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Fushimi K, Miyagawa T, Iwai C, Nozawa S, Iinuma N, Tanaka R, Shirai G, Tanahashi H, Yokoi T, Akiyama H. Transforaminal Lumbar Interbody Fusion with Double Banana Cages: Clinical Evaluations and Finite Element Model Analysis. Global Spine J 2024; 14:2031-2038. [PMID: 36944178 DOI: 10.1177/21925682231165709] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/23/2023] Open
Abstract
STUDY DESIGN Clinical and basic study. OBJECTIVES This study aimed to investigate whether transforaminal lumbar interbody fusion (TLIF) using 2 banana-shaped cages leads to good clinical outcomes. METHODS First, we conducted a clinical study to compare outcomes among patients who underwent TLIF using different types or numbers of cages. Propensity matched patients in each group were reviewed. Thirty-four patients who underwent surgery with 2 bullet-shaped cages (group A), 34 with a banana-shaped cage (group B), and 34 with 2 banana-shaped cages (group C) were compared. Twelve months after the surgery, bony fusion and cage subsidence were evaluated. RESULTS The mean amount of cage subsidence was 14.9% in group A, 19.9% in group B, and 11.8% in group C. Subsidence in group B was significantly greater than that in group C (P < .01). Radiological bony fusion was not achieved in 2 cases in group B. Second, we performed a finite element model (FEM) analysis to determine the biomechanical stress of the vertebral endplate by comparing the single-banana cage construct with a double banana-shaped cage construct. FEM analysis showed that the maximum stress of the endplate in the single-cage model was 1.72-times greater than the maximum stress in the double-cage model. Furthermore, the maximal stress in the single-cage model was significantly higher than in the double-cage model during lumbar extension and side bending. CONCLUSION This study showed that TLIF with double banana-shaped cages led to good clinical outcomes with less cage subsidence, probably because of decreased mechanical stress on the vertebral endplate.
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Affiliation(s)
- Kazunari Fushimi
- Department of Orthopaedic Surgery, Spine Surgery Center, Gifu Prefectural General Medical Center, Gifu, Japan
- Department of Orthopaedic Surgery, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Takaki Miyagawa
- Department of Orthopaedic Surgery, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Chizuo Iwai
- Department of Orthopaedic Surgery, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Satoshi Nozawa
- Department of Orthopaedic Surgery, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Nobuki Iinuma
- Department of Orthopaedic Surgery, Spine Surgery Center, Gifu Prefectural General Medical Center, Gifu, Japan
| | - Ryo Tanaka
- Department of Orthopaedic Surgery, Spine Surgery Center, Gifu Prefectural General Medical Center, Gifu, Japan
| | - Goshi Shirai
- Department of Orthopaedic Surgery, Spine Surgery Center, Gifu Prefectural General Medical Center, Gifu, Japan
| | - Hiroyuki Tanahashi
- Department of Orthopaedic Surgery, Spine Surgery Center, Gifu Prefectural General Medical Center, Gifu, Japan
| | - Tatsuo Yokoi
- Department of Orthopaedic Surgery, Spine Surgery Center, Gifu Prefectural General Medical Center, Gifu, Japan
| | - Haruhiko Akiyama
- Department of Orthopaedic Surgery, Gifu University Graduate School of Medicine, Gifu, Japan
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Hajilo P, Imani B, Zandi S, Mehrafshan A, Khazaei S. The comparison study of laminectomy with unilateral and bilateral pedicle screws fixation and laminectomy alone without fusion interbody in young patients with lumbar spinal stenosis: A randomized clinical trial. Heliyon 2024; 10:e35435. [PMID: 39170337 PMCID: PMC11336607 DOI: 10.1016/j.heliyon.2024.e35435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2024] [Revised: 07/25/2024] [Accepted: 07/29/2024] [Indexed: 08/23/2024] Open
Abstract
Background There are many reports about the risk factors for recurrence after laminectomy surgery. Some surgeons use unilateral and bilateral fusion to provide sufficient stability to the lumbar spine. However, its strength, safety, and effectiveness in young patients are not widely known. Therefore, this study was conducted to compare surgical methods of laminectomy with unilateral and bilateral fixation and laminectomy alone without interbody fusion in young patients with lumbar spinal stenosis. Methods 90 patients eligible for lumbar spinal stenosis surgery were selected through convenience sampling and randomly divided into three groups: laminectomy without fixation (A), laminectomy with unilateral fixation (B), and bilateral fixation (C). Pain, functional disability, quality of life, recurrent disc, adjacent segment disease (ASD), and fusion rate were evaluated and compared among the three groups six months post-surgery. The data were analyzed using SPSS version 16. Results Six months after surgery, the mean score of functional disability in the bilateral group was significantly higher than the other groups (12.92 (3.30) vs 5.52 (1.91) and 4.30 (1.84), P < 0.05). Also, the highest mean score of pain after surgery was observed in the bilateral group (4.33 (0.70) vs 1.81(0.68) and 1.63(0.56), P < 0.05). The mean score of quality of life in the unilateral group was significantly higher than the other groups (87.81 (5.67) vs 68.58 (3.08) and 56.07 (4.04), P < 0.05). No significant difference was observed between the groups (P > 0.05) regarding fusion, recurrent disc herniation, and adjacent segment disease. Conclusions Unilateral fixation provides the same benefits as bilateral fixation but has the additional benefits of being less invasive and minimizing the disadvantages of other investigated techniques during and after surgery.
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Affiliation(s)
- Parisa Hajilo
- Student Research Committee, Hamadan University of Medical Sciences, Hamadan, Iran
| | - Behzad Imani
- Department of Operating Room, School of Paramedicine, Hamadan University of Medical Sciences, Hamadan, Iran
| | - Shirdel Zandi
- Department of Operating Room, School of Paramedicine, Hamadan University of Medical Sciences, Hamadan, Iran
| | - Ali Mehrafshan
- Department of Neurosurgery, Nekuii Forghani Hospital University of Medical Sciense Qom, Qom, Iran
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Issa TZ, Lee Y, Heard J, Henry TW, McCurdy MA, Siegel N, Zaworksi C, Dambly J, Canseco JA, Hilibrand AS, Vaccaro AR, Schroeder GD, Mangan J, Lambrechts M, Kepler CK. An evaluation of fusion status following lumbar fusion surgery utilizing multi-planar computed tomography. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2024:10.1007/s00586-024-08408-1. [PMID: 39095491 DOI: 10.1007/s00586-024-08408-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Revised: 03/11/2024] [Accepted: 07/09/2024] [Indexed: 08/04/2024]
Abstract
PURPOSE To report the rate of fusion in a sample of patients undergoing lumbar fusion surgery and assess interrater reliability of computed tomography (CT)-based parameters for the assessment of fusion. METHODS All adult patients who underwent lumbar fusion surgery from 2017 to 2021 were retrospectively identified. Patient demographics and surgical characteristics were collected through chart review of the electronic medical records. CT scans were reviewed independently by two attending spine surgeons and two spine fellows. Fusion was defined as evidence of bone bridging in any one of (1) posterolateral gutters, (2) facets, or (3) interbody (when applicable) on any CT views. Evidence of screw haloing was indicative of nonunion. Interrater reliability was determined using cohen's kappa. Afterwards, a consensus agreement for each component of fusion was reached between participants. RESULTS The overall fusion rate among all procedures was 63/69 (91.3%). Overall 22/25 (88.0%) TLIF, 16/19 (84.2%) PLDF, 3/3 (100%) LLIF, and 22/22 (100%) circumferential fusions experienced a successful fusion. Interrater reliability was good for interbody fusion (k = 0.734) and moderate for all other measures (k = 0.561 for posterolateral fusion; k = 0.471 for facet fusion; k = 0.458 for screw haloing). Overall, interrater reliability as to whether a patient had a fusion or nonunion was moderate (k = 0.510). CONCLUSION There was only moderate interrater reliability across most radiographic measures used in assessing lumbar fusion status. Reliability was highest when evaluating the presence of interbody fusion. The majority of fusions occurred across the facet joints.
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Affiliation(s)
- Tariq Z Issa
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, PA, USA.
- Department of Orthopaedic Surgery, Mount Sinai Hospital, New York, NY, USA.
| | - Yunsoo Lee
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Jeremy Heard
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Tyler W Henry
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Michael A McCurdy
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Nicholas Siegel
- Department of Orthopaedic Surgery, Johns Hopkins University, Baltimore, MD, USA
| | - Caroline Zaworksi
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Julia Dambly
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Jose A Canseco
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Alan S Hilibrand
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Alexander R Vaccaro
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Gregory D Schroeder
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - John Mangan
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Mark Lambrechts
- Department of Orthopaedic Surgery, Washington University Hospital, St. Louis, MO, USA
| | - Christopher K Kepler
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, PA, USA
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Daher M, Aoun M, El-Sett P, Kreichati G, Kharrat K, Sebaaly A. Unilateral Versus Bilateral Cages in Lumbar Interbody Fusions: A Meta-Analysis of Clinical and Radiographic Outcomes. World Neurosurg 2024; 186:158-164. [PMID: 38561031 DOI: 10.1016/j.wneu.2024.03.142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2024] [Accepted: 03/25/2024] [Indexed: 04/04/2024]
Abstract
BACKGROUND Bilateral cages are often used for interbody fusion. However, this procedure may not be possible in some cases making unilateral cages a reasonable alternative. The literature remains divided on the clinical and radiological distinctions when comparing unilateral to bilateral cages in lumbar interbody fusion. Thus, this meta-analysis will analyze the clinical and radiographic outcomes between these 2 groups. METHODS PubMed, Cochrane, and Google Scholar (page 1-20) were searched till January 2024. The clinical outcomes evaluated were the incidence of adverse events, surgery-related parameters, and patient reported outcomes. RESULTS Lower rates of pseudoarthrosis, subsidence, were reported in the bilateral cages group (P = 0.01, P = 0.001, respectively) whereas shorter operative time (OR time), and lower estimated blood loss were seen in unilateral cage group (P < 0.001, and P = 0.003). There was no statistically significant difference in the remaining analyzed outcomes. CONCLUSIONS Unilateral cages were shown to be superior due to their reduced OR time and estimated blood loss. As for the higher rate of pseudoarthrosis, this outcome may not be related to the cage numbers and it did not affect clinical outcomes. Nevertheless, one must consider other factors such as radiographic sagittal parameters before making a surgical decision.
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Affiliation(s)
- Mohammad Daher
- Faculty of medicine, Saint Joseph University, Beirut, Lebanon; Department of Orthopedic Surgery, Brown University, Providence, Rhode Island, USA
| | - Marven Aoun
- Faculty of medicine, Saint Joseph University, Beirut, Lebanon
| | - Pierre El-Sett
- Faculty of medicine, Saint Joseph University, Beirut, Lebanon
| | - Gaby Kreichati
- Faculty of medicine, Saint Joseph University, Beirut, Lebanon; Department of Orthopedic Surgery, Hotel Dieu de France Hospital, Beirut, Lebanon
| | - Khalil Kharrat
- Department of Orthopedic Surgery, Hotel Dieu de France Hospital, Beirut, Lebanon
| | - Amer Sebaaly
- Faculty of medicine, Saint Joseph University, Beirut, Lebanon; Department of Orthopedic Surgery, Hotel Dieu de France Hospital, Beirut, Lebanon.
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Capo G, Calvanese F, Vandenbulcke A, Zaed I, Di Carlo DT, Cao R, Barrey CY. Lateral-PLIF for spinal arthrodesis: concept, technique, results, complications, and outcomes. Acta Neurochir (Wien) 2024; 166:123. [PMID: 38451339 DOI: 10.1007/s00701-024-06024-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2023] [Accepted: 02/13/2024] [Indexed: 03/08/2024]
Abstract
BACKGROUND Posterior lumbar interbody fusion (PLIF) surgery represents an effective option to treat degenerative conditions in the lumbar spine. To reduce the drawbacks of the classical technique, we developed a variant, so-called Lateral-PLIF, which we then evaluated through a prospective consecutive series of patients. METHODS All adult patients treated at our institute with single or double level Lateral-PLIF for lumbar degenerative disease from January to December 2017 were prospectively collected. Exclusion criteria were patients < 18 years of age, traumatic patients, active infection, or malignancy, as well as unavailability of clinical and/or radiological follow-up data. The technique consists of insert the cages bilaterally through the transition zone between the central canal and the intervertebral foramen, just above the lateral recess. Pre- and postoperative (2 years) questionnaires and phone interviews (4 years) assessed pain and functional outcomes. Data related to the surgical procedure, postoperative complications, and radiological findings (1 year) were collected. RESULTS One hundred four patients were selected for the final analysis. The median age was 58 years and primary symptoms were mechanical back pain (100, 96.1%) and/or radicular pain (73, 70.2%). We found a high fusion rate (95%). A statistically significant improvement in functional outcome was also noted (ODI p < 0.001, Roland-Morris score p < 0.001). Walking distance increased from 812 m ± 543 m to 3443 m ± 712 m (p < 0.001). Complications included dural tear (6.7%), infection/wound dehiscence (4.8%), and instrument failure (1.9%) but no neurological deterioration. CONCLUSIONS Lateral-PLIF is a safe and effective technique for lumbar interbody fusion and may be considered for further comparative study validation with other techniques before extensive use to treat lumbar degenerative disease.
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Affiliation(s)
- Gabriele Capo
- Department of Spine and Spinal Cord Surgery, Pierre Wertheimer Hospital, Hospices Civils de Lyon, 59 Boulevard Pinel, 696777, Lyon-Bron, France
- IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano, Milan, Italy
| | - Francesco Calvanese
- Department of Spine and Spinal Cord Surgery, Pierre Wertheimer Hospital, Hospices Civils de Lyon, 59 Boulevard Pinel, 696777, Lyon-Bron, France.
- Department of Neurosurgery, Helsinki University Hospital and University of Helsinki, Haartmaninkatu 4, 00290, Helsinki, Finland.
| | - Alberto Vandenbulcke
- Department of Spine and Spinal Cord Surgery, Pierre Wertheimer Hospital, Hospices Civils de Lyon, 59 Boulevard Pinel, 696777, Lyon-Bron, France
| | - Ismail Zaed
- Department of Spine and Spinal Cord Surgery, Pierre Wertheimer Hospital, Hospices Civils de Lyon, 59 Boulevard Pinel, 696777, Lyon-Bron, France
| | - Davide Tiziano Di Carlo
- Department of Neurosurgery, Azienda Ospedaliero Universitaria Pisana (AOUP), Via Paradisa 2, 56100, Pisa, Italy
- Department of Translational Research On New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Roberta Cao
- Department of Neuroradiology, Pierre Wertheimer Hospital, GHE, Hospices Civils de Lyon, and Claude Bernard University of Lyon 1, 59 Boulevard Pinel, 696777, Lyon-Bron, France
| | - Cédric Y Barrey
- Department of Spine and Spinal Cord Surgery, Pierre Wertheimer Hospital, Hospices Civils de Lyon, 59 Boulevard Pinel, 696777, Lyon-Bron, France
- Laboratory of Biomechanics, ENSAM, Arts Et Metiers ParisTech, 153 Boulevard de L'Hôpital, 75013, Paris, France
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Chen C, Liu C, Wu Z, Su J. How I do it? Uniportal full-endoscopic transforaminal lumbar interbody fusion with a complete reduction for L5 isthmic grade 2 spondylolisthesis. Acta Neurochir (Wien) 2023; 165:3969-3974. [PMID: 37946000 DOI: 10.1007/s00701-023-05886-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Accepted: 10/30/2023] [Indexed: 11/12/2023]
Abstract
BACKGROUND Endoscopic transforaminal lumbar interbody fusion (endo-TLIF) with bilateral percutaneous pedicle screw fixation is an emerging option for low-grade spondylolisthesis. However, uniportal full endo-TLIF with a complete reduction for high-grade spondylolisthesis is challenging. METHODS We attempted uniportal endo-TLIF for L5 isthmic grade 2 spondylolisthesis with a complete reduction, and have described the procedures, with a discussion of the indications, limitations, potential complications, and ways to avoid complications. CONCLUSION We had successfully completed a perfect reduction of L5 isthmic grade 2 spondylolisthesis via uniportal endo-TLIF with bilateral pedicle screw fixation. Uniportal endo-TLIF is suitable for isthmic grade 2 spondylolisthesis.
