Minimally invasive versus open transforaminal lumbar interbody fusion for degenerative spondylolisthesis: comparative effectiveness and cost-utility analysis

Comparison of complication rates of minimally invasive transforaminal lumbar interbody fusion and lateral lumbar interbody fusion: a systematic review of the literature

OBJECT Minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) and lateral lumbar interbody fusion (LLIF) are 2 currently popular techniques for lumbar arthrodesis. The authors compare the total risk of each procedure, along with other important complication outcomes. METHODS This systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Relevant studies (up to May 2015) that reported complications of either MI-TLIF or LLIF were identified from a search in the PubMed database. The primary outcome was overall risk of complication per patient. Secondary outcomes included risks of sensory deficits, temporary neurological deficit, permanent neurological deficit, intraoperative complications, medical complications, wound complications, hardware failure, subsidence, and reoperation. RESULTS Fifty-four studies were included for analysis of MI-TLIF, and 42 studies were included for analysis of LLIF. Overall, there were 9714 patients (5454 in the MI-TLIF group and 4260 in the LLIF group) with 13,230 levels fused (6040 in the MI-TLIF group and 7190 in the LLIF group). A total of 1045 complications in the MI-TLIF group and 1339 complications in the LLIF group were reported. The total complication rate per patient was 19.2% in the MI-TLIF group and 31.4% in the LLIF group (p < 0.0001). The rate of sensory deficits and temporary neurological deficits, and permanent neurological deficits was 20.16%, 2.22%, and 1.01% for MI-TLIF versus 27.08%, 9.40%, and 2.46% for LLIF, respectively (p < 0.0001, p < 0.0001, p = 0.002, respectively). Rates of intraoperative and wound complications were 3.57% and 1.63% for MI-TLIF compared with 1.93% and 0.80% for LLIF, respectively (p = 0.0003 and p = 0.034, respectively). No significant differences were noted for medical complications or reoperation. CONCLUSIONS While there was a higher overall complication rate with LLIF, MI-TLIF and LLIF both have acceptable complication profiles. LLIF had higher rates of sensory as well as temporary and permanent neurological symptoms, although rates of intraoperative and wound complications were less than MI-TLIF. Larger, prospective comparative studies are needed to confirm these findings as the current literature is of relative poor quality.

Guideline summary review: An evidence-based clinical guideline for the diagnosis and treatment of degenerative lumbar spondylolisthesis

BACKGROUND CONTEXT

The North American Spine Society's (NASS) Evidence-Based Clinical Guideline for the Diagnosis and Treatment of Degenerative Lumbar Spondylolisthesis features evidence-based recommendations for diagnosing and treating degenerative lumbar spondylolisthesis. The guideline updates the 2008 guideline on this topic and is intended to reflect contemporary treatment concepts for symptomatic degenerative lumbar spondylolisthesis as reflected in the highest quality clinical literature available on this subject as of May 2013. The NASS guideline on this topic is the only guideline on degenerative lumbar spondylolisthesis included in the Agency for Healthcare Research and Quality's National Guideline Clearinghouse (NGC).

PURPOSE

The purpose of this guideline is to provide an evidence-based educational tool to assist spine specialists when making clinical decisions for patients with degenerative lumbar spondylolisthesis. This article provides a brief summary of the evidence-based guideline recommendations for diagnosing and treating patients with this condition.

STUDY DESIGN

A systematic review of clinical studies relevant to degenerative spondylolisthesis was carried out.

METHODS

This NASS spondyolisthesis guideline is the product of the Degenerative Lumbar Spondylolisthesis Work Group of NASS' Evidence-Based Guideline Development Committee. The methods used to develop this guideline are detailed in the complete guideline and technical report available on the NASS website. In brief, a multidisciplinary work group of spine care specialists convened to identify clinical questions to address in the guideline. The literature search strategy was developed in consultation with medical librarians. Upon completion of the systematic literature search, evidence relevant to the clinical questions posed in the guideline was reviewed. Work group members used the NASS evidentiary table templates to summarize study conclusions, identify study strengths and weaknesses, and assign levels of evidence. Work group members participated in webcasts and in-person recommendation meetings to update and formulate evidence-based recommendations and incorporate expert opinion when necessary. The draft guidelines were submitted to an internal peer review process and ultimately approved by the NASS Board of Directors. Upon publication, the Degenerative Lumbar Spondylolisthesis guideline was accepted into the NGC and will be updated approximately every 5 years.

