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Ali EMS, Abdeen M, Saleh MK. Minimally invasive versus mini-open transforaminal lumbar interbody fusion in managing low-grade degenerative spondylolisthesis. Acta Neurochir (Wien) 2024; 166:365. [PMID: 39264454 PMCID: PMC11392987 DOI: 10.1007/s00701-024-06231-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2024] [Accepted: 08/13/2024] [Indexed: 09/13/2024]
Abstract
DATA BACKGROUND Because the traditional open-TLIF approach has several drawbacks, minimally invasive surgery (MIS) approaches for TLIF (MISTLIF) have been developed to speed up recovery after surgery and minimize pressure on the para-spinal muscles, necessitating a cost-utility analysis for comparison in healthcare reforms. OBJECTIVES AND AIM OF THE WORK This study aimed to compare the radiological and clinical parameters between mini-open TLIF and minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) surgery in patients with single-level lumbar degenerative spondylolisthesis. HYPOTHESIS This study hypothesizes that both minimally invasive and mini-open methods using sublaminar trimming laminoplasty (SLTL) (while preserving midline structures) and interbody cages have comparable mid- and long-term clinical and radiological outcomes. METHODS Retrospective analyses were performed on 120 patients who underwent single-level TLIF procedures with a minimum of two years of follow-up utilizing either the mini-open (n = 60) or MIS (n = 60) technique. Records of the operation's time frame, intraoperative fluoroscopy, blood loss, postoperative drainage volume, duration of bed rest, and complications were recorded. The Oswestry Disability Index (ODI) and visual analog scale (VAS) scores for both groups were utilized to assess improvements in clinical scores, and t tests were employed to statistically compare the outcomes. For comparison, radiological parameters, including lumbar lordosis, pelvic incidence (PI), and localized lordosis at the index level, were measured preoperatively, postoperatively, and at the final follow-up. To assess postoperative interbody fusion, the Bridwell grading system was used. RESULTS In the Mini-open TLIF group, the average follow-up time was 24.91 ± 5.7 months, while in the MIS-TLIF group, the average follow-up time was 25.15 ± 4.2 months. In the MIS-TLIF group, the mean operation and radiological time were longer. However, compared to the Mini-open TLIF group, the MISTLIF group experienced less blood loss and a shorter hospital stay. The MIS-TLIF group outperformed the Open-TLIF group in terms of the VAS score for back pain and the ODI at less than 6 months following surgery, and the differences were statistically significant. However, at the final follow-up, there were no statistically significant differences in the VAS score for the back between the two groups, but the ODI score was significantly greater in the MIS-TLIF group. Both groups' lumbar lordosis and focal lordosis significantly improved at the index level, with the Mini-open-TLIF group showing more focal lordosis. The interbody fusion rate did not significantly differ between the two groups. CONCLUSION MIS-TLIF and mini-open-TLIF can be surgically effective in treating single-level degenerative lumbar spine spondylolisthesis.
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Affiliation(s)
| | - Mohamed Abdeen
- Orthopedic Department, Faculty of Medicine, Zagazig University Hospital, Zagazig, Egypt
| | - Mohammed Khalid Saleh
- Orthopedic Department, Faculty of Medicine, Zagazig University Hospital, Zagazig, Egypt
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Tang T, Wan B, Zhang X, Zhang A. Impact of Obesity on Outcomes of Minimally Invasive Transforaminal Lumbar Interbody Fusion Surgeries: A Systematic Review and Meta-Analysis. World Neurosurg 2024; 185:e835-e849. [PMID: 38432511 DOI: 10.1016/j.wneu.2024.02.136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2024] [Accepted: 02/24/2024] [Indexed: 03/05/2024]
Abstract
OBJECTIVE To evaluate the impact of obesity on various outcomes in patients undergoing minimally invasive transforaminal lumbar interbody fusion (TLIF) surgeries. METHODS PubMed, Scopus, Embase, and Cochrane Library databases were screened for studies reporting outcomes in obese and nonobese patients undergoing TLIF surgeries. Studies reporting operative time, estimated blood loss, length of hospital stay, incidence of pseudoarthrosis, Oswestry Disability Index (ODI) scores, pain scores (Visual Analog Scale, VAS), and PROMIS PF scores were included. A qualitative and quantitative analysis was performed to calculate mean differences or odds ratios (ORs) using random-effects models. RESULTS Fourteen good-quality studies were included in this review, with a combined sample size of 4,889 participants. The analysis revealed that patients with obesity had slightly longer operative times compared to patients with normal weight, with a mean difference of 14.87 minutes, though not significant. Similarly, morbidly obese patients had a mean difference of 21.44 minutes in operative time. Estimated blood loss was comparable in both groups. However, morbidly obese patients had longer hospital stays, with a mean difference of 8.18 days and obese patients have 20% higher odds of experiencing complications compared to nonobese patients. The incidence of pseudoarthrosis, ODI scores, or pain scores (VAS back and leg) were similar in obese and normal weight patients. CONCLUSIONS Obesity, particularly morbid obesity, may have an impact on certain outcomes in patients undergoing minimally invasive TLIF surgeries. Morbidly obese patients tend to have significantly longer operative times with significantly longer hospital stays than nonobese patients.
