Perioperative complications in patients undergoing open transforaminal lumbar interbody fusion as a revision surgery

Transforaminal Versus Lateral Interbody Fusions for Treatment of Adjacent Segment Disease in the Lumbar Spine

STUDY DESIGN

Retrospective comparative study.

OBJECTIVE

This study compared outcomes for patients managed with a lateral approach to interbody fusion [lateral (LLIF) or oblique (OLIF)] versus a posterior (PLIF) or transforaminal interbody fusion (TLIF) for treatment of adjacent segment disease (ASD) above or below a prior lumbar fusion construct.

SUMMARY OF BACKGROUND DATA

No study has compared outcomes of lateral approaches to more traditional posterior approaches for the treatment of ASD.

METHODS

Retrospective review was performed of patients who underwent single-level lateral or posterior approaches for lumbar interbody fusion for symptomatic ASD between January 2010 and December 2021. Exclusion criteria included skeletal immaturity (age below 18 y old) and surgery indication for malignancy or infection. Patient demographics, medical comorbidities, operative details, postoperative complications, and revision surgery profiles were collected for all patients. Standard descriptive statistics were used to summarize data. Comparative statistical analyses were performed using Statistical Package for the Social Sciences (Version 28.0.1.0; Chicago, IL).

RESULTS

A total of 152 patients (65±10 y) were included in the study with a mean duration of follow-up of 1.6±1.4 years. The cohort included 123 PLIF/TLIF (81%), 18 LLIF (12%), 11 OLIF (7%). TLIF/PLIF experienced greater mean operative time (210±62 min vs. 184±80 OLIF/105±64 LLIF, P <0.001) and estimated blood loss (414±254 mL vs. 49±29 OLIF/36±33 LLIF, P <0.001). No significant difference in rate of postoperative complications. Postoperative radicular pain was significantly greater in OLIF (7, 64%) and LLIF (7, 39%) compared with PLIF/TLIF (16, 13%), P <0.001. No statistically significant difference in health care utilization was noted between the groups.

CONCLUSION

Lateral fusions to treat ASD demonstrated no significantly different risk of complication compared with posterior approaches. Our study demonstrated significantly increased operative time and estimated blood loss for the posterior approach and an increased risk of radicular pain from manipulation/retraction of psoas following lateral approaches.

LEVEL OF EVIDENCE

Level III.

Adjacent segment degeneration after posterolateral lumbar fusion: results and complications of posterior revision surgery

BACKGROUND

Lumbar fusion is an important technique for the treatment of degenerative pathologies. Adjacent segment degeneration is a known complication after lumbar fusion that causes significant morbidity. Our objective was to evaluate the demographics, risk factors, type of surgery, and surgical complications in patients who underwent reoperation through a posterior route due to adjacent segment degeneration.

METHODS

We performed a retrospective analysis of all patients who underwent instrumented posterolateral fusion in the lumbar spine for the treatment of degenerative diseases from January 2000 to December 2015 at a single institution. Patients who developed symptomatic adjacent segment degeneration requiring a second surgery were noted and compared with patients who did not develop adjacent segment degeneration.

RESULTS

A total of 750 patients with degenerative pathologies who underwent fusion with instrumentation were identified. Forty-five patients (6%) required a second surgery for symptomatic adjacent segment degeneration. The average onset of adjacent segment degeneration symptoms after fusion was 5.89 years. Adjacent segment degeneration occurred above the level of fusion in 40 cases and below in 5 cases. The risk factor identified in our series was L5-S1 fusion. The main complication seen after the second surgery was infection in 5 cases (11%).

CONCLUSIONS

This study identifies the L5-S1 fusion as a possible risk factor for adjacent segment degeneration. Reoperation through a posterior route is a therapeutic option but is associated with considerable morbidity. Further studies are necessary to elucidate this pathology and the best options for its management.

Application of the oblique lateral interbody fusion technique in salvage surgery: technical note and case series

Objective

The oblique lateral interbody fusion (OLIF) technique is a promising interbody fusion technique. This study summarizes the technical aspects of OLIF as a salvage surgery and the preliminary outcomes of a series of cases.

Patients and methods

A retrospective review of patients with leg or back pain induced by pseudoarthrosis or adjacent segment disease after posterior lumbar interbody fusion/transforaminal lumbar interbody fusion was done. These patients underwent salvage OLIF surgeries in our institution from January 2021 to March 2022. Variables such as the demographic, clinical, surgical, and radiological characteristics of the enrolled patients were recorded and analyzed.

Results

Eight patients (five females and three males; mean age 69.1 ± 5.7 years, range 63-80 years) were enrolled in this study. The mean operative time was 286.25 min (range: 230-440 min), and the estimated blood loss was 90 ml (range: 50-150 ml). Only one of the eight patients experienced a complication of lower limb motor weakness, which disappeared within 5 days after surgery. The latest data showed that the mean intervertebral space height increased from 8.36 mm preoperatively to 12.70 mm and the mean segmentary lordosis increased from 8.92° preoperatively to 15.05°. Bone fusion was achieved in all but one patient, who was followed up for only 3 months. The JOA scores Japanese Orthopaedic Association (JOA) Scores for low back pain of all patients significantly improved at the final follow-up.

Conclusion

OLIF provides a safe and effective salvage strategy for patients with failed posterior intervertebral fusion surgery. Patients effectively recovered intervertebral and foraminal height with no additional posterior direct decompression.

