Using minimally invasive techniques adds to the value equation for select patients

Complications in Minimally Invasive Spine Surgery in the Last 10 Years: A Narrative Review

OBJECTIVE

Minimally invasive spine surgery (MISS) employs small incisions and advanced techniques to minimize tissue damage while achieving similar outcomes to open surgery. MISS offers benefits such as reduced blood loss, shorter hospital stays, and lower costs. This review analyzes complications associated with MISS over the last 10 years, highlighting common issues and the impact of technological advancements.

METHODS

A systematic review following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines was conducted using PubMed, MEDLINE, Embase via OVID, and Cochrane databases, covering publications from January 2013 to March 2024. Keywords related to MISS and complications were used. Studies on adult patients undergoing MISS with tubular, uniportal, or biportal endoscopy, reporting intraoperative or postoperative complications, were included. Non-English publications, abstracts, and small case series were excluded. Data on MISS approach, patient demographics, and complications were extracted and reviewed by 2 independent researchers.

RESULTS

The search identified 880 studies, with 137 included after screening and exclusions. Key complications in cervical MISS were hematomas, transient nerve root palsy, and dural tears. In thoracic MISS, complications included cerebrospinal fluid leaks and durotomy. In lumbar MISS, common complications were incidental dural injuries, postoperative neuropathic conditions, and disc herniation recurrences. Complications varied by surgical approach.

CONCLUSION

MISS offers reduced anatomical disruption compared to open surgery, potentially decreasing nerve injury risk. However, complications such as nerve injuries, durotomies, and hardware misplacement still occur. Intraoperative neuromonitoring and advanced technologies like navigation can help mitigate these risks. Despite variability in complication rates, MISS remains a safe, effective alternative with ongoing advancements enhancing its outcomes.

The Impact of Preoperative Sagittal Imbalance on Long-term Postoperative Outcomes Following Minimally Invasive Laminectomy

Background: Postoperative sagittal alignment has been shown to be associated with patient-reported outcome measures (PROMs) following open lumbar decompression procedures, although it is unknown whether preoperative sagittal imbalance affects clinical outcomes of minimally invasive surgical (MIS) decompression only surgery. Purpose: We sought to evaluate the impact of preoperative pelvic incidence-lumbar lordosis (PI-LL) imbalance on PROMs after MIS laminectomy for the treatment of neurogenic claudication symptoms. Methods: We conducted a retrospective cohort study of adult patients undergoing MIS laminectomy for degenerative lumbar spinal stenosis between April 2017 and April 2021 at a single institution. Of the 52 patients included (mean follow-up, 17 months) radiographs were taken prior to surgery and assessed for sagittal alignment parameters. Patients were grouped based on the preoperative PI-LL (balanced vs unbalanced). Changes in PROMs were compared between unbalanced PI-LL and balanced PI-LL groups. Minimal clinically important difference (MCID) for Oswestry Disability Index (ODI) was also assessed. Results: Of the 52 patients, 17 (32.7%) had unbalanced age-adjusted preoperative PI-LL. There was no significant difference found in PROMs between unbalanced and balanced PI-LL groups preoperatively or at final follow-up. Compared with those with unbalanced PI-LL, patients with balanced PI-LL were shown to have no added benefit in achieving MCID for ODI at long-term follow-up and no added benefit in the time to achieving MCID. Conclusion: These retrospective findings suggest that patients with unbalanced preoperative PI-LL may experience significant benefit in long-term clinical outcomes following MIS laminectomy, similarly to those with balanced PI-LL at baseline. The findings also suggest that the presence of sagittal imbalance preoperatively may not appreciably influence the long-term clinical outcomes following MIS laminectomy. Prospective study involving a larger population is warranted.

