Comparison of minimally invasive and open transforaminal lumbar interbody fusion in the treatment of single segmental lumbar spondylolisthesis: minimum two-year follow up

Evaluating the efficacy and suggesting technical optimizations for endoscopic lumbar interbody fusion across different lumbar spondylolisthesis types

Purpose

To evaluate the efficacy of the endoscopic lumbar interbody fusion technique across different types of lumbar spondylolisthesis, specifically Grade I and Grade II, and suggest technical optimizations based on therapeutic outcomes, complications, and patient satisfaction for both grades.

Methods

We analyzed data from 57 L4 to 5 spondylolisthesis patients, all categorized as either Grade I or Grade II, comprising 31 males and 26 females. Of these, 36 were diagnosed with Grade I and 21 with Grade II. All subjects underwent the endoscopic lumbar interbody fusion procedure. Primary evaluation metrics included pre and post-operative Vasual Analogue Scale（VAS） pain scores, Osewewtry Disability Index（ODI） functional scores, surgical duration, intraoperative blood loss, degree of spondylolisthesis correction, complications, and patient satisfaction levels.

Results

At a minimum of 6 months post-operation, the VAS score for the Grade I cohort reduced from an initial 7.30 ± 0.69 to 2.97 ± 0.47, while the Grade II cohort saw a decrease from 7.53 ± 0.56 to 3.37 ± 0.62 (P = 0.0194). The ODI score in the Grade I group declined from 66.88 ± 5.15 % pre-operation to 29.88 ± 6.36 % post-operation, and in the Grade II group, it decreased from 69.33 ± 5.27 % to 34.66 ± 6.01 % (P = 0.0092). The average surgical duration for the Grade I group stood at 155.72 ± 17.75 min, compared to 180.38 ± 14.72 min for the Grade II group (P < 0.001). The mean intraoperative blood loss for the Grade I group was 144.58 ± 28.61 ml, whereas the Grade II group registered 188.23 ± 9.41 ml (P < 0.001). Post-surgery, 83 % of the Grade I patients achieved a correction degree exceeding 80 %, and 61 % of the Grade II patients surpassed 50 % (P = 0.0055). Complication rates were recorded at 8 % for Grade I and 16 % for Grade II. Patient satisfaction reached 94 % in the Grade I cohort and 90 % in the Grade II cohort.

Conclusion

Endoscopic lumbar interbody fusion showcases promising therapeutic outcomes for both Grade I and Grade II lumbar spondylolisthesis. However, surgeries for Grade II spondylolisthesis tend to be lengthier, more challenging, involve greater blood loss, and have a heightened complication risk. Tailored technical adjustments and enhancements are essential for addressing the distinct spondylolisthesis types.

Comparison of Fusion Rate and Clinical Outcomes in Minimally Invasive and Conventional Posterior Fusion for Lumbar Degenerative Disease: A Network Meta-Analysis

BACKGROUND

The fusion rate, clinical efficacy, and complications of minimally invasive fusion surgery and open fusion surgery in the treatment of lumbar degenerative disease are still unclear.

METHODS

We conducted a literature search using PubMed, Embase, Cochrane Library, CNKI, and WANFANG databases.

RESULTS

This study included 38 retrospective studies involving 3097 patients. Five intervention modalities were considered: unilateral biportal endoscopic-lumbar interbody fusion (UBE-LIF), percutaneous endoscopic-lumbar interbody fusion (PE-LIF), minimally invasive-transforaminal lumbar interbody fusion (MIS-TLIF), transforaminal lumbar interbody fusion (TLIF), and posterior lumbar interbody fusion (PLIF). Quality assessment indicated that each study met acceptable quality standards. PE-LIF demonstrated reduced low back pain (Odds Ratio = 0.50, Confidence Interval: 0.38-0.65) and lower complication rate (Odds Ratio = 0.46, Confidence Interval: 0.25-0.87) compared to PLIF. However, in indirect comparisons, PE-LIF showed the lowest fusion rates, with the ranking as follows: UBE-LIF (83.2%) > MIS-TLIF (59.6%) > TLIF (44.3%) > PLIF (39.8%) > PE-LIF (23.1%). With respect to low back pain relief, PE-LIF yielded the best results, with the order of relief as follows: PE-LIF (96.4%) > MIS-TLIF (64.8%) > UBE-LIF (62.6%) > TLIF (23.0%) > PLIF (3.2%). Global and local consistency tests showed satisfactory results, and heterogeneity tests indicated good stability.

CONCLUSIONS

Compared to conventional open surgery, minimally invasive fusion surgery offered better scores for low back pain and Oswestry Disability Index, lower complication rates, reduced bleeding, and shorter hospital stays. However, minimally invasive fusion surgery did not show a significant advantage in terms of fusion rate and had a longer operative time.

Comparison of clinical outcomes and complications between endoscopic and minimally invasive transforaminal lumbar interbody fusion for lumbar degenerative diseases: a systematic review and meta-analysis

OBJECTIVE

This study compares the efficacy and complications of endoscopic transforaminal lumbar fusion (Endo-TLIF) and minimally invasive transforaminal lumbar fusion (MIS-TLIF) in treating lumbar degenerative diseases. It aims to provide reference data for clinical decision-making.

METHODS

We identified randomized controlled studies and non-randomized controlled studies on Endo-TLIF and MIS-TLIF for treating lumbar degenerative diseases based on specific inclusion and exclusion criteria. Data were managed with Endnote X9 software and meta-analyzed using Revman 5.3 software. Extracted outcomes included lower back VAS score, lower extremity pain VAS score, low back pain ODI score, complication rate, fusion rate, time to surgery, blood loss, and length of hospital stay.