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Affiliation(s)
- Changxian Chen
- Department of Spinal Surgery, Quanzhou Orthopedic-Traumatological Hospital, Quanzhou, Fujian Province, China
| | - Chunhua Liu
- Department of Spinal Surgery, Quanzhou Orthopedic-Traumatological Hospital, Quanzhou, Fujian Province, China.
| | - Zhiqiang Wu
- Department of Spinal Surgery, Quanzhou Orthopedic-Traumatological Hospital, Quanzhou, Fujian Province, China
| | - Jinzhi Su
- Department of Spinal Surgery, Quanzhou Orthopedic-Traumatological Hospital, Quanzhou, Fujian Province, China
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Park SC, Bae JS, Jung SO, Sung KH, Chung HJ. Comparison of Unilateral versus Bilateral Instrumented Transforaminal Lumbar Interbody Fusion in Lumbar Degenerative Diseases: A Minimum of 5-Year Follow-Up. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1898. [PMID: 38003948 PMCID: PMC10673228 DOI: 10.3390/medicina59111898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Revised: 10/21/2023] [Accepted: 10/24/2023] [Indexed: 11/26/2023]
Abstract
Background and Objective: There is a paucity of literature comparing unilateral instrumented transforaminal lumbar interbody fusion (UITLIF) with bilateral instrumented TLIF (BITLIF) regarding radiological alignment, including the coronal balance, even though UITLIF might have asymmetric characteristics in the coronal plane. This retrospective study aimed to compare the clinical and long-term radiological outcomes of 1-level UITLIF and BITLIF in lumbar degenerative diseases (LDD) including lumbar spinal stenosis with or without spondylolisthesis (degenerative or spondylolytic). Materials and Methods: Patients who underwent 1-level UITLIF with two rectangular polyetheretherketone (PEEK) cages or BITLIF between November 2009 and June 2016 by four surgeons with ≥5 years of follow-up at a single hospital were included. We compared the clinical and radiological outcomes between the UITLIF and BITLIF. Results: In total, 63 and 111 patients who underwent UITLIF and BITLIF, respectively, were enrolled. The median follow-up was 85.55 months (range: 60-130). The UITLIF group had a significantly shorter operation time (185.0 [170.0-210.0] vs. 225.0 [200.0-265.0], p < 0.001) and lower estimated blood loss (300.0 [250.0-500.0] vs. 550.0 [400.0-800.0], p < 0.001) than the BITLIF group. Regarding the clinical outcomes, there were no significant differences in the intermittent claudication score (p = 0.495) and Kirkaldy-Willis criteria (p = 0.707) at 1 year postoperatively. The interval changes in the local coronal Cobb angle at the index level, L1-S1 lordotic angle, and coronal off-balance from the immediate postoperative radiograph to the last follow-up were not significantly different (p = 0.687, p = 0.701, and p = 0.367, respectively). Conclusions: UITLIF with two rectangular PEEK cages may provide comparable clinical outcomes and radiological longevity including coronal alignment to BITLIF in 1-level LDD. In addition, UITLIF has advantages over BITLIF in terms of operative time and blood loss.
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Affiliation(s)
- Sung Cheol Park
- Department of Orthopedic Surgery, Bumin Hospital Seoul, Seoul 07590, Republic of Korea;
| | - Jae Seong Bae
- Department of Spine Surgery, Seoul 21st Century Spine Hospital, Seoul 06654, Republic of Korea; (J.S.B.); (S.O.J.); (K.-H.S.)
| | - Seon Ok Jung
- Department of Spine Surgery, Seoul 21st Century Spine Hospital, Seoul 06654, Republic of Korea; (J.S.B.); (S.O.J.); (K.-H.S.)
| | - Kyeong-Hoon Sung
- Department of Spine Surgery, Seoul 21st Century Spine Hospital, Seoul 06654, Republic of Korea; (J.S.B.); (S.O.J.); (K.-H.S.)
| | - Hoon-Jae Chung
- Department of Orthopedic Surgery, Bumin Hospital Seoul, Seoul 07590, Republic of Korea;
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Zhu C, Liang J, Pan H, Zhang W. Far lateral lumbar interbody fusion with unilateral pedicle screw fixation and double traversing cages using a biportal endoscopic technique. Acta Neurochir (Wien) 2023; 165:2165-2169. [PMID: 37439886 DOI: 10.1007/s00701-023-05702-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 06/26/2023] [Indexed: 07/14/2023]
Abstract
BACKGROUND Transforaminal lumbar interbody fusion (TLIF) with a single cage and bilateral pedicle screw fixation results in decreased stability or increased risk of cage displacement Wang and Guo (Comput Methods Biomech Biomed Eng, 24(3):308-319, 6). We succeeded in inserting double traversing cages with unilateral pedicle screw fixation (UPSF) during far lateral TLIF using unilateral biportal endoscopy (UBE). METHOD We attempted far lateral UBE-TLIF through two small incisions for degenerative lumbar spondylolisthesis with unilateral stenosis. With the help of novel instruments, far lateral UBE-TLIF with double traversing cages and UPSF was performed under tracheal intubation anaesthesia. CONCLUSIONS We successfully performed far lateral UBE-TLIF with double traversing cages and UPSF. This procedure may be an alternative minimally invasive method for treating lumbar instability.
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Affiliation(s)
- Chengyue Zhu
- Department of Orthopaedics, Hangzhou Traditional Chinese Medicine Hospital Affiliated to Zhejiang Chinese Medical University, Tiyuchang Road No. 453, Hangzhou, 310007, China
| | - Jiaming Liang
- Department of Orthopaedics, Hangzhou Traditional Chinese Medicine Hospital Affiliated to Zhejiang Chinese Medical University, Tiyuchang Road No. 453, Hangzhou, 310007, China
| | - Hao Pan
- Department of Orthopaedics, Hangzhou Traditional Chinese Medicine Hospital Affiliated to Zhejiang Chinese Medical University, Tiyuchang Road No. 453, Hangzhou, 310007, China
| | - Wei Zhang
- Department of Orthopaedics, Hangzhou Traditional Chinese Medicine Hospital Affiliated to Zhejiang Chinese Medical University, Tiyuchang Road No. 453, Hangzhou, 310007, China.
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Lambrechts MJ, Heard J, D'Antonio N, Bodnar J, Schneider G, Bloom E, Canseco J, Woods B, Kaye ID, Kurd M, Rihn J, Hilibrand A, Schroeder G, Vaccaro A, Kepler C. A Comparison of Radiographic Alignment between Bilateral and Unilateral Interbody Cages in Patients Undergoing Transforaminal Lumbar Interbody Fusion. Asian Spine J 2023; 17:666-675. [PMID: 37226381 PMCID: PMC10460650 DOI: 10.31616/asj.2022.0316] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2022] [Revised: 09/17/2022] [Accepted: 10/17/2022] [Indexed: 05/26/2023] Open
Abstract
STUDY DESIGN Retrospective cohort study. PURPOSE To compare radiographic outcomes between unilateral and bilateral cage placement in transforaminal lumbar interbody fusions (TLIF) and to determine if the rate of fusion at the 1-year postoperative point was different in patients who received bilateral versus unilateral cages. OVERVIEW OF LITERATURE There is no clear evidence to dictate whether bilateral or unilateral cages promote superior radiographic or surgical outcomes in TLIF. METHODS Patients >18 years old who underwent primary one- or two-level TLIFs at our institution were identified and propensitymatched in a 3:1 fashion (unilateral:bilateral). Patient demographics, surgical characteristics, and radiographic outcomes, including vertebral endplate obliquity, segmental lordosis, subsidence, and fusion status, were compared between groups. RESULTS Of the 184 patients included, 46 received bilateral cages. Bilateral cage placement was associated with greater subsidence (1.06±1.25 mm vs. 0.59±1.16 mm, p=0.028) and enhanced restoration of segmental lordosis (5.74°±14.1° vs. -1.57°±10.9°, p=0.002) at the 1-year postoperative point, while unilateral cage placement was associated with an increased correction of endplate obliquity (-2.02°±4.42° vs. 0.24°±2.81°, p<0.001). Bilateral cage placement was significantly associated with radiographic fusion on bivariate analysis (89.1% vs. 70.3%, p=0.018) and significantly predicted radiographic fusion on multivariable regression analysis (estimate, 1.35; odds ratio, 3.87; 95% confidence interval, 1.51-12.05; p=0.010). CONCLUSIONS Bilateral interbody cage placement in TLIF procedures was associated with restoration of lumbar lordosis and increased fusion rates. However, endplate obliquity correction was significantly greater for patients who received a unilateral cage.
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Affiliation(s)
- Mark James Lambrechts
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Jeremy Heard
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Nicholas D'Antonio
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - John Bodnar
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Gregory Schneider
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Evan Bloom
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Jose Canseco
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Barrett Woods
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Ian David Kaye
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Mark Kurd
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Jeffrey Rihn
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Alan Hilibrand
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Gregory Schroeder
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Alexander Vaccaro
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Christopher Kepler
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, Thomas Jefferson University Hospital, Philadelphia, PA, USA
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Xu L, Lin X, Wu C, Tan L. Is unilateral pedicle screw fixation as effective as bilateral pedicle screw fixation in transforaminal lumbar interbody fusion: a meta-analysis of randomized controlled trials. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2023; 32:700-711. [PMID: 36598572 DOI: 10.1007/s00586-022-07524-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 11/02/2022] [Accepted: 12/29/2022] [Indexed: 01/05/2023]
Abstract
PURPOSE This meta-analysis aimed to investigate whether unilateral pedicle screw fixation (UPSF) is comparable to bilateral pedicle screw fixation (BPSF) in transforaminal lumbar interbody fusion (TLIF) for lumbar degenerative diseases. METHODS Up to September 2022, established electronic literature databases including PubMed, Web of Science, EMBASE, and the Cochrane Library were systematically searched. Randomized controlled trials (RCTs) published in English that compared the efficacy of UPSF versus BPSF in TLIF were included. The methodological quality was evaluated, relevant data was extracted, and suitable meta-analysis was carried out. Data of fusion rate, complications, cage migration, visual analog scale (VAS), and Oswestry Disability Index (ODI), total blood loss (TBL), operation time, and hospital stay were extracted and analyzed. Pooled mean differences and risk ratio (RR) along with 95% confidence intervals (95% CI) were calculated for the results. RESULTS Ten RCTs including 614 patients (UPSF = 294, BPSF = 320) were included in our meta-analysis. There were no significant differences in terms of fusion rate, VAS (VAS-BP and VAS-LP), ODI, complications, or hospital stay between UPSF and BPSF groups (P > 0.05, respectively). The UPSF group clearly had the advantage of less blood loss (SMD = -2.99, 95% CI [-4.54, -1.45], P = 0.0001) and operation time (SMD = -2.05, 95% CI [-3.10, -1.00], P = 0.0001). However, UPSF increased cage migration more than BPSF (10.7% vs 4.8%, RR = 2.23, 95% CI [1.07, 4.65], P = 0.03). CONCLUSION According to the findings of this meta-analysis, UPSF is just as effective as BPSF in TLIF and may reduce blood loss and operation time. Nevertheless, UPSF may result in more cage migration than BPSF.
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Affiliation(s)
- Lian Xu
- Department of Orthopedics, Zigong Fourth People's Hospital, Tanmulin Street 19#, Zigong, 643000, Sichuan Province, China
| | - Xu Lin
- Department of Orthopedics, Zigong Fourth People's Hospital, Tanmulin Street 19#, Zigong, 643000, Sichuan Province, China.
| | - Chao Wu
- Department of Orthopedics, Zigong Fourth People's Hospital, Tanmulin Street 19#, Zigong, 643000, Sichuan Province, China
| | - Lun Tan
- Department of Orthopedics, Zigong Fourth People's Hospital, Tanmulin Street 19#, Zigong, 643000, Sichuan Province, China
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Sun L, Tian AX, Ma JX, Ma XL. Successful outcomes of unilateral vs bilateral pedicle screw fixation for lumbar interbody fusion: A meta-analysis with evidence grading. World J Clin Cases 2022; 10:13337-13348. [PMID: 36683615 PMCID: PMC9851015 DOI: 10.12998/wjcc.v10.i36.13337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Revised: 11/16/2022] [Accepted: 12/05/2022] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Whether it’s better to adopt unilateral pedicle screw (UPS) fixation or to use bilateral pedicle screw (BPS) one for lumbar degenerative diseases is still controversially undetermined.
AIM To make a comparison between UPS and BPS fixation as to how they work efficaciously and safely in patients suffering from lumbar degenerative diseases.
METHODS We have searched a lot in the databases through 2020 with index terms such as “unilateral pedicle screw fixation” and “bilateral pedicle screw fixation.” Only randomized controlled trials and some prospective cohort studies could be found, yielding 15 studies. The intervention was unilateral pedicle screw fixation; Primarily We’ve got outcomes of complications and fusion rates. Secondarily, we’ve achieved outcomes regarding total blood loss, operative time, as well as length of stay. Softwares were installed and utilized for subgroup analysis, analyzing forest plots, sensitivity, heterogeneity, forest plots, publication bias, and risk of bias.
RESULTS Fifteen previous cases of study including 992 participants have been involved in our meta-analysis. UPS had slightly lower effects on fusion rate [relative risk (RR) = 0.949, 95%CI: 0.910 to 0.990, P = 0.015], which contributed mostly to this meta-analysis, and similar complication rates (RR = 1.140, 95%CI: 0.792 to 1.640, P = 0.481), Δ visual analog scale [standard mean difference (SMD) = 0.178, 95%CI: -0.021 to 0.378, P = 0.080], and Δ Oswestry disability index (SMD = -0.254, 95%CI: -0.820 to 0.329, P = 0.402). In contrast, an obvious difference has been observed in Δ Japanese Orthopedic Association (JOA) score (SMD = 0.305, 95%CI: 0.046 to 0.563, P = 0.021), total blood loss (SMD = -1.586, 95%CI: -2.182 to -0.990, P = 0.000), operation time (SMD = -2.831, 95%CI: -3.753 to -1.909, P = 0.000), and length of hospital stay (SMD = -0.614, 95%CI: -1.050 to -0.179, P = 0.006).
CONCLUSION Bilateral fixation is more effective than unilateral fixation regarding fusion rate after lumbar interbody fusion. However, JOA, operation time, total blood loss, as well as length of stay were improved for unilateral fixation.
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Affiliation(s)
- Lei Sun
- Orthopedic Research Institute, Tianjin Hospital, Tianjin University, Tianjin 300050, China
| | - Ai-Xian Tian
- Orthopedic Research Institute, Tianjin Hospital, Tianjin University, Tianjin 300050, China
| | - Jian-Xiong Ma
- Orthopedic Research Institute, Tianjin Hospital, Tianjin University, Tianjin 300050, China
| | - Xin-Long Ma
- Orthopedic Research Institute, Tianjin Hospital, Tianjin University, Tianjin 300050, China
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12
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Changes in lumbar lordosis and predicted minimum 5-year surgical outcomes after short-segment transforaminal lumbar interbody fusion. Sci Rep 2022; 12:14353. [PMID: 35999248 PMCID: PMC9399127 DOI: 10.1038/s41598-022-18679-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Accepted: 08/17/2022] [Indexed: 11/29/2022] Open
Abstract
Although most patients who undergo transforaminal lumbar interbody fusion (TLIF) show favorable surgical results, some still have unfavorable results for various reasons. This study aimed to investigate the influence of differences in lumbar lordosis (LL) between the standing and supine positions (DiLL: supine LL–standing LL) on minimum 5-year surgical outcomes after short-segment TLIF. Ninety-one patients with lumbar degenerative disease who underwent short-segment TLIF (1–2 levels) were categorized based on preoperative differences in LL as DiLL (+) and DiLL (−). Comparison and correlation analyses were performed. The incidence of adjacent segment disease (ASD) by radiology (R-ASD) and symptomatic ASD (S-ASD), bony fusion rates, and pre- and postoperative clinical scores (visual analog scale [VAS]; Japanese Orthopaedic Association [JOA] score; Oswestry disability index (ODI); and Nakai’s score) were evaluated. Postoperatively, VAS for low back pain (LBP) in the sitting position, JOA scores for LBP, lower leg pain, intermittent claudication, ODI, and Nakai’s score were significantly worse in the DiLL (+) group than in the DiLL (−) group. DiLL values were significantly correlated with VAS for LBP, ODI, and Nakai’s score, postoperatively. Positive DiLL values were associated with poorer postoperative outcomes. DiLL is a simple and useful method for predicting mid-term outcomes after TLIF.
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13
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Lynch CP, Cha EDK, Rush Iii AJ, Jadczak CN, Mohan S, Geoghegan CE, Singh K. Outcomes of Transforaminal Lumbar Interbody Fusion Using Unilateral Versus Bilateral Interbody Cages. Neurospine 2022; 18:854-862. [PMID: 35000341 PMCID: PMC8752695 DOI: 10.14245/ns.2142248.124] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Accepted: 03/28/2021] [Indexed: 01/03/2023] Open
Abstract
Objective To assess the impact of bilateral versus unilateral interbody cages on outcomes for minimally invasive transforaminal lumbar interbody fusion (MIS TLIF) procedures.
