Awake Endoscopic Transforaminal Lumbar Interbody Fusion: A Technical Note

BACKGROUND

Advances in modern spinal fusion techniques have allowed for less peri-operative morbidity and more rapid recovery from surgery. The addition of endoscopy to minimally invasive surgery (MIS) fusion techniques represents the latest progression of efforts to minimize the impact of surgical intervention.

TECHNIQUE

MIS transforaminal lumbar interbody fusion (TLIF) is performed endoscopically through a sub-centimeter working portal. Patients undergo light conscious sedation and remain awake to facilitate feedback with the surgeon and enhance post-operative recovery.

RESULTS

Previously reported results of the first 100 cases performed by the senior author at a single institution are summarized. This cohort has been characterized by brief post-operative length of stay, low complication profile, and marked improvement in patient-reported outcomes scores, with no cases of pseudarthrosis at 1-year follow up.

CONCLUSIONS

The latest technical considerations and adaptations of a novel technique for endoscopic MIS spinal fusion without general anesthesia are described. A refined surgical technique and anesthetic protocol are presented in detail with recommendations for the successful implementation and performance of the procedure.

Retrospective Assessment of the Use of Liposomal Bupivacaine in Lumbar Fusions in Immediate Postoperative Hospital Care

BACKGROUND

Liposomal bupivacaine (LB) is approved by the U.S. Food and Drug Administration for administration into surgical sites for postsurgical analgesia. The liposomal formulation allows for sustained effects up to 72 hours.

METHODS

A retrospective study assessed patients undergoing lumbar interbody surgery. Visual analog scale pain scores and amount of opioids consumed were recorded at 12-hour intervals for 72 hours postoperatively, as were patterns of discharge and hospital length of stay (LOS).

RESULTS

A total of 122 patients (97 LB vs. 25 control group) were reviewed. Median LOS was shorter in the LB cohort compared with controls (1.94 vs. 3.08 days, respectively; P = 0.0043). When assessing the percentage of discharges between groups at 12-hour intervals, there were significantly more discharges in the LB cohort at 36-48 hours (P = 0.0226), and no differences elsewhere. There was a decrease in intravenous opioids consumed at 48-60 hours in the LB cohort compared with controls (P = 0.0494), a difference not detected at other time points or with oral or total opioids. Mean visual analog scale scores were significantly higher in the LB cohort compared with controls at 0-12 hours (5.2 vs. 3.9, respectively; P = 0.0079), but insignificantly different subsequently up to 72 hours. The LB cohort and controls were not significantly different in total amount of opioids consumed, overall pain scores, or regarding how the opioid amount consumed or pain scores changed over time.

CONCLUSIONS

The use of LB in lumbar interbody fusion decreases patients' LOS but has little effect on reducing overall pain scores or opioid use in the 72-hour postoperative hospital period.

Technical Considerations of Endoscopic Kambin's Triangle Lumbar Interbody Fusion

The performance of transforaminal endoscopic lumbar interbody fusion through a Kambin's triangle approach requires significant modifications when compared to a traditional transforaminal discectomy. Indeed, due to the inherently limited field of view, small working corridor, and need to deploy an adequately sized interbody graft, there are several important technical adaptations which can help improve the efficacy of this approach. In this manuscript, the technical aspects of a percutaneous, endoscopic interbody fusion are discussed in detail.

[Comparative study on effectiveness of modified-transforaminal lumbar interbody fusion and posterior lumbar interbody fusion surgery in treatment of mild to moderate lumbar spondylolisthesis in middle-aged and elderly patients]

OBJECTIVE

To compare the effectiveness of modified transforaminal lumbar interbody fusion (modified-TLIF) and posterior lumbar interbody fusion (PLIF) for mild to moderate lumbar spondylolisthesis in middle-aged and elderly patients.