RESULTS

① Thirteen high-quality studies were included in this meta-analysis, totaling 1015 patients-493 in the Endo-TLIF group and 522 in the MIS-TLIF group. ② Meta-analysis results revealed no significant differences in preoperative, postoperative 6-month, and final follow-up waist VAS scores, lower limb pain VAS score, ODI index, complications, and fusion rate between the two groups (P > 0.05). The MIS-TLIF group had a shorter operative time (MD = 29.13, 95% CI 10.86, 47.39, P = 0.002) than the Endo-TLIF group. However, the Endo-TLIF group had less blood loss (MD = - 76.75, 95% CI - 111.59, - 41.90, P < 0.0001), a shorter hospital stay (MD = - 2.15, 95% CI - 2.95, - 1.34, P < 0.00001), and lower lumbar VAS scores both immediately postoperative (≤ 2 week) (MD = - 1.12, 95% CI - 1.53, - 0.71, P < 0.00001) compared to the MIS-TLIF group.

CONCLUSION

Meta-analysis results indicated that Endo-TLIF is similar to MIS-TLIF in terms of long-term clinical outcomes, fusion rates, and complication rates. Although MIS-TLIF has a shorter operation time, Endo-TLIF can significantly reduce blood loss and hospital stay duration. Endo-TLIF offers the advantages of less surgical trauma, reduced blood loss, faster recovery, and early alleviation of postoperative back pain.

Endoscopic Lumbar Interbody Fusion, Minimally Invasive Transforaminal Lumbar Interbody Fusion, and Open Transforaminal Lumbar Interbody Fusion for the Treatment of Lumbar Degenerative Diseases: A Systematic Review and Network Meta-Analysis

STUDY DESIGN

network meta-analysis.

OBJECTIVE

To compare the clinical efficacy and safety of endoscopic lumbar interbody fusion (Endo-LIF), minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF), and open transforaminal lumbar interbody fusion (OTLIF) in the treatment of lumbar degenerative diseases (LDDs).

METHOD

A literature search was conducted in the PubMed, Embase, and Cochrane Library databases. Studies comparing Endo-LIF, MIS-TLIF and OTLIF published from September 2017 to September 2022 for the treatment of LDD were retrieved. Data were extracted from preset clinical outcome measures, including operation time, estimated intraoperative estimated blood loss (EBL), length of hospital stay (LOS), complications, visual analog scale (VAS) score, Oswestry disability index (ODI) score, etc.

RESULT

Thirty-one studies with 3467 patients were included in this study. Network meta-analysis showed that in the comparison of the 3 procedures, Endo-LIF was superior to MIS-TLIF and OTLIF in terms of reducing EBL, LOS, time to ambulation, and VAS score of back pain. MIS-TLIF was superior to Endo-LIF in terms of ODI improvement, and OTLIF required the shortest intraoperative fluoroscopy time. There was no significant difference in operative time, complication rate, fusion rate, VAS score of leg pain, or JOA score among the 3 procedures.

CONCLUSION

Endo-LIF, MIS-TLIF and OTLIF each have their own advantages and disadvantages and show similar results in many respects, except for better early outcomes achieved with the more minimally invasive procedure.

Comparison of minimally invasive transforaminal lumbar interbody fusion and endoscopic lumbar interbody fusion for lumbar degenerative diseases: a retrospective observational study

BACKGROUND

Minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) and endoscopic lumbar interbody fusion (Endo-LIF) are both minimally invasive interbody fusion procedures for lumbar degenerative diseases. In this study, we attempted to compare the clinical efficacy and postoperative outcomes of MIS-TLIF and Endo-LIF for lumbar degenerative diseases.

METHODS

The study cohort comprised 99 patients with lumbar degenerative diseases treated by MIS-TLIF or Endo-LIF from January 2019 to July 2021. The clinical outcomes (visual analogue scale (VAS), Oswestry disability index (ODI), and MacNab criteria) preoperatively, 1 month postoperatively, 3 months postoperatively, and 1 year postoperatively were compared between the two groups.

RESULTS

There were no significant differences between the two groups in sex, age, disease duration, affected spine segment, and complications (P > 0.05). The operation time was significantly longer in the Endo-LIF group than the MIS-TLIF group (155.25 ± 12.57 vs. 123.14 ± 14.50 min; P < 0.05). However, the Endo-LIF group had a significantly smaller blood loss volume (61.79 ± 10.09 vs. 259.97 ± 14.63 ml) and shorter hospital stay (5.46 ± 1.11 vs. 7.06 ± 1.42 days) than the MIS-TLIF group. In both groups, the ODI and VAS scores for lower back pain and leg pain were significantly lower at each postoperative timepoint than preoperatively (P < 0.05). Although there were no significant differences between the two groups in the ODI and VAS scores for lower back pain and leg pain (P > 0.05), the VAS for lower back pain was lower in the Endo-LIF group than the MIS-TLIF group at each postoperative timepoint. The MacNab criteria showed that the improvement rate was 92.2% in the MIS-TLIF group and 91.7% in the Endo-LIF group, with no significant difference between the two groups (P > 0.05).

CONCLUSIONS

There were no significant differences in short-term surgical outcomes between the MIS-TLIF and Endo-LIF groups. Compared with the MIS-TLIF group, the Endo-LIF group incurred less damage to surrounding tissues, experienced less intraoperative blood loss, and had less lower back pain, which is more conducive to recovery.

Minimally invasive versus open transforaminal lumbar interbody fusion for grade I lumbar spondylolisthesis: 5-year follow-up from the prospective multicenter Quality Outcomes Database registry

OBJECTIVE

Minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) has been used to treat degenerative lumbar spondylolisthesis and is associated with expedited recovery, reduced operative blood loss, and shorter hospitalizations compared to those with traditional open TLIF. However, the impact of MI-TLIF on long-term patient-reported outcomes (PROs) is less clear. Here, the authors compare the outcomes of MI-TLIF to those of traditional open TLIF for grade I degenerative lumbar spondylolisthesis at 60 months postoperatively.