Stand-Alone Oblique Lumbar Interbody Fusion (OLIF) for the Treatment of Adjacent Segment Disease (ASD) after Previous Posterior Lumbar Fusion: Clinical and Radiological Outcomes and Comparison with Posterior Revision Surgery

Background: Radiological evidence of adjacent segment disease (ASD) has been reported to have a prevalence of more than 30% and several risk factors have been reported. The aim of this study is to evaluate the clinical and radiological outcomes of patients with symptomatic ASD treated with stand-alone OLIF and compare results with a posterior revision surgery cohort. Methods: This is a retrospective case-control study. Clinical-patient-reported outcomes were obtained at preoperative, postoperative and final follow-up visits using the Short Form (SF-36) scale, the Oswestry Disability Index (ODI) and the visual analog scale (VAS). Radiological measures include lumbar lordosis (LL), segmental lordosis (SL), pelvic incidence-lumbar lordosis (PI-LL) mismatch, segmental coronal Cobb angle and intervertebral disc height (DH). The data are compared with a retrospective series of patients that underwent a posterior revision surgery for ASD. Results: Twenty-eight patients in the OLIF group and 25 patients in the posterior group meet inclusion criteria. The mean ages at the time of the surgery are 65.1 years and 67.5, respectively. The mean follow-up time is 36.1 months (range of 14-56). The clinical outcomes significantly improve from preoperative values from the surgery in both groups. The radiological parameters are significantly improved postoperatively and were maintained at the last follow-up in both groups. A statistically significant difference is observed between the two groups for minor complication rate, length of surgery, blood loss and DH restoration. Conclusions: Stand-alone OLIF is an effective and safe technique with low morbidity and complication rates for the treatment of selected patients with symptomatic ASD following a previous lumbar fusion.

Comparing the medium-term outcomes of lumbar interbody fusion via transforaminal and oblique approach in treating lumbar degenerative disc diseases

BACKGROUND CONTEXT

Oblique lumbar interbody fusion (OLIF) has been proven to be effective in treating lumbar degenerative disorders (LDDs) via indirect decompression. However, its superiority over transforaminal lumbar interbody fusion (TLIF) remains questionable, especially in terms of medium-term follow-up.

PURPOSE

To compare the medium-term clinical and radiological outcomes of TLIF and OLIF in treating patients with LDDs.

STUDY DESIGN

Retrospective comparative study.

PATIENT SAMPLE

Fifty-two patients treated by TLIF and forty-six patients treated by OLIF.

OUTCOME MEASURES

Clinical records including the visual analog scale (VAS) score of the lower back and leg and the Oswestry Disability Index (ODI). Radiological records including disk height (DH), lumbar lordosis (LL), segmental lordosis (SL), the cross-sectional area (CSA) of the spinal canal, and fusion rate. Surgical-related information and complications were also recorded.

METHODS

A retrospective review was performed on patients who were surgically managed for LDDs at L4-5 between 2015 and 2017 and completed at least 4 years of follow-up. A total of 98 patients were analyzed, with 46 patients treated by OLIF combined with anterolateral single screw-rod fixation (OLIF-AF group), and 52 patients treated by TLIF (TLIF group). Parameters including postoperative outcomes and perioperative complications were compared with evaluate the efficacy of the two approaches.

RESULTS

There was significantly less bleeding, surgical duration, and hospitalization in the OLIF-AF group than in the TLIF group. Significant improvements in the clinical score were achieved in both groups. However, the VAS score of the lower back was significantly higher in the TLIF group than in the OLIF-AF group throughout the whole follow-up period. Significantly higher expansion of the CSA was found in the TLIF group than in the OLIF-AF group. However, the improvements in DH, LL, and SL were significantly lower in the TLIF group. The fusion rate was significantly higher in the OLIF-AF group than in the TLIF group within 6 months postoperatively, and there was no significant difference between the two groups at the final record. No significant difference was found in the rate of overall complications between the two groups (25.0% vs. 23.9%, p=.545). The intraoperative complication rate in the TLIF group (13.5%) was slightly higher than that in the OLIF-AF group (6.5%) (p=.257). There was no significant difference in the incidence of adjacent segment disorder (ASD) between the two groups (7.7% vs. 10.9%, p=.422). Cage subsidence was slightly lower in the TLIF group (5.8%) than in the OLIF-AF group (13.0%) (p=.298).

CONCLUSIONS

Both the TLIF and OLIF-AF approaches demonstrated good medium-term outcomes in treating LDDs. Compared with TLIF, OLIF-AF showed advantages in postoperative recovery, improvement of intervertebral space and lumbar sagittal balance, and early intervertebral fusion but was associated with inferior spinal canal decompression efficacy. The two approaches shared comparable overall complication rates. However, OLIF-AF tended to have fewer intraoperative complications, and a higher incidence of subsidence.

Oblique Lumbar Interbody Fusion Using a Stand-Alone Construct for the Treatment of Adjacent-Segment Lumbar Degenerative Disease

Objective

Adjacent-segment disease (ASD) is common in patients undergone previous lumbar fusion. A typical revision treatment from posterior approach requires management of postoperative scar tissue and previously implanted instrumentation. An oblique lumbar interbody fusion (OLIF) approach allows surgeon to reduce the potential risk of posterior approach. This study aimed to analyze the clinical and radiographic efficacy of stand-alone OLIF for the treatment of lumbar adjacent-segment disease.

