Multitrack and multianchor point screw technique combined with the Wiltse approach for lesion debridement for lumbar tuberculosis

BACKGROUND

The incidence of lumbar tuberculosis is high worldwide, and effective treatment is a continuing problem.

AIM

To study the safety and efficacy of the multitrack and multianchor point screw technique combined with the contralateral Wiltse approach for lesion debridement to treat lumbar tuberculosis.

METHODS

The C-reactive protein (CRP) level, erythrocyte sedimentation rate (ESR), visual analogue scale (VAS) score, oswestry disability index (ODI) and American Spinal Injury Association (ASIA) grade were recorded and analysed pre- and postoperatively.

RESULTS

The CRP level and ESR returned to normal, and the VAS score and ODI were decreased at 3 mo postoperatively, with significant differences compared with the preoperative values (P < 0.01). Neurological dysfunction was relieved, and the ASIA grade increased, with no adverse events.

CONCLUSION

The multitrack, multianchor point screw fixation technique combined with the contralateral Wiltse approach for debridement is an effective and safe method for the treatment of lumbar tuberculosis.

Recent Efficacy of Oblique Lateral Interbody Fusion Combined With Wiltse Approach Pedicle Screw Fixation for Degenerative Single-Level Lumbar Spondylolisthesis

BACKGROUND

The study aimed to explore the recent efficacy of oblique lateral interbody fusion (OLIF) combined with Wiltse approach pedicle screw fixation in the treatment of single-level degenerative lumbar spondylolisthesis (DLS).

METHODS

This is a retrospective study. The study enrolled 54 patients with single-level DLS who were treated at the Affiliated Jiangnan Hospital of Zhejiang Chinese Medical University from May 2018 to June 2020. (OLIF group) 24 cases operated using OLIF combined with Wiltse approach pedicle screw fixation, and (PLIF group) 30 cases operated by PLIF. The primary outcome measures were visual analog scale (VAS) pain scores, Oswestry dysfunction index (ODI), and the lower lumbar spine anterior convexity angle.

RESULTS

There were significant differences in VAS (2.63 ± 0.58 vs. 3.57 ± 0.63, P < 0.001) and ODI (9.67 ± 0.92 vs. 10.63 ± 1.40, P < 0.05) between the OLIF group and PLIF group on postoperative 3 days. And there was a significant decrease in VAS (2.63 ± 0.58 vs. 1.08 ± 0.28, P < 0.05) and ODI (3.57 ± 0.63 vs. 1.10 ± 0.31, P < 0.05) in both groups on postoperative 3 days and at 6 months postoperative comparisons. OLIF group showed better intervertebral space height and the lower lumbar spine anterior convexity angle scores on postoperative 3 days and 6 months, the difference was statistically significant(all P < 0.05).

CONCLUSIONS

OLIF combined with the Wiltse approach pedicle screw fixation can achieve good short-term clinical results in the treatment of single-level DLS. This surgical approach is less invasive, promotes early functional recovery, shortens hospitalization time, and improves the quality of life.

Wiltse transforaminal thoracic interbody fusion approach for the treatment of single‑segment thoracic spinal tuberculosis in elderly patients with osteoporosis: A retrospective study of 20 cases

The aim of the present study was to investigate the clinical feasibility and efficacy of the Wiltse approach and TTIF in elderly patients with single-segment thoracic tuberculosis (SSTTB) complicated with osteoporosis and neurological dysfunction. Between January 2017 and January 2019, 20 elderly patients underwent the Wiltse TTIF approach at a single hospital. The follow-up time of these patients was 37.15±7.37 months (range, 24-48 months). The preoperative kyphosis angle was 35.41±6.71˚. The degree of neurological deficit in each patient was assessed using the Frankel spinal cord injury classification. In addition, TB activity was monitored using erythrocyte sedimentation rate and C-reactive protein levels, and the degree of osteoporosis was evaluated using femoral neck bone mineral density T-scores. The 20 patients with SSTTB were completely cured without recurrence. The postoperative kyphotic angle was 8.80±0.79˚, without significant loss of correction at the final follow-up. Bone graft fusion was observed within 6-9 months, with all patients reporting relief of their back pain. The neurological condition of all the patients improved postoperatively. The present study indicates that Wiltse TTIF surgery combined with anti-TB chemotherapy has satisfactory efficacy in elderly patients with SSTTB complicated by osteoporosis and neurological impairment.