Methods A retrospective review for primary, elective, single-level MIS TLIF procedures with bilateral posterior instrumentation from 2008–2020 was performed. Patients were grouped according to unilateral or bilateral interbody cage use. Procedures performed without static interbody cages or indicated for trauma, infection, malignancy were excluded. Patient-reported outcomes (PROs) included visual analogue scale (VAS), Oswestry Disability Index, 12-item Short Form health survey physical composite score (SF-12 PCS), PatientReported Outcome Measurement Information System physical function (PROMIS-PF). PROs were collected preoperatively and postoperatively. Change in PROs (Δ) was calculated and compared between groups. Achievement of minimum clinically important difference (MCID) was calculated using established values from the literature. Achievement rates were compared between groups using logistic regression.
Results The study included 151 patients, with 111 unilateral and 40 bilateral cage placements. Charlson Comorbidity Index, diabetes, and insurance status differed between groups (p < 0.050). Prevalence of degenerative and isthmic spondylolisthesis (both p ≤ 0.002), operative level (p = 0.003), and postoperative length of stay (p = 0.022) significantly differed between groups. The unilateral group had lower 1-year arthrodesis rates (p = 0.035). Preoperative VAS leg (p = 0.017) and SF-12 PCS (p = 0.045) were worse for the unilateral group. ΔPROMIS-PF was greater for the bilateral group at 2 years (p = 0.001). Majority of patients achieved an overall MCID for all PROs, except VAS leg (bilateral group).
Conclusion While preoperative status and postoperative arthrodesis rates differed, patients achieved an MCID at similar rates regardless of use of unilateral or bilateral cages.
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Affiliation(s)
- Conor P Lynch
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Elliot D K Cha
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Augustus J Rush Iii
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Caroline N Jadczak
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Shruthi Mohan
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Cara E Geoghegan
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Kern Singh
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
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14
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Ohyama S, Aoki Y, Inoue M, Nakajima T, Sato Y, Watanabe A, Takahashi H, Kubota G, Nakajima A, Saito J, Eguchi Y, Orita S, Nakagawa K, Ohtori S. Predictors of Spontaneous Restoration of Lumbar Lordosis after Single-Level Transforaminal Lumbar Interbody Fusion for Degenerative Lumbar Diseases. Spine Surg Relat Res 2021; 5:397-404. [PMID: 34966866 PMCID: PMC8668222 DOI: 10.22603/ssrr.2020-0195] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Accepted: 01/20/2021] [Indexed: 12/31/2022] Open
Abstract
Introduction Preoperative factors that predict postoperative restoration of lumbar lordosis (LL) are not well understood. To investigate whether preoperative postural correction of LL, sagittal malalignment, or lumbar flexibility are associated with the postoperative restoration of LL in patients treated with a single-level transforaminal lumbar interbody fusion (TLIF), a retrospective cohort study was conducted. Methods We enrolled 104 patients (mean age: 67.5±10.7 years old; 47 men and 57 women) with lumbar degenerative diseases treated with a single-level TLIF. The pre- and postoperative LL were examined using lateral radiographs in the standing position and computed tomography (CT) images in the supine position. The correlation between postoperative LL restoration and preoperative postural correction of LL (difference in LL between the standing and supine positions: D-LL), sagittal imbalance (pelvic incidence minus LL: PI-LL), and lumbar flexibility (difference in LL between the flexion and extension postures) were analyzed. Patients were divided into two groups according to the D-LL (D-LL≥0° and D-LL<0°). The rates of postoperative LL restoration (postoperative LL-preoperative LL in standing) were compared between the two groups. Results Multiple regression analysis performed after adjustment for age, gender, body mass index, and cage angle revealed that postoperative LL restoration was significantly correlated with D-LL (p<0.001), but not with PI-LL, and lumbar flexibility. Patients with a preoperative D-LL≥0° showed a significantly greater increase of LL after TLIF (7.1°±11.2°) than those with D-LL<0° (1.4°±6.6°) (p=0.003). Conclusions A preoperative evaluation of a lateral radiograph or CT taken in the supine position is useful in predicting postoperative improvement of sagittal alignment. Postoperative improvement of sagittal spinopelvic alignment would be expected when LL is corrected in the supine position preoperatively. Surgeons should pay attention to the postural correction of LL when performing short-segment fusion surgery for lumbar degenerative disease with sagittal malalignment.
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Affiliation(s)
- Shuhei Ohyama
- Department of Orthopaedic Surgery, Eastern Chiba Medical Center, Togane, Japan
| | - Yasuchika Aoki
- Department of Orthopaedic Surgery, Eastern Chiba Medical Center, Togane, Japan.,Department of General Medical Science, Chiba University, Chiba, Japan
| | - Masahiro Inoue
- Department of Orthopaedic Surgery, Eastern Chiba Medical Center, Togane, Japan.,Department of General Medical Science, Chiba University, Chiba, Japan
| | - Takayuki Nakajima
- Department of Orthopaedic Surgery, Eastern Chiba Medical Center, Togane, Japan.,Department of General Medical Science, Chiba University, Chiba, Japan
| | - Yusuke Sato
- Department of Orthopaedic Surgery, Eastern Chiba Medical Center, Togane, Japan.,Department of General Medical Science, Chiba University, Chiba, Japan
| | - Atsuya Watanabe
- Department of Orthopaedic Surgery, Eastern Chiba Medical Center, Togane, Japan.,Department of General Medical Science, Chiba University, Chiba, Japan
| | - Hiroshi Takahashi
- Department of Orthopaedic Surgery, University of Tsukuba, Tsukuba, Japan
| | - Go Kubota
- Department of Orthopaedic Surgery, Sawara Prefectural Hospital, Katori, Japan
| | - Arata Nakajima
- Department of Orthopaedic Surgery, Toho University Sakura Medical Center, Sakura, Japan
| | - Junya Saito
- Department of Orthopaedic Surgery, Toho University Sakura Medical Center, Sakura, Japan
| | - Yawara Eguchi
- Department of Orthopaedic Surgery, Chiba University, Chiba, Japan
| | - Sumihisa Orita
- Department of Orthopaedic Surgery, Chiba University, Chiba, Japan
| | - Koichi Nakagawa
- Department of Orthopaedic Surgery, Toho University Sakura Medical Center, Sakura, Japan
| | - Seiji Ohtori
- Department of Orthopaedic Surgery, Chiba University, Chiba, Japan
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15
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Ohyama S, Aoki Y, Inoue M, Kubota G, Watanabe A, Nakajima T, Sato Y, Takahashi H, Nakajima A, Saito J, Eguchi Y, Orita S, Inage K, Shiga Y, Nakagawa K, Ohtori S. Influence of Preoperative Difference in Lumbar Lordosis Between the Standing and Supine Positions on Clinical Outcomes After Single-level Transforaminal Lumbar Interbody Fusion: Minimum 2-year Follow-up. Spine (Phila Pa 1976) 2021; 46:1070-1080. [PMID: 33492084 DOI: 10.1097/brs.0000000000003955] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVE The aim of this study was to investigate whether a preoperative difference in lumbar lordosis (D-LL) between the standing and supine positions is associated with clinical outcomes after transforaminal lumbar interbody fusion (TLIF). SUMMARY OF BACKGROUND DATA Several factors have been reported to be associated with surgical outcomes after TLIF. However, the association between preoperative D-LL and clinical outcomes after TLIF is unknown. METHODS We enrolled 45 lumbar degenerative disease patients (mean age: 65.7 ± 11.3 years old; 24 males) treated with single-level TLIF. Surgical outcomes were assessed using Oswestry disability index, visual analog scale (VAS; low back pain [LBP], lower-extremity pain, numbness, LBP in motion, in standing, and in sitting), Japanese Orthopaedic Association Back Pain Evaluation Questionnaire, Japanese Orthopaedic Association score for intermittent claudication (JOA score), and Nakai's scoring system. The preoperative D-LL between the standing radiograph and computed tomography (CT) in the supine position was defined as LL in supine CT-standing radiograph. Patients were divided into two groups according to D-LL value (D-LL >-4°, and D-LL ≤-4°). Clinical outcomes were compared between the groups, and correlations between preoperative D-LL and clinical outcomes were analyzed. RESULTS There were no significant differences in preoperative clinical parameters between the two groups. Postoperative VASs for lower extremity pain, numbness, LBP in standing, and JOA score in D-LL >-4° group were significantly worse than in the D-LL ≤-4° group (P < 0.05). Preoperative D-LL showed a weak correlation with postoperative lower extremity pain and numbness (P < 0.05). CONCLUSION This study revealed that lumbar degenerative disease patients, who have greater preoperative kyphotic lumbar alignment in the standing versus supine position, tend to have postoperative residual symptoms after TLIF. A preoperative comparison of lateral radiographs between the standing and supine positions is useful to predict patients' postoperative residual symptoms.Level of Evidence: 3.
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Affiliation(s)
- Shuhei Ohyama
- Department of Orthopaedic Surgery, Eastern Chiba Medical Center, Togane, Chiba, Japan
| | - Yasuchika Aoki
- Department of Orthopaedic Surgery, Eastern Chiba Medical Center, Togane, Chiba, Japan
- Department of General Medical Science, Graduate School of Medicine, Chiba University, Chiba-city, Chiba, Japan
| | - Masahiro Inoue
- Department of Orthopaedic Surgery, Eastern Chiba Medical Center, Togane, Chiba, Japan
- Department of General Medical Science, Graduate School of Medicine, Chiba University, Chiba-city, Chiba, Japan
| | - Go Kubota
- Department of Orthopaedic Surgery, Sawara Prefectural Hospital, Katori, Chiba, Japan
| | - Atsuya Watanabe
- Department of Orthopaedic Surgery, Eastern Chiba Medical Center, Togane, Chiba, Japan
- Department of General Medical Science, Graduate School of Medicine, Chiba University, Chiba-city, Chiba, Japan
| | - Takayuki Nakajima
- Department of Orthopaedic Surgery, Eastern Chiba Medical Center, Togane, Chiba, Japan
- Department of General Medical Science, Graduate School of Medicine, Chiba University, Chiba-city, Chiba, Japan
| | - Yusuke Sato
- Department of Orthopaedic Surgery, Eastern Chiba Medical Center, Togane, Chiba, Japan
- Department of General Medical Science, Graduate School of Medicine, Chiba University, Chiba-city, Chiba, Japan
| | - Hiroshi Takahashi
- Department of Orthopaedic Surgery, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Arata Nakajima
- Department of Orthopaedic Surgery, Toho University Sakura Medical Center, Sakura, Chiba, Japan
| | - Junya Saito
- Department of Orthopaedic Surgery, Toho University Sakura Medical Center, Sakura, Chiba, Japan
| | - Yawara Eguchi
- Department of Orthopaedic Surgery, Graduate School of Medicine, Chiba University, Chiba-city, Chiba, Japan
| | - Sumihisa Orita
- Department of Orthopaedic Surgery, Graduate School of Medicine, Chiba University, Chiba-city, Chiba, Japan
| | - Kazuhide Inage
- Department of Orthopaedic Surgery, Graduate School of Medicine, Chiba University, Chiba-city, Chiba, Japan
| | - Yasuhiro Shiga
- Department of Orthopaedic Surgery, Graduate School of Medicine, Chiba University, Chiba-city, Chiba, Japan
| | - Koichi Nakagawa
- Department of Orthopaedic Surgery, Toho University Sakura Medical Center, Sakura, Chiba, Japan
| | - Seiji Ohtori
- Department of Orthopaedic Surgery, Graduate School of Medicine, Chiba University, Chiba-city, Chiba, Japan
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Faulkner JE, Khalifeh K, Hara J, Ozgur B. Interspinous Process (ISP) Devices in Comparison to the Use of Traditional Posterior Spinal Instrumentation. Cureus 2021; 13:e13886. [PMID: 33868850 PMCID: PMC8043769 DOI: 10.7759/cureus.13886] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/14/2021] [Indexed: 11/05/2022] Open
Abstract
A systematic literature review was conducted on studies comparing interspinous process (ISP) devices to traditional methods of posterior spinal instrumentation (pedicle screw-rod construct), in terms of indications of use, complications, pain assessment, estimated blood loss, length of hospital stay, reoperation rates, and return to work. The objective was to analyze, evaluate and summarize the current published literature on the proposed efficacy and clinical and surgical long-term outcomes of the ISP device in comparison to the traditional posterior spinal instrumentation (pedicle screw-rod construct). The ISP device is a minimally invasive and less disruptive alternative to traditional methods of posterior spinal instrumentation (pedicle screw-rod construct). However, very few published literature studies to date have reported the comparison of ISPs in terms of efficacy and clinical and surgical outcomes, to traditional posterior spinal instrumentation. A systematic literature review was performed in PubMed and Google Scholar to evaluate the results of published research that meet the defined inclusion and exclusion criteria and to analyze clinical indications and surgical outcomes of the ISP device compared to traditional methods of posterior spinal instrumentation (pedicle screw-rod construct). Inclusion criteria included keywords such as "ISP device, ISP, posterior spinal instrumentation, pedicle screw fixation, bilateral pedicle screws, interbody fusion with posterior spinal instrumentation, lumbar spinal stenosis, and posterior lumbar stability." No exclusion criteria keywords were included in this literature review. ISPs provide a high degree of spinal stability in multiple planes, including a decreased range of motion restriction in flexion-extension, and comparable results to bilateral pedicle screw (BPS) in axial rotation. The use of the ISP device in adjunct with an interbody fusion, ensures less estimated operative blood loss (EBL), shorter operative time, less bony exposure without the need for extensive soft tissue or muscle retraction, a decrease in the rate of pseudoarthrosis, and a shorter length of hospital stay (LOHS) when compared to the traditional posterior instrumentation (pedicle screw-rod construct). Based on the various published literature reviews noted throughout this research paper, it is safe to conclude, that an ISP device that is accompanied by interbody fusion, including posterior approaches posterior lumbar interbody fusion (PLIF) and transforaminal lumbar interbody fusion (TLIF); anterior approaches such as anterior interbody fusion (ALIF), and lateral approaches including direct lateral interbody fusion (DLIF), lateral lumbar interbody fusion (LLIF), extreme lateral interbody fusion (XLIF), is considered a credible and an effective minimally invasive option for the treatment of mild to moderate lumbar stenosis and stable low-grade spondylolisthesis (less than two) when compared to the traditional posterior spinal instrumentation of a pedicle screw-rod construct. Surgeons that are relatively new to the ISP technologies for spinal instrumentation would likely benefit from more clinical and surgical evidence of safety and efficacy in published peer-reviewed medical literature. Further clinical trials are needed to manifest the efficacy of ISPs regarding postoperative outcomes when compared to traditional posterior instrumentation techniques (pedicle screw-rod construct) with adjunct interbody fusions.
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Affiliation(s)
- Jordan E Faulkner
- Neurological Surgery, Hoag Memorial Hospital, Newport Beach, USA
- Neurosurgery, ONE Brain and Spine Center, Irvine, USA
| | | | - Junko Hara
- Neurosurgery, Pickup Family Neurosciences Institute, Newport Beach, USA
| | - Burak Ozgur
- Neurosurgery, Hoag Memorial Hospital, Newport Beach, USA
- Neurosurgery, Pickup Family Neurosciences Institute, Newport Beach, USA
- Neurosurgery, ONE Brain and Spine Center, Irvine, USA
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17
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Chang CC, Chou D, Pennicooke B, Rivera J, Tan LA, Berven S, Mummaneni PV. Long-term radiographic outcomes of expandable versus static cages in transforaminal lumbar interbody fusion. J Neurosurg Spine 2021; 34:471-480. [PMID: 33186902 DOI: 10.3171/2020.6.spine191378] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2019] [Accepted: 06/30/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Potential advantages of using expandable versus static cages during transforaminal lumbar interbody fusion (TLIF) are not fully established. The authors aimed to compare the long-term radiographic outcomes of expandable versus static TLIF cages. METHODS A retrospective review of 1- and 2-level TLIFs over a 10-year period with expandable and static cages was performed at the University of California, San Francisco. Patients with posterior column osteotomy (PCO) were subdivided. Fusion assessment, cage subsidence, anterior and posterior disc height, foraminal dimensions, pelvic incidence (PI), segmental lordosis (SL), lumbar lordosis (LL), pelvic incidence-lumbar lordosis mismatch (PI-LL), pelvic tilt (PT), sacral slope (SS), and sagittal vertical axis (SVA) were assessed. RESULTS A consecutive series of 178 patients (with a total of 210 levels) who underwent TLIF using either static (148 levels) or expandable cages (62 levels) was reviewed. The mean patient age was 60.3 ± 11.5 years and 62.8 ± 14.1 years for the static and expandable cage groups, respectively. The mean follow-up was 42.9 ± 29.4 months for the static cage group and 27.6 ± 14.1 months for the expandable cage group. Within the 1-level TLIF group, the SL and PI-LL improved with statistical significance regardless of whether PCO was performed; however, the static group with PCOs also had statistically significant improvement in LL and SVA. The expandable cage with PCO subgroup had significant improvement in SL only. All of the foraminal parameters improved with statistical significance, regardless of the type of cages used; however, the expandable cage group had greater improvement in disc height restoration. The incidence of cage subsidence was higher in the expandable group (19.7% vs 5.4%, p = 0.0017). Within the expandable group, the unilateral facetectomy-only subgroup had a 5.6 times higher subsidence rate than the PCO subgroup (26.8% vs 4.8%, p = 0.04). Four expandable cages collapsed over time. CONCLUSIONS Expandable TLIF cages may initially restore disc height better than static cages, but they also have higher rates of subsidence. Unilateral facetectomy alone may result in more subsidence with expandable cages than using bilateral PCO, potentially because of insufficient facet release. Although expandable cages may have more power to induce lordosis and restore disc height than static cages, subsidence and endplate violation may negate any significant gains compared to static cages.
