Surgical Treatments for Lumbar Spine Diseases (TLIF vs. Other Surgical Techniques): A Systematic Review and Meta-Analysis

Cyclic testing of standalone ALIF versus TLIF in lumbosacral spines of low bone mineral density: an ex vivo biomechanical study

PURPOSE

Screwed anterior lumbar interbody fusion (SALIF) alleviates the need for supplemental posterior fixation leading to reduction of perioperative morbidity. Specifically, elderly and multimorbid patients would benefit from shorter operative time and faster recovery but tend to have low bone mineral density (BMD). The current study aimed to compare loosening, defined as increase of ROM and NZ, of SALIF versus transforaminal lumbar interbody fusion (TLIF) under cyclic loading in cadaveric spines with reduced BMD.

METHODS

Twelve human spines (L4-S2; 6 male 6 female donors; age 70.6 ± 19.6; trabecular BMD of L5 84.2 ± 24.4 mgHA/cm3, range 51-119 mgHA/cm3) were assigned to two groups. SALIF or TLIF were instrumented at L5/S1. Range of motion (ROM) and neutral zone (NZ) were assessed before and after axial cyclic loading (0-1150 N, 2000 cycles, 0.5 Hz) in flexion-extension (Flex-Ext), lateral bending, (LB), axial rotation (AR).

RESULTS

ROM of the SALIF specimens increased significantly in all loading directions (p ≤ 0.041), except for left AR (p = 0.053), whereas for TLIF it increased significantly in left LB (p = 0.033) and Flex (p = 0.015). NZ of SALIF showed increase in Flex-Ext and LB, whereas NZ of TLIF did not increase significantly in any motion direction.

CONCLUSIONS

Axial compression loading caused loosening of SALIF in Flex-Ext and LB, but not TLIF at L5/S1 in low BMD specimens. Nevertheless, Post-cyclic ROM and NZ of SALIF is comparable to TLIF. This suggests that, neither construct is optimal for the use in patients with reduced BMD.

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

Objectives

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

Materials and Methods

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

Results

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

Conclusion

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

Percutaneous transforaminal endoscopic surgery (PTES) and mini-incision L5/S1 OLIF with a self-lock cage for the surgical treatment of L5 spondylolisthesis

OBJECTIVES

We reported thirteen cases of percutaneous transforaminal endoscopic surgery (PTES) under local anesthesia and mini-incision L5/S1 OLIF (OLIF51) with a self-lock cage for the treatment of L5 spondylolisthesis.

METHODS

From Jan 2019 to Feb 2020, the patients with L5 spondylolisthesis with nerve root symptoms undergoing PTES and OLIF51 were included in this study. PTES under local anesthesia was performed in a prone position, and OLIF51 with a self-lock cage and allograft was then undertaken through a left abdominal mini-incision and oblique retroperitoneal approach between bilateral iliac vessels with the external oblique, internal oblique and transverse abdominal muscles bluntly separated in turn for L5/S1 in a right oblique position under general anesthesia. Back and leg pain were preoperatively and postoperatively evaluated using the VAS, and the clinical outcomes were evaluated with the ODI before surgery and at the 2-year follow-up. The anterior and posterior intervertebral space height (AISH, PISH), lumbar lordotic, and surgical segmental lordotic angle (SLA) were measured on lumbar spine X-rays preoperatively and postoperatively. The fusion status was assessed according to Bridwell's fusion grades.

RESULTS

Thirteen cases of L5 spondylolisthesis were included. The operation duration was 49.1 ± 5.6 min for PTES and 73.6 ± 8.2 min for OLIF. There was blood loss of 25 (15-45) ml. The incision length was 7.5 ± 1.1 mm for PTES and 46.8 ± 3.8 mm for OLIF. The hospital stay was 5 (4-6) days, and the follow-up duration was 29 (24-37) months. For the clinical evaluation, the VAS of back and leg pain significantly dropped after surgery (p < 0.001), and the ODI significantly decreased from 64.7 ± 7.8% to 12.9 ± 4.3% 2 years after surgery (p < 0.001). AISH, PISH and SLA significantly improved after surgery (p < 0.05). Fusion grades based on the Bridwell grading system at the 2-year follow-up were grade I in 9 segments (69.2%) and grade II in 4 segments (30.8%). No patients had any form of permanent iatrogenic nerve damage or major complications. No failure of instruments was observed.

CONCLUSIONS

PTES and mini-incision OLIF51 with a self-lock cage is a viable option of minimally invasive surgery for L5 spondylolisthesis, which can achieve direct neurologic decompression, satisfactory fusion and hardly destroys the rectus abdominis and its sheath, paraspinal muscles and bone structures.