Study of single-level lumbar degenerative diseases treated by unilateral wiltse access with unilateral nail rod fixation assisted by a new automatic retraction device

OBJECTIVE

To evaluate the clinical efficacy of unilateral wiltse transforaminal lumbar interbody fusion (TLIF) combined with unilateral nail bar system fixation for single-level lumbar degenerative diseases with the assistance of a new automatic retraction device in a retrospective comparative study.

METHODS

A total of 46 patients with single-level lumbar degenerative diseases from September 2019 to December 2021 were retrospectively analyzed. Bilateral nail bar fixation with bullet-type fusion cage (ctrl group, 24 patients) and unilateral nail bar fixation on the affected side with kidney-like fusion cage (study group, 22 patients) were performed in TLIF via wiltse intermuscular approach assisted by a new automatic retraction device. The differences in intraoperative blood loss, operative time, intraoperative fluoroscopy time, postoperative drainage, bed rest, VAS score, ODI score, JOA score, serological creatine kinase (CK), the proportion of multifidus atrophy, modified Pfirrmann classification and intervertebral space height of the upper intervertebral disc were compared between the two groups based on clinical and imaging data.

RESULTS

Intraoperative bleeding, operative time, and postoperative drainage were significantly lower in study group than ctrl group, and there were no significant differences in bed rest time and intraoperative fluoroscopy time between them. In addition, there was no statistical difference in CK between the study group and the ctrl group at 24 and 48 h postoperatively. Moreover, no statistically significant difference was found in VAS score of low back pain, VAS score of lower limb pain, ODI index, modified Pfirrmann classification of the upper intervertebral disc and intervertebral space height of the upper intervertebral disc between two groups. The atrophy ratio of multifidus muscle was significantly lower in the study group.

CONCLUSION

The new automatic retraction device assisted unilateral TLIF surgery with wiltse approach combined with unilateral nail bar fixation is a simple, effective and easy to master surgical method for single-level lumbar degenerative diseases.

[Clinical efficacy of oblique lumbar interbody fusion combined with unilateral pedicle screw fixation via Wiltse approach in the treatment of lumbar spinal stenosis]

OBJECTIVE

To evaluate the efficacy of oblique lumbar interbody fusion combined with unilateral pedicle screw fixation via Wiltse approach in the treatment of lumbar spinal stenosis.

METHODS

From July 2017 to January 2019, 90 patients with lumbar spinal stenosis, including 38 males and 52 females, aged from 43 to 75 years old with an average of(59.9±8.8) years old, and were treated with oblique lumbar interbody fusion(OLIF) combined with Wiltse unilateral pedicle screw fixation. Surgical decompression and fixation was performed in 50 cases of single segment, 32 cases of double segments and 8 cases of three segments. The distribution of responsible segments included 8 cases of L₂-L₃, 12 cases of L₃-L₄ and 30 cases of L₄-L₅ on single segment, 10 cases of L₂-L₄ and 22 cases of L₃-L₅ on double segments, and 8 cases of L₂-L₅ on three segments. The operation time, blood loss and occurrence of complications were recorded, Visual analogue scale(VAS), Oswestry Disability Index(ODI) and SF-36 scale were used to evaluate clinical efficacy. Lumbar X-ray and MRI were taken at three days after operation, interverterbral space height, intervertebral foraminal height, interverterbral foraminal area, and spinal canal area were measured, and interbody fusion was evaluated according to CT at half a year after operation.

RESULTS

All patients were followed up from 12 to 33 months, with an average of (20.2±6.6) months. Mean operation time was (103.3±35.9) min, and mean intraoperative blood loss was (70.4±17.8) ml. VAS of low back pain leg pain, and ODI decreased from 6.2±1.1, 6.1±0.9 and (59.9±4.2)% to 2.7±0.5, 2.5±0.5 and (31.3±8.8)%. SF-36 scale significantly increased from (37.2±3.1) to (54.9±6.1) at the six months postoperation(P<0.05). The intervertebral space height, intervertebral foraminal height, intervertebral foraminal area, and spinal canal area were significantly improved at 3 days after operation(P<0.05). Six months after operation, CT scan showed well fusion in 87 cases, but 3 cases with poor fusion, including 1 case of single segment, 2 cases of multi-segments. The total fusion rate was 96.7% (87/90), the single segment fusion rate was 98.0% (49/50), and the multi-segments fusion rate was 95.0%(38/40). The overall incidence of complications was 17.8%(16/90), including transient iliopsoas muscle weakness in 5 cases (5.6%), endplate fracture in 2 cases (2.2%), peritoneal injury in 1 case (1.1%), postoperative hematoma in 1 case (1.1%), adjacent segment disease in 1 case(1.1%), and fusion cage subsidence in 6 cases (6.7%). Three patients was followed up for recurrent nerve root pain and the symptoms were relieved after revision operation. All complications were relieved or disappeared in varying degrees during the follow-up period, and there were no complications such as cage displacement and screw fracture.

