Perioperative surgical complications of transforaminal lumbar interbody fusion: a single-center experience

Set screw fracture with cage dislocation after two-level transforaminal lumbar interbody fusion (TLIF): a case report

Introduction

Transforaminal lumbar interbody fusion is a popular procedure used to achieve spondylodesis in patients with degenerative lumbar spinal diseases. We present a rare case of a patient with a set screw fracture with cage dislocation after an open transforaminal lumbar interbody fusion procedure. To the best of our knowledge, this case is the first of its kind to be reported.

Case presentation

A 44-year-old Caucasian woman attended a follow-up appointment at our hospital 3 months after treatment for second-degree lumbar spondylolisthesis (L4/L5) and osteochondrosis (L5/S1) with transforaminal lumbar interbody fusion and dorsal spondylodesis. She complained of severe leg pain on the left side. Her physical examination revealed a normal neurological status, except for paresthesia of the entire left lower limb and at the ball of the left foot. Radiological imaging showed breaking of the set screws with cage dislocation. Surgical revision was then performed with exchange of the whole dorsal instrumentation and the dislocated cage. Six weeks post-operatively, the patient was seen again at our clinic without neurological complaints, except for decreased sensitivity on the dorsum of her left foot. The wound healing and radiological follow-up were uneventful.

Conclusions

Hardware-related complications are rarely seen in patients with open transforaminal lumbar interbody fusion, but must be kept in mind and can potentially cause severe neurological deficits.

Biomechanical analysis of a newly developed shape memory alloy hook in a transforaminal lumbar interbody fusion (TLIF) in vitro model

Objective

The objective of this biomechanical study was to evaluate the stability provided by a newly developed shape memory alloy hook (SMAH) in a cadaveric transforaminal lumbar interbody fusion (TLIF) model.

Methods

Six human cadaveric spines (L1-S2) were tested in an in vitro flexibility experiment by applying pure moments of ±8 Nm in flexion/extension, left/right lateral bending, and left/right axial rotation. After intact testing, a TLIF was performed at L4-5. Each specimen was tested for the following constructs: unilateral SMAH (USMAH); bilateral SMAH (BSMAH); unilateral pedicle screws and rods (UPS); and bilateral pedicle screws and rods (BPS). The L3–L4, L4–L5, and L5-S1 range of motion (ROM) were recorded by a Motion Analysis System.

Results

Compared to the other constructs, the BPS provided the most stability. The UPS significantly reduced the ROM in extension/flexion and lateral bending; the BSMAH significantly reduced the ROM in extension/flexion, lateral bending, and axial rotation; and the USMAH significantly reduced the ROM in flexion and left lateral bending compared with the intact spine (p<0.05). The USMAH slightly reduced the ROM in extension, right lateral bending and axial rotation (p>0.05). Stability provided by the USMAH compared with the UPS was not significantly different. ROMs of adjacent segments increased in all fixed constructs (p>0.05).

Conclusions

Bilateral SMAH fixation can achieve immediate stability after L4–5 TLIF in vitro. Further studies are required to determine whether the SMAH can achieve fusion in vivo and alleviate adjacent segment degeneration.

Perioperative complications related to minimally invasive transforaminal lumbar fusion: evaluation of 204 operations on lumbar instability at single center

BACKGROUND CONTEXT

Minimally invasive transforaminal lumbar fusion (MIS-TLIF) has demonstrated efficacy in the treatment of lumbar degenerative diseases. The reported incidence of perioperative complications associated with MIS-TLIF surgery is highly variable. Studies concerning perioperative complications in broad patient populations are quite rare. This study analyzes a retrospectively collected database of patients who underwent an MIS-TLIF surgery at a single center.

PURPOSE

To determine the incidence of perioperaive complications with MIS-TLIF procedure based on our definition of Type I and II perioperative complications.

STUDY DESIGN

Retrospective cohort study; a review of complications.

PATIENT SAMPLE

The sample comprises 204 patients who underwent MIS-TLIF for the treatment of lumbar degenerative diseases.

OUTCOME MEASURES

Type I complication including all medical adverse events without direct connection to the specific surgical procedure performed. Type II complication including adverse events with direct connection to the surgical procedure performed.

METHODS

A total of 204 MIS-TLIF surgeries on lumbar instability or spondylolisthesis, performed between June 2007 and July 2012, were examined in a retrospective study. A complication classification based on the relation to the surgical procedure and the effect duration was used. Perioperative complications until 1 month postoperatively were reviewed for the patients.