METHODS

The clinical data of 106 patients with mild to moderate lumbar spondylolisthesis (Meyerding classification≤Ⅱ degree) who met the selection criteria between January 2015 and January 2017 were retrospectively analysed. All patients were divided into modified-TLIF group (54 cases) and PLIF group (52 cases) according to the different surgical methods. There was no significant difference in preoperative clinical data of gender, age, disease duration, sliding vertebra, Meyerding grade, and slippage type between the two groups ( P>0.05). The intraoperative blood loss, operation time, postoperative drainage volume, postoperative bed time, hospital stay, and complications of the two groups were recorded and compared. The improvement of pain and function were evaluated by the visual analogue scale (VAS) score and Japanese Orthopedic Association (JOA) score at preoperation, 1 week, and 1, 6, 12 months after operation, and last follow-up, respectively. The effect of slip correction was evaluated by slip angle and intervertebral altitude at preoperation and last follow-up, and the effectiveness of fusion was evaluated according to Suk criteria.

RESULTS

All patients were followed up, the modified-TLIF group was followed up 25-36 months (mean, 32.7 months), the PLIF group was followed up 24-38 months (mean, 33.3 months). The intraoperative blood loss, operation time, postoperative drainage volume, postoperative bed time, and hospital stay of the modified-TLIF group were significantly less than those of the PLIF group ( P<0.05). The VAS score and JOA score of both groups were significantly improved at each time point after operation ( P<0.05); the scores of the modified-TLIF group were significantly better than those of the PLIF group at 1 and 6 months after operation ( P<0.05). The slip angle and intervertebral altitude of both groups were obviously improved at last follow-up ( P<0.05), and there was no significant difference between the two groups at preoperation and last follow-up ( P>0.05). At last follow-up, the fusion rate of the modified-TLIF group and the PLIF group was 96.3% (52/54) and 98.1% (51/52), respectively, and no significant difference was found between the two groups ( χ 2=0.000, P=1.000). About complications, there was no significant difference between the two groups in nerve injury on the opposite side within a week, incision infection, and pulmonary infection ( P>0.05). No case of nerve injury on the operation side within a week or dural laceration occurred in the modified-TLIF group, while 8 cases (15.4%, P=0.002) and 4 cases (7.7%, P=0.054) occurred in the PLIF group respectively.

CONCLUSION

Modified-TLIF and PLIF are effective in the treatment of mild to moderate lumbar spondylolisthesis in middle-aged and elderly patients. However, modified-TLIF has relatively less trauma, lower blood loss, lower drainage volume, lower incidence of dural laceration and nerve injury, which promotes enhanced recovery after surgery.

Readmission following complex spine surgery in a prospective cohort of 679 patients - 2-years follow-up using the Spine AdVerse Event Severity (SAVES) system

BACKGROUND CONTEXT

Recent studies suggest that prospective registration more accurately reflects the true incidence of adverse events (AEs). To our knowledge, no previous study has investigated prospectively registered AEs' influence on hospital readmission following spine surgery.

PURPOSE

To determine the frequency and type of unplanned readmissions after complex spine surgery, and to investigate if prospectively registered AEs can predict readmissions.

DESIGN

This is a prospective, consecutive cohort study.

PATIENT SAMPLE

We conducted a single-center study of 679 consecutive patients who underwent complex spine surgery defined as conditions deemed too complicated for surgery at a secondary institute, or patients with severe comorbidities requiring multidisciplinary observation and treatment.

OUTCOME MEASURES

The outcomes in this study were (1) readmission to any hospital department within 30 days of discharge and (2) readmission to a surgical spine center at any time in follow-up.

METHODS

All patients undergoing complex spine surgery, at our tertiary referral center, were consecutively, and prospectively, included from January 1 to December 31, 2013. Demographics and perioperative AEs were registered using the Spine AdVerse Events Severity (SAVES) system. Patients were followed for a minimum of two years. A competing risk survival model was used to estimate rates of readmissions with death as a competing risk. Patient characteristics, surgical parameters and perioperative AEs were analyzed to identify factors associated with readmission. Analyses of 30-day readmission were performed using logistic regression models. A proportional odds model, with death as competing risk, was used for readmissions to a spine center at any time in follow-up. Results were reported as odds ratios with 95% confidence intervals (95% CI).