RESULTS

Twenty-seven clinical questions were addressed in this guideline update, including 15 clinical questions from the original guideline and 12 new clinical questions. The respective recommendations were graded by strength of the supporting literature, which was stratified by levels of evidence. Twenty-one new or updated recommendations or consensus statements were issued and 13 recommendations or consensus statements were maintained from the original guideline.

CONCLUSIONS

The clinical guideline was created using the techniques of evidence-based medicine and best available evidence to aid practitioners in the care of patients with degenerative lumbar spondylolisthesis. The entire guideline document, including the evidentiary tables, literature search parameters, literature attrition flow chart, suggestions for future research, and all of the references, is available electronically on the NASS website at https://www.spine.org/Pages/ResearchClinicalCare/QualityImprovement/ClinicalGuidelines.aspx and will remain updated on a timely schedule.

How High Are Radiation-related Risks in Minimally Invasive Transforaminal Lumbar Interbody Fusion Compared With Traditional Open Surgery?: A Meta-analysis and Dose Estimates of Ionizing Radiation

STUDY DESIGN

Meta-analysis and dose estimation.

OBJECTIVE

The aim of this study was to estimate radiation dose during minimally invasive transforaminal lumbar interbody fusion (MiTLIF) compared with open transforaminal lumbar interbody fusion (OTLIF) and evaluate the risk of radiation-related disease.

SUMMARY OF BACKGROUND DATA

MiTLIF was introduced to reduce soft tissue injury and shows favorable perioperative outcomes. However, the disadvantage of MiTLIF is that, compared with OTLIF, it involves high radiation exposure because MiTLIF usually depends on a fluoroscopic guide. The additional cancer risk due to medical radiation exposure during the MiTLIF procedure has not yet been assessed.

METHODS

We searched PubMed, Embase, and the Cochrane Central Register of Controlled Trials in June 2014 for studies directly comparing MiTLIF and OTLIF. Patient demographics, fluoroscopy time, intraoperative bleeding, and hospitalization period were extracted. The effective dose was converted from fluoroscopy time using formulas from prior studies.

RESULTS

Eight cohort studies with a total of 619 patients were identified. Mean fluoroscopy time was 39.42 seconds [95% confidence interval (CI), 38.01-40.83] during OTLIF and 94.21 seconds (95% CI, 91.51-96.91) during MiTLIF according to the meta-analysis. The pooled data revealed that patients who underwent MiTLIF were exposed to 2.4-fold more radiation than those who underwent OTLIF. Patients who underwent OTLIF and MiTLIF were exposed to 0.66 mSv (95% CI, 0.64-0.69) and 1.58 mSv (95% CI, 1.54-1.63) during the surgery, respectively. The lifetime risk of cancer was theoretically increased by 36.4×10 and 87.0×10 after OTLIF and MiTLIF, respectively. The risk of detrimental hereditary disorders associated with OTLIF and MiTLIF is 1.32×10 and 3.16×10, respectively.

CONCLUSIONS

Patients who underwent MiTLIF were exposed to 2.4-fold more radiation than those who underwent OTLIF. Although the theoretical cancer risk associated with radiation exposure may be tolerable, stochastic effects should not be disregarded.

Cost-utility of minimally invasive versus open transforaminal lumbar interbody fusion: systematic review and economic evaluation

PURPOSE

To assess the cost-utility and perioperative costs of minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) versus open-TLIF for degenerative lumbar pathologies.

METHODS

Relevant articles were identified from six electronic databases. Predefined end points were extracted and meta-analysis conducted from the identified studies.

RESULTS

For each study, the direct hospital cost for MI-TLIF was found to be less than that of open-TLIF. When these outcomes were pooled, direct hospital costs were found to be significantly lower in the MI-TLIF group [weighted mean difference (WMD), -$2820; I (2) = 61 %; P < 0.00001]. MI-TLIF was also associated with shorter hospitalization (WMD, 0.99; 95 % CI -1.81, -0.17; I (2) = 96 %; P = 0.02), trend toward reduced complications (relative risk 0.53; 95 % CI 0.23, 1.06; I (2) = 0 %; P = 0.07), and reduced blood loss (WMD, -246.40 mL; I (2) = 98 %; P = 0.003), but was not associated with a significant difference in operation time (WMD, -67.05; 95 % CI -169.44, 35.35; I (2) = 100 %; P = 0.20).