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Affiliation(s)
- Chih-Chang Chang
- Departments of1Neurosurgery and
- 3Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
- 5School of Medicine and
- 6Department of Biomedical Engineering, National Yang-Ming University, Taipei, Taiwan
| | | | | | - Joshua Rivera
- 4University of California, San Francisco, California; and
| | | | - Sigurd Berven
- 2Orthopaedic Surgery, University of California, San Francisco, California
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Kato S, Terada N, Niwa O, Yamada M. Risk Factors Affecting Cage Retropulsion into the Spinal Canal Following Posterior Lumbar Interbody Fusion: Association with Diffuse Idiopathic Skeletal Hyperostosis. Asian Spine J 2020; 15:840-848. [PMID: 33371621 PMCID: PMC8696061 DOI: 10.31616/asj.2020.0434] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Accepted: 09/27/2020] [Indexed: 11/23/2022] Open
Abstract
Study Design This was a retrospective observational study. Purpose We identify risk factors, including physical and surgical factors, and comorbidities affecting cage retropulsion following posterior lumbar interbody fusion (PLIF). Overview of Literature Diffuse idiopathic skeletal hyperostosis (DISH) is considered a risk factor for reoperation after PLIF. We evaluated the effect of DISH on cage retropulsion into the spinal canal, which may require surgical revision for severe neurological disorders. Methods A total of 400 patients (175 men, 225 women) who underwent PLIF were observed for >1 year. Factors investigated included the frequency of cage retropulsion and surgical revision. In addition, physical (age, sex, disease), surgical (fusion and PLIF levels, cage number, grade 2 osteotomy), and comorbid (DISH, existing vertebral fracture) factors were compared between patients with and without cage retropulsion. Factors related to surgical revision during the observation period were also considered. Results Cage retropulsion occurred in 15 patients and surgical revision was performed in 11. Revisions included the replacement of pedicle screws (PSs) with larger screws in all patients and supplementary implants in 10. Among the patients with cage retropulsion, the average PLIF level was 2.7, with DISH present in nine patients and existing vertebral fractures in six. Factors affecting cage retropulsion were diagnoses of osteoporotic vertebral fracture, multilevel fusion, single-cage insertion, grade 2 osteotomy, presence of DISH, and existing vertebral fracture. Multivariable analysis indicated that retropulsion of a fusion cage occurred significantly more frequently in patients with DISH and multilevel PLIF. Conclusions DISH and multilevel PLIF were significant risk factors affecting cage retropulsion. Revision surgery for cage retropulsion revealed PS loosening, suggesting that implant replacement was necessary to prevent repeat cage retropulsion after revision.
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Affiliation(s)
- Shinichi Kato
- Department of Orthopedic Surgery, Restorative Medicine of Neuro-Musculoskeletal System, School of Medicine, Fujita Health University, Nagoya, Japan
| | - Nobuki Terada
- Department of Orthopedic Surgery, Restorative Medicine of Neuro-Musculoskeletal System, School of Medicine, Fujita Health University, Nagoya, Japan
| | - Osamu Niwa
- Department of Orthopedic Surgery, Restorative Medicine of Neuro-Musculoskeletal System, School of Medicine, Fujita Health University, Nagoya, Japan
| | - Mitsuko Yamada
- Department of Orthopedic Surgery, Restorative Medicine of Neuro-Musculoskeletal System, School of Medicine, Fujita Health University, Nagoya, Japan
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Ahmed OEF, Morad SH, Abdelbar AS. Management of recurrent unilateral lumbar disc herniation in a single level: unilateral versus bilateral pedicle screws fixation with interbody fusion. THE EGYPTIAN JOURNAL OF NEUROLOGY, PSYCHIATRY AND NEUROSURGERY 2020. [DOI: 10.1186/s41983-020-0161-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Abstract
Background
Lumbar interbody fusion procedure is a recognized surgical technique in management of a variety of lumbar pathologies including recurrent lumbar disc prolapse. Interbody fusion augmented by pedicle screw fixation has been considered to improve fusion rates and clinical outcomes. Interbody fusion is commonly associated with better fusion potentials through applying the bone graft in the load bearing, vascular position of the anterior, and middle spinal columns. However, it still remains unknown whether interbody fusion with unilateral pedicle screw fixation (UPSF) is superior to that with bilateral pedicle screw fixation (BPSF).
Aim of the work
The aim of this study is to evaluate the efficacy and safety of unilateral versus bilateral pedicle screw fixation associated with interbody fusion for the management of single level unilateral recurrent lumbar disc prolapse as regard the clinical and biomechanical results, operation time, intraoperative blood loss, and postoperative stay.
Material and methods
This observational prospective comparative study of the two groups who were operated either unilateral (group A /15 patients) or bilateral (group B/15 patients) pedicle screw fixation with interbody fusion was done. Patients were followed up for 1, 6, ad 12 months.
Results
Significant improvement in functional outcome of the two groups was noted compared to preoperatively, except in early postoperative period where the back VAS and ODI in the unilateral group was better than bilateral group. However, on further follow up, no significant difference was noticed. There was no significant difference comparing fusion rate, complication rate, and duration of hospital stay between the two groups at postoperative follow-up. There was significantly less blood loss, and significantly shorter operation time in the unilateral PS fixation group as compared with the bilateral PS fixation group in our study.
Conclusion
Our study suggested that TLIF with unilateral PS fixation was as safe and effective as that with bilateral PS fixation for the management of recurrent single level lumbar disc prolapse; it showed better clinical outcome scores of ODI and back VAS, and a significant reduction of the intraoperative blood loss as well as the operation time, without significant differences considering fusion rate, complication rate, and duration of hospital stay between the two groups at postoperative follow-up. However, BPSF with TLIF likely causes more degeneration at the cranial adjacent segment compared with UPSF techniques. Nevertheless, the long-term follow up is required to demonstrate the impact of these findings.
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Massel DH, Mayo BC, Shifflett GD, Bohl DD, Louie PK, Basques BA, Long WW, Modi KD, Hijji FY, Narain AS, Singh K. Minimally Invasive Transforaminal Lumbar Interbody Fusion: Comparison of Isthmic Versus Degenerative Spondylolisthesis. Int J Spine Surg 2020; 14:115-124. [PMID: 32355615 DOI: 10.14444/7015] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
Background Minimally invasive transforaminal lumbar interbody fusion (MIS TLIF) is a common surgical procedure for treatment of degenerative spondylolisthesis (DS) but remains controversial for treatment of isthmic spondylolisthesis (IS). Few studies have compared IS and DS outcomes after MIS TLIF. Therefore, the objective of the current study was to compare outcomes of patients with IS and DS after MIS TLIF. Methods A retrospective cohort analysis was performed on a prospectively maintained database of patients who underwent a primary, 1-level MIS TLIF for grade I or II IS or DS. Grade I and II DS and grade I IS patients were treated with MIS TLIF via a unilateral tubular approach, whereas the grade II IS patients were treated via a bilateral tubular approach. Differences in patient demographics and preoperative characteristics were assessed using independent sample t tests and χ2 tests. The type of spondylolisthesis and its effect on postoperative outcomes was analyzed using Poisson regression with robust error variance (binary outcomes) or linear regression (continuous outcomes) adjusted for preoperative characteristics. Subgroup analysis comparing grade I IS versus DS and grade II IS versus DS was performed. Results A total of 223 patients were included (IS: 62 [27.8%]; DS: 161 [72.2%]). IS patients were younger (P < .001), had a lower comorbidity burden (P < .001), and a greater incidence of grade II spondylolisthesis (P < .001) at L5-S1 (P < .001) than the DS cohort. Patients with IS experienced longer operative times (P < .001) and lower, but not statistically significant, arthrodesis rates compared to the DS cohort. No differences were observed in the remaining preoperative patient characteristics, perioperative or postoperative outcomes. Conclusions Despite being younger and having a lower comorbidity burden than the DS cohort, similar outcomes were observed after MIS TLIF for IS patients. Level of Evidence 3. Clinical Relevance These results suggest MIS TLIF is an appropriate treatment option for IS patients despite the increased instability inherent with IS.
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Affiliation(s)
- Dustin H Massel
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Benjamin C Mayo
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Grant D Shifflett
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Daniel D Bohl
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Philip K Louie
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Bryce A Basques
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
| | - William W Long
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Krishna D Modi
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Fady Y Hijji
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Ankur S Narain
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Kern Singh
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
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Unilateral versus bilateral pedicle screw fixation in lumbar fusion: A systematic review of overlapping meta-analyses. PLoS One 2019; 14:e0226848. [PMID: 31860651 PMCID: PMC6924673 DOI: 10.1371/journal.pone.0226848] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Accepted: 12/04/2019] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVES To carry out a systematic review on the basis of overlapping meta-analyses that compare unilateral with bilateral pedicle screw fixation (PSF) in lumbar fusion to identify which study represents the current best evidence, and to provide recommendations of treatment on this topic. METHODS A comprehensive literature search in PubMed, Embase, and the Cochrane Library databases was conducted to identify meta-analyses that compare unilateral with bilateral PSF in lumbar fusion. Only meta-analyses exclusively covering randomized controlled trials were included. Study quality was evaluated using the Oxford Levels of Evidence and Assessment of Multiple Systematic Reviews (AMSTAR) instrument. Then, the Jadad decision algorithm was applied to select the highest-quality study to represent the current best evidence. RESULTS A total of 9 studies with Level II of evidence fulfilled the eligibility criteria and were included. The scores of AMSTAR criteria for them varied from 5 to 9 (mean 7.78). The current best evidence detected no significant differences between unilateral and bilateral PSF for short-segment lumbar fusion in the functional scores, length of hospital stay, fusion rate, and complication rate. However, unilateral PSF involved a remarkable decrease in operative time and blood loss but increase of cage migration when compared with bilateral PSF. CONCLUSIONS According to this systematic review, unilateral PSF is an effective method of fixation for short-segment lumbar fusion, has the advantages of reduced operative time and blood loss over bilateral PSF, but increases the risk of cage migration.
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Lin GX, Park CK, Hur JW, Kim JS. Time Course Observation of Outcomes between Minimally Invasive Transforaminal Lumbar Interbody Fusion and Posterior Lumbar Interbody Fusion. Neurol Med Chir (Tokyo) 2019; 59:222-230. [PMID: 31068542 PMCID: PMC6580044 DOI: 10.2176/nmc.oa.2018-0194] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
The purpose of this study is to compare the long-term patient-outcomes, spinal fusion, and incidence of adjacent segment degeneration (ASD) between minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) and open posterior lumbar interbody fusion (O-PLIF). We retrospectively reviewed 70 consecutive cases who underwent single-level MIS-TLIF or O-PLIF from March 2010 to July 2013. All the patients achieved a minimum of 5-year follow-up. Data collected for each patient included demographic data, perioperative data, and complications. Clinical outcomes were evaluated with Oswestry disability index and visual analogue scale (VAS). Radiological outcomes included fusion rate and ASD. About 34 patients of MIS-TLIF and 36 patients of O-PLIF were enrolled. Higher Charlson comorbidity index scores were noted in MIS-TLIF than in O-PLIF. Blood loss was significantly lower in MIS-TLIF than O-PLIF. There were significant improvements in clinical and radiological outcomes in both groups. At 6 months, in MIS-TLIF group had significantly lower VAS for back pain and disc height compared with in O-PLIF group. The fusion rate was similar between the two groups at 5-year follow-up. Although the total complication rates were similar between the two groups, both the incidence of ASD was significantly higher in O-PLIF group than MIS-TLIF group (P = 0.032). In conclusion, this study indicates that MIS-TLIF is comparable to O-PLIF in terms of fusion rates and clinical outcomes in single-segment degenerative lumbar diseases. In addition, compared with O-PLIF, MIS-TLIF has the advantages of lesser blood loss, faster recovery, and lower incidence of ASD.
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Affiliation(s)
- Guang-Xun Lin
- Department of Neurosurgery, Seoul St. Mary's Hospital, The Catholic University of Korea
| | - Chun-Kun Park
- Department of Neurosurgery, Good Doctor Teun Teun Hospital
| | - Jung-Woo Hur
- Department of Neurosurgery, Seoul St. Mary's Hospital, The Catholic University of Korea
| | - Jin-Sung Kim
- Department of Neurosurgery, Seoul St. Mary's Hospital, The Catholic University of Korea
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Lu P, Pan T, Dai T, Chen G, Shi KQ. Is unilateral pedicle screw fixation superior than bilateral pedicle screw fixation for lumbar degenerative diseases: a meta-analysis. J Orthop Surg Res 2018; 13:296. [PMID: 30466462 PMCID: PMC6249771 DOI: 10.1186/s13018-018-1004-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Accepted: 11/12/2018] [Indexed: 01/03/2023] Open
Abstract
Background To investigate whether unilateral pedicle screw fixation is superior than bilateral pedicle screw fixation for lumbar degenerative diseases. Methods Electronic databases including PubMed, Embase, and the Cochrane Library up to August 2018 were searched. All the high-quality randomized controlled trials (RCTs) and prospective clinical controlled studies comparing the unilateral pedicle screw fixation and bilateral pedicle screw fixation for lumbar degenerative diseases were enrolled in this study. Fusion rate was the main outcome. Stata 12.0 was used for the meta-analysis. Results Twelve RCTs including 808 patients (unilateral pedicle screw fixation = 393, bilateral pedicle screw fixation = 415) were included in our meta-analysis. There was a significant difference between unilateral pedicle screw fixation and bilateral pedicle screw fixation in terms of the fusion rate (risk ratio (RR) = 0.96, 95%CI [0.92, 1.00], P = 0.073), visual analog scale (VAS) at final follow-up, Oswestry Disability Index (ODI), Japanese Orthopedic Association scores (JOA), short-form health survey (SF-36), and length of hospital stay. Compared with bilateral pedicle screw fixation, unilateral pedicle screw fixation was associated with a reduction of the total blood loss and operation time (P < 0.05). Unilateral pedicle screw fixation was associated with an increase of the cage migration than bilateral pedicle screw fixation (17.1% vs 7.1%, RR = 2.40, 95% CI = 1.17 to 4.93; P = 0.017). Conclusions Unilateral pedicle screw fixation and bilateral pedicle screw fixation has similar fusion rate when treating for lumbar degenerative diseases. Our meta-analysis suggested that compared with bilateral pedicle screw fixation, unilateral pedicle screw fixation significantly reduced total blood loss and operation time for lumbar degenerative diseases. The use of unilateral pedicle screw for lumbar degenerative diseases increases the cage migration.
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Affiliation(s)
- Pei Lu
- Orthopedics Department, The Affiliated Wuxi No.2 People's Hospital of Nanjing Medical University, No. 68 Zhongshan Road, Wuxi, Jiangsu Province, 214000, China
| | - Ting Pan
- Orthopedics Department, The Affiliated Wuxi No.2 People's Hospital of Nanjing Medical University, No. 68 Zhongshan Road, Wuxi, Jiangsu Province, 214000, China
| | - Teng Dai
- Orthopedics Department, The Affiliated Wuxi No.2 People's Hospital of Nanjing Medical University, No. 68 Zhongshan Road, Wuxi, Jiangsu Province, 214000, China
| | - Gang Chen
- Orthopedics Department, The Affiliated Wuxi No.2 People's Hospital of Nanjing Medical University, No. 68 Zhongshan Road, Wuxi, Jiangsu Province, 214000, China
| | - Ke-Qin Shi
- Orthopedics Department, The Affiliated Wuxi No.2 People's Hospital of Nanjing Medical University, No. 68 Zhongshan Road, Wuxi, Jiangsu Province, 214000, China.