RESULTS

The study group comprised 204 patients (106 women, 98 men; mean age at surgery, 52.4 years; age range, 39-84 years). Overall, there were 75 perioperative complications in 204 patients (36.76%). Only one complication occurred in 54 patients. Nine patients had two complications. One patient had three complications. The incidence of perioperative complication was 31.37% (64/204 patients) in the MIS-TLIF operations. Of all complications, seven (9.33%) were classified as persistent complications and 68 (90.67%) were classified as transient complications. The incidence of Type I and II complications were 13.73% and 23.04%, respectively.

CONCLUSIONS

Minimally invasive transforaminal lumbar fusion has gained popularity as a procedure for the treatment of lumbar instability or spondylolisthesis, with similar complications as in the open surgery. Transient sensory disturbance was the most common complication in this series.

Lumbar alignment and clinical outcome after single level asymmetrical transforaminal lumbar interbody fusion for degenerative spondylolisthesis with local coronal imbalance

Transforaminal lumbar interbody fusion (TLIF) is widely accepted for the treatment of lumbar arthrodesis. However, the exact characteristics of TLIF depend on the number, location, shape, or materials of the interbody implants, and the type of posterior instrument. Clinical and biomechanical characteristics of each TLIF procedure are still unclear. The present study investigated the clinical and radiological improvements after single level asymmetrical TLIF, in which a single box-shaped spacer was obliquely inserted into the intervertebral space, for lumbar degenerative spondylolisthesis in patients with or without local coronal imbalance (LCI) at the operated level. The clinical records of 60 patients who underwent single level asymmetrical TLIF augmented with the pedicle screw fixation system from January 2005 to January 2011, were retrospectively reviewed. The patients were divided into the LCI group (n = 19) and non-LCI group (n = 41), based on segmental lateral translation or disc wedging at the operated site. Clinical recovery was significantly good in both groups at 2 years after surgery, but improvement of low back pain was significantly worse in the LCI group. Radiological examination revealed that the mean lumbar scoliotic angle was significantly worse in the LCI group postoperatively. Preoperative greater scoliotic angle and coronal off balance of the lumbar spine were related to unfavorable radiological outcomes. The present study showed that single level asymmetrical TLIF is an acceptable method for achieving good clinical and radiological outcomes for patients with symptomatic degenerative spondylolisthesis, however, the clinical benefits and realignment are limited if the patient has LCI at the operated site with greater scoliotic angle or coronal off balance of the lumbar spine.

Minimally invasive transforaminal lumbar interbody fusion for spondylolisthesis and degenerative spondylosis: 5-year results

BACKGROUND

Multiple studies have reported favorable short-term results after treatment of spondylolisthesis and other degenerative lumbar diseases with minimally invasive transforaminal lumbar interbody fusion. However, to our knowledge, results at a minimum of 5 years have not been reported.

QUESTIONS/PURPOSES

We determined (1) changes to the Oswestry Disability Index, (2) frequency of radiographic fusion, (3) complications and reoperations, and (4) the learning curve associated with minimally invasive transforaminal lumbar interbody fusion at minimum 5-year followup.

METHODS

We reviewed our first 124 patients who underwent minimally invasive transforaminal lumbar interbody fusion to treat low-grade spondylolisthesis and degenerative lumbar diseases and did not need a major deformity correction. This represented 63% (124 of 198) of the transforaminal lumbar interbody fusion procedures we performed for those indications during the study period (2003-2007). Eighty-three (67%) patients had complete 5-year followup. Plain radiographs and CT scans were evaluated by two reviewers. Trends of surgical time, blood loss, and hospital stay over time were examined by logarithmic curve fit-regression analysis to evaluate the learning curve.

RESULTS

At 5 years, mean Oswestry Disability Index improved from 60 points preoperatively to 24 points and 79 of 83 patients (95%) had improvement of greater than 10 points. At 5 years, 67 of 83 (81%) achieved radiographic fusion, including 64 of 72 patients (89%) who had single-level surgery. Perioperative complications occurred in 11 of 124 patients (9%), and another surgical procedure was performed in eight of 124 patients (6.5%) involving the index level and seven of 124 patients (5.6%) at adjacent levels. There were slowly decreasing trends of surgical time and hospital stay only in single-level surgery and almost no change in intraoperative blood loss over time, suggesting a challenging learning curve.

