Morphologic Changes of Intervertebral Foramen After Minimally Invasive Transforaminal Lumbar Interbody Fusion: A Radiographic and Clinical Study

Exploring Pathways for Pain Relief in Treatment and Management of Lumbar Foraminal Stenosis: A Review of the Literature

BACKGROUND

Lumbar foraminal stenosis (LFS) involves the narrowing of neural foramina, leading to nerve compression, significant lower back pain and radiculopathy, particularly in the aging population. Management includes physical therapy, medications and potentially invasive surgeries such as foraminotomy. Advances in diagnostic and treatment strategies are essential due to LFS's complexity and prevalence, which underscores the importance of a multidisciplinary approach in optimizing patient outcomes.

METHOD

This literature review on LFS employed a systematic methodology to gather and synthesize recent scientific data. A comprehensive search was conducted across PubMed, Scopus and Cochrane Library databases using specific keywords related to LFS. The search, restricted to English language articles from 1 January 2000 to 31 December 2023, focused on peer-reviewed articles, clinical trials and reviews. Due to the heterogeneity among the studies, data were qualitatively synthesized into themes related to diagnosis, treatment and pathophysiology.

RESULTS

This literature review on LFS analyzed 972 articles initially identified, from which 540 remained after removing duplicates. Following a rigorous screening process, 20 peer-reviewed articles met the inclusion criteria and were reviewed. These studies primarily focused on evaluating the diagnostic accuracy, treatment efficacy and pathophysiological insights into LFS.

CONCLUSION

The comprehensive review underscores the necessity for precise diagnostic and management strategies for LFS, highlighting the role of a multidisciplinary approach and the utility of a unified classification system in enhancing patient outcomes in the face of this condition's increasing prevalence.

Analysis of risk factors for contralateral symptomatic foraminal stenosis after unilateral transforaminal lumbar interbody fusion

PURPOSE

To analyze the risk factors of contralateral symptomatic foraminal stenosis (FS) after unilateral transforaminal lumbar interbody fusion (TLIF) and to guide and standardize the operation process of unilateral TLIF to reduce the occurrence of contralateral symptomatic FS.

METHODS

A retrospective study was undertaken on 487 patients with lumbar degeneration who underwent unilateral TLIF in the Department of Spinal Surgery of Ningbo Sixth Hospital between January 2017 and January 2021, comprising 269 males and 218 females, with a mean age of 57.1 years (range, 48-77 years). Cases of intraoperative improper operations, such as screw deviation, postoperative hematoma, and contralateral disc herniation, were excluded, and cases of nerve root symptoms caused by contralateral FS were analyzed. Post-surgery, 23 patients with nerve root symptoms caused by contralateral FS were categorized as group A, and 60 patients without nerve root symptoms were randomly selected as group B during the same period. The general data (gender, age, body mass index (BMI), bone mineral density (BMD), and diagnosis) and imaging parameters before and after operation (including contralateral foramen area (CFA), lumbar lordosis angle (LL), segmental lordosis angle (SL), disc height (DH), foramen height (FH), foramen width (FW), fusion cage position, and the difference between postoperative and preoperative) were compared between the two groups. Univariate analysis was performed, and multivariate analysis was undertaken through logistics analysis to determine the independent risk factors. Additionally, the clinical outcomes of the two groups were compared immediately before surgery and one year after surgery, using the visual analogue scale (VAS) score and the Japanese Orthopaedic Association (JOA) score for evaluation.

RESULTS

The patients in this study were followed up for a period of 19-25 (22.8atien months. Among them, 23 cases (4.72% incidence) were diagnosed with contralaterally symptomatic FS after the surgery. Univariate analysis indicated significant differences between the two groups in CFA, SL, FW, and cage coronal position. Logistic regression analysis identified preoperative contralateral foramen area (OR = 1.176, 95% CI (1.012, 1.367)), small segmental lordosis angle (OR = 2.225, 95% CI (1.124, 4.406)), small intervertebral foramen width (OR = 2.706, 95% CI (1.028, 7.118)), and cage coronal position not crossing the midline (OR = 1.567, 95% CI (1.142, 2.149)) as independent risk factors for contralateral symptomatic FS after unilateral TLIF. However, there was no statistically significant difference in the pain VAS score between the two groups one year after the operation. In contrast, there was a significant difference in the JOA score between the two groups.