Methods

A total of 13 consecutive patients who underwent stand-alone OLIF for the treatment of adjacent-segment disease from December 2016 to January 2019 were reviewed. Visual analog scale (VAS) of back pain and leg pain and the Oswestry Disability Index (ODI) before surgery and at last postoperative clinic visits were obtained. Radiography, CT and MRI before and at last follow-up after surgery was evaluated in all patients.

Results

During the study period, 13 cases were successfully treated with stand-alone OLIF. The mean follow-up was 17.7 ± 8.3 months. The back pain VAS improved from 6.2 ± 1.0 to 2.0 ± 1.1 (P < 0.01), and the leg pain VAS improved from 7.0 ± 1.9 to 1.0 ± 0.9 (P < 0.01). ODI improved from 28.0 ± 7.5 to 10.8 ± 4.0 (P < 0.01). The disc height (DH) increased from 9 ± 2 to 12 ± 2 mm (P < 0.01), the cross-sectional area (CSA) of spinal canal increased from 85 ± 26 to 132 ± 24 mm² (P < 0.01), the foraminal height increased from 17 ± 2 to 21 ± 3 mm (P < 0.01) and the CSA of foramen increased from 95 ± 25 to 155 ± 36 mm² (P < 0.01). Cage subsidence was observed in 2 cases.

Conclusions

Stand-alone OLIF provides a safe and effective alternative way to treat ASD.

Traumatic Vertebral Fracture in a Patient With Transforaminal Lumbar Interbody Fusion: A Rare Complication

Transforaminal lumbar interbody fusion (TLIF) offers the potential benefits of anterior and posterior column decompression and fusion. Pseudarthrosis and infection are among the most common perioperative complications. Vertebral fracture after TLIF is a rare and unusual complication. A 74-year-old female underwent L3-5 TLIF for lumbar spondylolisthesis that caused back pain and neurogenic claudication. She recovered well after surgery. However, she subsequently experienced progressive back pain and recurrent claudication after a fall. Elongated anterior-posterior length of the L5 body with progressive L5-S1 listhesis was observed in the serial radiographic follow-ups. The CT scan revealed complicated fracture lines crossing the L5 body. Further extended fixation was performed for decompression and reconstruction of the lumbosacral alignment. Although vertebral fracture after TLIF is a rare complication, a high index of suspicion is the key to early diagnosis, preferably with CT scans, for patients with traumatic accidents after TLIF surgery.

Placement of Unilateral Cortical Bone Trajectory Screws in Previously Instrumented Pedicle without Removal of Existing Hardware for Adjacent Segment Disease

Adjacent segment disease (ASD) in the lumbar spine is a possible consequence in segments adjacent to a fusion. As the number of lumbar fusions in the United States increases, the rates of ASD will continue to climb. There are several treatment options for ASD with open decompression and extension of the fusion being common. However, need for exposure and removal of existing instrumentation can lead to increased operative times resulting in increasing blood loss and infection risk. The purpose of this paper is to describe a case report for unilateral cortical trajectory screw instrumentation, allowing for posterior instrumentation without having to remove the existing pedicle screws in the setting of ASD. Our technique can be done with standard c-arm fluoroscopy without the need for navigation.

Clinical and Radiographic Outcomes of Lateral Interbody Fusion for Adjacent Segment Degeneration

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

Assessment of outcomes in patients undergoing lateral interbody fusion as part of the surgical treatment of adjacent segment deterioration after previous lumbar spine fusion.

METHODS

Adult patients with previous lumbar posterior spinal fusion who presented with adjacent segment degeneration and stenosis refractory to nonoperative treatment and who underwent lateral lumbar interbody fusion were retrospectively analyzed. Clinical and radiographic outcomes were assessed and comparisons made between preoperative baseline and postoperative values.

RESULTS

Thirty-six patients with symptomatic adjacent segment degeneration at 46 motion segments were included. Thirty (83.3%) of the 36 patients had complete relief of both preoperative lower extremity pain and back pain at the time of final follow-up. Six (16.7%) of the 36 patients had persistent pain, though in all 6 cases, the pain was less postoperatively than preoperatively. Oswestry Disability Index scores were improved significantly at final follow-up (P = .001). Compared with preoperative baseline parameters, initial and final postoperative radiographs had an increase in segmental lordosis (P < .001 and P < .001, respectively), increase in overall lumbar lordosis (P < .05 and P = .094, respectively), decrease in segmental coronal angulation (P = .63 and P < .01, respectively), decrease in overall coronal angulation (P = .063 and P = .009, respectively), and increase in intervertebral height (P < .001 and P < .001, respectively).

CONCLUSION

Lateral lumbar interbody fusion achieves favorable clinical and radiographic outcomes for the treatment of adjacent segment degeneration after previous lumbar fusion.

LEVEL OF EVIDENCE

4.

Lateral lumbar interbody fusion in revision surgery for restenosis after posterior decompression

OBJECTIVE

The purpose of this study was to compare the clinical results of revision interbody fusion surgery between lateral lumbar interbody fusion (LLIF) and posterior lumbar interbody fusion (PLIF) or transforaminal lumbar interbody fusion (TLIF) with propensity score (PS) adjustments and to investigate the efficacy of indirect decompression with LLIF in previously decompressed segments on the basis of radiological assessment.