CONCLUSION

OLIF combined with unilateral pedicle screw fixation via Wiltse approach is effective in treating lumbar spinal stenosis with minimally invasive advantages such as less trauma and less complications. Under the premise of strictly grasping the indications, this method could also achieve satisfactory clinical results in multi-segments oprations.

[Clinical study of Wiltse approach with fulcrum reduction technique in the treatment of AO-A type thoracolumbar fractures]

OBJECTIVE

To investigate the effectiveness of Wiltse approach with fulcrum reduction technique and pedicle internal fixation in the treatment of AO-A type thoracolumbar fractures.

METHODS

The clinical data of 16 patients with AO-A type thoracolumbar fractures treated with Wiltse approach with fulcrum reduction technique and pedicle internal fixation between September 2013 and January 2019 were retrospectively analyzed. There were 9 males and 7 females, the age ranged from 38 to 60 years, with an average age of 50.7 years. Causes of injury included 9 cases of falling from height, 3 cases of traffic accidents, 3 cases of falling, and 1 case crushed by heavy objects. Fractured segment involved T ₁₁ in 2 cases, T ₁₂ in 5 cases, L ₁ in 7 cases, and L ₂ in 2 cases. There were 6 cases of type A1, 3 cases of type A2, 5 cases of type A3, and 2 cases of type A4 according to AO fracture classification. The operation time, intraoperative blood loss, and removal time of internal fixator were recorded. Before operation, immediately after operation, before and after removal of internal fixator, the local kyphotic angle (LKA), anterior vertebral height (AVH), and posterior vertebral height (PVH) of fractured vertebral body were measured; visual analogue scale (VAS) score of back pain were evaluated before operation, at 3 days after operation, before and after removal of internal fixator.

RESULTS

The operation time of the patients was 50-95 minutes, with an average of 70.7 minutes; the intraoperative blood loss was 50-230 mL, with an average of 132.9 mL; the internal fixator was removed after 18-30 months, with an average of 23.6 months. All patients were followed up 20-32 months, with an average of 25.6 months. No incision infection, hematoma, and other surgery-related complications, and internal fixator rupture residual complications occurred. All 16 patients achieved satisfactory reduction results. Immediate postoperative LKA, AVH, and PVH were significantly improved when compared with preoperative ones ( P<0.05). There was a certain degree of reduction loss before internal fixator removal, and the difference in LKA was significant ( P<0.05), but the difference in AVH and PVH were not significant ( P>0.05). There was a certain degree of reduction loss after internal fixator removal, but only the difference in AVH was significant ( P<0.05), and there was no significant difference in LKA and PVH ( P>0.05). The VAS score of the back pain significantly improved at 3 days after operation and before internal fixator removal when compared with preoperative score ( P<0.05). The pain after internal fixator removal was significantly worse than that before internal fixator removal ( P<0.05).

CONCLUSION

The Wiltse approach with fulcrum reduction technique and pedicle internal fixation in the treatment of AO-A thoracolumbar fractures has a short operation time, less intraoperative blood loss, and the posterior soft tissue and other structures are well protected during the operation. It can provide satisfactory clinical reduction results.

Wiltse Approach Versus Conventional Transforaminal Interbody Fusion for Unstable Thoracolumbar Fracture with Intervertebral Disc Lesions

Objective

To compare the clinical results of two surgical techniques, Wiltse approach and conventional transforaminal interbody fusion, for the treatment of unstable thoracolumbar fracture associated with traumatic intervertebral disc lesion (TIDL).

