Comparison of Perioperative and Postoperative Outcomes of Minimally Invasive and Open TLIF in Obese Patients: A Systematic Review and Meta‑Analysis

Comparative Effectiveness of Open Versus Minimally Invasive Transforaminal Lumbar Interbody Fusion: An Umbrella Review of Meta-Analyses

STUDY DESIGN

Umbrella review of meta-analyses.

OBJECTIVE

To compile existing meta-analyses to provide analysis of the multiple postoperative outcomes in a comparison of open-transforaminal lumbar interbody fusions (O-TLIFs) versus minimally invasive transforaminal interbody fusions (MI-TLIFs).

SUMMARY OF BACKGROUND DATA

TLIF is the standard surgical intervention for spinal fusion in degenerative spinal diseases. The comparative effectiveness of MI-TLIFs and O-TLIFs remains controversial.

METHODS

A literature search was conducted in the PubMed, Scopus, and Web of Science databases. Titles and abstracts were initially screened, followed by a full-text review based on the inclusion criteria. Twenty articles were deemed eligible for the umbrella review. Data extraction and quality assessment using A Measurement Tool to Assess Systematic Reviews were performed. Effect sizes of the outcomes of interest from primary studies included in the meta-analyses were repooled. Repooling and stratification of the credibility of the evidence were performed using the R package metaumbrella . The pooled effect sizes were compared and interpreted using equivalent Hedges' g values.

RESULTS

When the meta-analyses were pooled, MI-TLIF was found to have a shorter length of stay, less blood loss, and a higher radiation exposure time, with a highly suggestive level of evidence. Data regarding less postoperative drainage, infections, and Oswestry disability index for MI-TLIF were supported by weak evidence. Conversely, data regarding other postoperative outcomes were nonsignificant to draw any conclusions.

CONCLUSION

Our umbrella review provides a comprehensive overview of the relevant strengths and weaknesses of each surgical technique. This overview revealed that MI-TLIF had better outcomes in terms of length of stay, blood loss, postoperative drainage, infections, and Oswestry disability index when compared with those of O-TLIF. However, O-TLIF had a better outcome for radiation exposure when compared with MI-TLIF.

Comparing Outcomes of Banana-Shaped and Straight Cages in Transforaminal Lumbar Interbody Fusion for Lumbar Degenerative Diseases: A Systematic Review and Meta-Analysis

OBJECTIVE

This meta-analysis aims to refine the understanding of the optimal choice between different cage shapes in transforaminal lumbar interbody fusion (TLIF) by systematically comparing perioperative data, radiological outcomes, clinical results, and complications associated with banana-shaped and straight bullet cages.

METHODS

A meticulous literature search encompassing PubMed, Embase, Scopus, Web of Science, China Knowledge Network, and Wanfang Data was executed up to October 5, 2023. Inclusion criteria focused on studies comparing banana-shaped and straight bullet cages in TLIF. The quality of included studies was assessed using appropriate tools such as the Newcastle-Ottawa Scale (NOS) for nonrandomized studies. Rigorous evaluations were performed for radiographic outcomes, including disc height (DH), segmental lordosis (SL), lumbar lordosis (LL), subsidence, and fusion rates. Clinical outcomes were meticulously evaluated using visual analogue scale (VAS), Oswestry Disability Index (ODI), and complications.

RESULTS

The analysis incorporated 7 studies, involving 573 patients (297 with banana-shaped cages, 276 with straight cages), all with NOS ratings exceeding 5 stars. No statistically significant differences were observed in operative time, blood loss, or hospitalization between the 2 cage shapes. Banana-shaped cages exhibited greater changes in DH (p = 0.001), SL (p = 0.02), and LL (p = 0.01). Despite statistically higher changes in ODI for straight cages (26.33, p < 0.0001), the actual value remained similar to banana-shaped cages (26.15). Both cage types demonstrated similar efficacy in VAS, complication rates, subsidence, and fusion rates.

CONCLUSION

Although banana-shaped cages can excel in restoring DH, SL, and LL, straight bullet cages can provide comparable functional improvements, pain relief, and complication rates.

Does indirect decompression by oblique lateral interbody fusion produce similar clinical and radiological outcomes to direct decompression by open transforaminal lumbar interbody fusion

Objectives

Open transforaminal lumbar interbody fusion (O-TLIF) remains the most popular and widely practiced lumbar fusion method even today, providing direct decompression. Oblique lateral interbody fusion (OLIF) is a novel retroperitoneal approach that allows placement of a large interbody cage which provides an indirect neural decompression, and screws can be placed minimal invasively or through the Wiltse OLIF (W-OLIF) approach. We aim to find out the short-term efficacy of W-OLIF to O-TLIF in terms of radiological and clinical outcomes in patients of lumbar degenerative diseases.

