Comparison of Farfan modified and Frobin methods to evaluate the intervertebral disc height

Percutaneous transforaminal endoscopic surgery (PTES) and mini-incision L5/S1 OLIF with a self-lock cage for the surgical treatment of L5 spondylolisthesis

OBJECTIVES

We reported thirteen cases of percutaneous transforaminal endoscopic surgery (PTES) under local anesthesia and mini-incision L5/S1 OLIF (OLIF51) with a self-lock cage for the treatment of L5 spondylolisthesis.

METHODS

From Jan 2019 to Feb 2020, the patients with L5 spondylolisthesis with nerve root symptoms undergoing PTES and OLIF51 were included in this study. PTES under local anesthesia was performed in a prone position, and OLIF51 with a self-lock cage and allograft was then undertaken through a left abdominal mini-incision and oblique retroperitoneal approach between bilateral iliac vessels with the external oblique, internal oblique and transverse abdominal muscles bluntly separated in turn for L5/S1 in a right oblique position under general anesthesia. Back and leg pain were preoperatively and postoperatively evaluated using the VAS, and the clinical outcomes were evaluated with the ODI before surgery and at the 2-year follow-up. The anterior and posterior intervertebral space height (AISH, PISH), lumbar lordotic, and surgical segmental lordotic angle (SLA) were measured on lumbar spine X-rays preoperatively and postoperatively. The fusion status was assessed according to Bridwell's fusion grades.

RESULTS

Thirteen cases of L5 spondylolisthesis were included. The operation duration was 49.1 ± 5.6 min for PTES and 73.6 ± 8.2 min for OLIF. There was blood loss of 25 (15-45) ml. The incision length was 7.5 ± 1.1 mm for PTES and 46.8 ± 3.8 mm for OLIF. The hospital stay was 5 (4-6) days, and the follow-up duration was 29 (24-37) months. For the clinical evaluation, the VAS of back and leg pain significantly dropped after surgery (p < 0.001), and the ODI significantly decreased from 64.7 ± 7.8% to 12.9 ± 4.3% 2 years after surgery (p < 0.001). AISH, PISH and SLA significantly improved after surgery (p < 0.05). Fusion grades based on the Bridwell grading system at the 2-year follow-up were grade I in 9 segments (69.2%) and grade II in 4 segments (30.8%). No patients had any form of permanent iatrogenic nerve damage or major complications. No failure of instruments was observed.

CONCLUSIONS

PTES and mini-incision OLIF51 with a self-lock cage is a viable option of minimally invasive surgery for L5 spondylolisthesis, which can achieve direct neurologic decompression, satisfactory fusion and hardly destroys the rectus abdominis and its sheath, paraspinal muscles and bone structures.

Hybrid surgery of percutaneous transforaminal endoscopic surgery (PTES) combined with OLIF and anterolateral screws rod fixation for treatment of multi-level lumbar degenerative diseases with intervertebral instability

BACKGROUND

Oblique lumbar interbody fusion (OLIF) has been used to treat lumbar intervertebral instability, which has some advantages including less trauma, less blood loss, faster recovery and bigger cage. However, it usually needs posterior screws fixation for biomechanical stability, and possible direct decompression for relieving neurologic symptoms. In this study, OLIF and anterolateral screws rod fixation through mini-incision were combined with percutaneous transforaminal endoscopic surgery (PTES) for the treatment of multi-level lumbar degenerative diseases (LDDs) with intervertebral instability. The purpose of study is to evaluate the feasibility, efficacy and safety of this hybrid surgery.

METHODS

From July 2017 to May 2018, 38 cases of multi-level LDDs of disc herniation, foramen stenosis, lateral recess stenosis or central canal stenosis with intervertebral instability and neurologic symptoms undergoing one-stage PTES combined with OLIF and anterolateral screws rod fixation through mini-incision were recruited in this retrospective study. The culprit segment was predicted according to the position of patient's leg pain and PTES under local anesthesia was performed for the culprit segment in the prone position to enlarge the foramen, remove the flavum ligamentum and herniated disc for the lateral recess decompression and expose bilateral traversing nerve roots for the central spinal canal decompression through an unilateral incision. During the operation, communicate with the patients to confirm the efficacy using VAS. And then mini-incision OLIF using allograft, autograft bone harvested in PTES and anterolateral screws rod fixation were performed in the right lateral decubitus position under general anesthesia. Back and leg pain were preoperatively and postoperatively evaluated using VAS. And the clinical outcomes were evaluated with ODI at the 2-year follow-up. The fusion status was assessed according to Bridwell's fusion grades.