METHODS

A retrospective study of patients who underwent revision surgery for recurrence of neurological symptoms after posterior decompression surgery was performed. Postoperative complications and operative factors were evaluated and compared between LLIF and PLIF/TLIF. Moreover, postoperative improvement in cross-sectional areas (CSAs) in the spinal canal and intervertebral foramen was evaluated in LLIF cases.

RESULTS

A total of 56 patients (21 and 35 cases of LLIF and PLIF/TLIF, respectively) were included. In the univariate analysis, the LLIF group had significantly more endplate injuries (p = 0.03) and neurological deficits (p = 0.042), whereas the PLIF/TLIF group demonstrated significantly more dural tears (p < 0.001), surgical site infections (SSIs) (p = 0.02), and estimated blood loss (EBL) (p < 0.001). After PS adjustments, the LLIF group still showed significantly more endplate injuries (p = 0.03), and the PLIF/TLIF group demonstrated significantly more dural tears (p < 0.001), EBL (p < 0.001), and operating time (p = 0.04). The PLIF/TLIF group showed a trend toward a higher incidence of SSI (p = 0.10). There was no statistically significant difference regarding improvement in the Japanese Orthopaedic Association scores between the 2 surgical procedures (p = 0.77). The CSAs in the spinal canal and foramen were both significantly improved (p < 0.001).

CONCLUSIONS

LLIF is a safe, effective, and less invasive procedure with acceptable complication rates for revision surgery for previously decompressed segments. Therefore, LLIF can be an alternative to PLIF/TLIF for restenosis after posterior decompression surgery.

Complication Risk in Primary and Revision Minimally Invasive Lumbar Interbody Fusion: A Comparable Alternative to Conventional Open Techniques?

STUDY DESIGN

Retrospective cohort study of prospective patients undergoing minimally invasive lumbar fusion at a single academic institution.

OBJECTIVE

To assess differences in perioperative outcomes between primary and revision MIS (minimally invasive surgical) lumbar interbody fusion patients and compare with those undergoing corresponding open procedures.

METHODS

Patients ≥18 years old undergoing lumbar interbody fusion were grouped by surgical technique: MIS or open. Patients within each group were propensity score matched for comorbidities and levels fused. Patient demographics, surgical factors, and perioperative complication incidences were compared between primary and revision cases using means comparison tests, as appropriate.

RESULTS

Of the 214 lumbar interbody fusion patients included after propensity score matching, 44 (21%) cases were MIS, and 170 (79%) were open. For MIS patients, there were no significant differences between primary and revision cases in estimated blood loss (EBL; 344 vs 299 cm³, P = .682); however, primary cases had longer operative times (301 vs 246 minutes, P = .029). There were no differences in length of stay (LOS), intensive care unit LOS, readmission, and intraoperative or postoperative complications (all P > .05). For open patients, there were no differences between primary and revision cases in EBL (P > .05), although revisions had longer operative times (331 vs 278 minutes, P = .018) and more postoperative complications (61.7% vs 23.8%, P < .001). MIS revision procedures were shorter than open revisions (182 vs 213 minutes, P = .197) with significantly less EBL (294 vs 965 cm³, P < .001), shorter inpatient and intensive care unit LOS, and fewer postoperative complications (all P < .05).

CONCLUSIONS

Clinical outcomes of revision MIS lumbar interbody fusion were similar to those of primary surgery. Additionally, MIS techniques were associated with less EBL, shorter LOS, and fewer perioperative complications than corresponding open revisions.

Comparison of Stand-alone Lateral Lumbar Interbody Fusion Versus Open Laminectomy and Posterolateral Instrumented Fusion in the Treatment of Adjacent Segment Disease Following Previous Lumbar Fusion Surgery

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

The aim of this study was to compare clinical and radiographic outcomes of patients who underwent stand-alone lateral lumbar interbody fusion (LLIF) to those who underwent posterolateral fusion (PLF) for symptomatic adjacent segment disease (ASD).

SUMMARY OF BACKGROUND DATA

Recent studies have suggested that LLIF can successfully treat ASD; however, there are no studies to date that compare LLIF with the traditional open PLF in this cohort.

METHODS

A total of 47 consecutive patients who underwent LLIF or PLF for symptomatic ASD between January 2007 and August 2016 after failure of conservative management were reviewed for this study. Patient-reported outcomes (PROs) were collected on all patients at preoperative, postoperative, and most recent post-operative visit using the Oswestry Disability Index, Visual Analog Scale (VAS)-Back, and VAS-Leg surveys. Preoperative, immediate postoperative, and most recent postoperative radiographs were assessed for pelvic incidence, fusion, intervertebral disc height, segmental and overall lumbar lordosis (LL). Symptomatic ASD was diagnosed if back pain, neurogenic claudication, or lower extremity radiculopathy presented following a previous lumbar fusion. Preoperative plain radiographs were evaluated for evidence of adjacent segment degeneration.

