Clinical and radiological outcome of stand-alone percutaneous pedicle screw fixation (SAPF) versus minimally invasive transforaminal lumbar interbody fusion (MI-TLIF). A propensity-matched cohort study

In adult patients affected by degenerative disc disease with lumbar instability and chronic low back pain, spine surgery with lumbar fixation aims to reduce segmental instability and pain. Different techniques have been developed, but the optimal surgical technique remains controversial. No studies have compared the clinical and radiological outcomes between stand-alone pedicle screw fixation (SAPF) and minimally invasive transforaminal lumbar interbody fusion (MI-TLIF). This was a retrospective study. All patients who underwent surgery for single-level L4-L5 or L5-S1 lumbar stenosis, associated with minor lumbar instability and treated with SAPF or MI-TLIF techniques were included in the study. Data were collected preoperatively and at 24 monts follow-up. Clinical primary outcomes were Oswestry Disability Index (ODI) and Numerical Rating Scale (NRS). Secondary outcomes were patient satisfaction, walking ability and self reported back and leg pain. In addition, perioperative data and complications were recorded. Segmental lordosis (L4-L5 and L5-S1) and overall lumbar lordosis (L1-S1) were measured on lumbar X-Rays preoperatively and at least 24 months postoperatively. 277 patients were firstly identified. Baseline data and a minimum of two-year follow-up were available for 62 patients. After the propensity score matching, 44 patients (22 patients in the SAPF group and 22 patients in the MI-TLIF group) were matched. At 24 months follow-up, no difference between the two groups of patients in NRS (p = 0.11) and ODI scores (p = 0.21) were observed. Patients' satisfaction at follow-up was also not significantly different between the two groups. In both groups, a significant improvement in the walked distance was observed after surgery (p = 0.05) while no difference was observed regarding the type of surgery performed (p = 1.00). No differences were found in the pre- and post-operative median lumbar lordosis (p = 0.91 and p = 0.67) and the same findings were observed for lumbar segmental lordosis (p = 0.65 and p = 0.41 respectively). Significant improvements in ODI and NRS-scores were recorded after 24 months follow-up with both SAPF and MI-TLIF. No significant differences in postoperative PROMs and patients' satisfaction were observed between the groups. The results of our study indicate no superiority of either surgical technique concerning pain and functional outcomes after 24 months.

Comparing Patient-Reported Outcomes, Complications, Readmissions, and Revisions in Posterior Lumbar Fusion With, Versus Without, an Interbody Device

STUDY DESIGN

Retrospective analysis on prospectively collected data.

OBJECTIVES

To compare posterior lumbar fusions with versus without an interbody in: (1) Patient-reported outcomes (PROs) at 1 year and (2) postoperative complications, readmission, and reoperations.

SUMMARY OF BACKGROUND DATA

Elective lumbar fusion is commonly used to treat various lumbar pathologies. Two common approaches for open posterior lumbar fusion include posterolateral fusion (PLF) alone without an interbody and with an interbody through techniques, like transforaminal lumbar interbody fusion. Whether fusion with or without an interbody leads to better outcomes remains an area of active research.

PATIENTS AND METHODS

The Lumbar Module of the Quality Outcomes Database was queried for adults undergoing elective primary posterior lumbar fusion with or without an interbody. Covariates included demographic variables, comorbidities, primary spine diagnosis, operative variables, and baseline PROs, including Oswestry Disability Index, North American Spine Society satisfaction index, numeric rating scale-back/leg pain, and Euroqol 5-dimension. Outcomes included complications, reoperations, readmissions, return to work/activities, and PROs. Propensity score matching and linear regression modeling were used to estimate the average treatment effect on the treated to assess the impact of interbody use on patient outcomes.

RESULTS

After propensity matching, there were 1044 patients with interbody and 215 patients undergoing PLF. The average treatment effect on the treated analysis showed that having an interbody or not had no significant impact on any outcome of interest, including 30-day complications and reoperations, 3-month readmissions, 12-month return to work, and 12-month PROs.

CONCLUSION

There were no discernible differences in outcomes between patients undergoing PLF alone versus with an interbody in elective posterior lumbar fusion. These results add to the growing body of evidence that posterior lumbar fusions with and without an interbody seem to have similar outcomes up to 1 year postoperatively when treating degenerative lumbar spine conditions.

Transforaminal Lumbar Interbody Fusion Versus Posterolateral Fusion Alone in the Treatment of Grade 1 Degenerative Spondylolisthesis

BACKGROUND

Transforaminal lumbar interbody fusion (TLIF) and posterolateral fusion (PLF) alone are two operations performed to treat degenerative lumbar spondylolisthesis. To date, it is unclear which operation leads to better outcomes.

OBJECTIVE

To compare TLIF vs PLF alone regarding long-term reoperation rates, complications, and patient-reported outcome measures (PROMs) in patients with degenerative grade 1 spondylolisthesis.

METHODS

A retrospective cohort study using prospectively collected data between October 2010 and May 2021 was undertaken. Inclusion criteria were patients aged 18 years or older with grade 1 degenerative spondylolisthesis undergoing elective, single-level, open posterior lumbar decompression and instrumented fusion with ≥1-year follow-up. The primary exposure was presence of TLIF vs PLF without interbody fusion. The primary outcome was reoperation. Secondary outcomes included complications, readmission, discharge disposition, return to work, and PROMs at 3 and 12 months postoperatively, including Numeric Rating Scale-Back/Leg and Oswestry Disability Index. Minimum clinically important difference of PROMs was set at 30% improvement from baseline.

RESULTS

Of 546 patients, 373 (68.3%) underwent TLIF and 173 underwent (31.7%) PLF. Median follow-up was 6.1 years (IQR = 3.6-9.0), with 339 (62.1%) >5-year follow-up. Multivariable logistic regression showed that patients undergoing TLIF had a lower odds of reoperation compared with PLF alone (odds ratio = 0.23, 95% CI = 0.54-0.99, P = .048). Among patients with >5-year follow-up, the same trend was seen (odds ratio = 0.15, 95% CI = 0.03-0.95, P = .045). No differences were observed in 90-day complications ( P = .487) and readmission rates ( P = .230) or minimum clinically important difference PROMs.

CONCLUSION

In a retrospective cohort study from a prospectively maintained registry, patients with grade 1 degenerative spondylolisthesis undergoing TLIF had significantly lower long-term reoperation rates than those undergoing PLF.

In Single-Level, Open, Posterior Lumbar Fusion, Does Transforaminal Lumbar Interbody Fusion or Posterolateral Fusion Lead to Better Outcomes?