METHODS

The authors utilized the prospective Quality Outcomes Database registry and queried for patients with grade I degenerative lumbar spondylolisthesis who had undergone single-segment surgery via an MI or open TLIF method. PROs were compared 60 months postoperatively. The primary outcome was the Oswestry Disability Index (ODI). The secondary outcomes included the numeric rating scale (NRS) for back pain (NRS-BP), NRS for leg pain (NRS-LP), EQ-5D, North American Spine Society (NASS) satisfaction, and cumulative reoperation rate. Multivariable models were constructed to assess the impact of MI-TLIF on PROs, adjusting for variables reaching p < 0.20 on univariable analyses and respective baseline PRO values.

RESULTS

The study included 297 patients, 72 (24.2%) of whom had undergone MI-TLIF and 225 (75.8%) of whom had undergone open TLIF. The 60-month follow-up rates were similar for the two cohorts (86.1% vs 75.6%, respectively; p = 0.06). Patients did not differ significantly at baseline for ODI, NRS-BP, NRS-LP, or EQ-5D (p > 0.05 for all). Perioperatively, MI-TLIF was associated with less blood loss (108.8 ± 85.6 vs 299.6 ± 242.2 ml, p < 0.001) and longer operations (228.2 ± 111.5 vs 189.6 ± 66.5 minutes, p < 0.001) but had similar lengths of hospitalizations (MI-TLIF 2.9 ± 1.8 vs open TLIF 3.3 ± 1.6 days, p = 0.08). Discharge disposition to home or home health was similar (MI-TLIF 93.1% vs open TLIF 91.1%, p = 0.60). Both cohorts improved significantly from baseline for the 60-month ODI, NRS-BP, NRS-LP, and EQ-5D (p < 0.001 for all comparisons). In adjusted analyses, MI-TLIF, compared to open TLIF, was associated with similar 60-month ODI, ODI change, odds of reaching ODI minimum clinically important difference, NRS-BP, NRS-BP change, NRS-LP, NRS-LP change, EQ-5D, EQ-5D change, and NASS satisfaction (adjusted p > 0.05 for all). The 60-month reoperation rates did not differ significantly (MI-TLIF 5.6% vs open TLIF 11.6%, p = 0.14).

CONCLUSIONS

For symptomatic, single-level grade I degenerative lumbar spondylolisthesis, MI-TLIF was associated with decreased blood loss perioperatively, but there was no difference in 60-month outcomes for disability, back pain, leg pain, quality of life, or satisfaction between MI and open TLIF. There was no difference in cumulative reoperation rates between the two procedures. These results suggest that in appropriately selected patients, either procedure may be employed depending on patient and surgeon preferences.

OLIF versus MI-TLIF for patients with degenerative lumbar disease: Is one procedure superior to the other? A systematic review and meta-analysis

PURPOSE

To compare the effectiveness and safety of oblique lateral interbody fusion (OLIF) and minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) for degenerative lumbar disease.

METHODS

We searched relevant studies in Embase, PubMed, Cochrane, and Web of Science databases comprehensively from inception to March 2022. The data were extracted from included studies, including operation indications, radiographic parameters, and clinical outcomes. Random or fixed-effects models were used in all meta-analyses according to the between-study heterogeneity.

RESULTS

In total, 30 studies, including 2,125 patients, were included in this meta-analysis. Our study found similar disk height, length of hospital stay, visual analog scale (VAS), and Oswestry disability index(ODI) between the two groups. However, the OLIF showed an advantage in restoring lumbar lordotic angle compared with MI-TLIF, with the pooled mean change of 17.73° and 2.61°, respectively. Additionally, the operative time and blood loss in the OLIF group appeared to be less compared with the MI-TLIF group. Regarding complications, the rates of the two groups were similar (OLIF 14.0% vs. MI-TLIF 10.0%), but the major complications that occurred in these two procedures differed significantly.

CONCLUSION

The results of disk height, length of hospital stay, VAS, and ODI between the OLIF and MI-TLIF groups were similar. And the OLIF was superior in restoring lumbar lordotic angle, operative time, and blood loss. However, the OLIF group's complication rate was higher, although not significantly, than that in the MI-TLIF group.

Comparison of local and regional radiographic outcomes in minimally invasive and open TLIF: a propensity score-matched cohort

OBJECTIVE

Local and regional radiographic outcomes following minimally invasive (MI) transforaminal lumbar interbody fusion (TLIF) versus open TLIF remain unclear. The purpose of this study was to provide a comprehensive assessment of local and regional radiographic parameters following MI-TLIF and open TLIF. The authors hypothesized that open TLIF provides greater segmental and global lordosis correction than MI-TLIF.

METHODS

A single-center retrospective cohort study of consecutive patients undergoing MI- or open TLIF for grade I degenerative spondylolisthesis was performed. One-to-one nearest-neighbor propensity score matching (PSM) was used to match patients who underwent open TLIF to those who underwent MI-TLIF. Sagittal segmental radiographic measures included segmental lordosis (SL), anterior disc height (ADH), posterior disc height (PDH), foraminal height (FH), percent spondylolisthesis, and cage position. Lumbopelvic radiographic parameters included overall lumbar lordosis (LL), pelvic incidence (PI)-lumbar lordosis (PI-LL) mismatch, sacral slope (SS), and pelvic tilt (PT). Change in segmental or overall lordosis after surgery was considered "lordosing" if the change was > 0° and "kyphosing" if it was ≤ 0°. Student t-tests or Wilcoxon rank-sum tests were used to compare outcomes between MI-TLIF and open-TLIF groups.