RESULTS

A total of 47 patients (23 LLIF, 24 PLF) met inclusion criteria. Operative times (P < 0.001) and intraoperative blood loss (P < 0.001) were significantly higher in the PLF group. Patients who underwent PLF were discharged approximately 3 days after the LLIF patients (P < 0.001). PROs in the PLF and LLIF cohorts showed significant and equivalent improvement, with equivalent radiographic fusion rates. LLIF significantly improve segmental lordosis (P < 0.001), total LL (P = 0.003), and disc height (P < 0.001) from preoperative to immediate postoperative and final follow-up (P = 0.004, P = 0.019, P ≤ 0.001, respectively).

CONCLUSION

Although LLIF may provide less perioperative morbidity and shorter length of hospitalization, both techniques are safe and effective approaches to restore radiographic alignment and provide successful clinical outcomes in patients with adjacent segment degeneration following previous lumbar fusion surgery.

LEVEL OF EVIDENCE

3.

Safety and performance of a novel articulating cage for transforaminal lumbar interbody fusion in the setting of intraoperative spinal navigation

OBJECTIVE

Transforaminal lumbar interbody fusion (TLIF) has been described as safe and effective procedure for the treatment of low back pain. However, only a few retrospective articles describing articulating cages exist in literature. The aim of this study was to assess the clinical and radiological results, as well as patient safety and complications by using a novel articulating TLIF cage.

PATIENTS AND METHODS

Out of 50 patients, 49 were included in this prospective study. Under computer tomography (CT) guided spinal navigation the TLIF procedure was performed. Clinical outcome scores visual analog scale (VAS), Oswestry disability index (ODI) and short form-36 health survey questionnaire (SF-36) were obtained preoperatively, 6 and 12 months after surgery. Radiological data were acquired preoperatively, after 6 weeks, as well as 6 and 12 postoperatively and included measurements for disc height (anterior/posterior), foraminal height, segmental and global lumbar lordosis.

RESULTS

71% of the included patients have undergone previous lumbar surgery. In total, 80 SYNCHRO® cages have been implanted. The clinical results revealed a highly significant improvement of VAS, ODI and SF-36 after 6 and 12 months, compared to baseline levels (p < 0.05). Radiological analysis revealed a significant increase in anterior and posterior disc height, foraminal height, segmental and global lumbar lordosis postoperatively (p < 0.05). 47 out 49 patients (96%) showed evidence for fusion at the 12 months follow-up. Cage dislocation was found in 1 of 80 implanted cages (1%), which required revision surgery. Two dural tears occurred intraoperatively, which have been fixed. Another two patients needed surgical revision due to infection. The overall complication rate was 10% (n = 5/49).

CONCLUSIONS

The current study delineates satisfactory clinical and radiological results by using a novel articulating TLIF-cage. The implant-related complication rate was acceptable with low revision rate.

Minimally invasive transforaminal lumbar interbody fusion for dual-segment lower lumbar degenerative disease

Introduction

Transforaminal lumbar interbody fusion (TLIF) has been widely used to treat degenerative lumbar diseases. The PIPELINE Access minimally invasive system allows reduction of the trauma to the patient during TLIF.

Aim

To present our preliminary experience with the minimally invasive TLIF (mTLIF) technique performed on the first 7 patients with dual-segment lower lumbar degenerative disease (DS-LLDD).

Material and methods

A retrospective analysis was performed on the first 7 patients with spondylolisthesis and foraminal stenosis operated upon between January 2011 and June 2013. All 7 patients underwent fusion at the L4-S1 level.

Results

The pedicle screws entered the spinal canal in 2 patients. No other intraoperative or postoperative complications occurred with the mTLIF technique. Improvement of the leading symptom in the early postoperative period (sciatica: 7/7, low back pain: 7/7) was achieved in all patients. The mean improvements in the visual analog scale scores for low back and leg pain were 5.1 and 5.7 points, respectively. The mean Oswestry Disability Index scores were 52% (range: 20–74%) before surgery and 27% (range: 10–48%) at the 3-month follow-up (mean improvement: 25%). The average hospital stay was reduced to 6 days.

Conclusions

Our initial experience suggests that the mTLIF technique is a viable method for treating DS-LLDD. Nevertheless, longer observations on larger groups of patients are needed to reliably evaluate the safety of the method and sustainability of the results.

Controllable Risk Factors for Neurologic Complications in Posterior Lumbar Interbody Fusion as Revision Surgery

BACKGROUND

The main concern with revision lumbar surgery is the possibility of neurologic complications. This retrospective study was conducted to clarify the risk factors, especially the effects of nerve stretching, for postoperative neurologic complications in posterior lumbar interbody fusion (PLIF) without excessive nerve retraction by bilateral total facetectomy as revision surgery.

METHODS

Between 2005 and 2015, 50 consecutive patients underwent revision PLIF for recurrent stenosis or recurrent disc herniation. The patients were divided into two groups: patients with neurological complications (NC group) and patients without neurological complications (non-NC group). Radiological examinations to evaluate the magnitude of nerve stretching included the following pre- and postoperative plain radiograph measurements: anterolisthesis at flexion, intervertebral lordosis in the neutral position, and posterior disc height in the neutral position.

RESULTS

Sixteen patients (32%) had neurological complications. The decrease in intervertebral lordosis was significantly greater in the NC group than that in the non-NC group (0.8° vs. -1.5°, P<0.05). Distraction of the posterior disc height was significantly greater in the NC group than that in the non-NC group (5.0 mm vs. 2.6 mm, P < 0.01). Neurological complications were seen in all patients with a decrease in intervertebral lordosis >3° and distraction of the posterior disc height >3 mm.