CONCLUSIONS

Oswestry Disability Index scores improved for patients with spondylolisthesis and degenerative lumbar diseases treated with minimally invasive transforaminal lumbar interbody fusion at minimum 5-year followup. We suggest this procedure is reasonable for properly selected patients with these indications; however, traditional approaches should still be performed for patients with high-grade spondylolisthesis, patients with a severely collapsed disc space and no motion seen on the dynamic radiographs, patients who need multilevel decompression and arthrodesis, and patients with kyphoscoliosis needing correction.

LEVEL OF EVIDENCE

Level IV, therapeutic study. See the Instructions for Authors for a complete description of levels of evidence.

Minimally invasive transforaminal lumbar interbody fusion with unilateral pedicle screw fixation: comparison between primary and revision surgery

Minimally invasive surgery with a transforaminal lumbar interbody fusion (MIS TLIF) is an important minimally invasive fusion technique for the lumbar spine. Lumbar spine reoperation is challenging and is thought to have greater complication risks. The purpose of this study was to compare MIS TLIF with unilateral screw fixation perioperative results between primary and revision surgeries. This was a prospective study that included 46 patients who underwent MIS TLIF with unilateral pedicle screw. The patients were divided into two groups, primary and revision MIS TLIF, to compare perioperative results and complications. The two groups were similar in age, sex, and level of operation, and were not significantly different in the length of follow-up or clinical results. Although dural tears were more common with the revision group (primary 1; revision 4), operation time, blood loss, total perioperative complication, and fusion rates were not significantly different between the two groups. Both groups showed substantial improvements in VAS and ODI scores one year after surgical treatment. Revision MIS TLIF performed by an experienced surgeon does not necessarily increase the risk of perioperative complication compared with primary surgery. MIS TLIF with unilateral pedicle screw fixation is a valuable option for revision lumbar surgery.

Risk factors for postoperative complication after spinal fusion and instrumentation in degenerative lumbar scoliosis patients

Background

Relatively few studies have focused on the major medical complications that are more common in older adults. Furthermore, these studies have generally not reported how accurately a risk factor, or combination of risk factors, can distinguish between those who will have a complication and those who will not.

Methods

A total of 236 consecutive patients who had undergone surgical treatment for degenerative lumbar scoliosis between June 2008 and June 2012 were included retrospectively in this study. The demographic distribution, medical history, and clinical data were collected to investigate the predictive factors of postoperative complications by logistic regression.

Results

Among 236 eligible patients, major medical complications occurred in 7.2% of cases and wound complications occurred in 1.7% of cases. Ninety-day mortality rate was 0.4%. Postoperative complications were strongly associated with history of severe chronic obstructive pulmonary disease (COPD) (P = 0.031), dyspnea with minimal exertion (P = 0.041), being at least partially dependent (P = 0.041), smoking within the past year (P = 0.044), American Society of Anesthesiologists (ASA) class of more than 2 (P = 0.000), diabetes treated with insulin (P = 0.003), and steroid use for chronic condition (P = 0.003). In logistic regressions, operation time (odds ratio 2.45, 95% confidence interval 1.11–4.78), ASA class (class 3 or 4 vs. class 1 or 2: odds ratio 2.21, 95% confidence interval 1.22–3.45), insulin-dependent diabetes (odds ratio 1.72, 95% confidence interval 1.18–2.43), and steroid use for chronic condition (odds ratio 1.55, 95% confidence interval 1.06–2.32) may be reasonable predictors for an individual's likelihood of surgical complications.

Conclusions

The occurrence of postoperative complications is most likely multifactorial and is related to operation time, ASA class, insulin-dependent diabetes and steroid use for chronic condition.

Surgery in lumbar degenerative spondylolisthesis: indications, outcomes and complications. A systematic review

PURPOSE

This systematic review summarises the literature on patient selection, decision-making, effectiveness and outcomes in the surgical treatment of lumbar degenerative spondylolisthesis (LDS).

INTRODUCTION

In daily practice, decision-making in the treatment of LDS is challenging. There is little consensus on either the precise indications or prognostic factors for any specific therapy (operative or non-operative).

METHODS

We searched for LDS trials published between 01.01.1990 and 16.11.2011 in Medline, Embase, Cochrane Library and Cinahl. Two independent reviewers selected studies according to the inclusion criteria. Data were then extracted by two of the authors. Quality assessment was performed using the Downs and Black list for the clinical trials/studies and AMSTAR for the reviews.