RESULTS

Within 2 years of index discharge, 443 (65%) were readmitted. Only 20% of readmissions were to a spine center. Cumulative incidence (95% CI) of readmission was estimated to 13% (10%-16%) at 30 days, 26% (23%-30%) at 90 days, 50% (46%-54%) at 1 year, and 59% (55%-63%) at 2 years following discharge. Rates were markedly lower for readmissions to a spine center. Increased odds of 30-day readmission were correlated to intraoperative hypotension (p=.02) and major intraoperative blood loss (p<.01). Readmission to a spine center was associated with the number of instrumented vertebrae (p=.047), major intraoperative AE (p=.01), and intraoperative hypotension (p<.01).

CONCLUSIONS

To the best of our knowledge, this is the first study to analyze prospectively registered AEs' association to readmission up to 2 years after complex spine surgery. We found that readmissions were more frequent than previously reported when including readmissions to any department or hospital. Factors related to major intraoperative blood loss were associated to increased odds of readmission. This should be considered during planning of postoperative observation and care.

Improving recovery after elective degenerative spine surgery: 5-year experience with an enhanced recovery after surgery (ERAS) protocol

OBJECTIVEEnhanced recovery after surgery (ERAS) has led to a paradigm shift in various surgical specialties. Its application can result in substantial benefits in perioperative healthcare utilization through preoperative physical and mental patient optimization and modulation of the recovery process. Still, ERAS remains relatively new to spine surgery. The authors report their 5-year experience, focusing on ERAS application to a broad population of patients with degenerative spine conditions undergoing elective surgical procedures, including anterior lumbar interbody fusion (ALIF).METHODSA multimodal ERAS protocol was applied between November 2013 and October 2018. The authors analyze hospital stay, perioperative outcomes, readmissions, and adverse events obtained from a prospective institutional registry. Elective tubular microdiscectomy and mini-open decompression as well as minimally invasive (MI) anterior or posterior fusion cases were included. Their institutional ERAS protocol contains 22 pre-, intra-, and postoperative elements, including preoperative patient counseling, MI techniques, early mobilization and oral intake, minimal postoperative restrictions, and regular audits.RESULTSA total of 2592 consecutive patients were included, with 199 (8%) undergoing fusion. The mean hospital stay was 1.1 ± 1.2 days, with 20 (0.8%) 30-day and 36 (1.4%) 60-day readmissions. Ninety-four percent of patients were discharged after a maximum 1-night hospital stay. Over the 5-year period, a clear trend toward a higher proportion of patients discharged home after a 1-night stay was observed (p < 0.001), with a concomitant decrease in adverse events in the overall cohort (p = 0.025) and without increase in readmissions. For fusion procedures, the rate of 1-night hospital stays increased from 26% to 85% (p < 0.001). Similarly, the average length of hospital stay decreased steadily from 2.4 ± 1.2 days to 1.5 ± 0.3 days (p < 0.001), with a notable concomitant decrease in variance, resulting in an estimated reduction in nursing costs of 46.8%.CONCLUSIONSApplication of an ERAS protocol over 5 years to a diverse population of patients undergoing surgical procedures, including ALIF, for treatment of degenerative spine conditions was safe and effective, without increase in readmissions. The data from this large case series stress the importance of the multidisciplinary, iterative improvement process to overcome the learning curve associated with ERAS implementation, and the importance of a dedicated perioperative care team. Prospective trials are needed to evaluate spinal ERAS on a higher level of evidence.

Enhanced recovery after spine surgery: a systematic review

OBJECTIVEEnhanced recovery after surgery (ERAS) is a multidimensional approach to improving the care of surgical patients using subspecialty- and procedure-specific evidence-based protocols. The literature provides evidence of the benefits of ERAS implementation, which include expedited functional recovery, decreased postoperative morbidity, reduced costs, and improved subjective patient experience. Although extensively examined in other surgical areas, ERAS principles have been applied to spine surgery only in recent years. The authors examine studies investigating the application of ERAS programs to patients undergoing spine surgery.METHODSThe authors conducted a systematic review of the PubMed and MEDLINE databases up to November 20, 2018.RESULTSTwenty full-text articles were included in the qualitative analysis. The majority of studies were retrospective reviews of nonrandomized data sets or qualitative investigations lacking formal control groups; there was 1 protocol for a future randomized controlled trial. Most studies demonstrated reduced lengths of stay and no increase in rates of readmissions or complications after introduction of an ERAS pathway.CONCLUSIONSThese introductory studies demonstrate the potential of ERAS protocols, when applied to spine procedures, to reduce lengths of stay, accelerate return of function, minimize postoperative pain, and save costs.