RESULTS

A total of 267 patients were included in the study, 114 (43%) who underwent MI-TLIF and 153 (57%) who underwent open TLIF, with an average follow-up of 56.6 weeks (SD 23.5 weeks). After PSM, there were 75 patients in each group. At the latest follow-up both MI- and open-TLIF patients experienced significant improvements in assessment scores obtained with the Oswestry Disability Index (ODI) and the numeric rating scale for low-back pain (NRS-BP), without significant differences between groups (p > 0.05). Both MI- and open-TLIF patients experienced significant improvements in SL, ADH, and percent corrected spondylolisthesis compared to baseline (p < 0.001). However, the MI-TLIF group experienced significantly larger magnitudes of correction with respect to these metrics (ΔSL 4.14° ± 4.35° vs 1.15° ± 3.88°, p < 0.001; ΔADH 4.25 ± 3.68 vs 1.41 ± 3.77 mm, p < 0.001; percent corrected spondylolisthesis: -10.82% ± 6.47% vs -5.87% ± 8.32%, p < 0.001). In the MI-TLIF group, LL improved in 44% (0.3° ± 8.5°) of the cases, compared to 48% (0.9° ± 6.4°) of the cases in the open-TLIF group (p > 0.05). Stratification by operative technique (unilateral vs bilateral facetectomy) and by interbody device (static vs expandable) did not yield statistically significant differences (p > 0.05).

CONCLUSIONS

Both MI- and open-TLIF patients experienced significant improvements in patient-reported outcome (PRO) measures and local radiographic parameters, with neutral effects on regional alignment. Surprisingly, in our cohort, change in SL was significantly greater in MI-TLIF patients, perhaps reflecting the effect of operative techniques, technological innovations, and the preservation of the posterior tension band. Taking these results together, no significant overall differences in LL between groups were demonstrated, which suggests that MI-TLIF is comparable to open approaches in providing radiographic correction after surgery. These findings suggest that alignment targets can be achieved by either MI- or open-TLIF approaches, highlighting the importance of surgeon attention to these variables.

One-level open vs. minimally invasive transforaminal lumbar interbody fusion: a systematic review and advanced meta-analytic assessment of prospective studies with at least two years follow-up

PURPOSE

To determine whether the open or the minimally invasive transforaminal lumbar interbody fusion (O-TLIF, MI-TLIF) is the favored treatment, we provide first meta-analyses using prospective studies with at least two years follow-up only and present the clinical relevance of statistical results for the first time.

METHODS

After a systematic review of six databases, we conducted 10 meta-analyses of randomized controlled trials (RCTs) and 10 meta-analyses of eligible prospective studies (EPSs) to compare fusion rate, patient-reported outcome measures (back pain (B-VAS), leg pain, Oswestry Disability Index (ODI)), for the first time safety outcome measures as operative and postoperative complications per case, and the perioperative outcome measures estimated blood loss (EBL), operation time and length of hospital stay (LOS). The clinical relevance was assessed by overall effect sizes (OESs) of statistically significant meta-analytic results.

RESULTS

In our meta-analyses of RCTs, MI-TLIF is statistically significantly superior in ODI, EBL and LOS, with clinically meaningful OESs only in EBL and LOS. In meta-analyses of EPSs, MI-TLIF is statistically significantly superior in B-VAS, postoperative complications per case, EBL and LOS, all with clinically meaningful OESs except for B-VAS. The meta-analyses of remaining outcome measures present statistically nonsignificant results. In a descriptive analysis of complications, postoperative wound infections predominate in O-TLIF and hardware malposition in MI-TLIF.

CONCLUSION

After at least two years, O-TLIF and MI-TLIF can be considered equally efficacious, which simplifies surgeons' decision between both treatments, however, with the safety outcome measure postoperative complications per case and the perioperative outcome measures EBL and LOS in favor of MI-TLIF. LEVEL OF EVIDENCE I: Well conducted meta-analyses, systematic reviews, or RCTs with a low risk of bias.

Clinical outcomes, complications and fusion rates in endoscopic assisted intraforaminal lumbar interbody fusion (iLIF) versus minimally invasive transforaminal lumbar interbody fusion (MI-TLIF): systematic review and meta-analysis

This meta-analysis aims to determine the clinical outcomes, complications, and fusion rates in endoscopic assisted intra-foraminal lumbar interbody fusion (iLIF) and minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) for lumbar degenerative diseases. The MEDLINE, Embase, and Cochrane Library databases were searched. The inclusion criteria were: five or more consecutive patients who underwent iLIF or MI-TLIF for lumbar degenerative diseases; description of the surgical technique; clinical outcome measures, complications and imaging assessment; minimum follow-up of 12 months. Surgical time, blood loss, and length of hospital stay were extracted. Mean outcome improvements were pooled and compared with minimal clinically important differences (MCID). Pooled and direct meta-analysis were evaluated. We identified 42 eligible studies. The iLIF group had significantly lower mean intra-operative blood loss, unstandardized mean difference (UMD) 110.61 mL (95%CI 70.43; 150.80; p value < 0.0001), and significantly decreased length of hospital stay (UMD 2.36; 95%CI 1.77; 2.94; p value < 0.0001). Visual analogue scale (VAS) back, VAS leg and Oswestry disability index (ODI) baseline to last follow-up mean improvements were statistically significant (p value < 0.0001), and clinically important for both groups (MCID VAS back > 1.16; MCID VAS leg > 1.36; MCID > 12.40). There was no significant difference in complication nor fusion rates between both cohorts. Interbody fusion using either iLIF or MI-TLIF leads to significant and clinically important improvements in clinical outcomes for lumbar degenerative diseases. Both procedures provide high rates of fusion at 12 months or later, without significant difference in complication rates. iLIF is associated with significantly less intraoperative blood loss and length of hospital stay.

Study registration: PROSPERO international prospective register of systematic reviews: Registration No. CRD42020180980, accessible at https://www.crd.york.ac.uk/prospero/ April 2020.

Revision Surgery for Adjacent Segment Degeneration After Fusion for Lumbar Spondylolisthesis: Is there a Correlation with Roussouly Type?