Analysis of risk factors for contralateral symptomatic foraminal stenosis after unilateral transforaminal lumbar interbody fusion

PURPOSE

To analyze the risk factors of contralateral symptomatic foraminal stenosis (FS) after unilateral transforaminal lumbar interbody fusion (TLIF) and to guide and standardize the operation process of unilateral TLIF to reduce the occurrence of contralateral symptomatic FS.

METHODS

A retrospective study was undertaken on 487 patients with lumbar degeneration who underwent unilateral TLIF in the Department of Spinal Surgery of Ningbo Sixth Hospital between January 2017 and January 2021, comprising 269 males and 218 females, with a mean age of 57.1 years (range, 48-77 years). Cases of intraoperative improper operations, such as screw deviation, postoperative hematoma, and contralateral disc herniation, were excluded, and cases of nerve root symptoms caused by contralateral FS were analyzed. Post-surgery, 23 patients with nerve root symptoms caused by contralateral FS were categorized as group A, and 60 patients without nerve root symptoms were randomly selected as group B during the same period. The general data (gender, age, body mass index (BMI), bone mineral density (BMD), and diagnosis) and imaging parameters before and after operation (including contralateral foramen area (CFA), lumbar lordosis angle (LL), segmental lordosis angle (SL), disc height (DH), foramen height (FH), foramen width (FW), fusion cage position, and the difference between postoperative and preoperative) were compared between the two groups. Univariate analysis was performed, and multivariate analysis was undertaken through logistics analysis to determine the independent risk factors. Additionally, the clinical outcomes of the two groups were compared immediately before surgery and one year after surgery, using the visual analogue scale (VAS) score and the Japanese Orthopaedic Association (JOA) score for evaluation.

RESULTS

The patients in this study were followed up for a period of 19-25 (22.8atien months. Among them, 23 cases (4.72% incidence) were diagnosed with contralaterally symptomatic FS after the surgery. Univariate analysis indicated significant differences between the two groups in CFA, SL, FW, and cage coronal position. Logistic regression analysis identified preoperative contralateral foramen area (OR = 1.176, 95% CI (1.012, 1.367)), small segmental lordosis angle (OR = 2.225, 95% CI (1.124, 4.406)), small intervertebral foramen width (OR = 2.706, 95% CI (1.028, 7.118)), and cage coronal position not crossing the midline (OR = 1.567, 95% CI (1.142, 2.149)) as independent risk factors for contralateral symptomatic FS after unilateral TLIF. However, there was no statistically significant difference in the pain VAS score between the two groups one year after the operation. In contrast, there was a significant difference in the JOA score between the two groups.

CONCLUSION

The identified risk factors for contralateral symptomatic FS after TLIF include preoperative contralateral intervertebral foramen stenosis, a small segmental lordosis angle, a small intervertebral foramen width, and the coronal position of the cage not crossing the midline. For patients with these risk factors, it is recommended to carefully lock the screw rod during the recovery of lumbar lordosis and ensure that the coronal position of the fusion cage is implanted beyond the midline. If necessary, preventive decompression should also be considered. However, this study did not quantify the imaging data for each risk factor, and further research is needed to improve our understanding of the topic.

Effect of preoperative contralateral foramen stenosis on contralateral root symptoms after unilateral transforaminal lumbar interbody fusion: a ambispective cohort study

PURPOSE

To evaluate the correlation between the degree of preoperative contralateral foraminal stenosis(CFS) and the incidence of contralateral root symptoms after unilateral transforaminal lumbar interbody fusion(TLIF) and to evaluate the appropriate candidate of preventive decompression according to the degree of preoperative contralateral foraminal stenosis.

METHODS

An ambispective cohort study was conducted to investigate the incidence of contralateral root symptoms after unilateral transforaminal lumbar interbody fusion (TLIF) and the effectiveness of preventive decompression. A total of 411 patients were included in the study, all of whom met the inclusion and exclusion criteria and underwent surgery at the Department of Spinal Surgery, Ningbo Sixth Hospital, between January 2017 and February 2021. The study was divided into two groups: retrospective cohort study A and prospective cohort study B. The 187 patients included in study A from January 2017 to January 2019 did not receive preventive decompression. They were divided into four groups based on the degree of preoperative contralateral intervertebral foramen stenosis: no stenosis group A1, mild stenosis group A2, moderate stenosis group A3, and severe stenosis group A4. A Spearman rank correlation analysis was used to evaluate the correlation between the preoperative contralateral foramen stenosis degree and the incidence of contralateral root symptoms after unilateral TLIF. From February 2019 to February 2021, 224 patients were included in the prospective cohort group B. The decision to perform preventive decompression during the operation was based on the degree of preoperative contralateral foramen stenosis. Severe intervertebral foramen stenosis was treated with preventive decompression as group B1, while the rest were not treated with preventive decompression as group B2. The baseline data, surgical-related indicators, the incidence of contralateral root symptoms, clinical efficacy, imaging results, and other complications were compared between group A4 and group B1.