The role of innovative technologies in reducing health system inequity

The scarcity of Health Human Resources (HHR), regional disparities, and decentralized healthcare systems have profoundly affected health equity in Canada. Adequate HHR allocation is essential for equitable healthcare delivery, and the COVID-19 pandemic has revealed the importance of resilient and culturally diverse organizational HHR. Geography and infrastructure shortcomings aggravate healthcare equity. This study examines the role of innovative technologies in reducing inequity and provides four practice-based examples in different therapeutic areas. Long-term solutions such as collaborative networks, infrastructure improvements, and effective HHR planning can mitigate current challenges. However, in the short and medium terms, advanced medical technologies, digital health, and artificial intelligence can reduce health inequities by improving access, reducing disparities, optimizing resource utilization, and providing skill development opportunities for healthcare professionals.

Ambulatory Lumbar Fusion: A Systematic Review of Perioperative Protocols, Patient Selection Criteria, and Outcomes

STUDY DESIGN/SETTING

Systematic review.

OBJECTIVE

The primary purpose was to propose patient selection criteria and perioperative best practices that can serve as a starting point for an ambulatory lumbar fusion program. The secondary purpose was to review patient-reported outcomes (PROs) after ambulatory lumbar fusion.

SUMMARY OF BACKGROUND

As healthcare costs rise, there is an increasing emphasis on cost saving strategies (i.e. outpatient/ambulatory surgeries). Lumbar fusion procedures remain a largely inpatient surgery. Early studies have shown that fusion procedures can be safely preformed in an outpatient setting but no review has summarized these findings and best practices.

MATERIALS AND METHODS

This study was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. PubMed/MEDLINE, The Cochrane Library, and Embase were searched. The following data were collected: (1) study design; (2) number of participants; (3) patient population; (4) procedure types; (5) procedure setting; (6) inclusion criteria; (7) protocols; (8) adverse events; (9) PROs; and (10) associations between patient/surgical factors, setting, and outcomes.

RESULTS

The search yielded 20 publications. The following selection criteria for ambulatory lumbar fusion were identified: age below 70, minimal comorbidities, low/normal body mass index, no tobacco use, and no opioid use. The perioperative protocol can include a multimodal analgesic regimen. The patient should be observed for at least three hours after surgery. The patient should not be discharged without an alertness check and a neurological examination. Patients experienced significant improvements in PROs after ambulatory lumbar fusion; similarly, when compared to an inpatient group, ambulatory lumbar fusion patients experienced a comparable or superior improvement in PROs.

CONCLUSION

There are two critical issues surrounding ambulatory lumbar fusion: (1) Who is the ideal patient, and (2) What needs to be done to enable expedited discharge? We believe this review will provide a foundation to assist surgeons in making decisions regarding the performance of lumbar fusion on an ambulatory basis.

LEVEL OF EVIDENCE

Level III.

Improvement following minimally invasive transforaminal lumbar interbody fusion in patients aged 70 years or older compared with younger age groups

OBJECTIVE

The goal of this study was to assess the outcomes of minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) in patients ≥ 70 years old and compare them to younger age groups.

METHODS

This was a retrospective study of data that were collected prospectively. Patients who underwent primary single-level MI-TLIF were included and divided into 3 groups: age < 60, 60-69, and ≥ 70 years. The outcome measures were as follows: 1) patient-reported outcome measures (PROMs) (i.e., visual analog scale [VAS] for back and leg pain, Oswestry Disability Index [ODI], 12-Item Short-Form Health Survey Physical Component Summary [SF-12 PCS]); 2) minimum clinically important difference (MCID) achievement; 3) return to activities; 4) opioid discontinuation; 5) fusion rates; and 6) complications/reoperations.

RESULTS

A total of 147 patients (age < 60 years, 62; 60-69 years, 47; ≥ 70 years, 38) were included. All the groups showed significant improvements in all PROMs at the early (< 6 months) and late (≥ 6 months) time points and there was no significant difference between the groups. Although MCID achievement rates for VAS leg and ODI were similar, they were lower in the ≥ 70-year-old patient group for VAS back and SF-12 PCS. Although the time to MCID achievement for ODI and SF-12 PCS was similar, it was greater in the ≥ 70-year-old patient group for VAS back and leg. There was no significant difference between the groups in terms of return to activities, opioid discontinuation, fusion rates, and complication/reoperation rates.