BACKGROUND

Two common approaches for open, one-level, posterior lumbar fusions include transforaminal lumbar interbody fusion (TLIF) and posterolateral fusion (PLF) alone without an interbody.

OBJECTIVE

To compare TLIF vs PLF alone in (1) discharge disposition, (2) return to work (RTW), and (3) patient-reported outcomes (PROs).

METHODS

A single-center, retrospective cohort study was undertaken between October 2010 and May 2021, all with a 1-year follow-up and excluding patients with isthmic spondylolisthesis. Minimum clinically important difference for each PRO was used, which included Numeric Rating Scale (NRS) and Oswestry Disability Index (ODI). Logistic/linear regression controlled for age, body mass index, disc height, flexion-extension movement, amount of movement on flexion-extension, and spondylolisthesis grade.

RESULTS

Of 850 patients undergoing open, 1-level, posterior lumbar fusion, 591 (69.5%) underwent a TLIF and 259 (30.5%) underwent a PLF alone. Patients undergoing TLIF were younger (59.0 ± 11.3 vs 63.3 ± 12.6, P < .001), had higher body mass index (31.3 ± 6.6 vs 30.2 ± 12.6, P = .019), and more often had private insurance (50.3% vs 39.0%, P < .001). Regarding discharge disposition, no significance was found in multivariate regression (odds ratio = 2.07, 95% CI = 0.39-10.82, P = .385) with similar RTW between TLIF and PLF alone (80.8% vs 80.4%, P = .645) (odds ratio = 1.15, 95% CI = 0.19-6.81, P = .873). Regarding PROs, patients undergoing a TLIF had higher preoperative (6.7 ± 2.3 vs 6.4 ± 2.5, P = .046) and 3-month NRS-back pain (3.4 ± 2.6 vs 2.9 ± 2.5, P = .036), with similar 12-month NRS-back pain. Regarding NRS-leg pain, no differences were observed preoperatively ( P = .532) and at 3 months ( P = .808). No other significant differences were observed in ODI.

CONCLUSION

TLIF patients had slightly higher NRS-back pain at baseline and 3 months, but similar NRS-leg pain, despite the added risk of placing an interbody. No differences were seen in discharge disposition, RTW, and 12-month pain scores and ODI.

Characteristics of interbody bone graft fusion after transforaminal lumbar interbody fusion according to intervertebral space division

BACKGROUND

According to intervertebral space division, the characteristics of interbody bone graft fusion after transforaminal lumbar interbody fusion (TLIF) were assessed via computed tomography (CT) scan to provide a theoretical basis for selecting the bone grafting site of interbody fusion.

METHODS

The medical records of 57 patients with lumbar spinal stenosis and disc herniation treated with TLIF were analysed retrospectively. In total, 57 segments received lumbar interbody fusion. A thin-layer CT scan was performed to evaluate fusion in each zone of the fusion space.

RESULTS

The fusion rates were 57.89% (n = 33) in the anterior cage zone, 73.68% (n = 42) in the posterior cage zone, 66.67% (n = 38) in the decompression zone, 26.32% (n = 15) in the contralateral decompression zone and 94.74% (n = 54) in the inner cage zone. There were significant differences among the fusion rates of the five zones (P < 0.001). Further pairwise comparison revealed that the fusion rates in the inner cage significantly differed from the anterior and posterior cages and decompression and contralateral decompression zones (P = 0.001, 0.002, 0.001 and 0.001, respectively).

CONCLUSION

We think the central cage zone (i.e., inner cage) should be the focus of bone grafting. Although there is small volume of bone graft on the posterior cage zone, the fusion rate is relatively high, only secondary to the inner cage zone. The fusion rate is of the contralateral decompression zone is lower although there is a bone graft.

Surgical outcomes of patients who fail to reach minimal clinically important differences: comparison of minimally invasive versus open transforaminal lumbar interbody fusion

OBJECTIVE

Treatment of degenerative lumbar diseases has been shown to be clinically effective with open transforaminal lumbar interbody fusion (O-TLIF) or minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF). Despite this, a substantial proportion of patients do not meet minimal clinically important differences (MCIDs) in patient-reported outcomes (PROs). The objectives of this study were to compare the proportions of patients who did not meet MCIDs after O-TLIF and MIS-TLIF and to determine potential clinical factors associated with failure to achieve MCID.

METHODS

The authors performed a retrospective analysis of consecutive patients who underwent O-TLIF or MIS-TLIF for lumbar degenerative disorders and had been prospectively enrolled in the Canadian Spine Outcomes and Research Network. The authors analyzed the Oswestry Disability Index (ODI) scores, physical and mental component summary scores of SF-12, numeric rating scale (NRS) scores for leg and back pain, and EQ-5D scores of the patients in each group who did not meet the MCID of ODI at 2 years postoperatively.

RESULTS

In this study, 38.8% (137 of 353) of patients in the O-TLIF cohort and 41.8% (51 of 122) of patients in the MIS-TLIF cohort did not meet the MCID of ODI at 2 years postoperatively (p = 0.59). Demographic variables and baseline PROs were similar between groups. There were improvements across the PROs of both groups through 2 years, and there were no differences in any PROs between the O-TLIF and MIS-TLIF cohorts. Multivariable logistic regression analysis demonstrated that higher baseline leg pain score (p = 0.017) and a diagnosis of spondylolisthesis (p = 0.0053) or degenerative disc disease (p = 0.022) were associated with achieving the MCID at 2 years after O-TLIF, whereas higher baseline leg pain score was associated with reaching the MCID after MIS-TLIF (p = 0.038).

CONCLUSIONS

Similar proportions of patients failed to reach the MCID of ODI at 2 years after O-TLIF or MIS-TLIF. Higher baseline leg pain score was predictive of achieving the MCID in both cohorts, whereas a diagnosis of spondylolisthesis or degenerative disc disease was predictive of reaching the MCID after O-TLIF. These data provide novel insights for patient counseling and suggest that either MIS-TLIF or O-TLIF does not overcome specific patient factors to mitigate clinical success or failure in terms of the intermediate-term PROs associated with 1- to 2-level lumbar fusion surgical procedures for degenerative pathologies.

Postoperative Opioid Use Following Single-Level Transforaminal Lumbar Interbody Fusion Compared with Posterolateral Lumbar Fusion

OBJECTIVE

To compare postoperative opioid morphine milligram equivalents (MME) prescriptions for opioid-naïve patients undergoing single-level transforaminal lumbar interbody fusion (TLIF) versus posterolateral lumbar fusion (PLF) and total postoperative MME prescribed based on operative duration.

