Transforaminal Lumbar Interbody Fusion For Lumbar Degenerative Disease: Patient Selection And Perspectives

Does Bone Morphogenetic Protein Use Reduce Pseudarthrosis Rates in Single-Level Transforaminal Lumbar Interbody Fusion Surgeries?

BACKGROUND

Recombinant human bone morphogenetic protein 2 (rhBMP-2, or BMP for short) is a popular biological product used in spine surgeries to promote fusion and avoid the morbidity associated with iliac crest autograft. BMP's effect on pseudarthrosis in transforaminal lumbar interbody fusion (TLIF) remains unknown.

OBJECTIVE

To assess the rates of pseudarthrosis in single-level TLIF with and without concurrent use of BMP.

METHODS

This was a retrospective cohort study conducted at a single academic institution. Adults undergoing primary single-level TLIF with a minimum of 1 year of clinical and radiographic follow-up were included. BMP use was determined by operative notes at index surgery. Non-BMP cases with iliac crest bone graft were excluded. Pseudarthrosis was determined using radiographic and clinical evaluation. Bivariate differences between groups were assessed by independent t test and χ 2 analyses, and perioperative characteristics were analyzed by multiple logistic regression.

RESULTS

One hundred forty-eight single-level TLIF patients were included. The mean age was 59.3 years, and 52.0% were women. There were no demographic differences between patients who received BMP and those who did not. Pseudarthrosis rates in patients treated with BMP were 6.2% vs 7.5% in the no BMP group (P = 0.756). There was no difference in reoperation for pseudarthrosis between patients who received BMP (3.7%) vs those who did not receive BMP (7.5%, P = 0.314). Patients who underwent revision surgery for pseudarthrosis more commonly had diabetes with end-organ damage (revised 37.5% vs not revised 1.4%, P < 0.001). Multiple logistic regression analysis demonstrated no reduction in reoperation for pseudarthrosis related to BMP use (OR 0.2, 95% CI 0.1-3.7, P = 0.269). Diabetes with end-organ damage (OR 112.6,95% CI 5.7-2225.8, P = 0.002) increased the risk of reoperation for pseudarthrosis.

CONCLUSIONS

BMP use did not reduce the rate of pseudarthrosis or the number of reoperations for pseudarthrosis in single-level TLIFs. Diabetes with end-organ damage was a significant risk factor for pseudarthrosis.

CLINICAL RELEVANCE

BMP is frequently used "off-label" in transforaminal lumbar interbody fusion; however, little data exists to demonstrate its safety and efficacy in this procedure.

LEVEL OF EVIDENCE: 3

Budget Impact Analysis of Minimally Invasive versus Open Transforaminal Lumbar Interbody Fusion for Lumbar Degenerative Disease: A European Hospital Perspective

Purpose

When traditional therapies fail to provide relief from debilitating lower back pain, surgeries such as transforaminal lumbar interbody fusion (TLIF) may be required. This budget impact analysis (BIA) compared minimally-invasive (MI)-TLIF versus open (O)-TLIF for single-level fusion from an Italian hospital perspective.

Methods

The BIA compared costs of 100 MI-TLIF and 100 O-TLIF procedures from an Italian hospital perspective over a one-year time horizon. The base case included costs for length of hospital stay (LOS), blood loss, and sterilizing surgical trays. The scenario analysis also included operating room (OR) time and complication costs. Base case inputs were from the Miller et al meta-analysis; scenario analysis inputs were from the Hammad et al meta-analysis. The device costs for MI-TLIF and O-TLIF procedures were from Italian tender prices for Viper Prime™ System and Expedium™ Spine System, respectively.

Results

Base case deterministic analysis results showed cost savings of €207,370 for MI-TLIF compared with O-TLIF. MI-TLIF costs were lower for LOS (€215,277), transfusion for blood loss (€16,881), and surgical tray sterilization (€28,232), whereas device costs were lower for O-TLIF (€53,020). The probabilistic result was similar, with MI-TLIF resulting in savings of €211,026 (95% credible interval [CR]: €208,725 - €213,327). All 1000 base case probabilistic sensitivity analysis runs were cost saving. Deterministic scenario analysis results showed cost savings of €166,719 for MI-TLIF. MI-TLIF costs were lower for LOS (€190,813), transfusion for blood loss (€16,881), surgical tray sterilization (€28,232), and complications (€2076), whereas O-TLIF costs were lower for OR time (€18,263) and devices used (€53,020).

Conclusion

Despite the increase incremental cost for medical device innovation and OR time, this study demonstrates the economic savings of MI-TLIF compared to O-TLIF from a European hospital perspective. The findings will be useful to policy and hospital decision makers in assessing purchasing, funding and reimbursement decisions.