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Affiliation(s)
- Tao Tang
- Department of Second Orthopedics, First People's Hospital of Jiashan County, Jiashan County, China
| | - Bingwen Wan
- Department of Second Orthopedics, First People's Hospital of Jiashan County, Jiashan County, China
| | - Xu Zhang
- Department of Second Orthopedics, First People's Hospital of Jiashan County, Jiashan County, China
| | - Alei Zhang
- Department of Second Orthopedics, First People's Hospital of Jiashan County, Jiashan County, China.
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Thomas G, Thomas J, Tambi S, Chaudhry T, Almeida ND, Sherman JH. Impact of metabolic syndrome on morbidity and mortality following transforaminal interbody fusion (TLIF). J Orthop 2023; 46:102-106. [PMID: 37969227 PMCID: PMC10641559 DOI: 10.1016/j.jor.2023.10.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2023] [Revised: 10/24/2023] [Accepted: 10/26/2023] [Indexed: 11/17/2023] Open
Abstract
Study design Retrospective Multi-Institutional Database Study. Objective Investigate the effect of metabolic syndrome (MetS) on the outcomes of Transforaminal Lumbar Interbody Fusion (TLIF). Summary of background data TLIF procedures in lumbar spine pathology are common. MetS is a combination of conditions, including medication required hypertension, diabetes mellitus (DM), and body mass index (BMI) of 30 kg/m2s or more. The prevalence of MetS has increased drastically over the past two decades. Our study aimed to understand the effect of MetS on morbidity and mortality of TLIF postoperatively. Methods Our study used American College of Surgeons National Surgical Quality Improvement (ACS-NSQIP) data from 2006 to 2019 to find all patients who underwent TLIF. Patients with MetS were compared to those without MetS. Fisher's test identified univariate relationships between MetS and preoperative/postoperative variables. Multivariable logistic regression models were utilized to analyze the association between MetS and postoperative morbidity and mortality. Results 54,980 patients were identified who received TLIF. 10.7 % had MetS preoperatively. Patients with and without MetS showed statistically significant univariate differences in most preoperative and postoperative variables. After adjusting for preoperative comorbidities, patients with MetS had greater multivariate-adjusted odds of wound infections (aOR = 1.5889, CI 1.1952-2.112, p = 0.00144), pulmonary events (aOR = 1.5517, CI 1.1207-2.1485, p = 0.00813), renal events (aOR = 2.8685, CI 1.5511-5.3045, p = 0.00078), sepsis (aOR = 1.6773, CI 1.1647-2.4155, p = 5.44E-03), and return to OR (aOR = 1.4764, CI 1.2201-1.7866, p = 6.19E-05). Conclusions Patients with MetS are at elevated risk for various morbidity and mortality markers after TLIF. Surgeons performing TLIFs on these patients should be aware of the increased potential for postoperative events that may complicate the patient's recovery. Level of evidence Level III.
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Affiliation(s)
- George Thomas
- Department of Orthopaedic Surgery, University of Minnesota, Minneapolis, MN, USA
| | - John Thomas
- West Virginia School of Osteopathic Medicine, Lewisburg, WV, USA
| | - Sandra Tambi
- Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
| | - Taimur Chaudhry
- George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Neil D. Almeida
- Department of Neurosurgery, School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, NY, USA
| | - Jonathan H. Sherman
- Department of Neurosurgery, West Virginia University Rockefeller Neuroscience Institute, Morgantown, WV, 25401, USA
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Doria-Medina R, Hubbe U, Scholz C, Sircar R, Brönner J, Hoedlmoser H, Klingler JH. Free-Hand MIS TLIF without 3D Navigation-How to Achieve Low Radiation Exposure for Both Surgeon and Patient. J Clin Med 2023; 12:5125. [PMID: 37568527 PMCID: PMC10419541 DOI: 10.3390/jcm12155125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2023] [Revised: 07/26/2023] [Accepted: 08/02/2023] [Indexed: 08/13/2023] Open
Abstract
BACKGROUND Transforaminal lumbar interbody fusion (TLIF) is one of the most frequently performed spinal fusion techniques, and this minimally invasive (MIS) approach has advantages over the traditional open approach. A drawback is the higher radiation exposure for the surgeon when conventional fluoroscopy (2D-fluoroscopy) is used. While computer-assisted navigation (CAN) reduce the surgeon's radiation exposure, the patient's exposure is higher. When we investigated 2D-fluoroscopically guided and 3D-navigated MIS TLIF in a randomized controlled trial, we detected low radiation doses for both the surgeon and the patient in the 2D-fluoroscopy group. Therefore, we extended the dataset, and herein, we report the radiation-sparing surgical technique of 2D-fluoroscopy-guided MIS TLIF. METHODS Monosegmental and bisegmental MIS TLIF was performed on 24 patients in adherence to advanced radiation protection principles and a radiation-sparing surgical protocol. Dedicated dosemeters recorded patient and surgeon radiation exposure. For safety assessment, pedicle screw accuracy was graded according to the Gertzbein-Robbins classification. RESULTS In total, 99 of 102 (97.1%) pedicle screws were correctly positioned (Gertzbein grade A/B). No breach caused neurological symptoms or necessitated revision surgery. The effective radiation dose to the surgeon was 41 ± 12 µSv per segment. Fluoroscopy time was 64 ± 34 s and 75 ± 43 radiographic images per segment were performed. Patient radiation doses at the neck, chest, and umbilical area were 65 ± 40, 123 ± 116, and 823 ± 862 µSv per segment, respectively. CONCLUSIONS Using a dedicated radiation-sparing free-hand technique, 2D-fluoroscopy-guided MIS TLIF is successfully achievable with low radiation exposure to both the surgeon and the patient. With this technique, the maximum annual radiation exposure to the surgeon will not be exceeded, even with workday use.