METHODS

Patients undergoing single-level TLIF or PLF from September 2017 to June 2020 were identified from a single institution. Patients were first grouped based on procedure type (TLIF or PLF) and subsequently regrouped based on median operative duration. Statistical tests compared patient demographics and opioid prescription data between groups. Multivariate regressions were performed to control for demographics, operative time, and procedure type.

RESULTS

Of 345 patients undergoing single-level PLF or TLIF, 174 (50.4%) were opioid-naïve; 101 opioid-naïve patients (58.0%) underwent PLF and 73 (42.0%) underwent TLIF. Patients undergoing TLIF received more opioid prescriptions (1.99 vs. 1.26, P < 0.001) and total MME (91.2 vs. 66.8, P = 0.002). After regrouping patients based on operative duration, independent of procedure type, there were no differences in postoperative opioid prescriptions, and Spearman rank correlation coefficient between total MME and operative duration was r = 0.014. Multivariate analysis identified TLIF as an independent predictor of increased postoperative opioid prescriptions (β = 0.64, P < 0.001), prescribers (β = 0.49, P = 0.003), and MME (β = 24.4, P = 0.030).

CONCLUSIONS

Opioid-naïve patients undergoing single-level TLIF receive a greater number of postoperative opioids than patients undergoing single-level PLF, and TLIF was an independent predictor of increased postoperative opioid prescribers, prescribers, and MME. There were no differences in postoperative opioid prescriptions when assessing patients based on operative duration.

Comparison of electromagnetic and optical navigation assisted Endo-TLIF in the treatment of lumbar spondylolisthesis

Uniportal full endoscopic posterolateral transforaminal lumbar interbody fusion (Endo-TLIF) with percutaneous pedicle screw fixation is a promising, minimally invasive method for the treatment of lumbar spondylolisthesis. However, repeated radiation exposure from X-rays and the steep learning curve remain to be improved.

Oblique Lateral Interbody Fusion vs. Minimally Invasive Transforaminal Lumbar Interbody Fusion for Lumbar Spinal Stenosis: A Retrospective Cohort Study

Background

Minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) is an effective surgical option for lumbar spinal stenosis (LSS) with spondylolisthesis. However, few studies have discussed oblique lateral interbody fusion (OLIF) with MIS-TLIF.

Objective

To evaluate postoperative improvements, complications, and reoperation rates between patients with LSS undergoing OLIF or MIS-TLIF.

Methods

We retrospectively studied 113 LLS patients who underwent OLIF (53) or MIS-TLIF (60) with percutaneous pedicle screw fixation between January 2016 and December 2018. We measured estimated blood loss, operative time, hospital stay, reoperation, and complication incidence, visual analog scale (VAS), Oswestry Disability Index (ODI), Japanese Orthopedic Association (JOA), and Short Form-36 (SF-36) scores, discal and foraminal height and lumbar lordotic angle.

Results

The mean age was 58.81 ± 0.9 years. The TLIF group had increased operation time, blood loss, and hospital stays (p = 0.007, 0.001, and 0.016, respectively). Postoperatively, VAS and ODI scores significantly decreased while JOA and SF-36 scores significantly increased. The postoperative differences in main outcomes between the groups were insignificant (all p &gt; 0.05). The OLIF group had the lowest rates of overall (9.8% OLIF vs. 12.9% MIS-TLIF), intraoperative (3.9% OLIF vs. 4.8% MIS-TLIF), and postoperative complications (5.9% OLIF vs. 8.1% MIS-TLIF), but the differences were insignificant (p = 0.607, 0.813, and 0.653, respectively). The reoperation rate did not differ significantly (3.8% OLIF vs. 3.3% MIS-TLIF) (p = 0.842). OLIF restored disc height (74.4 vs. 32.0%), foraminal height (27.4 vs. 18.2%), and lumbar lordotic angle (3.5 vs. 1.1%) with greater success than did MIS-TLIF.

Conclusion

Patients undergoing OLIF with LSS improved similarly to MIS-TLIF patients. OLIF restored disc height, foraminal height and lumbar lordotic angle more successfully than did MIS-TLIF.

Transforaminal lumbar interbody fusion with a silicon nitride cage demonstrates early radiographic fusion

BACKGROUND

Degeneration of the lumbar spine is common in aging adults and reflects a significant morbidity burden in this population. In selected patients that prove unresponsive to non-surgical treatment, posterior lumbar fusion (PLF) surgery, with or without adjunctive transforaminal lumbar interbody fusion (TLIF) can relieve pain and improve function. We describe here the radiographic fusion rates for PLF versus TLIF, using an intervertebral spinal cage made of silicon nitride ceramic (chemical formula Si₃N₄).

METHODS

This retrospective cohort analysis enrolled 99 patients from August 2013 to January 2017; 17 had undergone PLF at 24 levels, while 82 had undergone TLIF at 104 levels. All operations were performed by a single surgeon at one institution. Radiographic and clinical outcomes were compared between PLF and TLIF at 2 and 6 weeks and then at 3, 6, 12, and 24 months.

RESULTS

TLIF patients fused at higher rates compared to PLF at the 3-month (38.5% vs. 8.3%, P=0.006), 6-month (78.7% vs. 35.0%, P<0.001) and 12-month time periods (97.9% vs. 81.3%, P=0.018), with no difference at 24 months (100% vs. 94.4%, P=0.102). Index level segmental motion was significantly less and intervertebral disc height was improved in TLIF over PLF at all follow up intervals. Foraminal height was only greater in early follow up periods (2 weeks, 6 weeks and 3 months). TLIF patients experienced lover rates of PI-LL mismatch which was maintained across long term follow-up. Pelvic tilt was lower following TLIF compared to PLF, with no differences in complication rates between study groups.

CONCLUSIONS

Our retrospective series demonstrated that TLIF performed with silicon nitride interbody cages led to earlier radiographic fusion, greater restoration of disc and foraminal height, increased segmental rigidity and improved sagittal alignment when compared to PLF alone.

Perioperative Modifications to the Open TLIF Provide Comparable Short-term Outcomes to the MIS-TLIF

STUDY DESIGN

This study is a retrospective review of patients' charts and data from longitudinally collected clinical outcomes and opioid use.

OBJECTIVE

In the current study, we aim to compare short-term outcomes data for 139 Open transforaminal interbody fusion (TLIF) patients to recently published data for tubular and endoscopic MIS-TLIF.

BACKGROUND CONTEXT

In response to the downsides associated with Open TLIF, such as large incision, blood loss, delayed ambulation, prolonged hospitalization, and opioid-reliance, spine surgeons developed tubular retractor based "minimally-invasive" TLIF. However, the traditional Open TLIF retains its significance in terms of providing successful fusion and improved patient-reported outcomes (PROs).