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Cao Y, Liang Y, Wan S, Jiang C, Jiang X, Chen Z. Pedicle Screw with Cement Augmentation in Unilateral Transforaminal Lumbar Interbody Fusion: A 2-Year Follow-Up Study. World Neurosurg 2018; 118:e288-e295. [PMID: 29969742 DOI: 10.1016/j.wneu.2018.06.181] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Revised: 06/20/2018] [Accepted: 06/21/2018] [Indexed: 10/28/2022]
Abstract
OBJECTIVE To evaluate safety and efficacy of pedicle screw with polymethyl methacrylate (PMMA) augmentation in unilateral transforaminal lumbar interbody fusion (uTLIF) in osteoporotic patients. METHODS We randomly divided 50 osteoporotic patients with degenerative lumbar diseases diagnosed between February 2014 and November 2015 into 2 groups. One group underwent standard uTLIF, and the other group underwent uTLIF with PMMA augmentation. All patients were scheduled to attend a series of regular follow-up evaluations. Oswestry Disability Index, Japanese Orthopaedic Association score, visual analog scale score, lumbar lordotic angle, segmental lordotic angle, and disc space height (DSH) at each follow-up were collected and analyzed. RESULTS The 2-year follow-up was completed by 24 patients in the uTLIF group and 23 patients in the PMMA group. Oswestry Disability Index, Japanese Orthopaedic Association score, and visual analog scale score showed significant improvements after surgery in both groups, with no significant difference between groups. DSH in the uTLIF group was 8.7 ± 2.3 mm and in the PMMA group was 10.7 ± 1.6 mm. Fusion rate in the uTLIF group was 19/24 and in the PMMA group was 21/23. DSH and fusion rate in the PMMA group were higher than those in the uTLIF group. No severe complications were observed after PMMA injection. CONCLUSIONS Pedicle screw with PMMA augmentation can increase fixation stability and reduce DSH loss in uTLIF. Moreover, PMMA in the vertebral body did not impede the interbody fusion ability in uTLIF.
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Affiliation(s)
- Yuanwu Cao
- Department of Orthopaedics, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yun Liang
- Department of Orthopaedics, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Shengcheng Wan
- Department of Orthopaedics, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Chun Jiang
- Department of Orthopaedics, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Xiaoxing Jiang
- Department of Orthopaedics, Zhongshan Hospital, Fudan University, Shanghai, China.
| | - Zixian Chen
- Department of Orthopaedics, Zhongshan Hospital, Fudan University, Shanghai, China.
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Ulutaş M, Özkaya M, Yaman O, Demir T. Do we need a transforaminal lumbar interbody fusion cage to increase the stability of functional spinal unit when comparing unilateral and bilateral fixation? Proc Inst Mech Eng H 2018; 232:655-664. [PMID: 29923451 DOI: 10.1177/0954411918783779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Transforaminal lumbar interbody fusion was an alternative to posterior lumbar interbody fusion for decompression surgeries. This study investigates the biomechanical responses of the unilateral and bilateral pedicle screw fixations with/without transforaminal lumbar interbody fusion cages under axial compression, flexion, and torsional loads. Ovine vertebrae were used in this study. Cadavers, randomly divided into five, were intact control group, bilateral pedicle screw fixation group, bilateral pedicle screw fixation group with transforaminal lumbar interbody fusion cage, unilateral pedicle screw fixation group, and unilateral pedicle screw fixation group with transforaminal lumbar interbody fusion cage. Axial compression, flexion, and torsion tests were performed on specimens. All study groups provided higher stiffness and yield load values than control group under axial compression. Addition of transforaminal lumbar interbody fusion cage to bilateral fixation increased the stiffness under axial compression. Moreover, additional use of transforaminal lumbar interbody fusion in unilateral fixation increased the yield load values under axial compression. Control group was the stiffest in flexion test. Placing a transforaminal lumbar interbody fusion cage to both unilateral and bilateral fixations did not significantly change the stiffness values. Additional transforaminal lumbar interbody fusion cage increased the yield moment of the bilateral fixation. In torsion test, control group had the highest stiffness and yield torque. The facet joints are the most important parts of the vertebrae on the stability. When comparing the bilateral and unilateral fixations with transforaminal lumbar interbody fusion addition, the more facet preserving approach has significantly higher stability under axial compression, flexion, and torsion. Unilateral fixation with transforaminal lumbar interbody fusion cage can be said biomechanically stable and advantageous fixation system because of the advantage on the less facet and soft tissue resection compared to bilateral fixation with transforaminal lumbar interbody fusion.
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Affiliation(s)
- Murat Ulutaş
- 1 Department of Neurosurgery, Sanko University, Gaziantep, Turkey
| | - Mustafa Özkaya
- 2 Mechanical Engineering Department, KTO Karatay University, Konya, Turkey
| | - Onur Yaman
- 3 Department of Neurosurgery, Koç University, Istanbul, Turkey
| | - Teyfik Demir
- 4 Department of Mechanical Engineering, TOBB University of Economics and Technology, Ankara, Turkey
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Du L, Sun XJ, Zhou TJ, Li YC, Chen C, Zhao CQ, Zhang K, Zhao J. The role of cage height on the flexibility and load sharing of lumbar spine after lumbar interbody fusion with unilateral and bilateral instrumentation: a biomechanical study. BMC Musculoskelet Disord 2017; 18:474. [PMID: 29162074 PMCID: PMC5696757 DOI: 10.1186/s12891-017-1845-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2017] [Accepted: 11/14/2017] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND One- and two-level lumbar interbody fusion with unilateral instrumentation is as effective as that with bilateral instrumentation. The height of the interbody cage influences the operated segment stability and the fusion technique success. The purpose of this research was to determine the effect of the fusion cage height (i.e. long and short) on both the stability (based on flexibility measures) and load sharing of the unilateral and bilateral instrumented transforaminal lumbar interbody fusion (TLIF) technique. METHODS The flexibility and load sharing tests were performed on seven human lumbar spines. Different configurations combining a long or short cage with a unilateral, bilateral, or no posterior fixation were used to stabilize the operated segment. Two sets of modular cages were designed for each type of test to simulate the long and short cages. During the flexibility test, a pure-moment load of 7.5 Nm was applied. The range of motion (ROM) was recorded for flexion-extension, lateral bending, and axial rotation. During the load sharing test, an axial-compression load of 400 N was applied. The load bearing of the cages was recorded using a cage-embedded load cell. RESULTS When the fusion cage height decreased 2 mm, the segment flexibility with unilateral fixation showed a significant increase in the ROM for flexion-extension, lateral bending, and axial rotation of 74.9, 83.8, and 175.2% (P < 0.01), respectively. In contrast, for bilateral fixation, the height decrease resulted in no significant change in ROM for flexion-extension (P = 0.686), lateral bending (P = 0.698), and axial rotation (P = 0.133). Using a short fusion cage, the load bearing decreased in 17.1, 21.5, and 54.1% (P < 0.05) for the cage alone, unilateral, and bilateral fixation, respectively. CONCLUSIONS A cage longer than the intervertebral space should be chosen to increase the stability and intervertebral graft load borne when performing TLIF with unilateral instrumentation.
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Affiliation(s)
- Lin Du
- Shanghai Key Laboratory of Orthopedic Implants, Department of Orthopedics, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, 639 Zhizaoju Road, Shanghai, 200011, People's Republic of China
| | - Xiao-Jiang Sun
- Shanghai Key Laboratory of Orthopedic Implants, Department of Orthopedics, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, 639 Zhizaoju Road, Shanghai, 200011, People's Republic of China
| | - Tang-Jun Zhou
- Shanghai Key Laboratory of Orthopedic Implants, Department of Orthopedics, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, 639 Zhizaoju Road, Shanghai, 200011, People's Republic of China
| | - Yuan-Chao Li
- School of Mechanical Engineering, Shanghai Jiao Tong University, 800 Dongchuan Road, Shanghai, 200240, People's Republic of China
| | - Chen Chen
- Shanghai Key Laboratory of Orthopedic Implants, Department of Orthopedics, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, 639 Zhizaoju Road, Shanghai, 200011, People's Republic of China
| | - Chang-Qing Zhao
- Shanghai Key Laboratory of Orthopedic Implants, Department of Orthopedics, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, 639 Zhizaoju Road, Shanghai, 200011, People's Republic of China
| | - Kai Zhang
- Shanghai Key Laboratory of Orthopedic Implants, Department of Orthopedics, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, 639 Zhizaoju Road, Shanghai, 200011, People's Republic of China
| | - Jie Zhao
- Shanghai Key Laboratory of Orthopedic Implants, Department of Orthopedics, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, 639 Zhizaoju Road, Shanghai, 200011, People's Republic of China.
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Ren C, Qin R, Sun P, Wang P. Effectiveness and safety of unilateral pedicle screw fixation in transforaminal lumbar interbody fusion (TLIF): a systematic review and meta-analysis. Arch Orthop Trauma Surg 2017; 137:441-450. [PMID: 28168642 DOI: 10.1007/s00402-017-2641-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2016] [Indexed: 01/03/2023]
Abstract
PURPOSE To evaluate the effectiveness and safety of unilateral pedicle screw fixation in transforaminal lumbar interbody fusion (TLIF) by comparing with bilateral pedicle screw fixation. MATERIALS AND METHODS PubMed, EMBASE, and the Cochrane Central Register of Controlled Trial database were used to search and identify clinical prospective trials that evaluated the efficacy and safety of unilateral fixation as compared with bilateral fixation in TLIF surgery. The methodological qualities of studies were assessed using the PEDro (Physiotherapy Evidence Database) score and Newcastle-Ottawa Scale. RESULTS Fourteen prospective studies comprising 954 participants were analyzed. Data synthesis show lower fusion rate (P = 0.03) and more cage migration (P = 0.04) in unilateral group compared to bilateral group. There was no significant difference in visual analog scale (VAS), Oswestry Disability Index (ODI), the Short Form 36 Health Survey (SF-36) physical component score (PCS), and length of hospital stay between unilateral and bilateral groups. The unilateral group had shorter operative time (P < 0.00001) and less blood loss (P = 0.0007). CONCLUSIONS Based on this systematic review and meta-analysis, the unilateral fixation in TLIF may achieve a similar clinical outcome and reduce blood loss and operative time when compared with that in bilateral fixation. However, the unilateral fixation may produce lower fusion rate and more cage migration than bilateral fixation in TLIF.
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Affiliation(s)
- Chunpeng Ren
- Department Orthoped, Lianyungang No.1 People's Hospital, Xuzhou Academy of Medical Sciences, 182 Tongguang Rd, Lianyungang, Jiangsu, 222002, People's Republic of China.
| | - Rujie Qin
- Department Orthoped, Lianyungang No.1 People's Hospital, Xuzhou Academy of Medical Sciences, 182 Tongguang Rd, Lianyungang, Jiangsu, 222002, People's Republic of China
| | - Penghao Sun
- Department Orthoped, Lianyungang No.1 People's Hospital, Xuzhou Academy of Medical Sciences, 182 Tongguang Rd, Lianyungang, Jiangsu, 222002, People's Republic of China
| | - Peng Wang
- Department Orthoped, Lianyungang No.1 People's Hospital, Xuzhou Academy of Medical Sciences, 182 Tongguang Rd, Lianyungang, Jiangsu, 222002, People's Republic of China
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Ulutaş M, Çınar K, Seçer M. The surgery and early postoperative radicular pain in cases with multifocal lumbar disc herniation. Medicine (Baltimore) 2017; 96:e6238. [PMID: 28248889 PMCID: PMC5340462 DOI: 10.1097/md.0000000000006238] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Persistence of postoperative radicular pain after surgery for multifocal disc herniation (MFDH) is a clinical problem. This study aims to evaluate the effects of a combined treatment approach compared with unilateral stabilization on early postoperative radicular pain in patients with MFDH.Age, sex, level of operation, clinical findings, and radicular pain visual analogue scale (VAS) scores before surgery in the early postoperative period and at 3 months after surgery were retrospectively reviewed for 20 cases of multifocal lumbar disc herniation. The combined approach (translaminar and far lateral) was used for 13 cases. Seven cases underwent transforaminal lumbar interbody fusion (TLIF) and unilateral transpedicular stabilization following total facetectomy.The mean age of the sample was 49.4 ± 10.1 years and the female-to-male ratio was 8:12. The mean VAS scores for radicular pain in cases treated with the combined approach were 8.2, 4.07, and 2.3 in the preoperative and early postoperative periods and 3 months after surgery, respectively. The mean score for radicular pain improved by 50.4% in the early postoperative period and by 72% in the late postoperative period. The mean VAS scores for radicular pain in cases who underwent TLIF and unilateral stabilization after facetectomy were 8.4, 2.1, and 1.4 in the preoperative and early postoperative periods and 3 months after surgery, respectively. The mean VAS score for radicular pain improved by 75% in the early postoperative period and by 83.3% in the late postoperative period.The combined approach is an effective alternative in cases with MFDH. TLIF and unilateral segmental stabilization provide substantial decompression and eliminate mechanical compression by conserving the height of the intervertebral foramen in the event that sufficient decompression is unable to obtain. We suggest that elimination of chemical mediators, particularly those causing pain in the dorsal ganglion, contributes to the absence of early radicular pain.
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Affiliation(s)
- Murat Ulutaş
- Sanko University Konukoglu hospital, Department of Neurosurgery Gaziantep, Turkey
| | - Kadir Çınar
- Sanko University Konukoglu hospital, Department of Neurosurgery Gaziantep, Turkey
| | - Mehmet Seçer
- Dr Ersin Arslan Research and Training Hospital Department of Neurosurgery, Gaziantep, Turkey
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Káplár Z, Wáng YXJ. South Korean degenerative spondylolisthesis patients had surgical treatment at earlier age than Japanese, American, and European patients: a published literature observation. Quant Imaging Med Surg 2016; 6:785-790. [PMID: 28090453 DOI: 10.21037/qims.2016.11.06] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Affiliation(s)
- Zoltán Káplár
- Department of Imaging and Interventional Radiology, the Chinese University of Hong Kong, Hong Kong, China
| | - Yì-Xiáng J Wáng
- Department of Imaging and Interventional Radiology, the Chinese University of Hong Kong, Hong Kong, China
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Wang YXJ, Káplár Z, Deng M, Leung JCS. Lumbar degenerative spondylolisthesis epidemiology: A systematic review with a focus on gender-specific and age-specific prevalence. J Orthop Translat 2016; 11:39-52. [PMID: 29662768 PMCID: PMC5866399 DOI: 10.1016/j.jot.2016.11.001] [Citation(s) in RCA: 94] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
The epidemiology of lumbar degenerative spondylolisthesis (DS) remains controversial. We performed a systematic review with the aim of gaining a better understanding of the prevalence of DS in the general population. The results showed that the prevalence of DS is very gender- and age-specific. Few women and men develop DS before they are 50 years old. After 50 years of age, both women and men begin to develop DS, with women having a faster rate of development than men. For elderly Chinese (≥ 65 years, mean age: 72.5 years), large population-based studies MsOS (Hong Kong, females: n = 2000) and MrOS (Hong Kong, males: n = 2000) showed DS prevalence was 25.0% in women and 19.1% in men. The female:male (F:M) prevalence ratio was 1.3:1. The published data for MsOS (USA) and MrOS (USA) studies seem to show that elderly Caucasian Americans have a higher DS prevalence, being approximately 60-70% higher than elderly Chinese; however, the F:M prevalence ratio was similar to the elderly Chinese population. Patient data showed that female patients more often received surgical treatment than male and preliminary data showed the ratio of female to male patients receiving surgical treatment did not differ between Northeast Asians (Chinese, Japanese, and Korean), Europeans, and American Caucasians, being around 2:1 in the elderly population. The existing data also suggest that menopause may be a contributing factor for the accelerated development of DS in postmenopausal women. The translational potential of this article: A better understanding of epidemiology of lumbar degenerative spondylolisthesis can support patient consultation and treatment planning.