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Affiliation(s)
- Roberto Doria-Medina
- Department of Neurosurgery, Medical Center, University of Freiburg, 79106 Freiburg, Germany
| | - Ulrich Hubbe
- Department of Neurosurgery, Medical Center, University of Freiburg, 79106 Freiburg, Germany
| | - Christoph Scholz
- Department of Neurosurgery, Medical Center, University of Freiburg, 79106 Freiburg, Germany
| | - Ronen Sircar
- Department of Neurosurgery, Medical Center, University of Freiburg, 79106 Freiburg, Germany
| | | | | | - Jan-Helge Klingler
- Department of Neurosurgery, Medical Center, University of Freiburg, 79106 Freiburg, Germany
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Schermann H, Hochberg U, Regev GJ, Salame K, Ofir D, Ankori R, Lidar Z, Khashan M. The effect of subcutaneous fat and skin-to-lamina distance on complications and functional outcomes of minimally invasive lumbar decompression. INTERNATIONAL ORTHOPAEDICS 2023:10.1007/s00264-023-05852-4. [PMID: 37249629 DOI: 10.1007/s00264-023-05852-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Accepted: 05/23/2023] [Indexed: 05/31/2023]
Abstract
PURPOSE Minimally invasive lumbar decompression (MIS) in obese pzatients is technically challenging due to the use of longer tube retractors. The purpose of this study was to evaluate the impact of the thickness of the soft tissue and subcutaneous fat on complications, revisions, and patient-reported functional outcomes after MIS. METHODS This is a retrospective analysis of 148 consecutive patients who underwent minimally invasive lumbar decompression at our institute between 2013 and 2017 and had at least one year of follow-up. Analysis was performed five times, each time the study group was defined by another measure of adiposity: BMI > 30, skin to lamina distance at the site of surgery and at L4 > 6 cm, and subcutaneous fat thickness at the site of surgery and at L4 > 3 cm. Outcomes included intraoperative complications (durotomy or neurological deficit), possibly inadequate decompression (residual disc, reoperation), length of stay, return to the emergency room or readmission, postoperative medical complications, and functional outcomes: visual analog scores for back and leg pain, and Oswestry Disability Index (ODI). RESULTS Patients with a thicker layer soft tissue had a significantly higher burden of comorbidities than controls, including higher prevalence of cardiovascular disease (p = 0.002), diabetes (p < 0.001), hypertension (p < 0.001) and higher ASA scores (p = 0.002). Nevertheless, there was no significant difference between the patient groups in surgical and medical complications, functional outcomes, and other assessed outcomes. CONCLUSION Our results indicate that minimally invasive lumbar decompression is safe and effective for patients with a thick layer of soft tissue and subcutaneous fat.
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Affiliation(s)
- Haggai Schermann
- Spine Surgery Unit, Department of Neurosurgery, Tel Aviv Sourasky Medical Center affiliated with Tel Aviv University, Tel Aviv, Israel.
| | - Uri Hochberg
- Pain Clinic, Tel Aviv Sourasky Medical Center affiliated with Tel Aviv University, Tel Aviv, Israel
| | - Gilad J Regev
- Spine Surgery Unit, Department of Neurosurgery, Tel Aviv Sourasky Medical Center affiliated with Tel Aviv University, Tel Aviv, Israel
| | - Khalil Salame
- Spine Surgery Unit, Department of Neurosurgery, Tel Aviv Sourasky Medical Center affiliated with Tel Aviv University, Tel Aviv, Israel
| | - Dror Ofir
- Spine Surgery Unit, Department of Neurosurgery, Tel Aviv Sourasky Medical Center affiliated with Tel Aviv University, Tel Aviv, Israel
| | - Ran Ankori
- Spine Surgery Unit, Department of Neurosurgery, Tel Aviv Sourasky Medical Center affiliated with Tel Aviv University, Tel Aviv, Israel
| | - Zvi Lidar
- Spine Surgery Unit, Department of Neurosurgery, Tel Aviv Sourasky Medical Center affiliated with Tel Aviv University, Tel Aviv, Israel
| | - Morsi Khashan
- Spine Surgery Unit, Department of Neurosurgery, Tel Aviv Sourasky Medical Center affiliated with Tel Aviv University, Tel Aviv, Israel
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Shu B, Xu F, Zheng X, Zhang Y, Liu Q, Li S, Chen J, Chen Y, Huang H, Duan G. Change in perioperative neutrophil-lymphocyte ratio as a potential predictive biomarker for chronic postsurgical pain and quality of life: an ambispective observational cohort study. Front Immunol 2023; 14:1177285. [PMID: 37122722 PMCID: PMC10130394 DOI: 10.3389/fimmu.2023.1177285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 03/27/2023] [Indexed: 05/02/2023] Open
Abstract
Introduction Accurate and accessible predictors of chronic postsurgical pain (CPSP) to identify high-risk postsurgical patients are prerequisite for preventive and interventional strategies. We investigated the incidence and risk factors of CPSP after abdominal surgery, with a focus on plasma immunological markers. Materials and methods This was a retrospective analysis of patients who underwent abdominal surgery under general anesthesia at a tertiary center between January 2021 and January 2022. The preoperative demographics, laboratory test data, and surgical factors of the participants were collected from the electronic medical record system. Postoperative pain intensity and living conditions at 1 year after discharge from the hospital were assessed via a phone survey. Univariate and multivariate analyses were used to explore independent risk factors associated with CPSP. Results A total of 968 patients were included, and 13.53% (n = 131 of 968) of patients reported CPSP 1 year after surgery. Patients with older age, open surgery, higher American Association of Anesthesiologists classification, patient-controlled intravenous analgesia application, longer surgery duration, higher postoperative absolute neutrophil count, and neutrophil-lymphocyte ratio (NLR), lower postoperative absolute lymphocyte count, and higher white blood cell count, were more likely to suffer from CPSP. A changed ratio of NLR (postoperative to preoperative) ≥ 5 significantly correlated with CPSP, moderate to severe pain, maximum numeric rating score since discharge from the hospital, and affected quality of life. Discussion The changed ratio of NLR could be used for the early identification of patients at risk for CPSP and affect the quality of life to alert the clinician to undertake further assessment.