STUDY DESIGN

Retrospective study.

OBJECTIVE

The aim of this study was to investigate whether there is an association between revision surgery rates for adjacent segment degeneration (ASD) and Roussouly type after L4-5 transforaminal lumbar interbody fusion (TLIF) for spondylolisthesis.

SUMMARY OF BACKGROUND DATA

Revision surgery for ASD is known to occur after spinal fusion; however, it is unclear whether rates of ASD are associated with certain Roussouly types.

METHODS

Patients who underwent L4-5 TLIF for spondylolisthesis at the University of California San Francisco from January 2006 to December 2016 with minimum 2-year follow-up were retrospectively analyzed by Roussouly type. Revision surgery for ASD was noted and correlated by Roussouly type. Spinopelvic parameters were also measured for correlation. A value of P < 0.05 was significant.

RESULTS

There were 174 patients who met inclusion criteria, (59 males and 115 females). The average age was 62.3 (25-80) years. A total of 132 patients had grade I spondylolisthesis, and 42 had grade II. Mean follow-up was 45.2 months (24-497). A total of 22 patients (12.6%) underwent revision surgery for ASD after L4-5 TLIF. When classified by Roussouly type, revision surgery rates for ASD were: 1, 14.3%; 2, 22.6%; 3, 4.9%; and 4, 15.6% (P = 0.013). Type 3 spines with normal PI-LL (8.85° ± 6.83°) had the lowest revision surgery rate (4.9%), and type 2 spines with PI-LL mismatch (11.06° ± 8.81°) had the highest revision surgery rate (22.6%), a four-fold difference (P = 0.013). The PI-LL mismatch did not change significantly in each type postoperatively (P > 0.05).

CONCLUSION

We found that there may be a correlation between Roussouly type and revision surgery for ASD after L4-5 TLIF for spondylolisthesis, with type 2 spines having the highest rate. Spinopelvic parameters may also correlate with revision surgery for ASD after L4-5 TLIF.Level of Evidence: 4.

Long-term clinical outcome of minimally invasive versus open single-level transforaminal lumbar interbody fusion for degenerative lumbar diseases: a meta-analysis

BACKGROUND CONTEXT

Minimally invasive surgical transforaminal lumbar interbody fusion (MIS-TLIF) was developed in addition to open-TLIF to minimize iatrogenic soft-tissue damage. A potential disadvantage of MIS-TLIF is inadequate visualization, which may lead to incomplete neural decompression and a less robust arthrodesis. This may cause long-term problems and result in decreased patient satisfaction.

PURPOSE

To evaluate the long-term clinical outcome, measured by patient-reported outcomes (PROMs), of patients with degenerative lumbar diseases treated with single-level TLIF (open vs. minimally invasive) with a minimum follow-up of 2-years.

STUDY DESIGN

Meta-analysis.

METHODS

The systematic review was conducted according to the PRISMA guidelines. Relevant studies were identified from Pubmed, MEDLINE, EMBASE, Scopus, Web of Science, and CENTRAL from the date of inception to August 2019. The inclusion criteria were (1) longitudinal comparative studies of MIS-TLIF versus open-TLIF approach for degenerative spine disease (2) outcomes reported as PROMs, (3) minimum follow-up of 2-years.

RESULTS

Sixteen studies were included in the analysis. In total, 1,321 patients were included (660 MIS-TLIF& 661 open-TLIF). The following PROMS were analyzed: EQ-5D, SF, ODI, and VAS. Both techniques resulted in significant improvement in PROM, which remained significant at 2-years follow-up. However, no significant differences were found in all PROMs at 2-years follow-up. Both treatments resulted in a high rate of spinal fusion (80.5% vs. 91.1%; p=.29) and low rate of reoperation (3.0% vs. 2.4%; p=.50) or adjacent segment disease (12.6% vs. 12.40%; p=.50).

CONCLUSIONS

MIS-TLIF and open-TLIF have comparable long-term clinical outscomes. Both operations can significantly reduce pain and positively improve PROMs. No significant differences were found between both treatments in clinical outcomes at a follow-up of minimal 2-years. Therefore, MIS-TLIF seems to be an effective and safe alternative to traditional open-TLIF in the long-term.

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.

MIS-TLIF versus O-TLIF for single-level degenerative stenosis: study protocol for randomised controlled trial

INTRODUCTION

Patients with symptomatic single-level combination of degenerative stenosis and low-grade spondylolisthesis are often treated by nerve root decompression and spinal fusion. The gold standard is traditional open decompression and fusion, but minimally invasive method is more and more prevailing. However, there is lack of high-quality studies comparing these two techniques in order to obtain the advantages and certain indications to use one of these methods. The current study includes clinical, safety and radiological endpoints to determine the effectiveness of minimally invasive decompression and fusion (MIS-TLIF) over the traditional open one (O-TLIF).

METHODS AND ANALYSIS

All patients aged 40-75 years with neurogenic claudication or bilateral radiculopathy caused by single-level combination of degenerative stenosis and low-grade spondylolisthesis, confirmed by MRI with these symptoms persisting for at least 3 months prior to surgery, are eligible. Patients will be randomised into MIS-TLIF or traditional O-TLIF. The primary outcome measure is Oswestry Disability Index at 3-month follow-up term. The secondary outcomes are patient-reported outcome measures by the number of clinical scales, radiological parameters including sagittal balance parameters, safety endpoints and cost-effectiveness of each method. All patients will be analysed preoperatively, as well as on the 14th day of hospital stay (or on the day of hospital discharge), 3 months, 6 months, 12 months and 24 months postoperatively. The study has the design of a parallel group to demonstrate the non-inferior clinical results of MIS-TLIF compared with the traditional O-TLIF.