METHODS

We adapted several techniques with an aim to improve short-term outcomes for our Open TLIF patients that combined extensive perioperative counselling, an emphasis on early mobilization, avoidance of overuse of opioid analgesics, early discharge with home care arrangements, use of a posthospitalization drainage tube with intraoperative surgical modifications using small incisions (4-5 cm), a narrow 20 mm retractor, minimal muscle injury, and use of a cell saver to minimize net blood loss. The demographics and perioperative results were compared with data from recent MIS-TLIF studies using Student t test for continuous and χ2/exact test for categorical variables.

RESULTS

Among the total 139 patients, 115 underwent a single-level procedure, 90% of whom were discharged on the first postoperative day (length of stay=1.13±0.47 d) with an average net estimated blood loss of 176.17±87.88 mL. There were 24 two-level procedures with an average length of stay of 1.57±0.84 days, average net estimated blood loss was 216.96±85.70 mL. The patients had statistically significant improvements in PROs at 3 and 12 months.

CONCLUSIONS

The results of this study identify that patients who underwent modified Open TLIF demonstrated favorable short-term outcomes, as compared with the tubular MIS-TLIF, by virtue of avoidance of blood transfusions, shorter hospital stays, and significantly less opioid usage while experiencing satisfactory PROs.

The Minimum Clinically Important Difference for Patient Health Questionnaire-9 in Minimally Invasive Transforaminal Interbody Fusion

STUDY DESIGN

Retrospective cohort.

OBJECTIVE

To investigate and establish minimum clinically important differences (MCID) for Patient Health Questionnaire-9 (PHQ-9) among patients undergoing minimally invasive transforaminal lumbar interbody fusion (MIS TLIF).

SUMMARY OF BACKGROUND

Spine surgery is linked to postoperative improvements in anxiety, depression, and mental health. These improvements have been documented using patient-reported outcome measures such as PHQ-9. Few studies evaluated the clinical significance of PHQ-9 for lumbar spine surgery.

METHODS

Patients who underwent single-level, primary MIS TLIF from 2015 to 2017 were retrospectively reviewed in a prospective database. Patients with incomplete preoperative and 2-year postoperative PHQ-9 surveys were excluded. Demographic and perioperative characteristics were recorded. PHQ-9, 12-Item Short Form (SF-12), and Veterans RAND 12-Item Health Survey (VR-12) Mental Component Summary (MCS) were collected at preoperative, 6-week, 12-week, 6-month, 1-year, and 2-year intervals. MCID was calculated using anchor and distribution-based methods. SF-12 served as an anchor. MCID was assessed using mean change methodology, four receiver operating characteristic curve assessments, and standard error measurement. Cutoff values were selected from receiver operating characteristic curve analysis. MCID achievement rates for all patient-reported outcome measures were calculated.

RESULTS

A total of 139 patients met inclusion criteria, with a mean age of 55 years and 39% females. The most common spinal pathology was radiculopathy (92%). MCID analysis revealed the following ranges of values: 2.0 to 4.8 (PHQ-9), 6.7 to 12.1 (SF-12 MCS), and 7.5 to 15.9 (VR-12 MCS). Final MCID thresholds were 3.0 (PHQ-9), 9.1 (SF-12 MCS), and 8.1 (VR-12 MCS). MCID achievement at 2-years for PHQ-9, SF-12 MCS, and VR-12 MCS was 89.2%, 85.6%, and 84.9% respectively.

CONCLUSION

Our 2-year postoperative MCID analysis is the first mental health calculation from an MIS TLIF cohort. We report a 2-year MCID value for PHQ-9 of 3.0 (2.0-4.8). MCID values for mental health instruments are important for determining overall success of lumbar spine surgery.Level of Evidence: 3.

Quality Outcomes Database Spine Care Project 2012-2020: milestones achieved in a collaborative North American outcomes registry to advance value-based spine care and evolution to the American Spine Registry

The Quality Outcomes Database (QOD), formerly known as the National Neurosurgery Quality Outcomes Database (N2QOD), was established by the NeuroPoint Alliance (NPA) in collaboration with relevant national stakeholders and experts. The overarching goal of this project was to develop a centralized, nationally coordinated effort to allow individual surgeons and practice groups to collect, measure, and analyze practice patterns and neurosurgical outcomes. Specific objectives of this registry program were as follows: "1) to establish risk-adjusted national benchmarks for both the safety and effectiveness of neurosurgical procedures, 2) to allow practice groups and hospitals to analyze their individual morbidity and clinical outcomes in real time, 3) to generate both quality and efficiency data to support claims made to public and private payers and objectively demonstrate the value of care to other stakeholders, 4) to demonstrate the comparative effectiveness of neurosurgical and spine procedures, 5) to develop sophisticated 'risk models' to determine which subpopulations of patients are most likely to benefit from specific surgical interventions, and 6) to facilitate essential multicenter trials and other cooperative clinical studies." The NPA has launched several neurosurgical specialty modules in the QOD program in the 7 years since its inception including lumbar spine, cervical spine, and spinal deformity and cerebrovascular and intracranial tumor. The QOD Spine modules, which are the primary subject of this paper, have evolved into the largest North American spine registries yet created and have resulted in unprecedented cooperative activities within our specialty and among affiliated spine care practitioners. Herein, the authors discuss the experience of QOD Spine programs to date, with a brief description of their inception, some of the key achievements and milestones, as well as the recent transition of the spine modules to the American Spine Registry (ASR), a collaboration between the American Association of Neurological Surgeons and the American Academy of Orthopaedic Surgeons (AAOS).

Comparative Study between Transforaminal Lumbar Interbody Fusion and Posterolateral Fusion for Treatment of Spondylolisthesis: Clinical Outcomes and Spino-Pelvic Sagittal Balance Parameters

Objective This retrospective study aims to compare the clinical and radiological outcomes of posterolateral fusion (PLF) with transforaminal lumbar interbody fusion (TLIF + PLF) for the treatment of patients with low-grade spondylolisthesis.

Methodology A total of 77 adult patients ≥18 years with low-grade spondylolisthesis, Meyerding grades I and II, were assigned into two groups: 36 patients treated with PLF and 41 patients treated with TLIF + PLF. The PLF group is composed of the patients that were operated with pedicle screw and the TLIF + PLF group is composed of the ones that were operated with fixation and TILF by autografting. Clinical evaluation was performed using the spino-pelvic sagittal balance, Numeric Rating Scale, Oswestry Disability Index, blood loss, operation times, and postoperative hospital stay of the PLF vs TLIF groups. The incidences of postoperative low back pain and radicular pain in the two groups were also recorded. Radiography was performed preoperatively and postoperatively to assess spino-pelvic parameters.