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Affiliation(s)
| | | | | | | | | | | | | | | | - He Huang
- *Correspondence: He Huang, ; Guangyou Duan,
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Cofano F, Perna GD, Bongiovanni D, Roscigno V, Baldassarre BM, Petrone S, Tartara F, Garbossa D, Bozzaro M. Obesity and Spine Surgery: A Qualitative Review About Outcomes and Complications. Is It Time for New Perspectives on Future Researches? Global Spine J 2022; 12:1214-1230. [PMID: 34128419 PMCID: PMC9210241 DOI: 10.1177/21925682211022313] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
STUDY DESIGN Literature review. OBJECTIVES An increasing number of obese patients requires operative care for degenerative spinal disorders. The aim of this review is to analyze the available evidence regarding the role of obesity on outcomes after spine surgery. Peri-operative complications and clinical results are evaluated for both cervical and lumbar surgery. Furthermore, the contribution of MIS techniques for lumbar surgery to play a role in reducing risks has been analyzed. METHODS Only articles published in English in the last 10 years were reviewed. Inclusion criteria of the references were based on the scope of this review, according to PRISMA guidelines. Moreover, only paper analyzing obesity-related complications in spine surgery have been selected and thoroughly reviewed. Each article was classified according to its rating of evidence using the Sacket Grading System. RESULTS A total number of 1636 articles were found, but only 130 of them were considered to be relevant after thorough evaluation and according to PRISMA checklist. The majority of the included papers were classified according to the Sacket Grading System as Level 2 (Retrospective Studies). CONCLUSION Evidence suggest that obese patients could benefit from spine surgery and outcomes be satisfactory. A higher rate of peri-operative complications is reported among obese patients, especially in posterior approaches. The use of MIS techniques plays a key role in order to reduce surgical risks. Further studies should evaluate the role of multidisciplinary counseling between spine surgeons, nutritionists and bariatric surgeons, in order to plan proper weight loss before elective spine surgery.
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Affiliation(s)
- Fabio Cofano
- Spine Surgery Unit, Humanitas Gradenigo Hospital, Turin, Italy,Department of Neuroscience “Rita Levi Montalcini,” Unit of Neurosurgery, University of Turin, Turin, Italy
| | - Giuseppe Di Perna
- Department of Neuroscience “Rita Levi Montalcini,” Unit of Neurosurgery, University of Turin, Turin, Italy
| | - Daria Bongiovanni
- Division of Endocrinology, Andrology and Metabolism, Humanitas Gradenigo Hospital, Turin, Italy
| | - Vittoria Roscigno
- Division of Endocrinology, Andrology and Metabolism, Humanitas Gradenigo Hospital, Turin, Italy
| | - Bianca Maria Baldassarre
- Department of Neuroscience “Rita Levi Montalcini,” Unit of Neurosurgery, University of Turin, Turin, Italy
| | - Salvatore Petrone
- Department of Neuroscience “Rita Levi Montalcini,” Unit of Neurosurgery, University of Turin, Turin, Italy,Salvatore Petrone, Department of Neuroscience “Rita Levi Montalcini,” Unit of Neurosurgery, University of Turin, Via Cherasco 15, Turin 10126, Italy.