Methods

A total of 76 patients with unstable thoracolumbar fracture associated with TIDL treated by posterior pedicle screw fixation and transforaminal thoracolumbar interbody fusion from June 2010 and July 2016 were reviewed retrospectively. These patients including 48 male and 28 female patients were divided into Wiltse approach transforaminal thoracolumbar interbody fusion (W‐TLIF) group (n = 38) and conventional transforaminal thoracolumbar interbody fusion (C‐TLIF) group (n = 38). Patients were followed up for about 33 months. Clinical and radiological records, kyphotic angle, fractured vertebral body height, visual analogue score (VAS), Oswestry Disability Index (ODI), complications, neurological improvement and fusion rate were compared between two groups.

Results

All patients underwent posterior surgery successfully. Blood loss, operation time and hospital stay in the W‐TLIF group was 437.84 ± 143.98 ml, 118.64 ± 20.55 min and 12.32 ± 2.87 days, respectively. While those parameters in the C‐TLIF group was 862.70 ± 300.24 ml, 141.35 ± 31.72 min and 15.51 ± 2.08 days, respectively. Average operation time and hospital stay time were significantly shorter, and blood loss was significantly less in the W‐TLIF group than in the C‐TLIF group (P < 0.05). VAS and ODI in the W‐TLIF group were significantly less than those in the C‐TLIF group at 1 week after operation and final follow‐up. The kyphotic angle and vertebral body height were improved. There was 1–2 grade improvement in patients with neurological deficit. Thirty‐three patients in the W‐TLIF group and 32 patients in the C‐TLIF group had achieved fusion during follow‐up. No internal fixation failure was observed in two groups.

Conclusions

The both techniques of W‐TLIF and C‐TLIF were feasible and effective for unstable thoracolumbar fracture with TIDL. Compare to C‐TLIF, The technique of W‐TLIF was a relatively less invasive way to decompress the neural elements and an easy method to reconstruct the anterior column using the same posterior approach.

Comparison of the Wiltse Approach and Percutaneous Pedicle Screw Fixation Under O-arm Navigation for the Treatment of Thoracolumbar Fractures

Objectives

The aim of this study was to evaluate the clinical outcomes of the Wiltse approach and percutaneous pedicle screw placement under O‐arm navigation for the treatment of thoracolumbar fracture.

Methods

We enrolled a total of 54 patients with neurologically intact thoracolumbar fracture who received minimally invasive treatments between October 2014 and October 2018 in this retrospective study. Among these, 28 patients (22 males and six females, with a mean age of 48.6 ± 9.6 years) were treated with pedicle screw fixation through the Wiltse approach (WPSF), and another 26 (15 males and 11 females, with a mean age of 45.7 ± 10.6 years) received percutaneous pedicle screw fixation under O‐arm navigation (OPSF). Statistical methods were used to perform a detailed comparison of clinical outcomes, radiologic findings, and complications between the two groups obtained preoperatively, postoperatively, and at last follow‐up.

Results

All patients underwent surgery successfully and finished a follow‐up of more than 12 months. No serious complications, such as infection, blood vessel injury, or spinal cord or nerve root injury occurred. Visual analog scale (VAS) scores, Oswestry disability index (ODI) scores, local Cobb angle (LCA), vertebral wedge angle (VWA), and R value were notably improved after surgery, though there was no clear discrepancy between the groups at each time point (P > 0.05). During the follow‐up period, no patients developed neurological impairment or implant‐related complications, and no patients underwent revision surgery. The WPSF group had a significantly shorter operation time than the OPSF group (68.1 ± 9.8 vs 76.1 ± 9.0 minutes, P = 0.005). Moreover, the WPSF group showed less cost of surgery than the WPSF group (48142.1 ± 1430.1 vs 59035.4 ± 1152.7 CNY, P < 0.001). There were no significant differences between the two groups in terms of the intraoperative bleeding, length of incision, or postoperative hospitalization time (P > 0.05). The accuracy of pedicle screw placement was 95.2% (160/168) in the WPSF group and 96.8% (151/156) in the OPSF group, with no significant difference between the groups (P = 0.432).

Conclusion

Both WPSF and OPSF were safe and effective for the treatment of thoracolumbar fracture. Although the two groups showed favorable clinical and radiologic outcomes through to final follow‐up, we recommended the minimally invasive WPSF given its shorter operation time and lower cost of surgery.