RESULTS

DATA SYNTHESIS

21 papers met the inclusion criteria (2 studies comprising both a RCT and a concurrent observational analysis, 1 RCT, 6 prospective studies, 8 retrospective studies, 3 reviews, 1 review guideline). The quality of the clinical studies was on average "fair" [mean score 15.6 points (range 10-19) out of 24 points (Downs and Black)]. The quality of the reviews ranged from 1 to 7 out of 11 points with an average of 5 points (AMSTAR). The study outcomes could not be subject to meta-analysis due to heterogeneity of study design and variable measure used.

CONCLUSIONS

Despite there being many articles describing and/or comparing different surgical options for LDS, there was insufficient evidence to draw conclusions concerning clear indications for specific types of surgical treatment, predictors of outcome or complication rates. There remains a need to establish a decision-making tool to facilitate daily clinical practice and to assure appropriate treatment for patients with LDS.

Transforaminal lumbar interbody fusion using a modified distractor handle: a midterm clinicoradiological follow-up study

In current TLIF practice, the choice of the cage size is empirical and primarily depends on the case volume and experience of the surgeon. We used a self-made modified distractor handle in TLIF procedure with the goal of standardizing the intervertebral space tension and determining the proper cage size.

Complications after surgery for lumbar stenosis in a veteran population

STUDY DESIGN

Secondary analysis of the prospectively collected Veterans Affairs National Surgical Quality Improvement Program database.

OBJECTIVE

Determine rates of major medical complications, wound complications, and mortality among patients undergoing surgery for lumbar stenosis and examine risk factors for these complications.

SUMMARY OF BACKGROUND DATA

Surgery for spinal stenosis is concentrated among older adults, in whom complications are more frequent than among middle-aged patients. Many studies have focused on infections or device complications, but fewer studies have focused on major cardiopulmonary complications, using prospectively collected data.

METHODS

We identified patients who underwent surgery for a primary diagnosis of lumbar stenosis between 1998 and 2009 from the Veterans Affairs National Surgical Quality Improvement Program database. We created a composite of major medical complications, including acute myocardial infarction, stroke, pulmonary embolism, pneumonia, systemic sepsis, coma, and cardiac arrest.

RESULTS

Among 12,154 eligible patients, major medical complications occurred in 2.1%, wound complications in 3.2%, and 90-day mortality in 0.6%. Major medical complications, but not wound complications, were strongly associated with age. American Society of Anesthesiologists (ASA) class was a strong predictor of complications. Insulin use, long-term corticosteroid use, and preoperative functional status were also significant predictors. Fusion procedures were associated with higher complication rates than with decompression alone. In logistic regressions, ASA class and age were the strongest predictors of major medical complications (odds ratio for ASA class 4 vs. class 1 or 2: 2.97; 95% confidence interval, 1.68-5.25; P = 0.0002). After adjustment for comorbidity, age, and functional status, fusion procedures remained associated with higher medical complication rates than were decompressions alone (odds ratio = 2.85; 95% confidence interval, 2.14-3.78; P < 0.0001).

CONCLUSION

ASA class, age, type of surgery, insulin or corticosteroid use, and functional status were independent risk factors for major medical complications. These factors may help in selecting patients and planning procedures, improving patient safety.

Incidence of and risk factors for superior facet violation in minimally invasive versus open pedicle screw placement during transforaminal lumbar interbody fusion: a comparative analysis

Object

A reported risk factor for adjacent-segment disease is injury to the superior facet joint from pedicle screw placement. Given that the facet joint is not typically visualized during percutaneous pedicle screw insertion, there is a concern for increased facet violation (FV) in minimally invasive fusion procedures. The purpose of this study was to analyze and compare the incidence of FV among patients undergoing minimally invasive transforaminal lumbar interbody fusion (MITLIF) and open transforaminal lumbar interbody fusion (TLIF). The impact of O-arm navigation compared with traditional fluoroscopy on FV in MITLIF is also assessed, as are risk factors for FV.

Methods

The authors identified a consecutive population of patients who underwent MITLIF with percutaneous pedicle screw placement, as well as a matched cohort of patients who underwent open TLIF. Postoperative CT imaging was assessed to determine intraarticular FV due to pedicle screw placement. Patients were stratified into minimally invasive and open TLIF groups. Within the MITLIF group, the authors performed a subanalysis of image guidance methods used in cases of FV. Two-tailed Student t-test, ANOVA, chi-square testing, and logistic regression were used for statistical analysis.