CONCLUSION

The identified risk factors for contralateral symptomatic FS after TLIF include preoperative contralateral intervertebral foramen stenosis, a small segmental lordosis angle, a small intervertebral foramen width, and the coronal position of the cage not crossing the midline. For patients with these risk factors, it is recommended to carefully lock the screw rod during the recovery of lumbar lordosis and ensure that the coronal position of the fusion cage is implanted beyond the midline. If necessary, preventive decompression should also be considered. However, this study did not quantify the imaging data for each risk factor, and further research is needed to improve our understanding of the topic.

Relationship Between the Foraminal Area and Demographic and Clinical Characteristics of Patients with Low Back Pain

OBJECTIVE

Our study aims to contribute to existing knowledge by evaluating patients with low back pain to provide a more accurate relationship between the diameter of the intervertebral foramen and the clinical, demographic, and lumbar spine anatomical factors such as age, sex, BMI, the Zurich Claudication Questionnaire (ZCQ) , facet joint, intervertebral disc, ligamentum flavum, and spinal canal.

METHODS

We studied 90 consecutive patients who had undergone evaluation for low back pain. We used magnetic resonance imaging to assess the cross-sectional areas of the intervertebral foramina at each level of the lumbar spine together with the ligamentum flavum area and the dural sac cross sectional area measurements. The presence of disc and facet joint degeneration was evaluated and data on symptoms was obtained.

RESULTS

Age (p<0.0001), lumbar disc degeneration (LDD) grade (p=0.016), and dural sac cross sectional area (DSCSA, p<0.0001) were found to statistically significantly influence the foraminal area (FA). The mean FA at all lumbar levels increased with increasing DSCSA. The mean FA decreased with age at all levels except of L5/S1. LDD grade 1-3 increased the mean FA at L5/S1, but not at other levels. No statistically significant effects of the side of the measurement, sex, BMI, ZCQ score, ligamentum flavum area, nor facet joint degeneration were found.

CONCLUSIONS

The results of the present study allow us to quantify the effect of age, dural sac cross-sectional area, and lumbar disc degeneration grade on the foraminal area.

Efficacy and Safety of Oblique Lumbar Interbody Fusion Versus Transforaminal Lumbar Interbody Fusion for Degenerative Lumbar Spondylolisthesis: A Systematic Review and Meta-Analysis

OBJECTIVE

We critically evaluated the efficacy and safety of oblique lumbar interbody fusion (OLIF) versus transforaminal lumbar interbody fusion (TLIF) for degenerative lumbar spondylolisthesis (DLS).

METHODS

PubMed, Embase, Cochrane Library, the Web of Science Core Collection, Chinese Biomedical Literature, China National Knowledge Infrastructure, Wanfang Digital Periodicals, and Chinese Science and Technology Periodicals were searched from their inception to February 2021. Randomized controlled trials and retrospective or prospective cohort studies (CSs) comparing OLIF and TLIF for DLS were included. A meta-analysis was conducted, if possible.

RESULTS

Ten studies were included in the statistical analysis. The pooled results of the CSs showed no statistically significant differences (P > 0.05) in pain relief at 3 or 6 months of follow-up and functional improvement at 1 or 3 months of follow-up in DLS patients between those who had undergone OLIF versus TLIF. The pooled results of the CSs showed that OLIF could significantly improve the degree of lumbar lordosis, foraminal height, and disc height and decrease the intraoperative blood loss, postoperative drainage volume, operative duration, bed rest time, and hospital length of stay (P < 0.05) compared with TLIF. The incidence of adverse events was not significantly different statistically between OLIF and TLIF.

CONCLUSIONS

The results from the present study suggest that pain relief and functional improvement were not significantly different between OLIF and TLIF. Nevertheless, the use of OLIF might improve radiological outcomes and reduce intraoperative blood loss, postoperative drainage volume, operative duration, bed rest duration, and hospital length of stay compared with TLIF. Additional high-quality randomized controlled trials are still required to confirm these findings.