CONCLUSIONS

Decreased intervertebral lordosis, and distraction of the posterior disc height, which can be controlled by surgeons, appear to be risk factors for neurological complications following revision PLIF. In revision PLIF, surgeons should create segmental lordosis without excessive disc height distraction.

Minimally Invasive Transforaminal Lumbar Interbody Fusion: An Attractive Option for Select Failed Backs

Study Design

Retrospective case series.

Purpose

To compare minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) outcomes in primary and revision surgeries.

Overview of Literature

Revision spinal fusion is often associated with an increased risk of approach-related complications. Patients can potentially benefit from the decreased approach-related morbidity associated with MI-TLIF.

Methods

Sixty consecutive MI-TLIF patients (20 failed back [Fa group], 40 primary [Pr group]) who underwent surgery between January 2011 and May 2012 were reviewed after Institutional Review Board approval to compare operative times, blood loss, complications, Oswestry Disability Index (ODI) scores, and Visual Analog Scale (VAS) scores for back and leg pain before surgery and at the last follow-up.

Results

Nineteen revision surgeries were compared with 36 primary surgeries. One failed back and four primary patients were excluded because of inadequate data. The mean follow-up times were 28 months and 24 months in the Pr and Fa groups, respectively. The mean pre- and postoperative ODI scores were 53.18 and 20.23 in the Pr group and 52.01 and 25.72 in the Fa group, respectively (ODI percentage change: Pr group, 60.36%±29.73%; Fa group, 69.32%±13.72%; p=0.304, not significant). The mean pre- and postoperative VAS scores for back pain were 4.77 and 1.75 in the Pr group and 4.1 and 2.0 in the Fa group, respectively, and the percentage changes were statistically significant (VAS back pain percentage change: Pr group, 48.78±30.91; Fa group, 69.32±13.72; p=0.027). The mean pre- and postoperative VAS scores for leg pain were 6.52 and 1.27 in the Pr group and 9.5 and 1.375 in the Fa group, respectively (VAS leg pain percentage change: Pr group, 81.07±29.39; Fa group, 75.72±15.26; p=0.538, not significant). There were no statistically significant differences in operative time and estimated blood loss and no complications.

Conclusions

MI-TLIF outcomes were comparable between primary and revision surgeries. The inherent technique of MI-TLIF is particularly suitable for select failed backs because it exploits the intact paramedian corridor.

Salvage Strategy for Failed Spinal Fusion Surgery Using Lumbar Lateral Interbody Fusion technique: A Technical Note

INTRODUCTION

Failed spinal fusion surgery sometimes requires salvage surgery when symptomatic, especially with postsurgical decrease in intervertebral disc height followed by foraminal stenosis. For such cases, an anterior approach to lumbar lateral interbody fusion (LLIF) provides safe, direct access to the pathological disc space and a potential improvement in the fusion rate. One LLIF approach, oblique lateral interbody fusion (OLIF), targets the oblique lateral window of the intervertebral discs to achieve successful lateral interbody fusion. The current technical note describes spinal revision surgery using the OLIF procedure.

TECHNICAL NOTE

The subjects were patients with leg pain and/or lower back pain derived from decreased intervertebral height followed by foraminal stenosis due to failed spinal fusion surgery. These patients underwent additional OLIF surgery and posterior fusion with no additional posterior direct decompression. Their outcomes were evaluated using the Japanese Orthopaedic Association (JOA) scores at baseline and final follow-up. Bony union was also evaluated using computed tomography images at final follow-up. Six subjects were evaluated, with two representative cases described in detail. Four patients had an adjacent segment disorder, and the other two patients had pseudarthrosis due to postoperative infection. The mean JOA score improved from 5.7 ± 5.4 to 21.2 ± 2.3, with a mean recovery rate of 65.0%. All cases showed intervertebral bony union.

CONCLUSIONS

We introduced a salvage strategy for failed posterior spine fusion surgery cases using the OLIF procedure. Patients effectively achieved recovered intervertebral and foraminal height with no additional posterior direct decompression.

[Minimally invasive extraforaminal lumbar interbody fusion]

OBJECTIVES

The objective of the present study was to determine the indications, surgical technique, results, and complications of minimally invasive extraforaminal lumbar interbody fusion (ELIF).

INTRODUCTION

ELIF is characterized as removal of the superior articular process (SAP) to access the intra-canalicular root and disc through Kambin's triangle.

METHODS

A retrospective study was conducted of 40 patients operated upon between 2013 and 2015. Patients with low back pain or root pain due to degenerative disc disease, spondylolisthesis grade 1 and 2, recurrent disc herniation, and recess-foraminal stenosis were included. A visual analogue scale (VAS), the Oswestry index, the Weiner scale and the modified MacNab criteria were used to assess pain, clinical and functional results and patient satisfaction one year after surgery. Complications were documented and rated according to their severity, in four degrees.

RESULTS

We operated on 25 women and 15 men of average age 57 years. Of the forty, 47.5% were treated for spondylolisthesis, 25% by recess foraminal stenosis. In total, 54 interbody cages and 188 percutaneous pedicle screws were placed; and the mean duration of surgery was 245 (±25.4) minutes. The mean hospitalization time was 3.5 (±0.49) days. We observed nine Grade 1 and one Grade 2 complication. The mean preoperative ODI score was 51.9 ± 4.96, which improved to 12.2 ± 3.19 at one year (P < 0.0001). The mean VAS low back pain rating improved from 8.81 ± 0.62 to 2.12 ± 0.89 (P < 0.0001). By one year post-operatively, 77.5% of the patients had fusion (Bridwell grade 1 or 2).