Assessment of the Quality and Reliability of YouTube as an Information Source for Transforaminal Interbody Fusion

BACKGROUND

This study aims to assess the quality and reliability of the information for patients from YouTube videos on transforaminal interbody fusion (TLIF).

MATERIAL AND METHODS

One hundred videos were listed by inputting "TLIF," "TLIF surgery," and "transforaminal interbody fusion" in the YouTube search engine. The top 50 most popular videos based on video power index (VPI), view ratio, and exclusion criteria were selected for review. One orthopedic consultant surgeon and one neurosurgeon consultant analyzed the videos together. The modified DISCERN score, the Global Quality Score (GQS), the Journal of the American Medical Association (JAMA) score, and a novel interbody fusion score were used to evaluate videos. Data of video length, view count, number of likes and dislikes, like ratio (like x 100/(like+dislike)), video source, and comment rate were collected.

RESULTS

The quality of the videos could have been better according to all scoring systems, regardless of the video source. The scores of the videos published by patients and commercials were significantly lower than those of physicians and allied professionals (p <0.05). VPI and view ratios were similar in all sources.  Conclusion: The study demonstrates that YouTube videos providing information related to TLIF surgery are available and accessed by the public. The results of this study would suggest that YouTube is not currently an appropriate source of information on TLIF surgery for patients. Most of the YouTube videos about TLIF surgery contain information about the surgical technique and have limited information about the post-operative condition of the patients.

Percutaneous endoscopic versus minimally invasive transforaminal lumbar interbody fusion for lumbar degenerative diseases: a meta-analysis

Introduction

Transforaminal lumbar interbody fusion (TLIF) is commonly used in patients with lumbar degenerative disease (LDD). The most commonly used techniques include minimally invasive TLIF (MIS-TLIF) and percutaneous endoscopic TLIF (PE-TLIF).

Aim

To compare the safety and clinical effectiveness of PE-TLIF and MIS-TLIF in treating LDD.

Material and methods

We screened for related articles in multiple scientific databases, namely, PubMed, Embase, Cochrane Library, Wanfang, VIP, and CINK, and analyzed the relative outcomes.

Results

Based on our inclusion criteria, we selected 8 studies for meta-analysis. There are a total of 229 patients who underwent PE-TLIF and 258 patients who underwent MIS-TLIF. MIS-TLIF and PE-TLIF have similar effectiveness in relieving leg pain and improving the Oswestry Disability Index. However, PE-TLIF is superior in relieving back pain. The pooled data of fusion rates, postoperative analgesic, and complication rates are comparable between the 2 groups. The pooled operation and intra-operative fluoroscopic time are both significantly higher in the PE-TLIF group than the MIS-TLIF group. The pooled intra-operative blood loss, incision length, duration from surgery to ambulation, and hospital stay are significantly lower in the PE-TLIF group than the MIS-TLIF group. Most of the endpoints reveal significant heterogeneity. The endpoints of operation time and intra-operative blood loss reveal significant publication bias.

Conclusions

Both PE-TLIF and MIS-TLIF are safe and effective interventions for patients with LDD. When compared, although MIS-TLIF results in reduced operative time, less intra-operative blood loss and enhanced post-operative recovery can be achieved by PE-TLIF.

Efficacy of the Dynesys Hybrid Surgery for Patients with Multi-Segmental Lumbar Spinal Stenosis

Objective

The efficacy of hybrid (Dynesys and fusion) surgery and the traditional transforaminal lumbar interbody fusion surgery was compared in patients with multi-segmental lumbar spinal stenosis.

Methods

A total of 68 patients with multi-segmental lumbar spinal stenosis subjected to surgery were recruited between January 2013 and October 2020 in the First Affiliated Hospital of Southern University of Science and Technology. The patients were divided into a hybrid group (N = 33) and a TLIF group (N = 35) by surgery. After surgery, follow-up was conducted for 12 months. Between the two groups, the following parameters were compared: general conditions, clinical symptom scores, imaging parameters, and early complications.

Results

A statistically significant difference in the duration of surgery was noted between the two groups. After 12 months of follow-up, the range of motion disappeared in the TLIF group, while 63.53% was preserved in the hybrid group with statistically significant differences. A statistically significant difference was identified in the Oswestry Disability Index one week after surgery. Nonetheless, no statistically significant differences were observed at the 12-month post-surgical follow-up. Pfirrmann grade showed a 3.03% upper adjacent segment degeneration rate in the hybrid group (1/33) at 12-month follow-up and 2.86% (1/35) in the TLIF group. Notably, no early complications (screw loosening and wound infection) were identified in the two groups.

Conclusion

The Dynesys hybrid surgery combined the advantages of two systems of dynamic stabilization and rigid fusion. Besides, hybrid surgery is potentially a novel approach for the treatment of multi-segmental lumbar spinal stenosis.