Results Significant restoration of spino-pelvic sagittal balance was observed in the TLIF group after surgery, and all spino-pelvic sagittal balance parameters showed significant improvement in the TLIF group after surgery, while in the PLF group, all spino-pelvic sagittal parameters had improved except the segmental angle lordosis (p = 0.316), which showed no significant difference after surgery in the PLF group. Postoperative pelvic incidence and pelvic tilt significantly improved in the TLIF group in comparison to PLF groups. Hence, TLIF can achieve better postoperative spino-pelvic sagittal balance parameters than PLF. There was no difference in the complication rates for each group. Both groups achieved significant improvement in postoperative clinical outcomes, and there was no significant difference in the incidence of postoperative low back pain or radicular pain between the two groups.

Conclusion Both surgical procedures PLF and TLIF were effective. PLF and TLIF can result in improved clinical and radiological outcomes for patients treated for low-grade spondylolisthesis. TLIF can achieve better restoration of spino-pelvic sagittal balance parameters than PLF alone.

The technical feasibility and preliminary results of minimally invasive endoscopic-TLIF based on electromagnetic navigation: a case series

Background

Uniportal full endoscopic posterolateral transforaminal lumbar interbody fusion (Endo-TLIF) with percutaneous pedicle screw fixation is a promising, minimally invasive method for the treatment of lumbar spondylolisthesis. However, repeated radiation exposure from X-rays and the steep learning curve remain to be improved.

Methods

This retrospective study explored the effects of electromagnetic navigation on improving Endo-TLIF with percutaneous pedicle screw fixation. Clinical information from 42 patients who had received Endo-TLIF with percutaneous pedicle screw fixation from May 2019 to November 2020 was analyzed retrospectively. The procedures were assisted under electromagnetic navigation. The rate of adjustment for guide wires, frequency of X-ray exposure, operative time, accuracy of pedicle screw location, and clinical outcomes were recorded.

Results

The mean follow-up for 42 patients was 11.9 ± 3.1 months. The mean age of the patients was 56.1 ± 9.26 years, with a female/male ratio of 25:17. According to postoperative CT scans and 3D reconstructions, the excellent and good rate of pedicle screws was 96.4%. The rate of adjustment for guide wires under the assistance of electromagnetic navigation was 1.78%, and the frequency of X-ray exposure was 8.27 ± 1.83. The operative time was 167.25 ± 28.16 min, including the duration of guide wire insertion (14.63 ± 5.45 min) and duration of decompression and cage placement (75.43 ± 13.97 min). The duration of hospitalization after operation was 2.59 ± 1.16 days. The preoperative VAS score was 7.51 ± 1.91, and the preoperative ODI was 82.42 ± 8.7%. At the last follow-up, the VAS score was 2.09 ± 0.59, and the ODI was 11.09 ± 3.2%. There were statistically significant improvements in the VAS score and ODI in all patients at the follow-up (p < 0.05).

Conclusions

Electromagnetic navigation can provide accurate positioning and guidance in real time, which improves the surgical efficiency of percutaneous pedicle screw placement and endoscopic decompression in Endo-TLIF with reduced radiation exposures.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12893-021-01148-9.

Single-level Posterolateral Fusion (PLF) Alone and Posterior Interbody Fusion (PLIF/TLIF) Alone Lead to a Decreased Risk of Short-term Complications Compared to Combined PLF With PLIF/TLIF Procedures: A Matched Analysis

STUDY DESIGN

Retrospective review of a database cohort.

OBJECTIVE

To compare short-term outcome measures and complications between single-level posterolateral fusion (PLF), single-level posterior interbody fusion (PLIF/TLIF), and combined single-level PLF+PLIF/TLIF.

SUMMARY OF BACKGROUND DATA

Both PLF and interbody fusion are well-established procedures for degenerative spinal disease. However, there is lack of consensus as to the ideal surgical approach for specific applications. Additionally, the difference in risk of complications with traditional PLF, interbody fusion with posterior approach, and circumferential fusion is still contested.

METHODS

The ACS NSQIP database was used to identify 24,228 patients who underwent either a single-level PLF, single-level PLIF/TLIF, or combined single-level PLF+PLIF/TLIF between 2014 and 2017. To control for potential confounding variables, exact matching was used to pair individuals from each treatment group based on several factors, including sex, age, body mass index, various comorbidities, and American Society of Anesthesiologists classification. After appropriate matching, the rate of various short-term outcome measures and complications were compared between the three treatment groups.

RESULTS

After exact matching, 13,251 patients were included in the final analysis. The rates of non-home discharge, overall surgical complications, and bleeding requiring transfusion were significantly lower in the PLF group and PLIF/TLIF group relative to the PLF+PLIF/TLIF group (P < 0.001 for all comparisons). The rate of deep venous thrombosis was lower in the PLIF/TLIF group relative to the PLF group (P = 0.006). There were no significant differences in other medical complications, unplanned readmission, reoperation, or return to the OR between any of the treatment groups.

CONCLUSIONS

The combination of single-level PLF+PLIF/TLIF is associated with higher rates of short-term complications relative to either single-level PLF or PLIF/TLIF alone. The associated risks of this therapy should be considered when considering surgical management for lumbar disease.

LEVEL OF EVIDENCE

3.

Treatment for lumbar spinal stenosis secondary to ligamentum flavum hypertrophy using percutaneous endoscopy through interlaminar approach: a retrospective study

Background

This paper is to describe percutaneous endoscopy in the treatment of lumbar spinal stenosis secondary to ligamentum flavum hypertrophy targeted and to investigate the efficacy and safety of percutaneous endoscopy in the treatment of this kind of lumbar spinal stenosis in elderly patients.

Method

A retrospective analysis of 40 elderly patients with lumbar spinal stenosis secondary to ligamentum flavum hypertrophy admitted between January 2016 and January 2018 was performed. According to different surgical methods, they were divided into two groups: the control group and the endoscopy group (interlaminar approach), 20 people per group. There were 9 males and 11 females in the control group; the age of patients was 65.65 ± 4.44 years, and the average disease duration was 4.55 ± 1.85 years. Besides, there were 10 males and 10 females in the endoscopy group; the age of patients was 67.30 ± 4.23 years, and the average disease duration was 4.95 ± 2.04 years. Collect and count surgical-related indicators, preoperative and postoperative radiologic findings, incision visual analog scale (VAS), lumbar and leg pain VAS, lumbar Japanese Orthopaedic Association (JOA), and Oswestry disability index (ODI) scores of all patients.