The Endoscopic Approach to Lumbar Discectomy, Fusion, and Enhanced Recovery: A Review

STUDY DESIGN

Review.

OBJECTIVES

To review the current state of endoscopic spine surgery with regard to discectomy, interbody fusion, and combination with Enhanced Recovery After Surgery programs in order to evaluate its relevance to the future of spine care.

METHODS

A review of the literature and expert opinion is used to accomplish the objectives.

RESULTS

The greatest strength of endoscopic spine surgery lies in its adherence to the basic tenets of minimally invasive surgery and its innate compatibility with Enhanced Recovery After Surgery programs, which aim to improve outcomes and reduce health care costs. The greatest challenge faced is the unique surgical skill set and significant learning curve.

CONCLUSIONS

Endoscopic spine surgery strives to achieve the core goals of minimally invasive surgery, while reducing cost and enhancing quality. In a healthcare market that is becoming increasingly burdened by cost and regulatory constraints, the utilization of endoscopy may become more widespread in the coming years.

Less Opioid Consumption With Enhanced Recovery After Surgery Transforaminal Lumbar Interbody Fusion (TLIF): A Comparison to Standard Minimally-Invasive TLIF

Objective

The concept of enhanced recovery after surgery (ERAS) is relatively new to the neurosurgical field. The introduction of an ERAS protocol in lumbar fusion surgery has aimed to accelerate patient recovery from surgery by reducing in-hospital opioid consumption.

Methods

Patients with 1- or 2-level degenerative lumbar spine disease and who underwent ERAS transforaminal lumbar interbody fusion (TLIF) were retrospectively reviewed. Patients’ general demographic data, in-hospital opioid dosage (converted to morphine equivalents), and hospital stay were compared to those who underwent standard minimally-invasive (MIS)-TLIF.

Results

Twenty-four patients who received ERAS TLIF (the ERAS group) were compared to a series of 24 patients who received standard MIS-TLIF (the MIS group). The demographic data were similar. The operation time and blood loss significantly favored ERAS TLIF. The average daily opioid consumption was remarkably lower in the ERAS group than the MIS group. Average opioid dosage throughout the entire in-hospital period was also significantly reduced in the ERAS group compared to the MIS group. The average length of hospital stay was substantially shorter in the ERAS group (1.4 ± 1.13 days vs. 4.0±1.98 days, p <0.001).

Conclusion

The present study demonstrated a significant decline in the consumption of opioids and in the hospital length of stay for patients undergoing ERAS TLIF for 1- or 2-level degenerative lumbar spine disease.

Early Discharged Lumbar Spine Fusion Reduced Postoperative Readmissions: A Retrospective Cohort Study

Early discharge (ED) has emerged and gained popularity in spine surgery. However, the benefits of ED in lumbar fusion have not yet been validated by large cohort studies. To evaluate the effects of ED on readmissions and reoperations in lumbar fusion, this study utilized a national database to enroll patients who had undergone lumbar fusion surgery at age 50–70 years, and grouped them into an ED group or a comparison group. In the comprehensive follow-up of 180 days post-operation, the two groups were compared. There were 18,008 patients in the cohort, including 2172 in the ED group and 15,836 in the comparison group. The ED group was slightly younger (59.9 vs. 60.7 years, p < 0.001), more male predominant (44.9% vs. 36.9%, p < 0.001), and had fewer medical comorbidities. The ED group had less incidences of readmission than the comparison group. (Crude hazard ratio = 0.73, and adjusted HR = 0.75, both p < 0.001). Overall, the cumulative incidences of readmission in the ED group (9.5%) were lower than those in the comparison group (12.8%, p < 0.001), whereas reoperations were insignificantly different (1.5% vs. 1.2%, p = 0.189). For patients aged 50–70 years and who require lumbar fusion surgery, ED could yield a 25% reduced risk of readmission for any cause within 180 days post-operation. Since the reoperation rates remained similar, our results suggest that ED may be a promising option for elderly patients undergoing lumbar spinal fusion surgery.