Comparison of outcomes between indirect decompression of oblique lumbar interbody fusion and MIS-TLIF in one single-level lumbar spondylosis

Minimal invasive spinal fusion has become popular in the last decade. Oblique lumbar interbody fusion (OLIF) is a relatively new surgical technique and could avoid back muscle stripping and posterior complex destruction as in minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF). Between December 2016 and September 2018, patients with single level degenerative spondylosis were selected to enroll in this retrospective study. A total of 21 patients that underwent OLIF and 41 patients that received MIS-TLIF were enrolled. OLIF showed significantly less blood loss and shorter surgery time compared to MIS-TLIF (p < 0.05). The improvement in segmental lordosis and coronal balance was significantly more in OLIF group than MIS-TLIF group (p < 0.05). When comparing with MIS-TLIF, OLIF was significantly better in Oswestry Disability Index (ODI) and visual analogue scale for back pain improvement at post-operative 6 months (p < 0.05). Both OLIF and MIS-TLIF are becoming mainstream procedures for lumbar degenerative-related disease, especially for spondylolisthesis. However, the indirect decompression of OLIF has shown to have less perioperative blood loss and shorter surgery time than that of MIS-TLIF. In addition, OLIF gives superior outcome in restoring segmental lordosis and coronal imbalance. While both OLIF and MIS-TLIF provide optimal clinical outcomes, upon comparison between the two techniques, the indirect decompression of OLIF seems to be a superior option in modern days.

Understanding the Future Prospects of Synergizing Minimally Invasive Transforaminal Lumbar Interbody Fusion Surgery with Ceramics and Regenerative Cellular Therapies

Transforaminal lumber interbody fusion (TLIF) is the last resort to address the lumber degenerative disorders such as spondylolisthesis, causing lower back pain. The current surgical intervention for these abnormalities includes open TLIF. However, in recent years, minimally invasive TLIF (MIS-TLIF) has gained a high momentum, as it could minimize the risk of infection, blood loss, and post-operative complications pertaining to fusion surgery. Further advancement in visualizing and guiding techniques along with grafting cage and materials are continuously improving the safety and efficacy of MIS-TLIF. These assistive techniques are also playing a crucial role to increase and improve the learning curve of surgeons. However, achieving an appropriate output through TLIF still remains a challenge, which might be synergized through 3D-printing and tissue engineering-based regenerative therapy. Owing to their differentiation potential, biomaterials such as stem/progenitor cells may contribute to restructuring lost or damaged tissues during MIS-TLIF, and this therapeutic efficacy could be further supplemented by platelet-derived biomaterials, leading to improved clinical outcomes. Thus, based on the above-mentioned strategies, we have comprehensively summarized recent developments in MIS-TLIF and its possible combinatorial regenerative therapies for rapid and long-term relief.

Automated Pipeline to Generate Anatomically Accurate Patient-Specific Biomechanical Models of Healthy and Pathological FSUs

State-of-the-art preoperative biomechanical analysis for the planning of spinal surgery not only requires the generation of three-dimensional patient-specific models but also the accurate biomechanical representation of vertebral joints. The benefits offered by computational models suitable for such purposes are still outweighed by the time and effort required for their generation, thus compromising their applicability in a clinical environment. In this work, we aim to ease the integration of computerized methods into patient-specific planning of spinal surgery. We present the first pipeline combining deep learning and finite element methods that allows a completely automated model generation of functional spine units (FSUs) of the lumbar spine for patient-specific FE simulations (FEBio). The pipeline consists of three steps: (a) multiclass segmentation of cropped 3D CT images containing lumbar vertebrae using the DenseVNet network, (b) automatic landmark-based mesh fitting of statistical shape models onto 3D semantic segmented meshes of the vertebral models, and (c) automatic generation of patient-specific FE models of lumbar segments for the simulation of flexion-extension, lateral bending, and axial rotation movements. The automatic segmentation of FSUs was evaluated against the gold standard (manual segmentation) using 10-fold cross-validation. The obtained Dice coefficient was 93.7% on average, with a mean surface distance of 0.88 mm and a mean Hausdorff distance of 11.16 mm (N = 150). Automatic generation of finite element models to simulate the range of motion (ROM) was successfully performed for five healthy and five pathological FSUs. The results of the simulations were evaluated against the literature and showed comparable ROMs in both healthy and pathological cases, including the alteration of ROM typically observed in severely degenerated FSUs. The major intent of this work is to automate the creation of anatomically accurate patient-specific models by a single pipeline allowing functional modeling of spinal motion in healthy and pathological FSUs. Our approach reduces manual efforts to a minimum and the execution of the entire pipeline including simulations takes approximately 2 h. The automation, time-efficiency and robustness level of the pipeline represents a first step toward its clinical integration.