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Affiliation(s)
- Yi Xiang J Wang
- Department of Imaging and Interventional Radiology, Faculty of Medicine, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, New Territories, Hong Kong Special Administrative Region
| | - Zoltán Káplár
- Department of Imaging and Interventional Radiology, Faculty of Medicine, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, New Territories, Hong Kong Special Administrative Region
| | - Min Deng
- Department of Imaging and Interventional Radiology, Faculty of Medicine, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, New Territories, Hong Kong Special Administrative Region
| | - Jason C S Leung
- School of Public Health and Primary Care, Faculty of Medicine, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, New Territories, Hong Kong Special Administrative Region
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Machado GC, Ferreira PH, Yoo RIJ, Harris IA, Pinheiro MB, Koes BW, van Tulder MW, Rzewuska M, Maher CG, Ferreira ML. Surgical options for lumbar spinal stenosis. Cochrane Database Syst Rev 2016; 11:CD012421. [PMID: 27801521 PMCID: PMC6464992 DOI: 10.1002/14651858.cd012421] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Hospital charges for lumbar spinal stenosis have increased significantly worldwide in recent times, with great variation in the costs and rates of different surgical procedures. There have also been significant increases in the rate of complex fusion and the use of spinal spacer implants compared to that of traditional decompression surgery, even though the former is known to incur costs up to three times higher. Moreover, the superiority of these new surgical procedures over traditional decompression surgery is still unclear. OBJECTIVES To determine the efficacy of surgery in the management of patients with symptomatic lumbar spinal stenosis and the comparative effectiveness between commonly performed surgical techniques to treat this condition on patient-related outcomes. We also aimed to investigate the safety of these surgical interventions by including perioperative surgical data and reoperation rates. SEARCH METHODS Review authors performed electronic searches of the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, CINAHL, AMED, Web of Science, LILACS and three trials registries from their inception to 16 June 2016. Authors also conducted citation tracking on the reference lists of included trials and relevant systematic reviews. SELECTION CRITERIA This review included only randomised controlled trials that investigated the efficacy and safety of surgery compared with no treatment, placebo or sham surgery, or with another surgical technique in patients with lumbar spinal stenosis. DATA COLLECTION AND ANALYSIS Two reviewers independently assessed the studies for inclusion and performed the 'Risk of bias' assessment, using the Cochrane Back and Neck Review Group criteria. Reviewers also extracted demographics, surgery details, and types of outcomes to describe the characteristics of included studies. Primary outcomes were pain intensity, physical function or disability status, quality of life, and recovery. The secondary outcomes included measurements related to surgery, such as perioperative blood loss, operation time, length of hospital stay, reoperation rates, and costs. We grouped trials according to the types of surgical interventions being compared and categorised follow-up times as short-term when less than 12 months and long-term when 12 months or more. Pain and disability scores were converted to a common 0 to 100 scale. We calculated mean differences for continuous outcomes and relative risks for dichotomous outcomes. We pooled data using the random-effects model in Review Manager 5.3, and used the GRADE approach to assess the quality of the evidence. MAIN RESULTS We included a total of 24 randomised controlled trials (reported in 39 published research articles or abstracts) in this review. The trials included 2352 participants with lumbar spinal stenosis with symptoms of neurogenic claudication. None of the included trials compared surgery with no treatment, placebo or sham surgery. Therefore, all included studies compared two or more surgical techniques. We judged all trials to be at high risk of bias for the blinding of care provider domain, and most of the trials failed to adequately conceal the randomisation process, blind the participants or use intention-to-treat analysis. Five trials compared the effects of fusion in addition to decompression surgery. Our results showed no significant differences in pain relief at long-term (mean difference (MD) -0.29, 95% confidence interval (CI) -7.32 to 6.74). Similarly, we found no between-group differences in disability reduction in the long-term (MD 3.26, 95% CI -6.12 to 12.63). Participants who received decompression alone had significantly less perioperative blood loss (MD -0.52 L, 95% CI -0.70 L to -0.34 L) and required shorter operations (MD -107.94 minutes, 95% CI -161.65 minutes to -54.23 minutes) compared with those treated with decompression plus fusion, though we found no difference in the number of reoperations (risk ratio (RR) 1.25, 95% CI 0.81 to 1.92). Another three trials investigated the effects of interspinous process spacer devices compared with conventional bony decompression. These spacer devices resulted in similar reductions in pain (MD -0.55, 95% CI -8.08 to 6.99) and disability (MD 1.25, 95% CI -4.48 to 6.98). The spacer devices required longer operation time (MD 39.11 minutes, 95% CI 19.43 minutes to 58.78 minutes) and were associated with higher risk of reoperation (RR 3.95, 95% CI 2.12 to 7.37), but we found no difference in perioperative blood loss (MD 144.00 mL, 95% CI -209.74 mL to 497.74 mL). Two trials compared interspinous spacer devices with decompression plus fusion. Although we found no difference in pain relief (MD 5.35, 95% CI -1.18 to 11.88), the spacer devices revealed a small but significant effect in disability reduction (MD 5.72, 95% CI 1.28 to 10.15). They were also superior to decompression plus fusion in terms of operation time (MD 78.91 minutes, 95% CI 30.16 minutes to 127.65 minutes) and perioperative blood loss (MD 238.90 mL, 95% CI 182.66 mL to 295.14 mL), however, there was no difference in rate of reoperation (RR 0.70, 95% CI 0.32 to 1.51). Overall there were no differences for the primary or secondary outcomes when different types of surgical decompression techniques were compared among each other. The quality of evidence varied from 'very low quality' to 'high quality'. AUTHORS' CONCLUSIONS The results of this Cochrane review show a paucity of evidence on the efficacy of surgery for lumbar spinal stenosis, as to date no trials have compared surgery with no treatment, placebo or sham surgery. Placebo-controlled trials in surgery are feasible and needed in the field of lumbar spinal stenosis. Our results demonstrate that at present, decompression plus fusion and interspinous process spacers have not been shown to be superior to conventional decompression alone. More methodologically rigorous studies are needed in this field to confirm our results.
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Affiliation(s)
- Gustavo C Machado
- Sydney Medical School, The University of SydneyThe George Institute for Global HealthPO Box M201SydneyAustraliaNSW 2050
| | - Paulo H Ferreira
- The University of SydneyDiscipline of Physiotherapy, Faculty of Health Sciences75 East StreetSydneyLidcombe NSWAustralia1825
| | - Rafael IJ Yoo
- Sydney Medical School, The University of SydneyThe George Institute for Global HealthPO Box M201SydneyAustraliaNSW 2050
| | - Ian A Harris
- South Western Sydney Clinical School, UNSW AustraliaIngham Institute for Applied Medical ResearchElizabeth StreetLiverpoolNew South WalesAustralia2170
| | - Marina B Pinheiro
- The University of SydneyDiscipline of Physiotherapy, Faculty of Health Sciences75 East StreetSydneyLidcombe NSWAustralia1825
| | - Bart W Koes
- Erasmus Medical CenterDepartment of General PracticePO Box 2040RotterdamNetherlands3000 CA
| | - Maurits W van Tulder
- VU University AmsterdamDepartment of Health Sciences, Faculty of Earth and Life SciencesPO Box 7057Room U454AmsterdamNetherlands1007 MB
| | - Magdalena Rzewuska
- University of São PauloDepartment of Social Medicine, Faculty of MedicineAv. Bandeirantes, 3900 ‐ Monte AlegreRibeirão PretoSão PauloBrazil
| | - Christopher G Maher
- Sydney Medical School, The University of SydneyThe George Institute for Global HealthPO Box M201SydneyAustraliaNSW 2050
| | - Manuela L Ferreira
- Sydney Medical School, The University of SydneyThe George Institute for Global Health & Institute of Bone and Joint Research, The Kolling InstituteSydneyNSWAustralia
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Bilateral versus unilateral instrumentation in spinal surgery: Systematic review and trial sequential analysis of prospective studies. J Clin Neurosci 2016; 30:15-23. [DOI: 10.1016/j.jocn.2016.01.013] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2015] [Revised: 01/12/2016] [Accepted: 01/17/2016] [Indexed: 01/03/2023]
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Liu X, Li G, Wang J, Zhang H. Minimally Invasive Unilateral vs. Bilateral Pedicle Screw Fixation and Lumbar Interbody Fusion in Treatment of Multi-Segment Lumbar Degenerative Disorders. Med Sci Monit 2015; 21:3652-7. [PMID: 26603050 PMCID: PMC4664222 DOI: 10.12659/msm.894890] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Background The choice for instrumentation with minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) in treatment of degenerative lumbar disorders (DLD) remains controversial. The goal of this study was to investigate clinical outcomes in consecutive patients with multi-segment DLD treated with unilateral pedicle screw (UPS) vs. bilateral pedicle screw (BPS) instrumented TLIF. Material/Methods Eighty-four consecutive patients who had multi-level MIS-TLIF were retrospectively reviewed. All data were collected to compare the clinical outcomes between the 2 groups. Results Both groups showed similar clinical function scores in VAS and ODI. The two groups differed significantly in operative time (P<0.001), blood loss (P<0.001), and fusion rate (P=0.043), respectively. Conclusions This study demonstrated similar clinical outcomes between UPS fixation and BPS procedure after MIS-TLIF for multi-level DLD. Moreover, UPS technique was superior in operative time and blood loss, but represented lower fusion rate than the BPS construct did.
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Affiliation(s)
- Xiaoyang Liu
- Department of Spine Surgery, Yuhuangding Hospital, Yantai, Shandong, China (mainland)
| | - Guangrun Li
- Department of Spine Surgery, Yuhuangding Hospital, Yantai, Shandong, China (mainland)
| | - Jiefeng Wang
- Department of Spine Surgery, Yuhuangding Hospital, Yantai, Shandong, China (mainland)
| | - Heqing Zhang
- Department of Spine Surgery, Yuhuangding Hospital, Yantai, Shandong, China (mainland)
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Aoki Y, Nakajima A, Takahashi H, Sonobe M, Terajima F, Saito M, Takahashi K, Ohtori S, Watanabe A, Nakajima T, Takazawa M, Orita S, Eguchi Y, Nakagawa K. Influence of pelvic incidence-lumbar lordosis mismatch on surgical outcomes of short-segment transforaminal lumbar interbody fusion. BMC Musculoskelet Disord 2015; 16:213. [PMID: 26289077 PMCID: PMC4545935 DOI: 10.1186/s12891-015-0676-1] [Citation(s) in RCA: 105] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2015] [Accepted: 08/12/2015] [Indexed: 11/25/2022] Open
Abstract
Background The importance of pelvic incidence-lumbar lordosis (PI-LL: PI minus LL) mismatch is emphasized in long-segment fusion for adult spinal deformity; however, there are few studies evaluating the influence of PI-LL on surgical outcomes after short-segment fusion. In this study, we have examined the effects of PI-LL mismatch on surgical outcomes of short-segment lumbar intervertebral fusion for lumbar degenerative diseases. Methods Patients with lumbar degenerative disease treated by short-segment (1 or 2 levels) transforaminal lumbar interbody fusion were divided into Group A (PI-LL ≤ 10°: n = 22) and Group B (PI-LL ≥ 11°: n = 30). Pre-and post-operative patient symptoms were assessed by the visual analogue scale (VAS: scores 0-100 mm; for LBP, lower-extremity pain, and lower-extremity numbness), a detailed VAS for LBP while in motion, standing, and sitting, and the Oswestry disability index (ODI). Surgical outcomes were evaluated by the Nakai score (3 = excellent to 0 = poor. Post-operative data were acquired for at least one year following surgery and were compared between the two groups. Multiple regression analyses were used to evaluate the relative influence of PI-LL on each pre-and post-operative parameter (VAS, detailed VAS and ODI) adjusted for age, sex, fusion levels, body mass index, presence of scoliosis, diabetes mellitus and depression. Results The surgical outcomes in Group A were significantly better than those of Group B. Group A showed better post-operative VAS scores for LBP, particularly LBP while standing (11.9 vs. 25.8). The results of the multivariate analyses showed no significant correlation between PI-LL and pre-operative symptoms, but did show a significant correlation between PI-LL and the post-operative VAS score for LBP, lower extremity pain, and numbness. Conclusions This study is the first to find that PI-LL mismatch influences post-operative residual symptoms, such as LBP, lower extremity pain and numbness. Among the three types of LBP examined in the detailed VAS, LBP while standing was most strongly related to PI-LL mismatch. The importance of maintaining spinopelvic alignment is emphasized, particularly when treating patients with adult spinal deformity using long-segment fusion surgery. However, our results indicate that surgeons should pay attention to sagittal spinopelvic alignment and avoid post-operative PI-LL mismatch even when treating patients with short-segment lumbar interbody fusion.
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Affiliation(s)
- Yasuchika Aoki
- Department of Orthopaedic Surgery, Eastern Chiba Medical Center, 3-6-2 Okayamadai, Togane, Chiba, 283-8686, Japan. .,Department of General Medical Science, Graduate School of Medicine, Chiba University, 1-8-1 Inohana,Chuo-ku, Chiba city, Chiba, 260-8670, Japan.
| | - Arata Nakajima
- Department of Orthopaedic Surgery, Toho University Sakura Medical Center, 564-1 Shimoshizu, Sakura, Chiba, 285-8741, Japan.
| | - Hiroshi Takahashi
- Department of Orthopaedic Surgery, Toho University Sakura Medical Center, 564-1 Shimoshizu, Sakura, Chiba, 285-8741, Japan.
| | - Masato Sonobe
- Department of Orthopaedic Surgery, Toho University Sakura Medical Center, 564-1 Shimoshizu, Sakura, Chiba, 285-8741, Japan.
| | - Fumiaki Terajima
- Department of Orthopaedic Surgery, Toho University Sakura Medical Center, 564-1 Shimoshizu, Sakura, Chiba, 285-8741, Japan.
| | - Masahiko Saito
- Department of Orthopaedic Surgery, Toho University Sakura Medical Center, 564-1 Shimoshizu, Sakura, Chiba, 285-8741, Japan.
| | - Kazuhisa Takahashi
- Department of Orthopaedic Surgery, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuoku, Chiba city, Chiba, 260-8677, Japan.
| | - Seiji Ohtori
- Department of Orthopaedic Surgery, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuoku, Chiba city, Chiba, 260-8677, Japan.
| | - Atsuya Watanabe
- Department of Orthopaedic Surgery, Eastern Chiba Medical Center, 3-6-2 Okayamadai, Togane, Chiba, 283-8686, Japan. .,Department of General Medical Science, Graduate School of Medicine, Chiba University, 1-8-1 Inohana,Chuo-ku, Chiba city, Chiba, 260-8670, Japan.
| | - Takayuki Nakajima
- Department of Orthopaedic Surgery, Eastern Chiba Medical Center, 3-6-2 Okayamadai, Togane, Chiba, 283-8686, Japan. .,Department of General Medical Science, Graduate School of Medicine, Chiba University, 1-8-1 Inohana,Chuo-ku, Chiba city, Chiba, 260-8670, Japan.
| | - Makoto Takazawa
- Department of Orthopaedic Surgery, Eastern Chiba Medical Center, 3-6-2 Okayamadai, Togane, Chiba, 283-8686, Japan. .,Department of General Medical Science, Graduate School of Medicine, Chiba University, 1-8-1 Inohana,Chuo-ku, Chiba city, Chiba, 260-8670, Japan.
| | - Sumihisa Orita
- Department of Orthopaedic Surgery, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuoku, Chiba city, Chiba, 260-8677, Japan.
| | - Yawara Eguchi
- Department of Orthopaedic Surgery, National Hospital Organization Shimoshizu Hospital, 934-5Shikawatashi, Yotsukaido, Chiba, 284-0003, Japan.
| | - Koichi Nakagawa
- Department of Orthopaedic Surgery, Toho University Sakura Medical Center, 564-1 Shimoshizu, Sakura, Chiba, 285-8741, Japan.
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Ambati DV, Wright EK, Lehman RA, Kang DG, Wagner SC, Dmitriev AE. Bilateral pedicle screw fixation provides superior biomechanical stability in transforaminal lumbar interbody fusion: a finite element study. Spine J 2015; 15:1812-22. [PMID: 24983669 DOI: 10.1016/j.spinee.2014.06.015] [Citation(s) in RCA: 92] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2014] [Revised: 03/27/2014] [Accepted: 06/17/2014] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Transforaminal lumbar interbody fusion (TLIF) is increasingly popular for the surgical treatment of degenerative lumbar disease. The optimal construct for segmental stability remains unknown. PURPOSE To compare the stability of fusion constructs using standard (C) and crescent-shaped (CC) polyetheretherketone TLIF cages with unilateral (UPS) or bilateral (BPS) posterior instrumentation. STUDY DESIGN Five TLIF fusion constructs were compared using finite element (FE) analysis. METHODS A previously validated L3-L5 FE model was modified to simulate decompression and fusion at L4-L5. This model was used to analyze the biomechanics of various unilateral and bilateral TLIF constructs. The inferior surface of the L5 vertebra remained immobilized throughout the load simulation, and a bending moment of 10 Nm was applied on the L3 vertebra to recreate flexion, extension, lateral bending, and axial rotation. Various biomechanical parameters were evaluated for intact and implanted models in all loading planes. RESULTS All reconstructive conditions displayed decreased motion at L4-L5. Bilateral posterior fixation conferred greater stability when compared with unilateral fixation in left lateral bending. More than 50% of intact motion remained in the left lateral bending with unilateral posterior fixation compared with less than 10% when bilateral pedicle screw fixation was used. Posterior implant stresses for unilateral fixation were six times greater in flexion and up to four times greater in left lateral bending compared with bilateral fixation. No effects on segmental stability or posterior implant stresses were found. An obliquely-placed, single standard cage generated the lowest cage-end plate stress. CONCLUSIONS Transforaminal lumbar interbody fusion augmentation with bilateral posterior fixation increases fusion construct stability and decreases posterior instrumentation stress. The shape or number of interbody implants does not appear to impact the segmental stability when bilateral pedicle screws are used. Increased posterior instrumentation stresses were observed in all loading modes with unilateral pedicle screw/rod fixation, which may theoretically accelerate implant loosening or increase the risk of construct failure.