Comparison of O-arm navigation and microscope-assisted minimally invasive transforaminal lumbar interbody fusion and conventional transforaminal lumbar interbody fusion for the treatment of lumbar isthmic spondylolisthesis

Objective

The objective of this study is to compare the clinical efficacy of O-arm navigation and microscope-assisted minimally invasive transforaminal lumbar interbody fusion (modified MIS-TLIF) versus conventional TLIF in the lumbar isthmic spondylolisthesis.

Materials and methods

Forty patients with 1-level lumbar isthmic spondylolisthesis were enrolled in the study. Perioperative indexes including operation time, intraoperative bleeding, bed rest time, time of hospitalisation stay and the accuracy rate of screw placement were analysed. Preoperative and postoperative visual analogue scale (VAS) and Oswestry disability index (ODI) were assessed.

Results

The operation time in the modified MIS-TLIF group was longer than the conventional TLIF group (p ​< ​0.05). However, intraoperative blood loss in the modified MIS-TLIF group was less than the comparative group (p ​< ​0.05). The average bed rest time and hospitalisation stay in the modified MIS-TLIF group was shorter than conventional TLIF group (p ​< ​0.05). The screw placement in the modified MIS-TLIF group was more precisely than that in the conventional TLIF group (p ​< ​0.05). Meanwhile, the improvement of VAS and ODI in the modified MIS-TLIF group were lower than that in the conventional TLIF group 1 and 6 months after operation (p ​< ​0.05). There was no difference in the VAS and ODI score between the two group at the last follow-up (p ​> ​0.05).

Conclusion

Navigation and microscope-assisted MIS-TLIF is safe and reliable for treatment of lumbar isthmic spondylolisthesis (Meyerding degree I or II) with potential advantages including less injury, less blood loss, higher screw accuracy and faster recovery after operation.

The translational potential of this article

Compared with conventional transforaminal lumbar interbody fusion, O-arm navigation and microscope-assisted minimally invasive transforaminal lumbar interbody fusion has a huge advantage in surgery treatment of lumbar isthmic spondylolisthesis. Hence, this article provided a better surgery method to deal with lumbar isthmic spondylolisthesis, and robot-assisted minimally invasive transforaminal lumbar interbody fusion will be adopted in the future.

Endoscopic transforaminal lumbar interbody fusion without general anesthesia: technical innovations and outcomes

Innovations in surgical techniques and technologies have enabled spine surgeons to offer patients less morbid alternatives to traditional spine procedures. This review will explore the development of the endoscopic transforaminal lumbar interbody fusion (TLIF) without general endotracheal anesthesia (GETA) and discuss the technical refinements and innovations learned from experiences with this technique. The Awake TLIF employs several key technological innovations: (I) conscious sedation; (II) endoscopic visualization; (III) an expandable interbody device; (IV) recombinant human bone morphogenetic protein; (V) long-acting local analgesia; and (VI) percutaneous instrumentation. Technical refinements, including premedication for prophylaxis against nausea, vomiting, and epistaxis, were made as a result of early experiences with this technique. Results from the first 100 patients to undergo the Awake TLIF demonstrated durable clinical benefit beyond one year postoperatively. Operating time, blood loss, and hospital length of stay averages well below those generally seen with conventional MIS TLIF. Patients achieved a significant reduction in Oswestry Disability Index from baseline of -12.3 points (P<0.0001). In this initial 100 patient cohort, four conversions to GETA were required and four complications resulted, three of which occurred during the first 50 cases. To date, over 200 Awake TLIF cases and the first three-level procedure have been performed. Endoscopic TLIF without the use of general anesthesia is a novel but promising approach for short-segment lumbar fusion. Continued technical innovations will likely afford greater improvements in outcomes, both in the acute and long-term recovery periods.