Result

A series of surgical indicators (including the operation time, the quantity of bleeding, and postoperative hospital stay) in the endoscopy group was significantly lower than that in the control group (p < 0.05). The incision VAS score in the endoscopy group was also significantly lower than that in the control group at each time after surgery (p < 0.05). Besides, compared with the control group, in the endoscopy group, the leg pain VAS score and lumbar ODI score after surgery were significantly decreased (p < 0.05). Compared with the control group, in the endoscopy group, the lumbar JOA score was significantly higher (p < 0.05).

Conclusion

Percutaneous endoscopic technique is a small trauma, quick recovery, safe, and effective minimally invasive surgery for patients with lumbar spinal stenosis secondary to ligamentum flavum hypertrophy.

ASPECTS OF THE USE OF PROPENSITY SCORE MATCHING METHODS IN NEUROSURGERY

ABSTRACT Objective Observational studies and register data provide researchers with ample opportunities to obtain answers to questions that randomized controlled trials cannot answer for organizational or ethical reasons. One of the most common tools for solving this problem is the use of propensity score matching (PSM) methods. The purposes of our study were to compare various models and algorithms for selecting PSM parameters, using retrospective clinical data, and to compare the results obtained using the PSM method with those of prospective studies. Methods The results of two studies (randomized prospective and retrospective) conducted at the Novosibirsk Research Institute of Traumatology and Orthopedics were used for comparative analysis. The trials aimed to study the effectiveness and safety of surgical treatment of degenerative dystrophic lesions in the lumbar spine. We compared the results using the recommended PSM parameters (caliper=0.2 and 0.6) the propensity score is the probability of assignment to one treatment conditional on a subject’s measured baseline covariates. Propensity-score matching is increasingly being used to estimate the effects of exposures using observational data. In the most common implementation of propensity-score matching, pairs of treated and untreated subjects are formed whose propensity scores differ by at most a pre-specified amount (the caliper widthand the caliper values often used in real-life studies (0.05, 0.1, 0.25, 0.5, and 0.8) with the those obtained in a similar prospective study. Results After eliminating systematic selection bias, the results of the retrospective and randomized prospective studies were qualitatively comparable. Conclusion The results of this study provide recommendations for the use of PSM: when evaluating efficacy scores in neurosurgical studies (with a sample size < 150 patients), we recommend matching on the logit of the propensity score using calipers of width equal to 0.6 of the standard deviation of the logit of the propensity score. Level of evidence V; Type of study is expert opinion.

Assessment of radiographic and clinical outcomes of an articulating expandable interbody cage in minimally invasive transforaminal lumbar interbody fusion for spondylolisthesis

OBJECTIVE The inability to significantly improve sagittal parameters has been a limitation of minimally invasive surgery for transforaminal lumbar interbody fusion (MIS TLIF). Traditional cages have a limited capacity to restore lordosis. This study evaluates the use of a crescent-shaped articulating expandable cage (Altera) for MIS TLIF. METHODS This is a retrospective review of 1- and 2-level MIS TLIF. Radiographic outcomes included differences in segmental and lumbar lordosis, disc height, evidence of fusion, and any endplate violations. Clinical outcomes included the numeric rating scale for leg and back pain and the Oswestry Disability Index (ODI) for low-back pain. RESULTS Thirty-nine patients underwent single-level MIS TLIF, and 5 underwent 2-level MIS TLIF. The mean age was 63.1 years, with 64% women. On average, spondylolisthesis was corrected by 4.3 mm (preoperative = 6.69 mm, postoperative = 2.39 mm, p < 0.001), the segmental angle was improved by 4.94° (preoperative = 5.63°, postoperative = 10.58°, p < 0.001), and segmental height increased by 3.1 mm (preoperative = 5.09 mm, postoperative = 8.19 mm, p < 0.001). At 90 days after surgery the authors observed the following: a smaller postoperative sagittal vertical axis was associated with larger changes in back pain at 90 days (r = -0.558, p = 0.013); a larger decrease in spondylolisthesis was associated with greater improvements in ODI and back pain scores (r = -0.425, p = 0.043, and r = -0.43, p = 0.031, respectively); and a larger decrease in pelvic tilt (PT) was associated with greater improvements in back pain (r = -0.548, p = 0.043). For the 1-year PROs, the relationship between the change in PT and changes in ODI and numeric rating scale back pain were significant (r = 0.612, p = 0.009, and r = -0.803, p = 0.001, respectively) with larger decreases in PT associated with larger improvements in ODI and back pain. Overall for this study there was a 96% fusion rate. Fourteen patients were noted to have endplate violation on intraoperative fluoroscopy during placement of the cage. Only 3 of these had progression of their subsidence, with an overall subsidence rate of 6% (3 of 49) visible on postoperative CT. CONCLUSIONS The use of this expandable, articulating, lordotic, or hyperlordotic interbody cage for MIS TLIF provides a significant restoration of segmental height and segmental lordosis, with associated improvements in sagittal balance parameters. Patients treated with this technique had acceptable levels of fusion and significant reductions in pain and disability.

Expandable spacers provide better functional outcomes than static spacers in minimally invasive transforaminal lumbar interbody fusion

Background

Transforaminal lumbar interbody fusion is an effective and frequently performed surgical treatment of chronic lower back pain. Expandable interbody spacers are designed to create greater disc height through in situ expansion. It remains unclear whether the benefits of expandable technology will translate into clinical benefits. The current study compares expandable to static interbody spacers.

Methods

This is a retrospective study of 99 patients (48 static and 51 expandable) at a single site. Radiographs were collected preoperatively and at 3 months postoperatively. Standard of care at this site requires radiographs to be taken past 3 months only if patients are suffering from a severe recurrence of symptoms. Patient reported outcomes, Oswestry disability index (ODI) and visual analog scale (VAS), were collected preoperatively, at 1 and 3 months postoperatively. Patients were contacted by the surgeon and patient reported outcomes were collected at a final time point. Average final follow-up for was 67.1±16.3 months and for expandable patients it was 43.0±4.2 months.

Results

At 3 months postoperatively and at final follow-up, patients treated with expandable interbody spacers had significantly lower average ODI scores than patients with static interbody spacers. Both groups reported significant reductions in VAS scores through all follow-up. At 4 years postoperative 8 static group patients and 3 expandable group patients returned for recurrence of symptoms.

Conclusions

Expandable interbody spacers in this study were found to be comparable to static interbody spacers, with improvements in VAS and ODI scores.