CONCLUSIONS

Although patients > 70 years of age may be less likely and/or take longer to achieve MCID compared to their younger counterparts, they show an overall significant improvement in PROMs, a similar likelihood of returning to activities and discontinuing opioids, and comparable fusion and complication/reoperation rates following MI-TLIF.

Practical answers to frequently asked questions in minimally invasive lumbar spine surgery

BACKGROUND CONTEXT

Surgical counseling enables shared decision-making (SDM) by improving patients' understanding.

PURPOSE

To provide answers to frequently asked questions (FAQs) in minimally invasive lumbar spine surgery.

STUDY DESIGN

Retrospective review of prospectively collected data.

PATIENT SAMPLE

Patients who underwent primary tubular minimally invasive lumbar spine surgery in form of transforaminal lumbar interbody fusion (MI-TLIF), decompression alone, or microdiscectomy and had a minimum of 1-year follow-up.

OUTCOME MEASURES

(1) Surgical (radiation exposure and intraoperative complications) (2)Immediate postoperative (length of stay [LOS] and complications) (3) Clinical outcomes (Visual Analog Scale- back and leg, VAS; Oswestry Disability Index, ODI; 12-Item Short Form Survey Physical Component Score, SF-12 PCS; Patient-Reported Outcomes Measurement Information System Physical Function, PROMIS PF; Global Rating Change, GRC; return to activities; complications/reoperations) METHODS: The outcome measures were analyzed to provide answers to ten FAQs that were compiled based on the authors' experience and a review of literature. Changes in VAS back, VAS leg, ODI, and SF-12 PCS from preoperative values to the early (<6 months) and late (>6 months) postoperative time points were analyzed with Wilcoxon Signed Rank Tests. % of patients achieving minimal clinically important difference (MCID) for these patient-reported outcome measures (PROMs) at the two time points was evaluated. Changes in PROs from preoperative values too early (<6 months) and late (≥6 months) postoperative time points were analyzed within each of the three groups. Percentage of patients achieving MCID was also evaluated.

RESULTS

Three hundred sixty-six patients (104 TLIF, 147 decompression, 115 microdiscectomy) were included. The following FAQs were answered: (1) Will my back pain improve? Most patients report improvement by >50%. About 60% of TLIF, decompression, and microdiscectomy patients achieved MCID at ≥6 months. (2) Will my leg pain improve? Most patients report improvement by >50%. 56% of TLIF, 67% of decompression, and 70% of microdiscectomy patients achieved MCID at ≥6 months. (3) Will my activity level improve? Most patients report significant improvement. Sixty-six percent of TLIF, 55% of decompression, and 75% of microdiscectomy patients achieved MCID for SF-12 PCS. (4) Is there a chance I will get worse? Six percent after TLIF, 14% after decompression, and 5% after microdiscectomy. (5) Will I receive a significant amount of radiation? The radiation exposure is likely to be acceptable and nearly insignificant in terms of radiation-related risks. (6) What is the likelihood that I will have a complication? 17.3% (15.4% minor, 1.9% major) for TLIF, 10% (9.3% minor and 0.7% major) for decompression, and 1.7% (all minor) for microdiscectomy (7) Will I need another surgery? Six percent after TLIF, 16.3% after decompression, 13% after microdiscectomy. (8) How long will I stay in the hospital? Most patients get discharged on postoperative day one after TLIF and on the same day after decompression and microdiscectomy. (9) When will I be able to return to work? >80% of patients return to work (average: 25 days after TLIF, 14 days after decompression, 11 days after microdiscectomy). (10) Will I be able to drive again? >90% of patients return to driving (average: 22 days after TLIF, 11 days after decompression, 14 days after microdiscectomy).