Results

A total of 282 patients were identified, with a total of 564 superior pedicle screw placements. The MITLIF group consisted of 142 patients with 284 screw insertions. The open TLIF group consisted of 140 patients with 280 screw insertions. Overall, 21 (7.4%) of 282 patients experienced FV. A total of 21 screws violated a facet joint for a screw-based FV rate of 3.7% (21 of 564 screws). There were no significant differences between the MITLIF and open TLIF groups in the percentage of patients with FV (6.3% vs 8.6%) and or the percentage of screws with FV (3.2% vs 4.3%) (p = 0.475 and p = 0.484, respectively). Further stratifying the MI group into O-arm navigation and fluoroscopic guidance subgroups, the patient-based rates of FV were 10.8% (4 of 37 patients) and 4.8% (5 of 105 patients), respectively, and the screw-based rates of FV were 5.4% (4 of 74 screws) and 2.4% (5 of 210 screws), respectively. There was no significant difference between the subgroups with respect to patient-based or screw-based FV rates (p = 0.375 and p = 0.442, respectively). The O-arm group had a significantly higher body mass index (BMI) (p = 0.021). BMI greater than 29.9 was independently associated with higher FV (OR 2.36, 95% CI 1.65–8.53, p = 0.039).

Conclusions

The findings suggest that minimally invasive pedicle screw placement is not associated with higher rates of FV. Overall violation rates were similar in MITLIF and open TLIF. Higher BMI, however, was a risk factor for increased FV. The use of O-arm fluoroscopy with computer-assisted guidance did not significantly decrease the rate of FV.

Perioperative complications in patients undergoing open transforaminal lumbar interbody fusion as a revision surgery

Object

Transforaminal lumbar interbody fusion (TLIF) has been increasingly used to treat degenerative spine disease, including that in patients in whom earlier decompressive procedures have failed. Reexploration in these cases is always challenging and is thought to pose a higher risk of complications. To the best of the authors' knowledge, there are no current studies specifically analyzing the effects of previous lumbar decompressive surgeries on the complication rates of open TLIF.

Methods

The authors performed a retrospective study of surgeries performed by a single surgeon. A total of 187 consecutive patients, in whom the senior author (A.N.) had performed open TLIF between January 2007 and January 2011, met the inclusion criteria. The patients were divided into two groups (primary and revision TLIF) for the comparison of perioperative complications.

Results

Overall, the average age of the patients was 49.7 years (range 18–80 years). Of the 187 patients, 73 patients had no history of lumbar surgery and 114 were undergoing revision surgery. Fifty-four patients (28.9%) had a documented complication intraoperatively or postoperatively. There was no difference in the rate on perioperative complications between the two groups (overall, medical, wound related, inadvertent dural tears [DTs], or neural injury). Patients who had undergone more than one previous lumbar surgery were, however, more likely to have suffered from DTs (p = 0.054) and neural injuries (p = 0.007) compared with the rest.

Conclusions

In the hands of an experienced surgeon, revision open TLIF does not necessarily increase the risk of perioperative complications compared with primary TLIF. Two or more previous lumbar decompressive procedures, however, increase the risk of inadvertent DTs and neural injury.

Fusão intersomática lombar transforaminal: experiência de uma instituição

OBJETIVO: Relatar a experiência inicial de um serviço de referência em cirurgia da coluna em São Paulo, Brasil com a técnica de fusão intersomática lombar transforaminal (TLIF) nas suas mais variadas indicações. MÉTODOS: Avaliamos retrospectivamente os dados gravados em prontuário de 25 pacientes que foram submetidos à cirurgia com a técnica de TLIF no ano de 2011. Um paciente foi excluído porque não consideramos que a TLIF foi a principal técnica empregada. As indicações incluíram nove casos de hérnia de disco lombar, sete espondilolisteses, quatro cirurgias de revisão, sendo duas por pseudoartrose e duas por lombalgias e, finalmente, quatro pacientes com estenose espinhal lombar. RESULTADOS: Todos os pacientes referiram melhora da dor e/ou claudicação neurológica em comparação com o estado pré-operatório. Apenas cinco pacientes continuaram usando alguma medicação analgésica. Cinco pacientes apresentaram alguma complicação, mas somente duas delas estão relacionadas diretamente com o procedimento. CONCLUSÕES: Trata-se de uma técnica segura, possível de ser realizada em todos os níveis da coluna lombar e aplicável a grande parte das doenças que acometem essa região da coluna.