| | - Fulvio Tartara
- Spine Surgery Unit, Humanitas Gradenigo Hospital, Turin, Italy
| | - Diego Garbossa
- Department of Neuroscience “Rita Levi Montalcini,” Unit of Neurosurgery, University of Turin, Turin, Italy
| | - Marco Bozzaro
- Spine Surgery Unit, Humanitas Gradenigo Hospital, Turin, Italy
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Cha EDK, Lynch CP, Mohan S, Geoghegan CE, Jadczak CN, Singh K. Impact of Obesity Severity on Achieving a Minimum Clinically Important Difference Following Minimally Invasive Transforaminal Lumbar Interbody Fusion. Clin Spine Surg 2022; 35:E267-E273. [PMID: 34050042 DOI: 10.1097/bsd.0000000000001205] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 04/14/2021] [Indexed: 11/26/2022]
Abstract
STUDY DESIGN This was a retrospective cohort study. OBJECTIVE The objective of this study was to determine the impact of obesity on postoperative outcomes and minimum clinically important difference (MCID) achievement following minimally invasive transforaminal lumbar interbody fusion (MIS TLIF). SUMMARY OF BACKGROUND DATA Obesity is a proven risk factor for poorer outcomes in MIS TLIF patients. However, few studies have investigated the impact of body mass index (BMI) on achievement of a MCID for Patient-Reported Outcome Measurement Information System Physical Function (PROMIS PF). METHODS A prospective surgical database was retrospectively reviewed for primary, elective, single level MIS TLIF patients. Patients were categorized into BMI groups: nonobese (<30 kg/m2); obese I (≥30 and <35 kg/m2); severe (≥35 and <40 kg/m2); and morbid (≥40 kg/m2). Demographic, perioperative information, and complication rates were compared between groups. Visual Analog Scale (VAS) back and leg, Oswestry Disability Index (ODI), 12-Item Short Form-12 Physical Composite Score (SF-12 PCS), and PROMIS PF were collected preoperatively and up to 2-year postoperatively. Impact of BMI on outcome measures and MCID achievement at all timepoints was evaluated. RESULTS A total of 162 patients were included with 88 patients categorized as normal weight, 37 obese I, 25 severe, and 12 morbid. SF-12 PCS, and PROMIS PF significantly differed by BMI at all timepoints, but only at 6- and 12-week for VAS back, preoperatively and 12 weeks for VAS leg, and preoperatively to 1-year for ODI. MCID achievement only differed for PROMIS PF and VAS back at 2 years, but did not for overall MCID achievement. CONCLUSIONS BMI is a significant predictor of ODI, SF-12 PCS, and PROMIS PF preoperatively to 1-year postoperatively, but only through 12-week for VAS scores. MCID achievement varied for PROMIS PF and VAS back, suggesting that though BMI may affect postoperative outcome values, obesity may impact a patient's perception of meaningful improvements in pain and physical function.
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Affiliation(s)
- Elliot D K Cha
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL
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The Effect of Morbid Obesity on Complications, Readmission, and Patient-Reported Outcomes Following Minimally Invasive Transforaminal Lumbar Interbody Fusion: An Inverse Propensity Score Weighted Analysis. Spine (Phila Pa 1976) 2021; 46:1394-1401. [PMID: 34559749 DOI: 10.1097/brs.0000000000004059] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective review of prospectively collected data at a single institution. OBJECTIVE To compare perioperative and clinical outcomes in morbidly obese patients who underwent minimally invasive transforaminal lumbar interbody fusion (MiTLIF). SUMMARY OF BACKGROUND DATA Obesity remains a serious public health concern. Obese patients who undergo lumbar fusion have historically thought to be at higher risk for complications and fare worse regarding quality-of-life outcomes. However, recent literature may demonstrate comparable risk and outcomes in obese patients. An increasing number of patients are categorized as morbidly obese (body mass index [BMI] ≥ 40 kg/m2). Perioperative and patient-reported outcomes (PROs) are lacking in this patient population. METHODS The authors retrospectively reviewed a prospectively collected database of all morbidly obese and non-obese patients that underwent MiTLIF between 2015 and 2018 for degenerative conditions who had minimum 1-year follow-up for outcome assessment. An inverse propensity/probability of treatment weighting was utilized to create a synthetic weighted sample in which covariates were independent of obesity designation to adjust for imbalance between groups. Generalized estimating equations (GEE) was used to estimate the association of morbid obesity and complications and 1-year PROs. RESULTS A total of 292 patients were analyzed with 234 non-obese patients and 58 morbidly obese patients. Multivariate analysis failed to demonstrate any association between morbid obesity and achieving minimal clinically important difference (MCID) for Oswestry disability index (ODI), visual analog scale (VAS), or short form-12 (SF-12) physical component score. However, morbid obesity was associated with significant decrease in odds of achieving MCID for SF-12 mental component score (P = 0.001). Increased surgery duration was significantly associated with morbid obesity (P = 0.001). Morbid obesity exhibited no statistically significant association with postoperative complications, readmission, pseudarthrosis, or adjacent segment disease (ASD). CONCLUSION Morbidly obese patients who undergo MiTLIF can achieve meaningful clinical improvement comparable to nonobese patients. Morbid obesity was associated with longer surgical times but was not associated with postoperative complications, readmission, or ASD.Level of Evidence: 3.
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Obesity in Patients Undergoing Lumbar Degenerative Surgery-A Retrospective Cohort Study of Postoperative Outcomes. Spine (Phila Pa 1976) 2021; 46:1191-1196. [PMID: 34384097 DOI: 10.1097/brs.0000000000004001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective cohort studying using a national, administrative database. OBJECTIVE The aim of this study was to determine the postoperative complications and quality outcomes of patients with and without obesity undergoing surgical management for lumbar degenerative disease (LDD). SUMMARY OF BACKGROUND DATA Obesity is a global epidemic that negatively impacts health outcomes. Characterizing the effect of obesity on LDD surgery is important given the growing elderly obese population. METHODS This study identified patients with who underwent surgery for LDD between 2007 and 2016. Patients were stratified based on whether the patient had a concurrent diagnosis of obesity at time of surgery. Propensity score matching (PSM) was then utilized to mitigate intergroup differences between patients with and without obesity. Patients who underwent three or more levels surgical correction, were under the age of 18 years, or those with any previous history of trauma or tumor were excluded from this study. Baseline comorbidities, postoperative complication rates, and reoperation rates were determined. RESULTS A total of 67,215 patients underwent primary lumbar degenerative surgery, of which 22,405 (33%) were obese. After propensity score matching, baseline covariates of the two cohorts were similar. The complication rate was 8.3% in the nonobese cohort and 10.4% in the obese cohort (P < 0.0001). Patients with obesity also had longer lengths of stay (2.7 days vs. 2.4 days, P < 0.05), and higher rates of reoperation and readmission at all time-points through the study follow-up period to their nonobese counterparts (P < 0.05). Including payments after discharge, lumbar degenerative surgery in patients with obesity was associated with higher payments throughout the 2-year follow-up period ($68,061 vs. $59,068 P < 0.05). CONCLUSION Patients with a diagnosis of obesity at time of LDD surgery are at a higher risk for postoperative complications, reoperation, and readmission.Level of Evidence: 4.