Application of New Allogeneic Lumbar Fusion Cage (Biocage) in Single-Segment Lumbar Degenerative Disease: A Prospective Controlled Study with Follow-Up for ≥2 Years

OBJECTIVE

We evaluated the clinical efficacy of the Biocage in lumbar fusion surgery and its safety and effectiveness.

METHODS

A total of 431 patients with single-segment lumbar degenerative disease diagnosed from January 2013 to December 2016 were considered for the present prospective, nonrandomized, and controlled study; 52 patient met the exclusion criteria and were excluded. The patients were divided into 2 groups according to their cage choice: Biocage (n = 206) and polyether ether ketone (PEEK) cage (n = 173). The patients were followed up for 24-48 months (average, 32). The operative time, blood loss, hospitalization duration, mean intervertebral fusion segment height, height of intervertebral foramen, fusion time, fusion rate, internal fixation failure rate, visual analog scale score, and Oswestry disability index were compared between the 2 groups.

RESULTS

All the patients underwent surgery successfully. No significant differences were found in gender, age, clinical diagnosis, lesion segment, operative time, blood loss, visual analog scale score, or Oswestry disability index between the 2 groups. No significant differences were found in the fusion rate; however, the Biocage group had a greater fusion rate and shorter fusion time than the PEEK group. During follow-up, the mean intervertebral height recovered significantly in the Biocage group compared with the PPEK group (P < 0.05). The height of the intervertebral foramen was significantly different between the 2 groups, and recovery was better in the Biocage group (P < 0.05). The Cobb angle of fusion segment in both groups improved significantly postoperatively compared with preoperatively (P < 0.05). The improvement in Cobb angle was significantly different between the 2 groups (P < 0.05).

CONCLUSIONS

The Biocage has excellent clinical efficacy in the treatment of lumbar degenerative disease. Although the Biocage achieved good therapeutic effects, it did not show obvious advantages compared with the PEEK cage. Therefore, the Biocage can only be used as a choice of bone graft materials for lumbar fusion surgery and should not completely replace the PEEK cage.

Cost-effectiveness of circumferential fusion for lumbar spondylolisthesis: propensity-matched comparison of transforaminal lumbar interbody fusion with anterior-posterior fusion

BACKGROUND CONTEXT

Transforaminal lumbar interbody fusion (TLIF) and dual-approach anteroposterior (AP) are common techniques to achieve circumferential fusion for lumbar spondylolisthesis. It is unclear which approach is more cost-effective.

PURPOSE

Our goal was to determine the incremental cost-effectiveness ratio (ICER) by calculating the cost per quality-adjusted life year (QALY) for each approach.

STUDY DESIGN/SETTING

This study is a propensity-matched cost-effectiveness comparison.

PATIENT SAMPLE

Patients with lumbar spondylolisthesis undergoing single-level AP fusion or TLIF and enrolled in a prospective observational surgical database were included in this study.

OUTCOME MEASURES

The outcome measures in this study were the Oswestry Disability Index (ODI) and the Short Form-6D (SF-6D).

METHODS

From a prospective surgical database, patients with lumbar spondylolisthesis undergoing single-level AP fusion were propensity matched to a TLIF cohort based on age, gender, body mass index, smoking status, workers compensation, preoperative ODI, and back and leg pain numeric scores. Quality-adjusted life years gained were determined using baseline and 1- and 2-yearpostoperative SF-6D scores. Cost was calculated from actual, direct hospital costs and included subsequent postsurgical costs (epidural spinal injections, spine-related emergency department visits, readmissions, and revision surgery).

RESULTS

Thirty-one cases of AP fusions were identified and propensity matched to 31 TLIF patients. Patients undergoing TLIF had a shorter mean operative time (270 vs. 328 minutes, p=.039) but no difference in estimated blood loss (526 vs. 548 cc, p=.804) or hospital length of stay (4.5 vs. 6.1 days, p=.146). Quality-adjusted life years gained at 2 years were also similar (0.140 vs. 0.130, p=.672). The mean index surgery and the total 2-year costs were lower for TLIF compared with AP (index: $29,428 vs. $31,466; final: $30,684 vs. $331,880). As overall costs were lower and QALYs gained were similar for TLIF compared with AP fusion, TLIF was the dominant intervention with an ICER of $116,327.

CONCLUSIONS

Under our study parameters, surgical treatment of lumbar spondylolisthesis with TLIF is more cost-effective compared with AP fusion. Because of the short-term follow-up, the longevity of this should be further investigated.

Posterolateral Versus Posterior Interbody Fusion in Lumbar Degenerative Spondylolisthesis

STUDY DESIGN

This was a retrospective study of 2 different fusion techniques for the treatment of lumbar degenerative spondylolisthesis.

OBJECTIVE

To determine whether posterior lumbar interbody fusion (IF) is associated with improved patient-rated satisfaction and functional outcome when compared with posterolateral fusion (PLF).

SUMMARY OF BACKGROUND DATA

IF and PLF are widely used surgical approaches in the treatment of spondylolisthesis. Numerous studies have compared IF and PLF techniques, but inconsistent results, heterogeneous cohorts, and conflicting scientific evidence have made it difficult to reach a consensus on the optimal fusion technique.

MATERIALS AND METHODS

A consecutive cohort of 87 patients who had single-level degenerative spondylolisthesis and either PLF or IF were identified from a prospectively maintained database. Short Form-36 physical and mental component score, Oswestry Disability Index, back and leg pain, and complication rate were assessed to 24 months postoperatively. Patient characteristics, clinical outcome, and complications were compared between groups.

RESULTS

Of the 87 patients identified, 29 patients (33%) had PLF and 58 patients (67%) had IF. Patient follow-up was ≥85%. Foraminal stenosis (PLF, 13.8% vs. IF, 34.5%; P=0.046) was more common among the participants in the IF group. Intraoperative and postoperative complications were not different between groups (P>0.05). The reoperation rate was 3.4% in the PLF group and 10.3% in the IF group (P=0.416). Patients in the PLF group experienced similar gains in improvement in all outcome measures as those in the IF group (P>0.05). Four patients in the IF group and 3 in the PLF group were lacking evidence of radiographic fusion. These patients did have increased moderate back pain compared with patients demonstrating radiographic fusion but did not differ in any other postoperative outcomes measures.

CONCLUSIONS

Type of fusion, IF or PLF, does not affect patient outcome or postoperative complication rates.

LEVEL OF EVIDENCE

Level IV.

Posterolateral fusion (PLF) versus transforaminal lumbar interbody fusion (TLIF) for spondylolisthesis: a systematic review and meta-analysis

BACKGROUND CONTEXT

Lumbar fusion is an effective and durable treatment for symptomatic lumbar spondylolisthesis; however, the current literature provides insufficient evidence to recommend an optimal surgical fusion strategy.