Trends in outpatient minimally invasive spine surgery

There has been a definite upward trend in outpatient minimally invasive spine (MIS) surgery over the past decade. This increasing prevalence has been driven by several factors including advanced MIS techniques, improvements in perioperative pain management, and economic necessity. There is now a myriad of different spine surgery procedures which can be effectively employed in the outpatient setting, and the concept of awake, endoscopic fusion surgery represents a notable advance in the field. Additionally, the use of multi-modality analgesic agents has shown significant promise in this arena and has become increasingly important in states where legislation affecting narcotic prescriptions have been enacted. Finally, with an aging population, the need for outpatient spine surgery has become imperative from an economic standpoint.

Enhanced recovery after elective spinal and peripheral nerve surgery: pilot study from a single institution

OBJECTIVE

Enhanced recovery after surgery (ERAS) protocols address pre-, peri-, and postoperative factors of a patient's surgical journey. The authors sought to assess the effects of a novel ERAS protocol on clinical outcomes for patients undergoing elective spine or peripheral nerve surgery.

METHODS

The authors conducted a prospective cohort analysis comparing clinical outcomes of patients undergoing elective spine or peripheral nerve surgery after implementation of the ERAS protocol compared to a historical control cohort in a tertiary care academic medical center. Patients in the historical cohort (September-December 2016) underwent traditional surgical care. Patients in the intervention group (April-June 2017) were enrolled in a unique ERAS protocol created by the Department of Neurosurgery at the University of Pennsylvania. Primary objectives were as follows: opioid and nonopioid pain medication consumption, need for opioid use at 1 month postoperatively, and patient-reported pain scores. Secondary objectives were as follows: mobilization and ambulation status, Foley catheter use, need for straight catheterization, length of stay, need for ICU admission, discharge status, and readmission within 30 days.

RESULTS

A total of 201 patients underwent surgical care via an ERAS protocol and were compared to a total of 74 patients undergoing traditional perioperative care (control group). The 2 groups were similar in baseline demographics. Intravenous opioid medications postoperatively via patient-controlled analgesia was nearly eliminated in the ERAS group (0.5% vs 54.1%, p < 0.001). This change was not associated with an increase in the average or daily pain scores in the ERAS group. At 1 month following surgery, a smaller proportion of patients in the ERAS group were using opioids (38.8% vs 52.7%, p = 0.041). The ERAS group demonstrated greater mobilization on postoperative day 0 (53.4% vs 17.1%, p < 0.001) and postoperative day 1 (84.1% vs 45.7%, p < 0.001) compared to the control group. Postoperative Foley use was decreased in the ERAS group (20.4% vs 47.3%, p < 0.001) without an increase in the rate of straight catheterization (8.1% vs 11.9%, p = 0.51).

CONCLUSIONS

Implementation of this novel ERAS pathway safely reduces patients' postoperative opioid requirements during hospitalization and 1 month postoperatively. ERAS results in improved postoperative mobilization and ambulation.

Endoscopic transforaminal lumbar interbody fusion without general anesthesia: operative and clinical outcomes in 100 consecutive patients with a minimum 1-year follow-up

OBJECTIVE

Open spinal fusion surgery is often associated with significant blood loss, postoperative pain, and prolonged recovery times. Seeking to minimize surgical and perioperative morbidity, the authors adopted an endoscopic minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) technique performed without general anesthesia. In this report, they present data on the first 100 patients treated with this procedure.

METHODS

The authors conducted a retrospective review of the first 100 patients who underwent awake endoscopic MIS-TLIF at a single institution between 2014 and 2017. Surgery was performed while the patient was sedated but without intubation or the use of general anesthetic or narcotic agents. Long-lasting (liposomal) bupivacaine was used for local analgesia. The discectomy and placement of an expandable interbody graft were performed endoscopically, followed by percutaneous pedicle screw implantation. Inclusion criteria for the procedure consisted of diagnosis of degenerative disc disease with grade I or II spondylolisthesis and evidence of spinal stenosis or nerve impingement with intractable symptomatology.