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Molina E, Zhao D, Dowlati E, Carroll AH, Mueller KB, Sandhu FA, Voyadzis JM. Minimally invasive posterior lumbar surgery in the morbidly obese, obese and non-obese populations: A single institution retrospective review. Clin Neurol Neurosurg 2021; 207:106746. [PMID: 34144463 DOI: 10.1016/j.clineuro.2021.106746] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Revised: 05/20/2021] [Accepted: 06/06/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND There is a paucity of information regarding outcomes in minimally invasive surgical (MIS) approaches to posterior lumbar surgery in morbidly obese patients. We seek to determine if there are differences in operative variables and early complication rates in morbidly obese patients undergoing MIS posterior lumbar surgery compared to obese and non-obese patients. METHODS A single institution retrospective review of patients undergoing MIS posterior lumbar surgery (decompression and/or fusion) between 2013 and 2016 was performed. Morbidly obese patients (BMI ≥ 40) were compared to obese (BMI 30-39.9) and non-obese (BMI < 30) cohorts. Postoperative complication rates and perioperative variables including estimated blood loss, operative time, and outcome measures including length of stay (LOS), in-hospital complications, readmission, and disposition were assessed. RESULTS 47 morbidly obese, 135 obese and 224 non-obese patients underwent posterior MIS instrumented fusion. 59 morbidly obese, 182 obese and 314 non-obese patients underwent posterior MIS decompression. The morbidly obese group experienced a greater rate of deep vein thrombosis and had an increased hospital LOS (p < 0.05). Morbidly obese patients who underwent MIS decompression experienced increased postoperative complications (p < 0.01), and increased LOS (p < 0.0001) compared to obese and non-obese patients. There were no differences in revision rates, readmissions, and other complications including surgical site infection. Morbid obesity was an independent predictor of overall complications and increased LOS on multivariate analysis. CONCLUSION Morbidly obese patients undergoing posterior MIS fusion had a higher rate of complications and increased LOS. While weight loss should be encouraged, complication rates remains acceptably low in morbidly obese patients and MIS posterior lumbar surgery should still be offered.
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Affiliation(s)
- Esteban Molina
- Georgetown University School of Medicine, Washington, DC, USA
| | - David Zhao
- Department of Neurosurgery, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Ehsan Dowlati
- Department of Neurosurgery, MedStar Georgetown University Hospital, Washington, DC, USA.
| | | | - Kyle B Mueller
- Department of Neurosurgery, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Faheem A Sandhu
- Department of Neurosurgery, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Jean-Marc Voyadzis
- Department of Neurosurgery, MedStar Georgetown University Hospital, Washington, DC, USA.
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12
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Mulvaney G, Rice OM, Rossi V, Peters D, Smith M, Patt J, Pfortmiller D, Asher AL, Kim P, Bernard J, McGirt M. Mild and Severe Obesity Reduce the Effectiveness of Lumbar Fusions: 1-Year Patient-Reported Outcomes in 8171 Patients. Neurosurgery 2021; 88:285-294. [PMID: 33009575 DOI: 10.1093/neuros/nyaa414] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Accepted: 07/05/2020] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Elevated body mass index (BMI) is a well-known risk factor for surgical complications in lumbar surgery. However, its effect on surgical effectiveness independent of surgical complications is unclear. OBJECTIVE To determine increasing BMI's effect on functional outcomes following lumbar fusion surgery, independent of surgical complications. METHODS We retrospectively analyzed a prospectively built, patient-reported, quality of life registry representing 75 hospital systems. We evaluated 1- to 3-level elective lumbar fusions. Patients who experienced surgical complications were excluded. A stepwise multivariate regression model assessed factors independently associated with 1-yr Oswestry Disability Index (ODI), preop to 1-yr ODI change, and achievement of minimal clinically important difference (MCID). RESULTS A total of 8171 patients met inclusion criteria: 2435 with class I obesity (BMI 30-35 kg/m2), 1328 with class II (35-40 kg/m2), and 760 with class III (≥40 kg/m2). Increasing BMI was independently associated with worse 12-mo ODI (t = 8.005, P < .001) and decreased likelihood of achieving MCID (odds ratio [OR] = 0.977, P < .001). One year after surgery, mean ODI, ODI change, and percentage achieving MCID worsened with class I, class II, and class III vs nonobese cohorts (P < .001) in stepwise fashion. CONCLUSION Increasing BMI is associated with decreased effectiveness of 1- to 3-level elective lumbar fusion, despite absence of surgical complications. BMI ≥ 30 kg/m2 is, therefore, a risk factor for both surgical complication and reduced benefit from lumbar fusion.