CONCLUSIONS

These concise answers to the FAQs in minimally invasive lumbar spine surgery can be used by physicians as a reference to enable patient education.

Minimally Invasive Procedures, Perioperative Telemedicine, and Decreased Hospital Stays Following Covid-19 Surgical Restrictions: Spinal Surgery

The 2019 severe acute respiratory syndrome coronavirus 2 pandemic had devastating impacts on healthcare system operations. Disruption of this delicate system led to international healthcare challenges with new policy changes that affected all specialties, including the global spine surgery community. The pandemic disrupted normal spine surgery proceedings, restricting, and postponing elective procedures, which comprise a large proportion of spine surgeries. This disruption may have contributed to significant economic losses for providers and resulted in the prolonged impairment of patients who were forced to postpone their procedures. However, response to the pandemic precipitated new procedural guidelines and practices that prioritize health outcomes and satisfaction. These new changes and innovations are positioned to provide lasting economic and procedural impacts in favor of both providers and patients. Thus, the objective of our review is to explore how spinal surgical practices and post-op recovery changed following COVID-19 and highlight some lasting impacts the pandemic created for future patients.

Improvement following minimally invasive lumbar decompression in patients 80 years or older compared with younger age groups

OBJECTIVE

The objective of this study was to assess the outcomes of minimally invasive lumbar decompression in patients ≥ 80 years of age and compare them with those of younger age groups.

METHODS

This was a retrospective cohort study. Patients who underwent primary unilateral laminotomy for bilateral decompression (ULBD) (any number of levels) and had a minimum of 1 year of follow-up were included and divided into three groups by age: < 60 years, 60-79 years, and ≥ 80 years. The outcome measures were 1) patient-reported outcome measures (PROMs) (visual analog scale [VAS] back and leg, Oswestry Disability Index [ODI], 12-Item Short-Form Health Survey [SF-12] Physical Component Summary [PCS] and Mental Component Summary [MCS] scores, and Patient-Reported Outcomes Measurement Information System Physical Function [PROMIS PF]); 2) percentage of patients achieving the minimal clinically important difference (MCID) and the time taken to do so; and 3) complications and reoperations. Two postoperative time points were defined: early (< 6 months) and late (≥ 6 months).

RESULTS

A total of 345 patients (< 60 years: n = 94; 60-79 years: n = 208; ≥ 80 years: n = 43) were included in this study. The groups had significantly different average BMIs (least in patients aged ≥ 80 years), age-adjusted Charlson Comorbidity Indices (greatest in the ≥ 80-year age group), and operative times (greatest in 60- to 79-year age group). There was no difference in sex, number of operated levels, and estimated blood loss between groups. Compared with the preoperative values, the < 60-year and 60- to 79-year age groups showed a significant improvement in most PROMs at both the early and late time points. In contrast, the ≥ 80-year age group only showed significant improvement in PROMs at the late time point. Although there were significant differences between the groups in the magnitude of improvement (least improvement in ≥ 80-year age group) at the early time point in VAS back and leg, ODI, and SF-12 MCS, no significant difference was seen at the late time point except in ODI (least improvement in ≥ 80-year group). The overall MCID achievement rate decreased, moving from the < 60-year age group toward the ≥ 80-year age group at both the early (64% vs 51% vs 41% ) and late (72% vs 58% vs 52%) time points. The average time needed to achieve the MCID in pain and disability increased, moving from the < 60-year age group toward the ≥ 80-year age group (2 vs 3 vs 4 months). There was no significant difference seen between the groups in terms of complications and reoperations except in immediate postoperative complications (5.3% vs 4.8% vs 14%).

CONCLUSIONS

Although in this study minimally invasive decompression led to less and slower improvement in patients ≥ 80 years of age compared with their younger counterparts, there was significant improvement compared with the preoperative baseline.