RESULTS

Of the first 100 patients, 56 were female and 44 were male. Single-level fusion was performed in 84 patients and two-level fusion in 16 patients. The most commonly fused level was L4–5, representing 77% of all fused levels. The mean (± standard deviation) operative time was 84.5 ± 21.7 minutes for one-level fusions and 128.1 ± 48.6 minutes for two-level procedures. The mean intraoperative blood loss was 65.4 ± 76.6 ml for one-level fusions and 74.7 ± 33.6 ml for two-level fusions. The mean length of hospital stay was 1.4 ± 1.0 days. Four deaths occurred in the 100 patients; all four of those patients died from complications unrelated to surgery. In 82% of the surviving patients, 1-year follow-up Oswestry Disability Index (ODI) data were available. The mean preoperative ODI score was 29.6 ± 15.3 and the mean postoperative ODI score was 17.2 ± 16.9, which represents a significant mean reduction in the ODI score of −12.3 using a two-tailed paired t-test (p = 0.000001). In four cases, the surgical plan was revised to include general endotracheal anesthesia intraoperatively and was successfully completed. Other complications included two cases of cage migration, one case of osteomyelitis, and one case of endplate fracture; three of these complications occurred in the first 50 cases.

CONCLUSIONS

This series of the first 100 patients to undergo awake endoscopic MIS-TLIF demonstrates outcomes comparable to those reported in our earlier papers. This procedure can provide a safe and efficacious option for lumbar fusion with less morbidity than open surgery. Further refinements in surgical technique and technologies will allow for improved success.

Benefits of Enhanced Recovery After Surgery for fusion in degenerative spine surgery: impact on outcome, length of stay, and patient satisfaction

OBJECTIVE

Enhanced Recovery After Surgery (ERAS) proposes a multimodal, evidence-based approach to perioperative care. Thanks to the improvement in care protocols and the fluidity of the patient pathway, the first goal of ERAS is the improvement of surgical outcomes and patient experience, with a final impact on a reduction in the hospital length of stay (LOS). The implementation of ERAS in spinal surgery is in the early stages. The authors report on their initial experience in applying an ERAS program to several degenerative spinal fusion procedures.

METHODS

The authors selected two 2-year periods: the first from before any implementation of ERAS principles (pre-ERAS years 2012–2013) and the second corresponding to a period when the paradigm was applied widely (post-ERAS years 2016–2017). Patient groups in these periods were retrospectively compared according to three degenerative conditions requiring fusion: anterior cervical discectomy and fusion (ACDF), anterior lumbar interbody fusion (ALIF), and posterior lumbar fusion. Data were collected on patient demographics, operative and perioperative data, LOSs, 90-day readmissions, and morbidity. ERAS-trained nurses were involved to support patients at each pre-, intra-, and postoperative step with the help of a mobile application (app). A satisfaction survey was included in the app.

RESULTS

The pre-ERAS group included 1563 patients (159 ALIF, 749 ACDF, and 655 posterior fusion), and the post-ERAS group included 1920 patients (202 ALIF, 612 ACDF, and 1106 posterior fusion). The mean LOS was significantly shorter in the post-ERAS group than in the pre-ERAS group for all three conditions. It was reduced from 6.06 ± 1.1 to 3.33 ± 0.8 days for the ALIF group (p < 0.001), from 3.08 ± 0.9 to 1.3 ± 0.7 days for the ACDF group (p < 0.001), and from 6.7 ± 4.8 to 4.8 ± 2.3 days for posterior fusion cases (p < 0.001). There was no significant difference in overall complications between the two periods for the ALIF (11.9% pre-ERAS vs 11.4% post-ERAS, p = 0.86) and ACDF (6.0% vs 8.2%, p = 0.12) cases, but they decreased significantly for lumbar fusions (14.8% vs 10.9%, p = 0.02). Regarding satisfaction with overall care among 808 available responses, 699 patients (86.5%) were satisfied or very satisfied, and regarding appreciation of the mobile e-health app in the perceived optimization of care management, 665 patients (82.3%) were satisfied or very satisfied.