ETHICS AND DISSEMINATION

The study will be performed according to Helsinki Declaration. The study protocol was approved by the Local Ethical Committee of Priorov National Medical Research Center of Traumatology and Orthopedics in August 2020. Preliminary and final results will be presented in peer-reviewed journals, especially orthopaedic and spine surgery journals, at national and international congresses.

TRIAL REGISTRATION NUMBER

NCT04594980.

Percutaneous Endoscopic Transforaminal Lumbar Interbody Fusion: Technique Note and Comparison of Early Outcomes with Minimally Invasive Transforaminal Lumbar Interbody Fusion for Lumbar Spondylolisthesis

Purpose

To compare the preliminary postoperative outcomes of percutaneous endoscopic transforaminal lumbar interbody fusion (Endo-TLIF) and minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) in the treatment of lumbar spondylolisthesis.

Methods

Sixty-two patients with single-segment lumbar spondylolisthesis received Endo-TLIF and MIS-TLIF were enrolled in present study. Perioperative parameters, including operation time, estimated blood loss (EBL), interoperative fluoroscopy time, ambulation time and operative complications were recorded, respectively. The results of clinical metrics such as the Visual Analog Scale (VAS) for back and leg pain, the Oswestry Disability Index (ODI) and the Japanese Orthopaedic Association (JOA) score were obtained, respectively. Postoperative fusion rates were assessed by clinical fusion and CT at 12-month after surgery.

Results

No significant differences were found in the demographic data between the two groups. Compared with MIS-TLIF group, Endo-TLIF group had similar operative time, less intraoperative blood loss and shorter ambulation time but longer duration of X-ray radiation. The postoperative VAS scores of back pain, ODI and JOA score were significantly improved comparing with the preoperative scores in two groups, but the Endo-TLIF group showed more significant improvement in the early follow-up (P < 0.05, respectively). There were no significant differences in terms of the interbody fusion rate between the two groups. Meanwhile, no serious postoperative complications were observed in the study.

Conclusion

Compared with MIS-TLIF, Endo-TLIF technique showed relatively faster recovery and better outcomes in terms of early curative effect, especially in 6 months after operation. However, intraoperative repeated fluoroscopy could result in highly cumulative radiation and longer operation time.

Obesity may be associated with adjacent-segment degeneration after single-level transforaminal lumbar interbody fusion in spinopelvic-mismatched patients with a minimum 2-year follow-up

OBJECTIVE

In this study, the authors' aim was to investigate whether obesity affects surgery rates for adjacent-segment degeneration (ASD) after transforaminal lumbar interbody fusion (TLIF) for spondylolisthesis.

METHODS

Patients who underwent single-level TLIF for spondylolisthesis at the University of California, San Francisco, from 2006 to 2016 were retrospectively analyzed. Inclusion criteria were a minimum 2-year follow-up, single-level TLIF, and degenerative lumbar spondylolisthesis. Exclusion criteria were trauma, tumor, infection, multilevel fusions, non-TLIF fusions, or less than a 2-year follow-up. Patient demographic data were collected, and an analysis of spinopelvic parameters was performed. The patients were divided into two groups: mismatched, or pelvic incidence (PI) minus lumbar lordosis (LL) ≥ 10°; and balanced, or PI-LL < 10°. Within the two groups, the patients were further classified by BMI (< 30 and ≥ 30 kg/m2). Patients were then evaluated for surgery for ASD, matched by BMI and PI-LL parameters.

RESULTS

A total of 190 patients met inclusion criteria (72 males and 118 females, mean age 59.57 ± 12.39 years). The average follow-up was 40.21 ± 20.42 months (range 24-135 months). In total, 24 patients (12.63% of 190) underwent surgery for ASD. Within the entire cohort, 82 patients were in the mismatched group, and 108 patients were in the balanced group. Within the mismatched group, adjacent-segment surgeries occurred at the following rates: BMI < 30 kg/m2, 2.1% (1/48); and BMI ≥ 30 kg/m2, 17.6% (6/34). Significant differences were seen between patients with BMI ≥ 30 and BMI < 30 (p = 0.018). A receiver operating characteristic curve for BMI as a predictor for ASD was established, with an AUC of 0.69 (95% CI 0.49-0.90). The optimal BMI cutoff value determined by the Youden index is 29.95 (sensitivity 0.857; specificity 0.627). However, in the balanced PI-LL group (108/190 patients), there was no difference in surgery rates for ASD among the patients with different BMIs (p > 0.05).

CONCLUSIONS

In patients who have a PI-LL mismatch, obesity may be associated with an increased risk of surgery for ASD after TLIF, but in obese patients without PI-LL mismatch, this association was not observed.

Risk factors of postoperative low back pain for low-grade isthmic spondylolisthesis: a retrospective study

Objective

To investigate the risk factors of postoperative low back pain (LBP) following posterior lumbar interbody fusion (PLIF) surgery for low-grade isthmic spondylolisthesis (IS).

Methods

This retrospective study enrolled patients with IS that underwent PLIF between January 2011 and January 2016. Demographic, clinical, surgical and radiological characteristics were analysed to determine associations between these characteristics and LBP as measured using a visual analogue scale (VAS) pain score.

Results

A total of 192 patients were enrolled in the study. The mean VAS pain score of LBP decreased significantly after surgery. The mean preoperative VAS pain score was significantly greater in patients with symptoms of ≤3 years duration compared with those with symptoms lasting >3 years. The postoperative VAS pain score was significantly lower in patients with grade 1 slippage compared with those with grade 2 slippage. There was a significant correlation between preoperative to postoperative change of VAS pain score and postoperative disc height (r = 0.99).

Conclusion

PLIF significantly improved LBP in patients with low-grade IS, although patients still reported some postoperative LBP. The grade of slippage was a risk factor for postoperative LBP. Restoring the disc height appeared to improve LBP.

Minimally Invasive Transforaminal Lumbar Interbody Fusion for the Surgical Management of Post-Discectomy Syndrome

STUDY DESIGN

This was a prospective case series of 30 patients with post-discectomy syndrome with an average of 18 months of follow-up (level IV).