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Affiliation(s)
- Graham Mulvaney
- Carolina Neurosurgery & Spine Associates, Charlotte, North Carolina.,Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, North Carolina
| | - Olivia M Rice
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, North Carolina
| | - Vincent Rossi
- Carolina Neurosurgery & Spine Associates, Charlotte, North Carolina.,Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, North Carolina
| | - David Peters
- Carolina Neurosurgery & Spine Associates, Charlotte, North Carolina.,Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, North Carolina
| | - Mark Smith
- Carolina Neurosurgery & Spine Associates, Charlotte, North Carolina.,Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, North Carolina
| | - Joshua Patt
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, North Carolina
| | - Deborah Pfortmiller
- Carolina Neurosurgery & Spine Associates, Charlotte, North Carolina.,Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, North Carolina
| | - Anthony L Asher
- Carolina Neurosurgery & Spine Associates, Charlotte, North Carolina.,Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, North Carolina
| | - Paul Kim
- Carolina Neurosurgery & Spine Associates, Charlotte, North Carolina
| | - Joe Bernard
- Carolina Neurosurgery & Spine Associates, Charlotte, North Carolina
| | - Matthew McGirt
- Carolina Neurosurgery & Spine Associates, Charlotte, North Carolina.,Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, North Carolina
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13
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Goertz L, Stavrinou P, Hamisch C, Perrech M, Czybulka DM, Mehdiani K, Timmer M, Goldbrunner R, Krischek B. Impact of Obesity on Complication Rates, Clinical Outcomes, and Quality of Life after Minimally Invasive Transforaminal Lumbar Interbody Fusion. J Neurol Surg A Cent Eur Neurosurg 2020; 82:147-153. [PMID: 33352610 DOI: 10.1055/s-0040-1718758] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND Percutaneous pedicle screw fixation in obese patients remains a surgical challenge. We aimed to compare patient-reported outcomes and complication rates between obese and nonobese patients who were treated by minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF). METHODS The authors retrospectively reviewed patients who underwent MIS-TLIF at a single institution between 2011 and 2014. Patients were classified as obese (body mass index [BMI] ≥30 kg/m2) or nonobese (BMI < 30 kg/m2), according to their BMI. Outcomes assessed were complications, numerical rating scale (NRS) scores for back and leg pain, Oswestry Disability Index (ODI), and 36-Item Short-Form Survey (SF-36) scores. RESULTS The final study group consisted of 71 patients, 24 obese (33.8%, 34.8 ± 3.8 kg/m2) and 47 nonobese (66.2%, 25.4 ± 2.9 kg/m2). Instrumentation failures (13.6 vs. 17.0%), dural tears (17.2 vs. 4.0%), and revision rates (16.7 vs. 19.1%) were similar between both groups (p > 0.05). Perioperative improvements in back pain (4.3 vs. 5.4, p = 0.07), leg pain (3.8 vs. 4.2, p = 0.6), and ODI (13.3 vs. 22.5, p = 0.5) were comparable among the groups and persisted at long-term follow-up. Obese patients had worse postoperative physical component SF-36 scores than nonobese patients (36.4 vs. 42.7, p = 0.03), while the mental component scores were not statistically different (p = 0.09). CONCLUSION Obese patients can achieve similar improvement of the pain intensity and functional status even at long-term follow-up. In patients with appropriate surgical indications, obesity should not be considered a contraindication for MIS-TLIF surgery.
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Affiliation(s)
- Lukas Goertz
- Center for Neurosurgery, University Hospital Cologne, Cologne, Nordrhein-Westfalen, Germany
| | - Pantelis Stavrinou
- Center for Neurosurgery, University Hospital Cologne, Cologne, Nordrhein-Westfalen, Germany
| | - Christina Hamisch
- Center for Neurosurgery, University Hospital Cologne, Cologne, Nordrhein-Westfalen, Germany
| | - Moritz Perrech
- Center for Neurosurgery, University Hospital Cologne, Cologne, Nordrhein-Westfalen, Germany
| | - Dierk-Marko Czybulka
- Center for Neurosurgery, University Hospital Cologne, Cologne, Nordrhein-Westfalen, Germany
| | - Kaveh Mehdiani
- Center for Neurosurgery, University Hospital Cologne, Cologne, Nordrhein-Westfalen, Germany
| | - Marco Timmer
- Center for Neurosurgery, University Hospital Cologne, Cologne, Nordrhein-Westfalen, Germany
| | - Roland Goldbrunner
- Center for Neurosurgery, University Hospital Cologne, Cologne, Nordrhein-Westfalen, Germany
| | - Boris Krischek
- Center for Neurosurgery, University Hospital Cologne, Cologne, Nordrhein-Westfalen, Germany
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14
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Prediction calculator for nonroutine discharge and length of stay after spine surgery. Spine J 2020; 20:1154-1158. [PMID: 32179154 DOI: 10.1016/j.spinee.2020.02.022] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2019] [Revised: 02/17/2020] [Accepted: 02/20/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Following spine surgery, delays in referral to rehabilitation facilities leads to increased length of hospital stay (LOS), increases costs, more risk of hospital acquired complications, and decreased patient satisfaction. PURPOSE We sought to create a prediction calculator to determine the expected LOS after spine surgery and identify patients most likely to need postoperative nonhome discharge. The goal would be to facilitate earlier referral to rehabilitation and thereby ultimately shorten LOS, reduce costs, and improve patient satisfaction. STUDY DESIGN Retrospective. PATIENT SAMPLE We retrospectively reviewed all adult patients who underwent spine surgery for all indications between January and June 2018. OUTCOME MEASURES Length of stay and discharge disposition. METHODS Demographic variables, insurance status, baseline comorbidities, narcotic use, operative characteristics, as well as postoperative length of stay and discharge disposition data were collected. Univariable and multivariable analyses were performed to identify independent predictors of LOS and discharge disposition. RESULTS Two hundred fifty-seven patients were included. Mean age was 59 years, 46% were females, and 52% had private insurance vs 7% with Medicaid and 41% with Medicare. The most commonly performed procedure was lumbar fusion (31.9%). Mean LOS after surgery was 4.8 days and 18% had prolonged LOS >7 days. Age, insurance type, marriage status, and surgical procedure were significantly associated with LOS and discharge disposition. The final model had an area under the curve of 89% with good discrimination. A web based calculator was developed: https://jhuspine1.shinyapps.io/RehabLOS/ CONCLUSIONS: This study established a novel pilot calculator to identify those patients most likely to be discharged to rehabilitation facilities and to predict LOS after spine surgery. Our calculator had a high predictive accuracy of 89% compared to others in the literature. With validation this tool may ultimately facilitate streamlining of the postoperative period to shorten LOS, optimize resource utilization, and improve patient care.