RESULTS

There were 27 cases of 2-level, 9 cases of 3-level and 2 cases of 4-level LDDs with single-level instability on the X-ray, CT and MRI. Five cases of L3/4 instability and 33 cases of L4/5 instability were included. PTES was performed for 1 segment of 31 cases (25 cases of instability segment, 6 cases of no instability segment) and 2 segments including instability segment of 7 cases. Then, all instability segments were treated using mini-incision OLIF and anterolateral screws rod fixation. The average operation duration was 48.9 ± 7.3 min per level for PTES and 69.2 ± 11.6 min for OLIF and anterolateral screws rod fixation. The mean frequency of intraoperative fluoroscopy was 6 (5-9) times per level for PTES and 7 (5-10) times for OLIF. There was a mean blood loss of 30 (15-60) ml, and the incision length was 8.1 ± 1.1 mm for PTES and 40.0 ± 3.2 mm for OLIF. The mean hospital stay was 4 (3-6) days. The average follow-up duration was 31.1 ± 4.0 months. For the clinical evaluation, the VAS pain index and the ODI showed excellent outcomes. Fusion grades based on the Bridwell grading system at 2-year follow-up were grade I in 29 segments (76.3%) and grade II in 9 segments (23.7%). One patient encountered nerve root sleeves rupture during PTES and did not confront cerebrospinal fluid leakage or other abnormal clinical symptoms. There were two cases of hip flexion pain and weakness, which was relieved during 1 week after surgery. No patients had any form of permanent iatrogenic nerve damage and a major complication. No failure of instruments was observed.

CONCLUSIONS

The hybrid surgery of PTES combined with OLIF and anterolateral screws rod fixation is a good choice of minimally invasive surgery for multi-level LDDs with intervertebral instability, which can get direct neurologic decompression, easy reduction, rigid fixation and solid fusion, and hardly destroy the paraspinal muscles and bone structures.

Percutaneous transforaminal endoscopic surgery combined with mini-incision OLIF and anterolateral screws rod fixation vs. MIS-TLIF for surgical treatment of single-level lumbar spondylolisthesis

Objective

Oblique lumbar interbody fusion (OLIF) has been used to treat lumbar spine spondylolisthesis. However, it usually needs posterior pedicle screws fixation for biomechanical stability and possible posterior direct decompression for relieving neurologic symptoms. We use percutaneous transforaminal endoscopic surgery (PTES) combined with mini-incision OLIF and anterolateral screws rod fixation for surgical treatment of lumbar spondylolisthesis. The purpose of study is to evaluate the feasibility, efficacy, and safety of this method compared with minimally invasive surgery-transforaminal lumbar interbody fusion (MIS-TLIF).

Methods

From July 2016 to May 2018, 65 patients of lumbar spondylolisthesis (L2-4) with neurologic symptoms were treated using PTES combined with mini-incision OLIF and anterolateral screws rod fixation (31 cases, group A) or MIS-TLIF (34 cases, group B) in this study. Operative duration, blood loss, incision length, fluoroscopy frequency, and hospital stay are compared. Preoperative and postoperative visual analog scale (VAS) pain scores of back and legs, Oswestry disability index (ODI), intervertebral space height, lumbar lordotic angle, operative segmental lordotic angle, and complications are recorded. The fusion status is assessed according to Bridwell's fusion grades.

Results

The VAS score of back and leg pain and ODI significantly dropped after surgery in both groups (p < 0.001). There was no statistical difference of back and leg VAS score and ODI between two groups except that back VAS scores in group A were significantly lower than that of group B immediately after surgery (p = 0.000). Group A had significantly more intervertebral space height and operative segmental lordotic angle than group B postoperatively (p = 0.022, p = 0.002). Twenty-three segments (74.2%) were grade I and 8 segments (25.8%) were grade II in group A; 20 segments (58.8%) were grade I and 14 segments (41.2%) were grade II in group B at a 2-year follow-up (p = 0.194). No difference was observed in the complication rate between the two groups (6.5% vs. 5.9%, p = 0.924).

Conclusion

The long-term clinical efficacy and complication rates of both groups are comparable. PTES combined with mini-incision OLIF and anterolateral screws rod fixation is a good choice of minimally invasive surgery for lumbar spondylolisthesis, which hardly destroys the paraspinal muscles and bone structures.