0 %, P = 0.486). VAS scores were decreased from 7.08 ± 1.13 to 2.84 ± 0.89 in the PLIF group, and from 7.18 ± 1.09 to 2.84 ± 0.91 in the TLIF group, respectively (P = 0.32). 85.6 % of patients in the TLIF group had good or excellent functional outcomes within the first post-operative week compared to 83.2 % in the PLIF group (P = 0.64). CONCLUSION Both PLIF and TLIF were equally beneficial in improving short-term functional outcomes for patients with DLS. However, PLIFs were associated with statistically significant higher incidences of nerve root injury, dural tears, allogeneic blood transfusion, increased intra-operative times, blood loss and re-operations. Therefore, caution should be exercised when considering PLIFs.
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Affiliation(s)
- Jiaming Liu
- Department of Orthopedic Surgery, The First Affiliated Hospital of Nanchang University, No. 17 Yongwaizheng Street, Donghu District, Nanchang, 330006, Jiangxi, People's Republic of China
| | - Huilin Deng
- Department of Orthopedic Surgery, The First Affiliated Hospital of Nanchang University, No. 17 Yongwaizheng Street, Donghu District, Nanchang, 330006, Jiangxi, People's Republic of China
| | - Xinhua Long
- Department of Orthopedic Surgery, The First Affiliated Hospital of Nanchang University, No. 17 Yongwaizheng Street, Donghu District, Nanchang, 330006, Jiangxi, People's Republic of China
| | - Xuanyin Chen
- Department of Orthopedic Surgery, The First Affiliated Hospital of Nanchang University, No. 17 Yongwaizheng Street, Donghu District, Nanchang, 330006, Jiangxi, People's Republic of China
| | - Risheng Xu
- Department of Neurosurgery, Johns Hopkins Hospital, 1800 Orleans St, Sheikh Zayed Tower, Baltimore, MD, 21287, USA.
| | - Zhili Liu
- Department of Orthopedic Surgery, The First Affiliated Hospital of Nanchang University, No. 17 Yongwaizheng Street, Donghu District, Nanchang, 330006, Jiangxi, People's Republic of China.
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