CONCLUSIONS

From the limited evidence, the available data suggest a trend of significantly reduced perioperative costs, length of stay, and blood loss for minimally invasive compared with open surgical approaches for TLIF. MI-TLIF may represent an opportunity for optimal utilization and allocation of health-care resources from both a hospital and societal perspective.

Intraoperative and perioperative complications in minimally invasive transforaminal lumbar interbody fusion: a review of 513 patients

OBJECT

Transforaminal lumbar interbody fusion (TLIF) has become one of the preferred procedures for circumferential fusion in the lumbar spine. Over the last decade, advances in surgical techniques have enabled surgeons to perform the TLIF procedure through a minimally invasive approach (MI-TLIF). There are a few studies reported in the medical literature in which perioperative complication rates of MI-TLIF were evaluated; here, the authors present the largest cohort series to date. They analyzed intraoperative and perioperative complications in 513 consecutive MI-TLIF–treated patients with lumbar degenerative disc disease.

METHODS

The authors performed a retrospective review of prospectively collected data on 513 consecutive patients treated over a 10-year period for lumbar degenerative disc disease using MI-TLIF. All patients undergoing either a first-time or revision 1- or 2-level MI-TLIF procedure were included in the study. Demographic, intraoperative, and perioperative data were collected and analyzed using bivariate analyses (Student t-test, analysis of variance, odds ratio, chi-square test) and multivariate analyses (logistic regression).

RESULTS

A total of 513 patients underwent an MI-TLIF procedure, and the perioperative complication rate was 15.6%. The incidence of durotomy was 5.1%, and the medical and surgical infection rates were 1.4% and 0.2%, respectively. A statistically significant increase in the infection rate was seen in revision MI-TLIF cases, and the same was found for the perioperative complication rate in multilevel MI-TLIF cases. Instrumentation failure occurred in 2.3% of the cases. After analysis, no statistically significant difference was seen in the rates of durotomy during revision and multilevel surgeries. There was no significant difference between the complication rates when stratified according to presenting diagnosis.

CONCLUSIONS

To the authors' knowledge, this is the largest study of perioperative complications in MI-TLIF in the literature. A total of 513 patients underwent MI-TLIF (perioperative complication rate 15.6%). The most common complication was a durotomy (5.1%), and there was only 1 surgical wound infection (0.2%). There were significantly more perioperative infections in revision MI-TLIF cases and more perioperative complications in multilevel MI-TLIF cases. The results of this study suggest that MI-TLIF has a similar or better perioperative complication profile than those documented in the literature for open-TLIF treatment of degenerative lumbar spine disease.

Minimally invasive versus open transforaminal lumbar interbody fusion for treatment of degenerative lumbar disease: systematic review and meta-analysis

PURPOSE

While open TLIF (O-TLIF) remains the mainstay approach, minimally invasive TLIF (MI-TLIF) may offer potential advantages of reduced trauma to paraspinal muscles, minimized perioperative blood loss, quicker recovery and reduced risk of infection at surgical sites. This meta-analysis was conducted to provide an updated assessment of the relative benefits and risks of MI-TLIF versus O-TLIF.

METHODS

Electronic searches were performed using six databases from their inception to December 2014. Relevant studies comparing MI-TLIF and O-TLIF were included. Data were extracted and analysed according to predefined clinical end points.

RESULTS

There was no significant difference in operation time noted between MI-TLIF and O-TLIF cohorts. The median intraoperative blood loss for MI-TLIF was significantly lower than O-TLIF (median: 177 vs 461 mL; (weighted mean difference) WMD, -256.23; 95% CI -351.35, -161.1; P < 0.00001). Infection rates were significantly lower in the minimally invasive cohort (1.2 vs 4.6%; relative risk (RR), 0.27; 95%, 0.14, 0.53; I2) = 0%; P = 0.0001). VAS back pain scores were significantly lower in the MI-TLIF group compared to O-TLIF (WMD, -0.41; 95% CI -0.76, -0.06; I2 = 96%; P < 0.00001). Postoperative ODI scores were also significantly lower in the minimally invasive cohort (WMD, -2.21; 95% CI -4.26, -0.15; I2 = 93%; P = 0.04).

CONCLUSIONS

In summary, the present systematic review and meta-analysis demonstrated that MI-TLIF appears to be a safe and efficacious approach compared to O-TLIF. MI-TLIF is associated with lower blood loss and infection rates in patients, albeit at the risk of higher radiation exposure for the surgical team. The long-term relative merits require further validation in prospective, randomized studies.