CONCLUSIONS

ELIF is a safe and effective surgical approach. Satisfactory clinical outcomes, comparable to traditional techniques, can be achieved with facet resection limited to the superior articular process.

Minimal invasive lumbar spine revision surgery at distance from the dura and postsurgical scar tissue: Extraforaminal Lumbar Interbody Fusion (ELIF)

Lumbar spine revision surgery is considered as challenging and related to longer operation time and complications because of the loss of anatomical landmarks and the formation of postoperative epidural fibrosis. Minimal invasive lumbar spinal surgery techniques have been refined over the last 5 years but the reexposure of the dura, the formation of postsurgical scar tissue and related dural tears remain a source of complications. For lumbar spinal revision surgery we advocate the minimal invasive Extraforaminal Lumbar Interbody Fusion (ELIF) technique. It employs a working corridor of 45° relative to the midline. This angle permits bypassing laterally the dural sac and postoperative epidural fibrosis so that dural tears do not occur. ELIF is performed without an expandable tubular retractor system, it is atraumatic following the natural intermuscular cleavage plane between the multifidus muscle and the longissimus thoracis muscle pars lumborum. Postoperatively the muscles do not show signs atrophy or fatty degeneration. In case of discectomy alone there is no need for the removal of the facets, if intracanalar lesions are targeted the partial removal of the superior facet is sufficient. ELIF represents an alternative to posterior lumbar interbody fusion (PLIF), conventional open transforaminal lumbar interbody fusion (TLIF), and minimal invasive (MIS) TLIF for lumbar spinal revision surgery.

Outcomes of Minimally Invasive Surgery Compared to Open Posterior Lumbar Instrumentation and Fusion

INTRODUCTION

Degenerative spine disease is increasingly common. There are many spinal fusion techniques used to treat degenerative spine disease. This study aims to compare the functional outcome of open versus minimally invasive surgery (MIS) technique in posterior lumbar instrumentation and fusion in degenerative spine disease and to evaluate the perioperative outcome and complications between MIS and open surgery.

MATERIALS AND METHODS

This is an observational cross-sectional study conducted on all degenerative spine disease patients who underwent both methods of posterior lumbar instrumentation and fusion from 2010 to 2014 by the Orthopedic and Neurosurgery Department, Sarawak General Hospital. The analyzed variables were method of surgery and the levels involved, demographic data, estimated blood loss, duration of operation, length of hospitalization, visual analog scale of back pain and radicular pain preoperative, postoperative 1 month, 3 months, 6 months, 1 year, and functional outcome.

RESULTS

One hundred and twenty-two patients underwent posterior lumbar instrumentation and fusion from 2010 to 2014. Seventy patients were subjected to MIS transforaminal lumbar interbody fusion (TLIF) and 52 open TLIF. Total 89 patients underwent single level of lumbar fusion with sixty patients in MIS group and 29 in open surgeries. MIS TLIF has less estimated blood loss and shorter hospitalization and longer operation time compared to open TLIF, which were statistically significance. MIS TLIF has statistically significance better functional outcome based on Oswestry disability index, Modified NASS score, and RAND 36-item Health Survey 1.0 score. Complications such as infection, new onsets of neurological, and dural tear are equal in both methods of surgery.

CONCLUSION

This study concluded that MIS has better functional outcome compared to open TLIF with shorter hospitalization, faster return to work, and less estimated blood loss.

Extreme lateral interbody fusion in spinal revision surgery: clinical results and complications

PURPOSE OF THE STUDY

To evaluate clinical outcomes and complications of extreme lumbar interbody fusion (XLIF) in spinal revision surgery comparing our data with the available literature evidence about other fusion techniques.

MATERIALS AND METHODS

Retrospective analysis of patients underwent revision surgery with XLIF as interbody fusion technique. Demographic, comorbidity, surgical data, clinical results, and intraoperative and postoperative complications were recorded.

RESULTS

36 patients, with a minimum follow-up of 28 ± 11.5 months, were included in the analysis. 41 levels were fused with XLIF. The mean number of previous spine surgery was 1.5 ± 0.7. Mean improvement in back pain and leg pain on VAS was 5.6 ± 1.4 (p < 0.01) and 3.5 ± 2 (p < 0.01), respectively. Mean improvement in the ODI score was 30.3 ± 7.3 (p < 0.01). 1 vertebral endplate fracture during interbody space preparation was reported during lateral approach. 5 patients (13.8%) complained quadriceps weakness and anterior thigh hypoesthesia fully recovered after 3 months from surgery, and in one case, a transient contralateral radiculopathy was observed. No implant failure was detected at final follow-up.

CONCLUSIONS

XLIF is a reasonably safe and effective fusion technique in revision surgery that allows valid arthrodesis avoiding scarred tissue created by previous surgical approaches. Especially, XLIF reduces the risk of nerve root lesions, postoperative radiculitis, and durotomies compared to posterior fusion techniques.