PURPOSE

The efficacy of post-discectomy syndrome managed by minimally invasive surgery transforaminal lumbar interbody fusion (MIS-TLIF) was evaluated.

OVERVIEW OF LITERATURE

In post-discectomy syndrome wherein conservative treatment had failed, the best surgical treatment modality still remains controversial.

METHODS

Patients were functionally assessed using the Visual Analog Scale (VAS) for low back pain (LBP) and leg pain (LP) and Oswestry Disability Index (ODI). Radiological fusion was confirmed with plain X-rays and when indicated with computed tomography scan at 12 months postoperatively. A total of 30 patients with 37 operated at lumbar levels with failed discectomy surgery who met our inclusion criteria were treated with MIS-TLIF.

RESULTS

The ODI of all patients showed significant improvement from a mean of 73.78% preoperatively to 16.67% at 1 month and 14.13% at 12 months postoperatively. The preoperative LBP VAS score (mean, 4.37) showed a significant decrease (p <0.001) to 1.90 at 1 month and 1.10 at 12 months. Preoperative LP VAS score of limb pain averaged 7.53 and showed a significant (p <0.001) decrease to 3.47 at 1 month and 1.10 at 12 months. All patients attained radiological fusion at 12 months.

CONCLUSIONS

MIS-TILF constitutes a valid and effective treatment option for patients with post-discectomy syndrome.

An updated meta-analysis of clinical outcomes comparing minimally invasive with open transforaminal lumbar interbody fusion in patients with degenerative lumbar diseases

BACKGROUND & AIMS

Open-transforaminal lumbar interbody fusion (O-TLIF) is regarded as the standard (S) approach which is currently available for patients with degenerative lumbar diseases patients. In addition, minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) has proposed and gradually obtained popularity compared with O-TLIF procedures due to its beneficial outcomes in minimized tissue injury and quicker recovery. Nonetheless, debates exist concerning the use of MI-TLIF with its conflicting outcomes of clinical effect and safety in several publications. The purpose of the current study is to conduct an updated meta-analysis to provide eligible and systematical assessment available for the evaluation of the efficacy and safety of MI-TLIF in comparison with O-TLIF.

METHODS

Publications on the comparison of O-TLIF and MI-TLIF in treating degenerative lumbar diseases in last 5 years were collected. After rigorous reviewing on the eligibility of publications, the available data was further extracted from qualified trials. All trials were conducted with the analysis of the summary hazard ratios (HRs) of the interest endpoints, including intraoperative and postoperative outcomes.

RESULTS

Admittedly, it is hard to run a clinical RCT to compare the prognosis of patients undergoing O-TLIF and MI-TLIF. A total of 10 trials including non-randomized trials in the current study were collected according to our inclusion criteria. The pooled results of surgery duration indicated that MI-TLIF was highly associated with shorter length of hospital stay, less blood loss, and less complications. However, there were no remarkable differences in the operate time, VAS-BP, VAS-LP, and ODI between the 2 study groups.

CONCLUSION

The quantitative analysis and combined results of our study suggest that MI-TLIF may be a valid and alternative method with safe profile in comparison of O-TLIF, with reduced blood loss, decreased length of stay, and complication rates. While, no remarkable differences were found or observed in the operate time, VAS-BP, VAS-LP, and ODI. Considering the limited available data and sample size, more RCTs with high quality are demanded to confirm the role of MI-TLIF as a standard approach in treating degenerative lumbar diseases.

Initial stability of one-stage anterior debridement and cage implantation combined with anterior-lateral fixation by a dual screw-rod construct in the treatment of lumbosacral tuberculosis: a cadaveric biomechanical study

Background

Although various surgical methods are used to treat lumbosacral tuberculosis, no unified surgical approach exists. Thus, exploring an optimal operation method has substantial clinical importance. Evaluate the initial stability of a new surgical method, a one-stage anterior debridement and cage implantation combined with anterior-lateral fixation by a dual screw-rod construct, in the treatment of lumbosacral tuberculosis and provide biomechanical support for its further promotion in clinical applications.

Methods

Fifteen fresh human lumbosacral spine specimens without fractures, deformities or osteoporosis were randomly divided into intact (I), anterior fixation (AF) and posterior fixation (PF) groups. All AF and PF group specimens had subtotal resections of the L5 vertebra and adjacent discs, while the I group specimens were kept intact. Then, titanium cages were implanted in the surgical site and a dual screw-rod construct was fixed anterior-laterally in the AF group, while the PF group specimens were fixed posteriorly with only the dual screw-rod construct. Mechanical tests were conducted for initial stability evaluations.

Results

The load at the maximum displacement (5 mm) or rotation angle (5 °) was less for the I group specimens than for the AF and PF group specimens in all directions (P < 0.05). The load at the maximum displacement (5 mm) was greater for the AF group specimens than for the PF group specimens in flexion, lateral bending and axial compression (P < 0.05) and lower than in the PF group specimens in extension (P < 0.05). In torsion, there was no difference between the loads in the AF and PF groups at the maximum rotation angle (5 °) (P > 0.05).

Conclusions: The proposed surgical approach can provide better immediate stability than anterior debridement with posterior dual screw-rod fixation in the treatment of lumbosacral tuberculosis in flexion, lateral bending and axial compression.

Radiographic and Clinical Outcomes of Oblique Lateral Interbody Fusion Versus Minimally Invasive Transforaminal Lumbar Interbody Fusion for Degenerative Lumbar Disease

BACKGROUND

The effects of oblique lateral interbody fusion (OLIF) and minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) have not been compared by a meta-analysis. The present study aimed to summarize the radiographic and clinical outcomes of OLIF and MI-TLIF for degenerative lumbar disease.