Economic impact of minimally invasive lumbar surgery

Cost effectiveness has been demonstrated for traditional lumbar discectomy, lumbar laminectomy as well as for instrumented and noninstrumented arthrodesis. While emerging evidence suggests that minimally invasive spine surgery reduces morbidity, duration of hospitalization, and accelerates return to activites of daily living, data regarding cost effectiveness of these novel techniques is limited. The current study analyzes all available data on minimally invasive techniques for lumbar discectomy, decompression, short-segment fusion and deformity surgery. In general, minimally invasive spine procedures appear to hold promise in quicker patient recovery times and earlier return to work. Thus, minimally invasive lumbar spine surgery appears to have the potential to be a cost-effective intervention. Moreover, novel less invasive procedures are less destabilizing and may therefore be utilized in certain indications that traditionally required arthrodesis procedures. However, there is a lack of studies analyzing the economic impact of minimally invasive spine surgery. Future studies are necessary to confirm the durability and further define indications for minimally invasive lumbar spine procedures.

Minimally invasive procedures on the lumbar spine

Degenerative disease of the lumbar spine is a common and increasingly prevalent condition that is often implicated as the primary reason for chronic low back pain and the leading cause of disability in the western world. Surgical management of lumbar degenerative disease has historically been approached by way of open surgical procedures aimed at decompressing and/or stabilizing the lumbar spine. Advances in technology and surgical instrumentation have led to minimally invasive surgical techniques being developed and increasingly used in the treatment of lumbar degenerative disease. Compared to the traditional open spine surgery, minimally invasive techniques require smaller incisions and decrease approach-related morbidity by avoiding muscle crush injury by self-retaining retractors, preventing the disruption of tendon attachment sites of important muscles at the spinous processes, using known anatomic neurovascular and muscle planes, and minimizing collateral soft-tissue injury by limiting the width of the surgical corridor. The theoretical benefits of minimally invasive surgery over traditional open surgery include reduced blood loss, decreased postoperative pain and narcotics use, shorter hospital length of stay, faster recover and quicker return to work and normal activity. This paper describes the different minimally invasive techniques that are currently available for the treatment of degenerative disease of the lumbar spine.

A prospective, multi-institutional comparative effectiveness study of lumbar spine surgery in morbidly obese patients: does minimally invasive transforaminal lumbar interbody fusion result in superior outcomes?

BACKGROUND

Obese and morbidly obese patients undergoing lumbar spinal fusion surgery are a challenge to the operating surgeon. Minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) and open-TLIF have been performed for many years with good results; however, functional outcomes after lumbar spine surgery in this subgroup of patients remain poorly understood. Furthermore, whether index MIS-TLIF or open-TLIF for the treatment of degenerative disc disease or spondylolisthesis in morbidly obese results in superior postoperative functional outcomes remains unknown.

METHODS

A total of 148 (MIS-TLIF: n = 40, open-TLIF: n = 108) obese and morbidly obese patients undergoing index lumbar arthrodesis for low back pain and/or radiculopathy between January 2003 and December 2010 were selected from a multi-institutional prospective data registry. We collected and analyzed data on patient demographics, postoperative complications, back pain, leg pain, and functional disability over 2 years. Patients completed the Oswestry Disability Index (ODI), Medical Outcomes Study Short-Form 36 (SF-36), and back and leg pain numerical rating scores before surgery and then at 12 and 24 months after surgery. Clinical outcomes and complication rates were compared between both patient cohorts.

RESULTS

Compared with preoperative status, Visual Analog Scale (VAS) back and leg pain, ODI, and SF-36 physical component score/mental component score were improved in both groups. Both MIS-TLIF and open-TLIF patients showed similar 2-year improvement in VAS for back pain (MIS-TLIF: 2.42 ± 3.81 vs. open-TLIF: 2.33 ± 3.67, P = 0.89), VAS for leg pain (MIS-TLIF: 3.77 ± 4.53 vs. open-TLIF: 2.67 ± 4.10, P = 0.18), ODI (MIS-TLIF: 11.61 ± 25.52 vs. open-TLIF: 14.88 ± 22.07, P = 0.47), and SF-36 physical component score (MIS-TLIF: 8.61 ± 17.72 vs. open-TLIF: 7.61 ± 15.55, P = 0.93), and SF-36 mental component score (MIS-TLIF: 4.35 ± 22.71 vs. open-TLIF: 5.96 ± 21.09, P = 0.69). Postoperative complications rates between both cohorts were also not significantly divergent between (12.50% vs. 11.11%, P = 0.51).