Minimally Invasive Extraforaminal Lumbar Interbody Fusion for Revision Surgery: A Technique through Kambin's Triangle

OBJECTIVE

The purpose of this study was to evaluate the clinical outcomes of minimally invasive extraforaminal lumbar interbody fusion (ELIF) for revision surgery.

METHODS

From January 2011 to December 2012, 12 patients who underwent minimally invasive ELIF through the Kambin's triangle for revision surgery were included in this study. All patients underwent the surgical procedure in the following sequence: (1) epidural anesthesia, (2) exposing the Kambin's triangle toward the lateral part of the dura (partial resection of the superior articular process), (3) bilateral cage insertion for reinforcement of stabilization and fusion, and (4) percutaneous transpedicular screwing. Clinical outcomes were assessed using the visual analogue scale (VAS), and Oswestry disability index (ODI). Imaging and clinical findings including surgical techniques, clinical outcomes, and related complications were depicted and analyzed.

RESULTS

The mean age of the patients (5 men, 7 women) was 60.7±13.4 years, and the mean follow-up period was 27.1±4.9 months. The mean VAS (back and leg) score improved significantly at final follow-up. The mean ODI score decreased as follows: preoperative, 76.78±6.08; 3 months after the surgery, 37.74±6.67; and at final follow-up, 29.91±2.98. Two patients presented with transient nerve root irritation, but there were no cases of incidental dural tear or serious infection. No significant neurological deterioration or major complication was noted in any of the patients.

CONCLUSION

Minimally invasive ELIF for revision surgery is an effective surgical option with a low complication rate.

Minimally invasive lateral interbody fusion for the treatment of rostral adjacent-segment lumbar degenerative stenosis without supplemental pedicle screw fixation

Object

Adjacent-segment degeneration and stenosis are common in patients who have undergone previous lumbar fusion. Treatment typically involves a revision posterior approach, which requires management of postoperative scar tissue and previously implanted instrumentation. A minimally invasive lateral approach allows the surgeon to potentially reduce the risk of these hazards. The technique relies on indirect decompression to treat central and foraminal stenosis and placement of a graft with a large surface area to promote robust fusion and stability in concert with the surrounding tensioned ligaments. The goal in this study was to determine if lateral interbody fusion without supplemental pedicle screws is effective in treating adjacent-segment disease.

Methods

For a 30-month study period at two institutions, the authors obtained all cases of lumbar fusion with new back and leg pain due to adjacent-segment stenosis and spondylosis failing conservative measures. All patients had undergone minimally invasive lateral interbody fusion from the side of greater leg pain without supplemental pedicle screw fixation. Patients were excluded from the study if they had undergone surgery for a nondegenerative etiology such as infection or trauma. They were also excluded if the intervention involved supplemental posterior instrumented fusion with transpedicular screws. Postoperative metrics included numeric pain scale (NPS) scores for leg and back pain. All patients underwent dynamic radiographs and CT scanning to assess stability and fusion after surgery.

Results

During the 30-month study period, 21 patients (43% female) were successfully treated using minimally invasive lateral interbody fusion without the need for subsequent posterior transpedicular fixation. The mean patient age was 61 years (range 37–87 years). Four patients had two adjacent levels fused, while the remainder had single-level surgery. All patients underwent surgery without conversion to a traditional open technique, and recombinant human bone morphogenetic protein–2 was used in the interbody space in all cases. The mean follow-up was 23.6 months. The mean operative time was 86 minutes, and the mean blood loss was 93 ml. There were no major intraoperative complications, but one patient underwent subsequent direct decompression in a delayed fashion. The leg pain NPS score improved from a mean of 6.3 to 1.9 (p < 0.01), and the back pain NPS score improved from a mean of 7.5 to 2.9 (p < 0.01). Intervertebral settling averaged 1.7 mm. All patients had bridging bone on CT scanning at the last follow-up, indicating solid bony fusion.

Conclusions

Adjacent-segment stenosis and spondylosis can be treated with a number of different operative techniques. Lateral interbody fusion provides an attractive alternative with reduced blood loss and complications, as there is no need to re-explore a previous laminectomy site. In this limited series a minimally invasive lateral approach provided high fusion rates when performed with osteobiological adjuvants.

Minimally invasive transforaminal lumbar interbody fusion with unilateral pedicle screw fixation: comparison between primary and revision surgery

Minimally invasive surgery with a transforaminal lumbar interbody fusion (MIS TLIF) is an important minimally invasive fusion technique for the lumbar spine. Lumbar spine reoperation is challenging and is thought to have greater complication risks. The purpose of this study was to compare MIS TLIF with unilateral screw fixation perioperative results between primary and revision surgeries. This was a prospective study that included 46 patients who underwent MIS TLIF with unilateral pedicle screw. The patients were divided into two groups, primary and revision MIS TLIF, to compare perioperative results and complications. The two groups were similar in age, sex, and level of operation, and were not significantly different in the length of follow-up or clinical results. Although dural tears were more common with the revision group (primary 1; revision 4), operation time, blood loss, total perioperative complication, and fusion rates were not significantly different between the two groups. Both groups showed substantial improvements in VAS and ODI scores one year after surgical treatment. Revision MIS TLIF performed by an experienced surgeon does not necessarily increase the risk of perioperative complication compared with primary surgery. MIS TLIF with unilateral pedicle screw fixation is a valuable option for revision lumbar surgery.