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Affiliation(s)
- Divya V Ambati
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, 6720-A Rockledge Dr., Suite 100, Bethesda, MD 20817, USA; Uniformed Services University of the Health Sciences, Division of Surgery, 4301 Jones Bridge Rd., Bethesda, MD 20814, USA
| | - Edward K Wright
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, 6720-A Rockledge Dr., Suite 100, Bethesda, MD 20817, USA; Uniformed Services University of the Health Sciences, Division of Surgery, 4301 Jones Bridge Rd., Bethesda, MD 20814, USA; Department of Orthopaedic Surgery, Walter Reed National Military Medical Center, Building 19, Room #2101, 8901 Wisconsin Ave., Bethesda, MD 20889, USA
| | - Ronald A Lehman
- Uniformed Services University of the Health Sciences, Division of Surgery, 4301 Jones Bridge Rd., Bethesda, MD 20814, USA; Department of Orthopaedic Surgery, Walter Reed National Military Medical Center, Building 19, Room #2101, 8901 Wisconsin Ave., Bethesda, MD 20889, USA.
| | - Daniel G Kang
- Department of Orthopaedic Surgery, Walter Reed National Military Medical Center, Building 19, Room #2101, 8901 Wisconsin Ave., Bethesda, MD 20889, USA
| | - Scott C Wagner
- Department of Orthopaedic Surgery, Walter Reed National Military Medical Center, Building 19, Room #2101, 8901 Wisconsin Ave., Bethesda, MD 20889, USA
| | - Anton E Dmitriev
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, 6720-A Rockledge Dr., Suite 100, Bethesda, MD 20817, USA; Uniformed Services University of the Health Sciences, Division of Surgery, 4301 Jones Bridge Rd., Bethesda, MD 20814, USA; Department of Orthopaedic Surgery, Walter Reed National Military Medical Center, Building 19, Room #2101, 8901 Wisconsin Ave., Bethesda, MD 20889, USA
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Chen C, Cao X, Zou L, Hao G, Zhou Z, Zhang G. Minimally invasive unilateral versus bilateral technique in performing single-segment pedicle screw fixation and lumbar interbody fusion. J Orthop Surg Res 2015; 10:112. [PMID: 26179281 PMCID: PMC4504127 DOI: 10.1186/s13018-015-0253-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2015] [Accepted: 07/01/2015] [Indexed: 01/03/2023] Open
Abstract
Purpose The minimally invasive transforaminal lumbar interbody fusion procedure with percutaneous pedicle screws was adopted in clinical practice, but the choice between a unilateral pedicle screw (UPS) or bilateral pedicle screw (BPS) fixation after lumbar fusion remains controversial. The purpose of the present retrospective study was to compare the clinical outcomes and radiological results of unilateral and bilateral pedicle screw fixations. Methods The retrospective study recruited seventy-eight patients with a single-level pedicle screw fixation and lumbar interbody fusion at L4–L5 or L5–S1 from January 2010 to January 2013. The patients were treated with MIS TLIF with BPS fixation, and since May 2012, all patients were treated with UPS fixation. The perioperative outcomes including operative time, blood loss, hospital-stay length, and complication rates were accessed. Radiological outcomes regarding fusion were determined with the Bridwell grading system. Clinical outcomes were evaluated with the Oswestry Disability Index (ODI) and visual analog scale (VAS) during the mean follow-up of 2 years. Results According to perioperative assessments, the operative time was significantly shorter for group UPS (84.7 ± 6.4 min) than for group BPS (103.6 ± 10.6 min; p < 0.0001), and similar results were found with regard to the mean blood loss (UPS, 96.3 ± 17.5; BPS, 137.4 ± 32.9, p < 0.0001). With regard to the hospital-stay period, though the UPS group seems shorter, there is no statistical significance (UPS, 10.0 ± 2.1; BPS, 10.4 ± 2.4, p = 0.428). There were four in the BPS group and six in the UPS group defined as unfused at 6 months pest-operative, but at 12 months post-surgery, all patients achieved solid fusion. Regarding clinical outcomes, the VAS and ODI scores were significantly lower in the UPS group than the BPS group at 7 days post-surgery, but there was no difference at 1 month post-surgery and during the later follow-up. Conclusion There was no difference between the UPS and BPS flexion techniques about the clinical outcomes at 24 months post-surgery. However, because the UPS involves a shorter surgical time, less blood loss, faster pain relief, and faster functional recovery, UPS might be more suitable in performing single-segment pedicle screw fixation and lumbar interbody fusion.
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Affiliation(s)
- Chen Chen
- Department of Orthopaedics, The General Hospital of Jinan Military, No.25 Shifan Road, Tianqiao Square, Jinan, 250031, China.
| | - Xuecheng Cao
- Department of Orthopaedics, The General Hospital of Jinan Military, No.25 Shifan Road, Tianqiao Square, Jinan, 250031, China.
| | - Lin Zou
- Department of Orthopaedics, The General Hospital of Jinan Military, No.25 Shifan Road, Tianqiao Square, Jinan, 250031, China.
| | - Guangliang Hao
- Department of Orthopaedics, The General Hospital of Jinan Military, No.25 Shifan Road, Tianqiao Square, Jinan, 250031, China.
| | - Zhenyu Zhou
- Department of Orthopaedics, The General Hospital of Jinan Military, No.25 Shifan Road, Tianqiao Square, Jinan, 250031, China.
| | - Guichun Zhang
- Department of Orthopaedics, The General Hospital of Jinan Military, No.25 Shifan Road, Tianqiao Square, Jinan, 250031, China.
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Unilateral versus bilateral pedicle screw fixation in short-segment lumbar spinal fusion: a meta-analysis of randomised controlled trials. INTERNATIONAL ORTHOPAEDICS 2015; 40:355-64. [PMID: 26174053 DOI: 10.1007/s00264-015-2842-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/17/2015] [Accepted: 05/23/2015] [Indexed: 01/03/2023]
Abstract
OBJECTIVE We performed this meta-analysis of randomised controlled trials to compare the efficacy and safety of unilateral with bilateral fixation in short-segment lumbar spinal fusion. METHODS Predefined terms were used to search electronic databases to identify relevant research. Randomised controlled trials (RCTs) published in English and Chinese during 1990-2015 investigating efficacy and safety of unilateral and bilateral fixation in short-segment lumbar spinal fusion were included. Data of fusion rate, complications, visual analogue scale (VAS), Oswestry Disability Index (ODI), estimated blood loss (EBL) and length of hospital stay were extracted and analysed. Two reviewers independently searched information sources, selected eligible research, analysed data and evaluated risk of bias. RESULTS Eleven RCTs comprising 756 participants were analysed. There was no significant difference in fusion rate, device-related complication, ODI, VAS and length of hospital stay between bilateral and unilateral groups. The unilateral group had the obvious advantage of reduced blood loss [mean difference (MD) -143.57, 95 % confidence interval (Cl) -206.61 to -80.54, P < 0.0001) and operation time (MD -52.72, 95 % Cl -73.58 to -31.87, P < 0.00001). CONCLUSION Unilateral pedicle screw fixation is equally as effective as bilateral pedicle screw fixation in short-segment lumbar spinal fusion and may reduce operation time and blood loss.
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Scheer JK, Auffinger B, Wong RH, Lam SK, Lawton CD, Nixon AT, Dahdaleh NS, Smith ZA, Fessler RG. Minimally Invasive Transforaminal Lumbar Interbody Fusion (TLIF) for Spondylolisthesis in 282 Patients: In Situ Arthrodesis versus Reduction. World Neurosurg 2015; 84:108-13. [DOI: 10.1016/j.wneu.2015.02.037] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2014] [Revised: 02/24/2015] [Accepted: 02/25/2015] [Indexed: 11/25/2022]
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Hart R, Hermsmeyer JT, Sethi RK, Norvell DC. Quality and Quantity of Published Studies Evaluating Lumbar Fusion during the Past 10 Years: A Systematic Review. Global Spine J 2015; 5:207-18. [PMID: 26131387 PMCID: PMC4472285 DOI: 10.1055/s-0035-1552984] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2015] [Accepted: 03/23/2015] [Indexed: 01/03/2023] Open
Abstract
Study Design Systematic review. Clinical Questions (1) Has the proportion and number of randomized controlled trials (RCTs) as an indicator of quality of evidence regarding lumbar fusion increased over the past 10 years? (2) Is there a difference in the proportion of RCTs among the four primary fusion diagnoses (degenerative disk disease, spondylolisthesis, deformity, and adjacent segment disease) over the past 10 years? (3) Is there a difference in the type and quality of clinical outcomes measures reported among RCTs over time? (4) Is there a difference in the type and quality of adverse events measures reported among RCTs over time? (5) Are there changes in fusion surgical approach and techniques over time by diagnosis over the past 10 years? Methods Electronic databases and reference lists of key articles were searched from January 1, 2004, through December 31, 2013, to identify lumbar fusion RCTs. Fusion studies designed specifically to evaluate recombinant human bone morphogenetic protein-2 or other bone substitutes, revision surgery studies, nonrandomized comparison studies, case reports, case series, and cost-effectiveness studies were excluded. Results Forty-two RCTs between January 1, 2004, and December 31, 2013, met the inclusion criteria and form the basis for this report. There were 35 RCTs identified evaluating patients diagnosed with degenerative disk disease, 4 RCTs evaluating patients diagnosed with degenerative spondylolisthesis, and 3 RCTs evaluating patients with a combination of degenerative disk disease and degenerative spondylolisthesis. No RCTs were identified evaluating patients with deformity or adjacent segment disease. Conclusions This structured review demonstrates that there has been an increase in the available clinical database of RCTs using patient-reported outcomes evaluating the benefit of lumbar spinal fusion for the diagnoses of degenerative disk disease and degenerative spondylolisthesis. Gaps remain in the standardization of reportage of adverse events in such trials, as well as uniformity of surgical approaches used. Finally, continued efforts to develop higher-quality data for other surgical indications for lumbar fusion, most notably in the presence of adult spinal deformity and revision of prior surgical fusions, appear warranted.
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Affiliation(s)
- Robert Hart
- Department of Orthopaedics, Oregon Health and Science University, Portland, Oregon, United States,Address for correspondence Robert Hart, MD Department of Orthopaedics, Oregon Health and Science UniversityPortland, OR 97219United States
| | | | - Rajiv K. Sethi
- Department of Orthopaedics and Health Services, Virginia Mason Medical Center, University of Washington, Seattle, Washington, United States
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Molinari RW, Saleh A, Molinari R, Hermsmeyer J, Dettori JR. Unilateral versus Bilateral Instrumentation in Spinal Surgery: A Systematic Review. Global Spine J 2015; 5:185-94. [PMID: 26131385 PMCID: PMC4472301 DOI: 10.1055/s-0035-1552986] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2015] [Accepted: 03/23/2015] [Indexed: 01/03/2023] Open
Abstract
Study Design Systematic review. Clinical Questions (1) What is the comparative efficacy of unilateral instrumentation compared with bilateral instrumentation in spine surgery? (2) What is the safety of unilateral instrumentation compared with bilateral instrumentation in spine surgery? Methods Electronic databases and reference lists of key articles were searched up to September 30, 2014, to identify studies reporting the comparative efficacy and safety of unilateral versus bilateral instrumentation in spine surgery. Studies including recombinant human bone morphogenetic protein 2 as adjunct therapy and those with follow-up of less than 2 years were excluded. Results Ten randomized controlled trials met the inclusion criteria: five compared unilateral with bilateral instrumentation using open transforaminal or posterior lumbar interbody fusion (TLIF/PLIF), one used open posterolateral fusion, and four used minimally invasive TLIF/PLIF. There were no significant differences between unilateral and bilateral screw instrumentation with respect to nonunion, low back or leg pain scores, Oswestry Disability Index, reoperation, or complications. Conclusions The existing literature does not identify significant differences in clinical outcomes, union rates, and complications when unilateral instrumentation is used for degenerative pathologic conditions in the lumbar spine. The majority of published reports involve single-level lumbar unilateral instrumentation.
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Affiliation(s)
- Robert W. Molinari
- Department of Orthopaedics, University of Rochester, Rochester, New York, United States,Address for correspondence Robert W. Molinari, MD Department of OrthopaedicsUniversity of Rochester601 Elmwood Avenue, Rochester, NY 14642United States
| | - Ahmed Saleh
- Department of Orthopaedics, University of Rochester, Rochester, New York, United States
| | - Robert Molinari
- Brooklyn College BA/MD Program, Brooklyn, New York, United States,Address for correspondence Robert W. Molinari, MD Department of OrthopaedicsUniversity of Rochester601 Elmwood Avenue, Rochester, NY 14642United States
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Liang Y, Shi W, Jiang C, Chen Z, Liu F, Feng Z, Jiang X. Clinical outcomes and sagittal alignment of single-level unilateral instrumented transforaminal lumbar interbody fusion with a 4 to 5-year follow-up. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2015; 24:2560-6. [PMID: 25870077 DOI: 10.1007/s00586-015-3933-y] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/26/2014] [Revised: 04/04/2015] [Accepted: 04/05/2015] [Indexed: 12/11/2022]
Abstract
PURPOSE A retrospective study was designed to evaluate clinical outcomes and sagittal alignment following single-level unilateral instrumented transforaminal lumbar interbody fusion (TLIF). METHODS From November 2008 to December 2010, a total of 139 patients, who suffered from single-level lumbar degenerative disease, were included in this study. Forty-seven males and seventy-two females with a mean age of 57.3 years were enrolled. The average follow-up period was 51.7 months with a range of 41-66 months. The follow-up rate was 85.6 %. Thirty-one patients had diagnosis of discogenic low back pain, ten had recurrent disk herniation, thirty-four had spinal stenosis, and fourty-four had spondylolisthesis. Clinical outcomes were evaluated using the Oswestry disability index (ODI), visual analog scale (VAS) and Japanese Orthopedic Association. Operating time, blood loss, length of stay, and complications were also evaluated. The sagittal alignment and fusion status were assessed by X-ray and three-dimensional computed tomography. RESULTS The average operating time was 92.1 ± 27.5 min, the average blood loss was 135.1 ± 113.5 ml, and the average length of stay was 12.0 ± 2.9 days. The overall complication rate was 13.4 %, and the fusion rate was 82.4 %. The postoperative clinical outcomes and sagittal alignment were significantly different from the preoperative values. The final lumbar lordosis angle and segment lordosis angle were associated with back pain VAS and ODI scores, respectively. CONCLUSION Unilateral instrumented TLIF is a safe and effective treatment option for single-level lumbar degenerative disease, and is less invasive, yields good outcomes and has a low complication rate. In addition, the procedure has the potential to partly restore sagittal alignment.
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Affiliation(s)
- Yun Liang
- Department of Orthopedics, Shanghai Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200032, People's Republic of China
| | - Weibin Shi
- Department of Orthopedics, Shanghai Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200032, People's Republic of China.,Radiology Department , Shanghai Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200032, People's Republic of China
| | - Chun Jiang
- Department of Orthopedics, Shanghai Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200032, People's Republic of China
| | - Zixian Chen
- Department of Orthopedics, Shanghai Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200032, People's Republic of China
| | - Fubing Liu
- Department of Orthopedics, Shanghai Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200032, People's Republic of China
| | - Zhenzhou Feng
- Department of Orthopedics, Shanghai Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200032, People's Republic of China.
| | - Xiaoxing Jiang
- Department of Orthopedics, Shanghai Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200032, People's Republic of China.
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Li X, Lv C, Yan T. Unilateral versus bilateral pedicle screw fixation for degenerative lumbar diseases: a meta-analysis of 10 randomized controlled trials. Med Sci Monit 2015; 21:782-90. [PMID: 25774950 PMCID: PMC4371713 DOI: 10.12659/msm.892593] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Background The common and effective treatment for degenerative lumbar diseases is lumbar spinal fusion. Controversy still exists on the choice for instrumentation with spinal fusion procedures. Therefore, we conducted this meta-analysis exclusively of RCTs to compare the clinical outcomes of patients receiving bilateral versus unilateral pedicle screw fixation (PSF). Material/Methods After systematic review of published and unpublished literature, a meta-analysis was conducted to compare the 2 treatment strategies. The methodological quality of the literature was assessed using the PEDro critical appraisal tool. Results Data synthesis showed less blood loss (P<0.001) and shorter operative time (P<0.001) in patients receiving unilateral PSF compared to bilateral PSF. However, there was no significant difference in fusion rates and functional outcomes between the 2 groups. Conclusions The meta-analysis indicated no significant difference in fusion rates and functional outcomes between the 2 treatment procedures, but unilateral PS fixation reduced blood loss and operative time.