CONCLUSION

MIS-TLIF is a safe and viable option for lumbar fusion in morbidly obese patients and, compared with open-TLIF, resulted in similar improvement in pain and functional disability. Postoperative complications rates between both cohorts were also not significantly divergent.

Disc space preparation in transforaminal lumbar interbody fusion: a comparison of minimally invasive and open approaches

BACKGROUND

Minimally invasive surgical (MIS) approaches to transforaminal lumbar interbody fusion (TLIF) have been developed as an alternative to the open approach. However, concerns remain regarding the adequacy of disc space preparation that can be achieved through a minimally invasive approach to TLIF.

QUESTIONS/PURPOSES

The purpose of this cadaver study is to compare the adequacy of disc space preparation through MIS and open approaches to TLIF. Specifically we sought to compare the two approaches with respect to (1) the time required to perform a discectomy and the number of endplate violations; (2) the percentage of disc removed; and (3) the anatomic location where residual disc would remain after discectomy.

METHODS

Forty lumbar levels (ie, L1-2 to L5-S1 in eight fresh cadaver specimens) were randomly assigned to open and MIS groups. Both surgeons were fellowship-trained spine surgeons proficient in the assigned approach used. Time required for discectomy, endplate violations, and percentage of disc removed by volume and mass were recorded for each level. A digital imaging software program (ImageJ; US National Institutes of Health, Bethesda, MD, USA) was used to measure the percent disc removed by area for the total disc and for each quadrant of the endplate.

RESULTS

The open approach was associated with a shorter discectomy time (9 versus 12 minutes, p = 0.01) and fewer endplate violations (one versus three, p = 0.04) when compared with an MIS approach, percent disc removed by volume (80% versus 77%, p = 0.41), percent disc removed by mass (77% versus 75%, p = 0.55), and percent total disc removed by area (73% versus 71%, p = 0.63) between the open and MIS approaches, respectively. The posterior contralateral quadrant was associated with the lowest percent of disc removed compared with the other three quadrants in both open and MIS groups (50% and 60%, respectively).

CONCLUSIONS

When performed by a surgeon experienced with MIS TLIF, MIS and open approaches are similar in regard to the adequacy of disc space preparation. The least amount of disc by percentage is removed from the posterior contralateral quadrant regardless of the approach; surgeons should pay particular attention to this anatomic location during the discectomy portion of the procedure to minimize the likelihood of pseudarthrosis.

The technological development of minimally invasive spine surgery

Minimally invasive spine surgery has its roots in the mid-twentieth century with a few surgeons and a few techniques, but it has now developed into a large field of progressive spinal surgery. A wide range of techniques are now called "minimally invasive," and case reports are submitted constantly with new "minimally invasive" approaches to spinal pathology. As minimally invasive spine surgery has become more mainstream over the past ten years, in this paper we discuss its history and development.

Minimally invasive transforaminal lumbar interbody fusion (MI-TLIF): surgical technique, long-term 4-year prospective outcomes, and complications compared with an open TLIF cohort

Transforaminal lumbar interbody fusion (TLIF) is an important surgical option for the treatment of back pain and radiculopathy. The minimally invasive TLIF (MI-TLIF) technique is increasingly used to achieve neural element decompression, restoration of segmental alignment and lordosis, and bony fusion. This article reviews the surgical technique, outcomes, and complications in a series of 144 consecutive 1- and 2-level MI-TLIFs in comparison with an institutional control group of 54 open traditional TLIF procedures with a mean of 46 months' follow-up. The evidence base suggests that MI-TLIF can be performed safely with excellent long-term outcomes.

Expert's comment concerning Grand Rounds case entitled "Minimal access bilateral transforaminal lumbar interbody fusion for high-grade isthmic spondylolisthesis" (by Nasir A. Quraishi and Y. Raja Rampersaud; doi:10.1007/s00586-012-2623-2)

This Expert's Comment discusses the Grand Rounds Case entitled "Minimal Access Bilateral Transforaminal Lumbar Interbody Fusion for High-Grade Isthmic Spondylolisthesis" by Nasir A Quraishi and Raja Y Rampersaud. It puts a technically elegant surgical method for minimally invasive reduction and arthrodesis of isthmic spondylolistheses into the context of short and long term outcomes and questions the motivations for performing such minimally invasive procedures in the absence of any proven mid or long term advantages over more traditional techniques. In addition, the use of BMP in spinal arthrodesis is discussed on the background of recently published IPD metaanalyses from the Infuse spinal FDA trials.