RESULTS

All 411 patients completed the operation and were followed up for an average of 13.5 ± 2.8 months. In the retrospective study, there was no significant difference in baseline data among the four groups (P > 0.05). The incidence of postoperative contralateral root symptoms increased gradually, and a weak positive correlation was found between the degree of preoperative intervertebral foramen stenosis and the incidence of postoperative root symptoms (rs = 0.304, P < 0.001). In the prospective study, there was no significant difference in baseline data between the two groups. The operation time and blood loss in group A4 were less than those in group B1 (P < 0.05). The incidence of contralateral root symptoms in group A4 was higher than that in group B1 (P = 0.003). However, there was no significant difference in leg VAS score and ODI index between the two groups at 3 months after the operation (P > 0.05). There was no significant difference in cage position, intervertebral fusion rate, and lumbar stability between the two groups (P > 0.05). No incisional infection occurred after the operation. No pedicle screw loosening, displacement, fracture, or interbody fusion cage displacement occurred during follow-up.

CONCLUSION

This study found a weak positive correlation between the degree of preoperative contralateral foramen stenosis and the incidence of contralateral root symptoms after unilateral TLIF. Intraoperative preventive decompression of the contralateral side may prolong the operation time and increase intraoperative blood loss to some extent. However, when the contralateral intervertebral foramen stenosis reaches the severe level, it is recommended to perform preventive decompression during the operation. This approach can reduce the incidence of postoperative contralateral root symptoms while ensuring clinical efficacy.

Application of Oblique Lateral Interbody Fusion Combined with Bridge-Locking Cage in Adjacent Segment Disease After Lumbar Fusion

OBJECTIVE

Adjacent segment disease (ASD) is considered any abnormal process that develops in the mobile segment next to spinal fusion, accompanied by related symptoms. To evaluate the efficacy and complications of oblique lateral interbody fusion (OLIF) combined with bridge-locking fusion on ASD after lumbar fusion.

METHODS

A total of 35 ASD patients who required re-operation after lumbar fusion in our hospital from March 2014 to March 2020 were retrospectively analyzed, among which 13 cases (seven males and six females; 62.3 ± 11.3 years old) received the treatment of OLIF + bridge-locking cage internal fixation (OLIF group), and 22 cases (14 males and eight females; 52.3 ± 17.8 years old) received the treatment of transforaminal lumbar interbody fusion (TLIF) + pedicle screw fixation (TLIF group). The comparison of the operation time, intraoperative blood loss, postoperative drainage volume, and length of hospital stay between the two groups of patients was performed using the t-test. The comparison of Visual Analogue Scale (VAS) and Oswestry Disability Index (ODI) at different time points before and after the operation was performed using analysis of variance for repeated measurement data. The fusion rate and postoperative complications of the two groups of patients were also evaluated.

RESULTS

The operation time of patients in the OLIF group (55.4 ± 12.4 min) was significantly shorter than that of patients in the TLIF group (94.3 ± 22.9 min) (P < 0.05), the length of stay of patients in the OLIF group (7.4 ± 2.3 day) was significantly shorter than that of patients in the TLIF group (12.4 ± 3.2 day) (P < 0.05); the intraoperative blood loss (62.2 ± 30.1 mL) and postoperative drainage (47.3 ± 22.4 mL) of patients in the OLIF group were significantly less than those of patients in the TLIF group with intraoperative blood loss (363.4 ± 120.2 mL) and postoperative drainage (285.5 ± 57.8 mL) (all Ps < 0.05). Besides, the VAS and ODI scores of the two groups of patients were improved 3 months after the operation and at the last follow-up (all Ps < 0.05). Three patients in the OLIF group developed complications such as hip flexion weakness and fusion cage sink, with an incidence of 23.1%. Three patients in the TLIF group developed complications including wound infection and intraoperative nerve injury, with an incidence of 22.7%.

CONCLUSION

The combination of OLIF and bridge-locking cage may be a safe and effective therapy for ASD patients after lumbar fusion operation.