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15
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Complications with Minimally Invasive Transforaminal Lumbar Interbody Fusion for Degenerative Spondylolisthesis in the Obese Population. Spine (Phila Pa 1976) 2019; 44:E1401-E1408. [PMID: 31725689 DOI: 10.1097/brs.0000000000003160] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A level-3 retrospective cohort analysis. OBJECTIVE The aim of this study was to describe obesity's effect on complications and outcomes in degenerative spondylolisthesis patients treated by minimally invasive transforaminal lumbar interbody fusion (MI TLIF). SUMMARY OF BACKGROUND DATA Obesity is associated with a greater complication rate among lumbar spine surgery patients. Poor clinical outcomes might likewise be supposed, but the association is not well established. Minimally invasive techniques have been developed to reduce complications and improve clinical outcomes in comparison to traditional open techniques. METHODS We reviewed 134 consecutive patients with degenerative spondylolisthesis undergoing MI TLIF. Subjects were grouped into nonobese (N = 65) and obese (N = 69) cohorts. The obese group was further subdivided by BMI. Patient demographics, perioperative complications, and outcome scores were collected over a minimum of 24 months. Four periods (intraoperative, postoperative hospitalization, 6-month, and 24-month postoperative) were assessed. RESULTS Cohort demographics were not significantly different, but it was noted that obese patients had more major comorbidities than nonobese patients. There was no difference in intraoperative complications between the two groups. The in-hospital complication rate was significantly greater in the obese group. The 6-month postoperative complication rate was not different between cohorts. Wound drainage was most common and noted only in the obese cohort. Complications at 24 months were not different but did trend toward significance in the obese for recurrence of symptoms and total complications. Functional outcome was better among nonobese subjects compared with obese subjects at every interval (significant at 6 and 12 months). Back pain scores were significantly better among nonobese subjects than obese subjects at 24 months, but Leg Pain scores were not different. CONCLUSIONS MI TLIF can be safely performed in the obese population despite a higher in-hospital complication rate. Knowledge of common complications will help the treatment team appropriately manage obese patients with degenerative spondylolisthesis. LEVEL OF EVIDENCE 3.
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16
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Uçar BY, Özcan Ç, Polat Ö, Aman T. Transforaminal Lumbar Interbody Fusion For Lumbar Degenerative Disease: Patient Selection And Perspectives. Orthop Res Rev 2019; 11:183-189. [PMID: 31807090 PMCID: PMC6857665 DOI: 10.2147/orr.s204297] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2019] [Accepted: 10/15/2019] [Indexed: 12/24/2022] Open
Abstract
Most adults will experience low back pain during their lifetime, with most of these instances resolving or improving without sequelae in a few weeks. For the small number of patients with severe, recalcitrant pain, lumbar fusion may be required, particularly when concomitant leg pain or deformity is present. Lumbar interbody fusion surgery is the usual treatment for degenerative lumbar disease, but it requires a long recovery period. Many surgical techniques have been described in the literature for spondylolisthesis. The main objective is to create interbody fusion, decompression of normal structures and a stable vertebrae. TLIF surgical techniques has a long learning curve. Comorbidities of the patient may make surgery more difficult. Methods such as transforaminal lumbar interbody fusion (TLIF), posterior lumbar interbody fusion, anterior lumbar interbody fusion and lateral lumbar interbody fusion are also available for interbody fusion in the literatüre. The aim of this review is to show which patients are more suitable for TLIF surgery and to discuss the advantages and disadvantages of TLIF surgery over other techniques.
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Affiliation(s)
- Bekir Yavuz Uçar
- University of Health Sciences, Umraniye Education and Research Hospital, Department of Orthopaedics and Traumatology, Istanbul, Turkey
| | - Çağri Özcan
- University of Health Sciences, Umraniye Education and Research Hospital, Department of Orthopaedics and Traumatology, Istanbul, Turkey
| | - Ömer Polat
- University of Health Sciences, Umraniye Education and Research Hospital, Department of Orthopaedics and Traumatology, Istanbul, Turkey
| | - Tayfun Aman
- University of Health Sciences, Umraniye Education and Research Hospital, Department of Orthopaedics and Traumatology, Istanbul, Turkey
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