Materials and Methods

Fifty-two patients were divided equally into two groups (group O-TLIF and group W-OLIF). Several parameters were measured, such as the spinal cord cross-sectional area (SC-CSA), foraminal cross-sectional area (F-CSA), disc height (DH), foraminal height (FH), Schizas grade for stenosis, and Meyerding's grading for olisthesis. Functional scores were measured using the visual analog scale (VAS) for low back pain (LBP) and lower limbs, Oswestry Disability Index. All parameters were repeat measured at 3 months follow-up. Statistical analysis was done using SPSS software.

Results

Both groups were similar in composition preoperatively. There was significant improvement in all clinical and radiological parameters post-surgery in either group. However, at 3 months, The DH, FH, FSA, and VAS (LBP) were better in the W-OLIF group than in O-TLIF. Procedure-related complications were seen in both groups (15% in the O-TLIF group and 19% in the W-TLIF group), but only one patient in O-TLIF required revision due to cage migration.

Conclusion

Similar improvement occurs in most of the clinical and radiological parameters in the W-OLIF group compared to the O-TLIF group. Few radiological parameters such as the DH, FH, and F-CSA and the VAS (LBP) correction are superior in the W-OLIF group in the short-term follow-up. We conclude that indirect decompression by W-OLIF provides equivalent, if not better, results than the traditional O-TLIF lumbar fusion.

Impact of metabolic syndrome on morbidity and mortality following transforaminal interbody fusion (TLIF)

Study design

Retrospective Multi-Institutional Database Study.

Objective

Investigate the effect of metabolic syndrome (MetS) on the outcomes of Transforaminal Lumbar Interbody Fusion (TLIF).

Summary of background data

TLIF procedures in lumbar spine pathology are common. MetS is a combination of conditions, including medication required hypertension, diabetes mellitus (DM), and body mass index (BMI) of 30 kg/m2s or more. The prevalence of MetS has increased drastically over the past two decades. Our study aimed to understand the effect of MetS on morbidity and mortality of TLIF postoperatively.

Methods

Our study used American College of Surgeons National Surgical Quality Improvement (ACS-NSQIP) data from 2006 to 2019 to find all patients who underwent TLIF. Patients with MetS were compared to those without MetS. Fisher's test identified univariate relationships between MetS and preoperative/postoperative variables. Multivariable logistic regression models were utilized to analyze the association between MetS and postoperative morbidity and mortality.

Results

54,980 patients were identified who received TLIF. 10.7 % had MetS preoperatively. Patients with and without MetS showed statistically significant univariate differences in most preoperative and postoperative variables. After adjusting for preoperative comorbidities, patients with MetS had greater multivariate-adjusted odds of wound infections (aOR = 1.5889, CI 1.1952-2.112, p = 0.00144), pulmonary events (aOR = 1.5517, CI 1.1207-2.1485, p = 0.00813), renal events (aOR = 2.8685, CI 1.5511-5.3045, p = 0.00078), sepsis (aOR = 1.6773, CI 1.1647-2.4155, p = 5.44E-03), and return to OR (aOR = 1.4764, CI 1.2201-1.7866, p = 6.19E-05).

Conclusions

Patients with MetS are at elevated risk for various morbidity and mortality markers after TLIF. Surgeons performing TLIFs on these patients should be aware of the increased potential for postoperative events that may complicate the patient's recovery.

Level of evidence

Level III.

Does the application of expandable cages in TLIF provide improved clinical and radiological results compared to static cages? A meta-analysis

Purpose

This study aimed to provide a direct meta-analysis of the evidence comparing outcomes between expandable cages and static cages in patients with transforaminal lumbar interbody fusion (TLIF).

Methods

A search of relevant materials from databases was performed from inception to March 7, 2022. Clinical and radiological outcomes were included.

Results

Ten studies (1,440 patients) were included. The anterior disc height and foraminal height for expandable cages were substantially higher than those for static cages at the final follow-up (P < 0.0001; P = 0.05). In comparison with static cages, although not statistically significant, expandable cages showed beneficial results, including an increase in posterior disc height and segmental lordosis. There were no statistically significant differences in segmental lordosis, lumbar lordosis, pelvic parameters, cage subsidence, or fusion rates (P > 0.05). Oswestry disability index scores for expandable cages were substantially lower than those for static cages at the final follow-up (P = 0.0007). Interestingly, although the preoperative visual analog scores for back and leg pain were significantly higher in the expandable group than in the static group (P < 0.0001; P = 0.008), there was no significant difference between the static and expandable groups during the final follow-up (P = 0.51; P = 0.85).

Conclusions

Expandable cages are associated with improved functional outcomes and restored postoperative disc and foraminal heights in patients with TLIF. In addition, no statistically significant differences were observed in segmental lordosis, lumbar lordosis, pelvic parameters, cage subsidence, or fusion rate.