CONCLUSIONS

The introduction of the ERAS approach at the authors’ institution for spinal fusion for three studied conditions resulted in a significant decrease in LOS without causing increased postoperative complications. Patient satisfaction with overall management, upstream organization of hospitalization, and the use of e-health was high. According to the study results, which are consistent with those in other studies, the whole concept of ERAS (primarily reducing complications and pain, and then reducing LOS) seems applicable to spinal surgery.

An enhanced recovery after surgery program in orthopedic surgery: a systematic review and meta-analysis

Objectives

There is an increased interest in enhanced recovery after surgery (ERAS) minimizing adverse events after orthopedic surgery. Little consensus supports the effectiveness of these interventions. The purpose of present systematic review and meta-analysis is to comprehensively analyze and evaluate the significance of ERAS interventions for postoperative outcomes after orthopedic surgery.

Methods

PubMed, EMBASE, and Cochrane databases were totally searched from the inception dates to May 31, 2018. Two reviewers independently extracted the data from the selected articles using a standardized form and assessed the risk of bias. The analysis was performed using STATA 12.0.

Results

A total of 15 published studies fulfilled the requirements of inclusion criteria. We found that the ERAS group showed a significant association with lower incidence of postoperative complications (OR, 0.70; 95% CI, 0.64 to 0.78). Meanwhile, ERAS was also associated with the decline in 30-day mortality rate and Oswestry Disability Index (ODI). However, no significant differences were identified between the two groups regarding the 30-day readmission rate (P = 0.397).

Conclusions

Our meta-analysis suggested that the ERAS group had more advantages in reducing incidence of postoperative complications, 30-day mortality rate, and ODI after orthopedic surgery, but not of 30-day readmission rate. However, further research with standardized, unbiased methods and larger sample sizes is required for deeper analysis.

Electronic supplementary material

The online version of this article (10.1186/s13018-019-1116-y) contains supplementary material, which is available to authorized users.

The evolution of minimally invasive spine surgery

The field of minimally invasive spine surgery (MISS) has rapidly evolved over the past 3 decades. This review follows the evolution of techniques and principles that have led to significant advances in the field. While still representing only a subset of spine surgeries, MISS’s goals of reducing soft-tissue trauma and mitigating the morbidity of surgery are being realized, translating into more rapid recovery, lower infection rates, and higher cost savings. Future advances in technology and techniques can be anticipated.

Radiographic and Clinical Outcomes of Oblique Lateral Interbody Fusion Versus Minimally Invasive Transforaminal Lumbar Interbody Fusion for Degenerative Lumbar Disease

BACKGROUND

The effects of oblique lateral interbody fusion (OLIF) and minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) have not been compared by a meta-analysis. The present study aimed to summarize the radiographic and clinical outcomes of OLIF and MI-TLIF for degenerative lumbar disease.

METHODS

We performed a systematic review of related studies and report the outcomes of OLIF and MI-TLIF for degenerative lumbar disease. The radiographic outcomes measures included disc height, segmental lordotic angle, lumbar lordotic angle, and fusion. The clinical and functional outcomes included operative blood loss, operative time, length of hospital stay, complications, visual analog scale, and Oswestry disability index. Data pooling and meta-analysis with the random effects model were performed to evaluate the results.

RESULTS

A total of 47 studies met the inclusion criteria. Similar changes in terms of disc height, segmental lordotic angle, lumbar lordotic angle, length of hospital stay, visual analog scale, Oswestry disability index, and radiological evidence of fusion of >90% were observed between the 2 groups. The OLIF group showed less operative blood loss and operative time. The incidence of intraoperative and postoperative complications was 9.5% and 19.9% for the OLIF group and 3.5% and 8.5% for the MI-TLIF group, respectively.

CONCLUSIONS

The radiographic and functional outcomes and length of hospital stay were similar between the 2 groups. The OLIF group showed advantages in operative blood loss and operative time; however, the incidence of complications in this technique was greater than that in the MI-TLIF group.