Combining Expandable Interbody Cage Technology With a Minimally Invasive Technique to Harvest Iliac Crest Autograft Bone to Optimize Fusion Outcomes in Minimally Invasive Transforaminal Lumbar Interbody Fusion Surgery

STUDY DESIGN

This was a retrospective cohort review.

OBJECTIVE

The objective of this study was to determine the rate of fusion associated with an expandable cage and iliac crest bone graft in minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) surgery.

SUMMARY OF BACKGROUND DATA

MI-TLIF is a commonly performed procedure, but challenges inherent in MI-TLIF technique can make achieving an interbody fusion difficult.

METHODS

A retrospective review was performed on consecutive patients treated with an MI-TLIF for degenerative lumbar pathology. Patients that completed patient-reported outcome measures and 1-year computed tomography (CT)-scans for fusion analysis were included. Fusion morphology was analyzed by evaluating CT scans for location of bridging trabecular bone in relation to the cage. Patients with bridging bone were considered fused. Preoperative and postoperative health-related quality of life scores were compared. A Kolmogrov-Smirnoff test was used to determine normality of health-related outcome scores. A Friedman 2-way analysis of variance by ranks with pairwise comparisons to determine statistical significance of differences between the date of a follow-up examination and preoperative examination was done.

RESULTS

Of 75 patients evaluated 23 patients were excluded due to loss to follow-up, adjacent segment degeneration, inability to obtain a CT scan, or reoperation for nonfusion related symptoms. Of 61 disk spaces that were included, 55 had bridging bone through the intervertebral cage, resulting in an overall fusion rate of 90.2%. There was a higher rate of fusion at L5-S1 as compared to L4-L5. There was mean improvement in patient-reported outcome measures for Oswestry Disability Index, Short Form-12 Physical Component Score, Visual Analog Scale Back/Leg pain, and Patient-Reported Outcome Measurement Information System Physical Function. There were no complications associated with iliac crest bone graft harvesting.

CONCLUSION

Combining an expandable cage with iliac crest autograft bone harvested through a minimally invasive technique can allow for improved fusion rates without graft-site complications in MI-TLIF surgery.

Does obesity affect long-term outcomes of extreme lateral interbody fusion with posterior stabilization?

BACKGROUND CONTEXT

Obese patients can pose significant challenges to spine surgeons in lumbar fusion procedures. The increased risk of complications has led surgeons to be wary in pursing operative interventions in these patients. Since the advent of minimally-invasive techniques in lumbar fusion, surgeons are turning to these procedures in an attempt to minimize operative time, blood loss and overall cost. With an increased proportion of obese patients in the population, it is imperative to understand the long-term outcomes in these minimally-invasive approaches.

PURPOSE

The purpose of this study was to evaluate the long-term safety and efficacy of extreme lateral interbody fusion (XLIF) in the obese.

STUDY DESIGN/SETTING

Retrospective cohort study.

PATIENT SAMPLE

A total of 115 patients (53 nonobese and 62 obese) who underwent XLIF with a minimum of 5-year follow-up.

OUTCOME MEASURES

(1) Patient reported outcome scores: Visual Analog Scale (VAS) for back pain, Oswestry Disability Index (ODI), (2) Reoperation rate, (3) Pelvic incidence (PI)- Lumbar lordosis (LL) mismatch correction, (4) Graft subsidence and fusion rate METHODS: A retrospective review was performed to identify patients who underwent XLIF with percutaneous posterior stabilization since 2007 with a minimum follow-up of 5 years. Demographics including BMI were recorded and patients were subdivided into 2 cohorts: nonobese (BMI <30 kg/m²) and obese (BMI ≥30 kg/m²). Functional outcomes were assessed by comparing pre- and postoperative VAS and ODI scores. Reoperation rates were compared between cohorts. PI-LL mismatch was calculated from both pre- and postoperative radiographs. Rates of graft subsidence and fusion were measured at final follow-up.