PURPOSE

The present study aims to compare the clinical outcomes, fusion rates, blood loss, and operative times between open posterolateral lumbar fusion (PLF) alone and open transforaminal lumbar interbody fusion (TLIF) + posterolateral fusion for spondylolisthesis.

STUDY DESIGN

This is a systematic literature review and meta-analysis of English language studies for the treatment of spondylolisthesis with PLF versus PLF + TLIF.

PATIENT SAMPLE

Data were obtained from published randomized controlled trials (RCTs) and retrospective cohort studies.

OUTCOME MEASURES

Clinical outcomes included Oswestry Disability Index (ODI), back pain, leg pain, and health-related quality of life (HRQOL) scores. Fusion rate, operative time, blood loss, and infection rate were also assessed.

METHODS

A literature search of three electronic databases was performed to identify investigations performed comparing PLF alone with PLF + TLIF for treatment of low-grade lumbar spondylolisthesis. The summary effect size was assessed from pooling observational studies for each of the outcome variables, with odds ratios (ORs) used for fusion and infection rate, mean difference used for improvement in ODI and leg pain as well as operative time and blood loss, and standardized mean difference used for improvement in back pain and HRQOL outcomes. Studies were weighed based on the inverse of the variance and heterogeneity. Heterogeneity was assessed using the I²-an estimate of the error caused by between-study variation. Effect sizes from the meta-analysis were then compared with data from the RCTs to assess congruence in outcomes.

RESULTS

The initial literature search yielded 282 unique, English language studies. Seven were determined to meet our inclusion criteria and were included in our qualitative analysis. Five observational studies were included in our quantitative meta-analysis. The pooled fusion success rates were 84.7% (100/118) in the PLF group and 94.3% (116/123) in the TLIF group. Compared with TLIF patients, PLF patients had significantly lower odds of achieving solid arthrodesis (OR 0.33, 95% confidence interval [CI] 0.13-0.82, p=.02; I²=0%). With regard to improvement in back pain, the point estimate for the effect size was -0.27 (95% CI -0.43 to -0.10, p=.002; I²=0%), in favor of the TLIF group. For ODI, the pooled estimate for the effect size was -3.73 (95% CI -7.09 to -0.38, p=.03; I²=35%), significantly in favor of the TLIF group. Operative times were significantly shorter in the PLF group, with a summary effect size of -25.55 (95% CI -43.64 to -7.45, p<.01; I²=54%). No significant difference was observed in leg pain, HRQOL improvement, blood loss, or infection rate. Our meta-analysis results were consistent with RCTs, in favor of TLIF for achieving radiographic fusion and greater improvement in ODI and back pain.

CONCLUSIONS

Our results demonstrate that for patients undergoing fusion for spondylolisthesis, TLIF is superior to PLF with regard to achieving radiographic fusion. However, current data only provide weak support, if any, favoring TLIF over PLF for clinical improvement in disability and back pain.

EFFECT OF PULSED ELECTROMAGNETIC FIELD ON THE CONSOLIDATION OF POSTEROLATERAL ARTHRODESES IN THE LUMBOSACRAL SPINE: A PROSPECTIVE, DOUBLE-BLIND, RANDOMIZED STUDY

ABSTRACT Objective: To assess the effect of pulsed electromagnetic field (PEMF) on the consolidation of instrumented lumbar posterolateral arthrodeses in patients who have been surgically treated for degenerative spine disease. Methods: Forty cases were recruited from 163 consecutive patients undergoing lumbar arthrodesis at the same center. The patients were randomized into two groups of 20 patients: Active Group, who were exposed to PEMF for 4 hours a day for 90 days after surgery, and Inactive Group, who received an identical device, with the same instructions for use but without the ability to generate PEMF. The patients underwent computed tomography scans at 45, 90, 180 and 360 days after surgery to check for the occurrence of arthrodesis at each operated spinal level. Results: In the course of the study, two patients were excluded from each group. There were no significant differences between the groups with respect to age, gender, smoking habit, or the number of vertebral levels included in the arthrodesis. The percentage of consolidation of the vertebral levels increased at 90, 180 and 360 days compared to 45 days (p<0.001) in both groups. The Active Group had a 276% greater chance of consolidation in the vertebral levels (OR = 3.76; 95% CI: 1.39-10.20), regardless of the time of evaluation. Patients in the Active Group presented 16% more consolidation than patients in the inactive group (p=0.018). Conclusions: Post-operative exposure to PEMF following instrumented arthrodesis of the lumbar spine for degenerative spine disease increased consolidation in the first year after surgery.

Transforaminal lumbar interbody fusion versus posterolateral fusion in degenerative lumbar spondylosis: A meta-analysis

OBJECTIVE

The aim of the study was to evaluate the efficacy and safety of transforaminal lumbar interbody fusion (TLIF) versus posterolateral fusion (PLF) in degenerative lumbar spondylosis.

METHODS

A systematic literature review was performed to obtain randomized controlled trials (RCTs) and observational studies (OSs) of TLIF and PLF for degenerative lumbar spondylosis. Trials performed before November 2015 were retrieved from the Medline, EMBASE, Cochrane library, and Chinese databases. Data extraction and quality evaluation of the trials were performed independently by 2 investigators. A meta-analysis was performed using STATA version 12.0.

RESULTS

Two RCTs and 5 OSs of 630 patients were included. Of these subjects, 325 were in the TLIF and 305 were in the PLF group. Results showed that TLIF did not increase the fusion rate based on RCTs (relative risk [RR] = 1.06; 95% confidence interval [CI]: 0.95-1.18; P = 0.321), but increased it based on OSs (RR = 1.14; 95% CI: 1.07-1.23; P = 0.000) and overall (RR = 1.11; 95% CI: 1.05-1.18; P = 0.001) as compared with PLF. TLIF was able to improve the clinical outcomes based on 1 RCT (RR = 1.33; 95% CI: 1.11-1.59, P = 0.002) and overall (RR = 1.19; 95% CI: 1.07-1.33; P = 0.001), but not based on OSs (RR = 1.11; 95% CI: 0.97-1.27; P = 0.129) as compared with PLF. There were no differences between TLIF and PLF in terms of visual analogue scale, Oswestry Disability Index, reoperation, complications, duration of surgical procedure, blood loss, and hospitalization.

CONCLUSIONS

In conclusion, evidence is not sufficient to support that TLIF provides higher fusion rate than PLF, and this poor evidence indicates that TLIF might improve only clinical outcomes. Higher quality, multicenter RCTs are needed to better define the role of TLIF and PLF.