METHODS

We performed a systematic review of related studies and report the outcomes of OLIF and MI-TLIF for degenerative lumbar disease. The radiographic outcomes measures included disc height, segmental lordotic angle, lumbar lordotic angle, and fusion. The clinical and functional outcomes included operative blood loss, operative time, length of hospital stay, complications, visual analog scale, and Oswestry disability index. Data pooling and meta-analysis with the random effects model were performed to evaluate the results.

RESULTS

A total of 47 studies met the inclusion criteria. Similar changes in terms of disc height, segmental lordotic angle, lumbar lordotic angle, length of hospital stay, visual analog scale, Oswestry disability index, and radiological evidence of fusion of >90% were observed between the 2 groups. The OLIF group showed less operative blood loss and operative time. The incidence of intraoperative and postoperative complications was 9.5% and 19.9% for the OLIF group and 3.5% and 8.5% for the MI-TLIF group, respectively.

CONCLUSIONS

The radiographic and functional outcomes and length of hospital stay were similar between the 2 groups. The OLIF group showed advantages in operative blood loss and operative time; however, the incidence of complications in this technique was greater than that in the MI-TLIF group.

Optimal medial transforaminal lumbar interbody fusion approach with five extensive options: A simulated study on three-dimensional digital reconstructed images

Objective

The objective of this study is to use 3D digital lumbar models to investigate and simulate the optimal posterior operative approach for safe decompression and insertion of an interbody cage.

Methods

Thirty lumbar spine (L3-S1) computed tomography data are collected for 3D reconstruction. We cut medial half part of the superior facet and define the distance between the margin of the operative side of the spinous process and the medial margin of the cut superior facet as "medial distance (MD)". Then, we cut the total superior facet and define the distance between the margin of the operative side of the spinous process and the lateral side of the junction of the pedicle and the vertebral body as "extend distance (ED)". The feasible insertion of the current standard width size (10 mm and 12 mm) interbody cages was assessed by the two aforementioned MD and ED approaches. Besides the ED, we also simulate four other extensive options of lateral upper, lateral lower, vertical upper and lower and transmedian contralateral decompression on 3D digital lumbar model.

Results

The MD increased from 13.48 ± 1.28 mm at L3/4 to 18.05 ± 1.43 mm at L5/S1, and the ED increased from 16.64 ± 1.34 mm at L3/4 to 21.12 ± 1.62 mm at L5/S1. To insert a 10-mm-wide cage, 16.7% (left) and 13.3% (right) of MD for L3/4 is not enough, 60.0% (left) and 46.7% (right) of MD for L3/4 is subsafe, 13.3% (left) and 16.7% (right) of MD for L4/5 is subsafe and all others are safe. To insert a 12-mm-wide cage, 76.7% (left) and 60.0% (right) of MD for L3/4 is not enough, 20.0% (left) and 30.0% (right) of MD for L3/4 is subsafe, 13.3%% (left) and 16.7% (right) of MD for L4/5 is not enough, 63.3% (left) and 56.7% (right) of MD for L4/5 is subsafe and 6.7% (left) and 10.0% (right) of MD for L5/S1 is subsafe, whereas 33.3%% (left) and 30.0% (right) of ED for L3/4 is subsafe, 3.3% (left) and 3.3% (right) of ED for L4/5 is subsafe and all others are safe. Besides the ED, on 3D models, four other extensive options could be simulated too and may need to be performed for different special individuals.

Conclusion

Our 3D digital image study provides a feasible optimal medial transforaminal lumbar interbody fusion approach with five extensive options on lower lumbar region. It can provide safe lumbar decompression and interbody fusion in most population. In addition, surgeons can choose the different extensive options for special individual conditions.

The translational potential of this article

Transforminal lumbar interbody fusion is very common used for lumbar degenerative diseases. The optimal medial transforminal lumbar interbody fusion with five options provide a safe and precise approach for surgeons in treatment of lumbar degenerative diseases.

The compression of L5 nerve root, single or double sites?-radiographic graded signs, intra-operative detect technique and clinical outcomes

Background

The L5 nerve root could be compressed at both L4-5 and L5-S1 regions. If L5 nerve root has confirmed compression at L4-5 level and questionable compression at L5-S1 foramina, performing both surgeries at L4-5 and L5-S1 levels may induce unnecessary extra surgery on L5-S1; however, ignoring foraminal stenosis of L5/S1 may require re-exploration.

Methods

Two hundred seventeen patients with L5 nerve root compressed at L4-5 lateral access were performed with L4-5 decompression and interbody fusion. Lee et al. grade classification was used to assess the foraminal stenosis of L5-S1 preoperatively. Nerve root probe was designed and used to detect if there were foraminal stenosis at L5-S1 level that compressing the exiting L5 nerve root. Visual analog scale (VAS) of low back pain, leg pain and Oswestry Disability Index (ODI) were used to assess clinical outcomes.

Results

For all of 217 patients who underwent L4-5 surgery, L5-S1 foramina were preoperatively assessed as: grade 0: 125 cases, grade 1: 58 cases, grade 2: 23 cases, and grade 3: 11 cases. After intra-operative L5 nerve root detection, 11/11 patients with grade 3 radiographic foraminal stenosis, 6/23 (26.1%) with grade 2 and 2/58 (3.4%) who had grade 1 underwent L4-5 and L5-S1 transforaminal lumbar interbody fusion (TLIF), the others received only L4-5 TLIF. Compared to pre-operative baseline data, both L4-5 TLIF and L4-5 and L5-S1 TLIF groups had significant decreased VAS of low back pain and leg pain, and ODI at 3 and 24 months after operation.

Conclusions

We suggested that our novel nerve root probe combined with pre-operative radiographic grade may be helpful to surgeons to identify the single or double compression of L5 nerve root and make a more precise surgical strategy to improve surgical outcome than the method depended on pre-operative radiographic grade alone.