RESULTS

A total of 115 consecutive patients were included (53 nonobese and 62 obese) with a mean follow up of 95.3 months. Mean BMI was 25.3 in the nonobese group and 35.3 in the obese group (p<.001). There were more females in nonobese cohort. VAS scores decreased by a mean of 5.7 in the nonobese cohort, and 5.4 in the obese cohort (p=.213). ODI improvement was also similar between the groups. 5.6% of nonobese patients required reoperation compared to 9.6% of obese patients (p=.503). Graft subsidence rates at final follow-up were 5.66% and 8.06% for the nonobese and obese groups, respectively (p=.613). Rates of successful fusion were 96.23% and 98.39% for the nonobese and obese groups, respectively (p=.469). Both cohorts achieved a similar proportion of PI-LL mismatch correction, 85% in obese versus 78% in nonobese patients (p=.526).

CONCLUSION

Obese patients have similar surgical outcomes to nonobese patients with respect to functional outcome scores, reoperation rates, graft subsidence and correction of PI-LL mismatch after long-term follow-up. With similar outcome and reoperation profiles, minimally-invasive approaches to the spine, such as XLIF, may be an acceptable alternative to traditional open procedures in obese patients.

Inferior Articular Process Fracture in a Collegiate Athlete Causing Back Pain: A Case Report of Surgical Treatment

CASE

A 20-year-old male athlete presented with 8 months of low back pain. Conservative management had been unsuccessful. He noted lumbar spine pain with extension, and imaging showed features of an L4-5 inferior articular facet tip fracture. The fragment was excised, he returned to college lacrosse and is without symptoms at the 9-month follow-up.

CONCLUSION

In similar cases with facet fragments, we would recommend a full workup and attempt nonoperative therapy. If not improved and a diagnostic injection provides near-complete relief, then resection of the facet fragment can be discussed as a potentially effective and conservative surgical option.

Does interbody cage lordosis impact actual segmental lordosis achieved in minimally invasive lumbar spine fusion?

OBJECTIVE

In an effort to prevent loss of segmental lordosis (SL) with minimally invasive interbody fusions, manufacturers have increased the amount of lordosis that is built into interbody cages. However, the relationship between cage lordotic angle and actual SL achieved intraoperatively remains unclear. The purpose of this study was to determine if the lordotic angle manufactured into an interbody cage impacts the change in SL during minimally invasive surgery (MIS) for lumbar interbody fusion (LIF) done for degenerative pathology.

METHODS

The authors performed a retrospective review of a single-surgeon database of adult patients who underwent primary LIF between April 2017 and December 2018. Procedures were performed for 1-2-level lumbar degenerative disease using contemporary MIS techniques, including transforaminal LIF (TLIF), lateral LIF (LLIF), and anterior LIF (ALIF). Surgical levels were classified on lateral radiographs based on the cage lordotic angle (6°-8°, 10°-12°, and 15°-20°) and the position of the cage in the disc space (anterior vs posterior). Change in SL was the primary outcome of interest. Subgroup analyses of the cage lordotic angle within each surgical approach were also conducted.

RESULTS

A total of 116 surgical levels in 98 patients were included. Surgical approaches included TLIF (56.1%), LLIF (32.7%), and ALIF (11.2%). There were no differences in SL gained by cage lordotic angle (2.7° SL gain with 6°-8° cages, 1.6° with 10°-12° cages, and 3.4° with 15°-20° cages, p = 0.581). Subgroup analysis of LLIF showed increased SL with 15° cages only (p = 0.002). The change in SL was highest after ALIF (average increase 9.8° in SL vs 1.8° in TLIF vs 1.8° in LLIF, p < 0.001). Anterior position of the cage in the disc space was also associated with a significantly greater gain in SL (4.2° vs -0.3°, p = 0.001), and was the only factor independently correlated with SL gain (p = 0.016).

CONCLUSIONS

Compared with cage lordotic angle, cage position and approach play larger roles in the generation of SL in 1-2-level MIS for lumbar degenerative disease.