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Affiliation(s)
- Xianzhou Li
- Department of Spine Surgery, Jining No.1 People's Hospital, Shandong Academy of Medical Sciences, Jining, Shangdong, China (mainland)
| | - Chaoliang Lv
- Department of Spine Surgery, Jining No.1 People's Hospital, Shandong Academy of Medical Sciences, Jining, Shangdong, China (mainland)
| | - Tingzhen Yan
- Department of Spine Surgery, Jining No.1 People's Hospital, Shandong Academy of Medical Sciences, Jining, Shangdong, China (mainland)
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Alijani B, Emamhadi M, Behzadnia H, Aramnia A, Chabok SY, Ramtinfar S, Leili EK, Golmohamadi S. Posterior lumbar interbody fusion and posterolateral fusion: Analogous procedures in decreasing the index of disability in patients with spondylolisthesis. Asian J Neurosurg 2015; 10:51. [PMID: 25767584 PMCID: PMC4352637 DOI: 10.4103/1793-5482.151517] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Objective: The purpose of this study was to evaluate the disability in patients with spondylolisthesis who assigned either to posterolateral fusion (PLF) or posterior lumbar interbody fusion (PLIF) and to compare it between two groups. Methods: In a prospective observational study, 102 surgical candidates with low-grade degenerative and isthmic spondylolisthesis enrolled from 2012 to 2014, and randomly assigned into two groups: PLF and PLIF. Evaluation of disability has been done by a questionnaire using Oswestry Disability Index (ODI). The questionnaire was completed by all patients before the surgery, the day after surgery, after 6 months and after 1-year. Results: There were no statistically significant differences in terms of age and sex distribution and pre-operation ODI between groups (P > 0.05). Comparison of the mean ODI scores of two groups over the whole study period showed no significant statistical difference (P = 0.074). ODIs also showed no significant differences between two groups the day after surgery, 6th months and 1-year after surgery (P = 0.385, P = 0.093, P = 0.122 and P = 433) respectively. Analyzing the course of ODI over the study period, showed a significant descending pattern for either of groups (P < 0.0001). Conclusion: Both surgical fusion techniques (PLF and PLIF) were efficient to lessen the disability of patients with spondylolisthesis, and none of the fusion techniques were related to a better outcome in terms of disability.
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Affiliation(s)
- Babak Alijani
- Department of Neurosurgery, Guilan University of Medical Science, Rasht, Guilan, Iran
| | - Mohamahreza Emamhadi
- Department of Neurosurgery, Guilan University of Medical Science, Rasht, Guilan, Iran
| | - Hamid Behzadnia
- Department of Neurosurgery, Guilan University of Medical Science, Rasht, Guilan, Iran
| | - Ali Aramnia
- Department of Neurosurgery, Guilan University of Medical Science, Rasht, Guilan, Iran
| | | | - Sara Ramtinfar
- Department of Neurosurgery, Guilan University of Medical Science, Rasht, Guilan, Iran
| | | | - Shabnam Golmohamadi
- Department of Neurosurgery, Guilan University of Medical Science, Rasht, Guilan, Iran
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Eliades P, Rahal JP, Herrick DB, Corliss BM, Riesenburger R, Hwang S, Kryzanski JT. Unilateral Pedicle Screw Fixation is Associated with Reduced Cost and Similar Outcomes in Selected Patients Undergoing Minimally Invasive Transforaminal Lumbar Interbody Fusion for L4-5 Degenerative Spondylolisthesis. Cureus 2015; 7:e249. [PMID: 26180673 PMCID: PMC4494589 DOI: 10.7759/cureus.249] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/10/2015] [Indexed: 11/05/2022] Open
Abstract
STUDY DESIGN Retrospective study of 24 patients who underwent either a bilateral or unilateral TLIF procedure for the treatment of degenerative spondylolisthesis. OBJECTIVE To analyze differences in cost and outcome between patients undergoing minimally invasive transforaminal lumbar interbody fusion (mi-TLIF) with unilateral or bilateral pedicle screw fixation for L4-5 degenerative spondylolisthesis. SUMMARY OF BACKGROUND DATA Lumbar fusion surgeries, including the TLIF procedure, have been shown to be an effective treatment for leg and low back pain caused by degenerative spondylolisthesis. Some studies have shown TLIF surgeries to be cost-effective, but there is still a paucity of data and no consensus. Unilateral TLIFs can provide the same benefits as bilateral TLIFs, but come with additional benefits of a less invasive surgery. METHODS We retrospectively analyzed a consecutive series of patients with L4-5 degenerative stenosis and spondylolisthesis who either received a unilateral or bilateral mi-TLIF, paying particular attention to hospital cost and clinical outcome. Of the 33 patients eligible for analysis, we were able to obtain appropriate clinical and radiographic follow-up data on 24 patients (72.7%), 14 patients who underwent unilateral fixation, and 10 patients who underwent bilateral fixation. RESULTS The cohorts were similar with regard to age, comorbidities, and demographics. Most patients reported good or excellent results, and there were no significant differences between the cohorts with regard to clinical outcome. There was one interbody graft extrusion in the unilateral cohort that required explantation, but no other hardware failures. Hospital cost was significantly lower in the unilateral cohort, and hardware savings accounted for only part of the difference. CONCLUSION Unilateral pedicle screw fixation is an acceptable surgical strategy in patients with stable L4-5 degenerative spondylolisthesis undergoing mi-TLIF. In our series, unilateral fixation led to significant hospital cost savings without compromising clinical or radiographic outcomes.
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Affiliation(s)
- Philip Eliades
- Department of Neurosurgery, Tufts University School of Medicine ; Wellman Center for Photomedicine and Department of Dermatology, Massachusetts General Hospital/ Harvard Medical School
| | | | | | | | | | - Steven Hwang
- Department of Neurosurgery, Tufts Medical Center
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Leute PJF, Hammad A, Hoffmann I, Hoppe S, Klinger HM, Lakemeier S. Set screw fracture with cage dislocation after two-level transforaminal lumbar interbody fusion (TLIF): a case report. J Med Case Rep 2015; 9:22. [PMID: 25609204 PMCID: PMC4333885 DOI: 10.1186/1752-1947-9-22] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2014] [Accepted: 12/10/2014] [Indexed: 12/11/2022] Open
Abstract
Introduction Transforaminal lumbar interbody fusion is a popular procedure used to achieve spondylodesis in patients with degenerative lumbar spinal diseases. We present a rare case of a patient with a set screw fracture with cage dislocation after an open transforaminal lumbar interbody fusion procedure. To the best of our knowledge, this case is the first of its kind to be reported. Case presentation A 44-year-old Caucasian woman attended a follow-up appointment at our hospital 3 months after treatment for second-degree lumbar spondylolisthesis (L4/L5) and osteochondrosis (L5/S1) with transforaminal lumbar interbody fusion and dorsal spondylodesis. She complained of severe leg pain on the left side. Her physical examination revealed a normal neurological status, except for paresthesia of the entire left lower limb and at the ball of the left foot. Radiological imaging showed breaking of the set screws with cage dislocation. Surgical revision was then performed with exchange of the whole dorsal instrumentation and the dislocated cage. Six weeks post-operatively, the patient was seen again at our clinic without neurological complaints, except for decreased sensitivity on the dorsum of her left foot. The wound healing and radiological follow-up were uneventful. Conclusions Hardware-related complications are rarely seen in patients with open transforaminal lumbar interbody fusion, but must be kept in mind and can potentially cause severe neurological deficits.
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Comparison of unilateral versus bilateral pedicle screw fixation with cage fusion in degenerative lumbar diseases: a meta-analysis. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2014; 24:764-74. [DOI: 10.1007/s00586-014-3717-9] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/21/2014] [Revised: 12/03/2014] [Accepted: 12/03/2014] [Indexed: 01/03/2023]
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Liu J, Tang J, Liu H. Comparison of one versus two cages in lumbar interbody fusion for degenerative lumbar spinal disease: a meta-analysis. Orthop Surg 2014; 6:236-43. [PMID: 25179359 DOI: 10.1111/os.12119] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2013] [Accepted: 05/27/2014] [Indexed: 02/05/2023] Open
Abstract
OBJECTIVE To systematically compare the fusion rate and safety of lumbar interbody fusion using one cage versus two cages for the treatment of degenerative lumbar spinal diseases. METHODS All randomized controlled trials (RCTs) and comparative observational studies written in English comparing the outcome of lumbar interbody fusion using one or two cages in patients with degenerative lumbar spinal diseases were identified by a comprehensive search of PubMed Central, MEDLINE, EMBASE, BIOSIS and the Cochrane Central Registry of Controlled Trials. An exhaustive electronic search up to July 2013. The quality of the methodology was assessed and relevant data retrieved independently by two reviewers, after which the resultant data were subjected to meta-analysis. All meta-analyses were performed using Review Manager 5.0, which is recommended and provided by the Cochrane Collaboration. RESULTS Our systematic search yielded 745 studies from the selected databases. After duplicate studies had been identified and the titles and abstracts screened, 736 studies were excluded because they were irrelevant to our topic. The full texts of the remaining nine potentially relevant references were comprehensively evaluated and four excluded for the following reasons: two studies involved co-interventions and the other two lacked control groups. Two relevant RCTs and three comparative observational studies involving 384 patients and 501 spinal segments with at least one year follow-up were identified. Analysis of the pooled data demonstrated no significant difference in fusion rate between the one-cage and two-cage groups. However, intraoperative blood loss and operating time were less and the complications rate lower in the one-cage group. CONCLUSION In patients with degenerative lumbar spinal diseases, lumbar interbody fusion using one cage has an equal fusion rate and is safer compared with using two cages. However, because this meta-analysis had some limitations, more high quality RCTs are needed to strengthen the evidence.
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Affiliation(s)
- Jin Liu
- Department of Spine Surgery, Sichuan Orthopaedic Hospital; Department of Orthopaedics, West China Hospital, Sichuan University, Chengdu, China
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Tumialán LM, Clark JC, Snyder LA, Marciano FF. Provisional ipsilateral expandable rod for disc space distraction in minimally invasive transforaminal lumbar interbody fusion: operative technique. Neurosurgery 2014; 10 Suppl 4:555-64; discussion 564. [PMID: 25161005 DOI: 10.1227/neu.0000000000000542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Lumbar disc degeneration may be so advanced and asymmetrical that transforaminal access to the interbody space is limited. The extent of collapse may compromise the capacity to restore disc height and coronal balance in minimally invasive approaches. Although a variety of distractors are available for open approaches, currently there is no feasible distractor that is functional within a minimally invasive retractor. OBJECTIVE To describe the development of a provisional ipsilateral expandable rod for use in minimally invasive surgery for transforaminal lumbar interbody fusions to optimize access to the disc space, thereby facilitating placement of an interbody spacer. METHODS The authors report the clinical and radiographic data for 30 patients (3 open and 27 minimally invasive surgeries) with advanced degenerative disc disease in whom a provisional ipsilateral expandable rod was used to restore coronal balance and maintain disc height for interbody preparation and placement. Preoperative disc heights were measured, and the height of interbody spacer recorded. Mean restoration of disc heights was calculated. RESULTS The provisional ipsilateral expandable rod was successfully applied in both open exposures and within a minimally invasive retractor. The mean preoperative disc height was 4.9 mm (range, 1-9 mm), the mean height of the spacer inserted was 11.1 mm (range, 8-15 mm), and the mean increase in disc height was 6.2 mm (range, 5-11 mm). CONCLUSION A provisional ipsilateral expandable rod is feasible in either minimally invasive or open approaches. It has the capacity to maintain the disc height achieved by paddle distractors. This facilitates both the disc preparation and optimizes restoration of disc height and interbody spacer placement.
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Affiliation(s)
- Luis M Tumialán
- *Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona; ‡Division of Neurological Surgery, Scottsdale Healthcare System, Scottsdale, Arizona
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Takahashi T, Hanakita J, Watanabe M, Kawaoka T, Takebe N, Kitahara T. Lumbar alignment and clinical outcome after single level asymmetrical transforaminal lumbar interbody fusion for degenerative spondylolisthesis with local coronal imbalance. Neurol Med Chir (Tokyo) 2014; 54:691-7. [PMID: 25169032 PMCID: PMC4533364 DOI: 10.2176/nmc.st.2013-0394] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Transforaminal lumbar interbody fusion (TLIF) is widely accepted for the treatment of lumbar arthrodesis. However, the exact characteristics of TLIF depend on the number, location, shape, or materials of the interbody implants, and the type of posterior instrument. Clinical and biomechanical characteristics of each TLIF procedure are still unclear. The present study investigated the clinical and radiological improvements after single level asymmetrical TLIF, in which a single box-shaped spacer was obliquely inserted into the intervertebral space, for lumbar degenerative spondylolisthesis in patients with or without local coronal imbalance (LCI) at the operated level. The clinical records of 60 patients who underwent single level asymmetrical TLIF augmented with the pedicle screw fixation system from January 2005 to January 2011, were retrospectively reviewed. The patients were divided into the LCI group (n = 19) and non-LCI group (n = 41), based on segmental lateral translation or disc wedging at the operated site. Clinical recovery was significantly good in both groups at 2 years after surgery, but improvement of low back pain was significantly worse in the LCI group. Radiological examination revealed that the mean lumbar scoliotic angle was significantly worse in the LCI group postoperatively. Preoperative greater scoliotic angle and coronal off balance of the lumbar spine were related to unfavorable radiological outcomes. The present study showed that single level asymmetrical TLIF is an acceptable method for achieving good clinical and radiological outcomes for patients with symptomatic degenerative spondylolisthesis, however, the clinical benefits and realignment are limited if the patient has LCI at the operated site with greater scoliotic angle or coronal off balance of the lumbar spine.
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Gologorsky Y, Skovrlj B, Steinberger J, Moore M, Arginteanu M, Moore F, Steinberger A. Increased incidence of pseudarthrosis after unilateral instrumented transforaminal lumbar interbody fusion in patients with lumbar spondylosis: Clinical article. J Neurosurg Spine 2014; 21:601-7. [PMID: 25084031 DOI: 10.3171/2014.6.spine13488] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECT Transforaminal lumbar interbody fusion (TLIF) with segmental pedicular instrumentation is a well established procedure used to treat lumbar spondylosis with or without spondylolisthesis. Available biomechanical and clinical studies that compared unilateral and bilateral constructs have produced conflicting data regarding patient outcomes and hardware complications. METHODS A prospective cohort study was undertaken by a group of neurosurgeons. They prospectively enrolled 80 patients into either bilateral or unilateral pedicle screw instrumentation groups (40 patients/group). Demographic data collected for each group included sex, age, body mass index, tobacco use, and Workers' Compensation/litigation status. Operative data included segments operated on, number of levels involved, estimated blood loss, length of hospital stay, and perioperative complications. Long-term outcomes (hardware malfunction, wound dehiscence, and pseudarthrosis) were recorded. For all patients, preoperative baseline and 6-month postoperative scores for Medical Outcomes 36-Item Short Form Health Survey (SF-36) outcomes were recorded. RESULTS Patient follow-up times ranged from 37 to 63 months (mean 52 months). No patients were lost to follow-up. The patients who underwent unilateral pedicle screw instrumentation (unilateral cohort) were slightly younger than those who underwent bilateral pedicle screw instrumentation (bilateral cohort) (mean age 42 vs. 47 years, respectively; p = 0.02). No other significant differences were detected between cohorts with regard to demographic data, mean number of lumbar levels operated on, or distribution of the levels operated on. Estimated blood loss was higher for patients in the bilateral cohort, but length of stay was similar for patients in both cohorts. The incidence of pseudarthrosis was significantly higher among patients in the unilateral cohort (7 patients [17.5%]) than among those in the bilateral cohort (1 patient [2.5%]) (p = 0.02). Wound dehiscence occurred for 1 patient in the unilateral cohort. Reoperation was offered to 8 patients in the unilateral cohort and 1 patient in the bilateral cohort (p = 0.03). The physical component scores of the Medical Outcomes SF-36 outcomes improved significantly for all patients (p < 0.001). CONCLUSIONS Transforaminal lumbar interbody fusion with either unilateral or bilateral segmental pedicular instrumentation is an effective treatment for lumbar spondylosis. Because patients with unilateral constructs were 7 times more likely to experience pseudarthrosis and require reoperation, TLIF with bilateral constructs might be the biomechanically superior technique.
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Affiliation(s)
- Yakov Gologorsky
- Department of Neurosurgery, Mount Sinai Medical Center, New York, New York
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