[Clinical and radiographic evaluation of oblique lumbar interbody fusion combined with posterior surgery via Wiltse approach for adult degenerative scoliosis]

Objective: To assess the clinical effect of oblique lumbar interbody fusion (OLIF) combined with posterior surgery via Wiltse approach for adult degenerative scoliosis. Methods: The clinical data of 27 patients with adult degenerative scoliosis who received OLIF operation from April 2015 to June 2018 in Tongji Hospital were analyzed retrospectively. There were 17 males and 10 females with an average age of (54±11) years. All patients were treated with OLIF combined with pedicle screw fixation via Wiltse approach. Operation time, blood loss and surgery complications were all recorded. Clinical and radiographic evaluation were investigated at 1 week, 3 months of post operation and final follow-up. Visual analog scale (VAS) for low back pain and leg pain, Oswestry disability index (ODI) for low back pain were used to evaluate the clinical efficacy of surgery. Lumbar coronal cobb angle, lumbar lordosis (LL), pelvic tilt (PT), mismatch of PI and PT, sagittal vertical axis (SVA) were investigated with full spine standing X-ray. The data were compared with factor analysis of variance. Results: All patients were followed-up for 6-52 months ((30±5) months). The operation time was (235±33) min, the blood loss was (433±62) ml. VAS for low back pain and eg pain and the ODI were significantly improved from 6.8±1.4, 7.3±1.4 and 71%±11% preoperatively to 1.1±1.2, 1.0±0.9 and 17%±6% at the latest follow-up (F=115.302,139.855,291.198, all P<0.05).Lumbar coronal Cobb angle of patients was reduced from 28°±8° preoperatively to 9°±4° at the latest follow-up (F=66.352, P<0.05). The LL was significantly increased from 20°±11° preoperatively to 33°±7° (F=17.678, P<0.05), and PT, PI-LL and SVA were significantly increased from 31°±6°,35°±12° and (90±29) mm preoperatively to 26°±5°, 21°±6° and (32±17) mm at the latest follow-up (F=6.211,23.809,53.372, all P<0.05). There was no severe vascular andnerve injuries during and after operation. Conclusion: OLIF combined with posterior surgery via Wiltse approach is a safe and effective operation in the treatment of adult degenerative scoliosis with mild to moderate sagittal imbalance, it can correct the coronal and sagittal deformity, and achieve less surgery injury, less complications and good clinical results.

[Early effectiveness of oblique lateral interbody fusion combined with pedicle screw fixation via small incision Wiltse approach for lumbar spondylolisthesis]

Objective

To investigate the early effctiveness of oblique lateral interbody fusion (OLIF) combined with pedicle screw fixation via small incision Wiltse approach for the treatment of lumbar spondylolisthesis.

Methods

Between January 2016 and December 2016, 21 patients with lumbar spondylolisthesis were treated with OLIF and pedicle screw fixation via small incision Wiltse approach. There were 9 males and 12 females, aged 57-73 years, with an average age of 64.5 years. The disease duration was 24-60 months, with an average of 34.6 months. All cases were spondylolisthesis at L ₄ (15 cases of degreeⅠ, 6 cases of degreeⅡ); 1 case had vertebral arch isthmus, and 20 cases had spinal stenosis. Japanese Orthopaedic Association (JOA) scoring system was used to evaluate the effectiveness before operation and at last follow-up. Before operation and at 2 days after operation, anteroposterior and lateral X-ray films and CT were taken to measure the sagittal diameter and cross-sectional area of the spinal canal, and calculate the intervertebral height and degree of spondylolisthesis. At 6 months after operation, the intervertebral fusion was evaluated by CT.

Results

The operation time was 120-180 minutes, with an average of 155 minutes; the intraoperative blood loss was 100-340 mL, with an average of 225.5 mL. One patient had slight injury of lower endplate, 1 patient had numbness of thigh and weakness of hip flexion after operation, 1 patient had sympathetic nerve trunk injury. All the cases were followed up 12-18 months, with an average of 14.3 months. The symptoms of low back pain, leg pain, and numbness of lower limbs significantly relieved after operation, and there was no complication such as protrusion of fusion cage, screw breakage, and endplate collapse. At 2 days after operation, the intervertebral height, degree of spondylolisthesis, sagittal diameter of spinal canal, and cross-sectional area of spinal canal significantly improved compared with preoperative ones ( P<0.05). At 6 months after operation, CT showed that 1 patient had poor interbody fusion (grade Ⅲ), the other 20 patients had good interbody fusion (grade Ⅰ and Ⅱ), and the interbody fusion rate was 95.2%. At last follow-up, JOA score of lumbar spine significantly increased compared with that before operation ( t=24.980, P=0.000).

Conclusion

OLIF combined with pedicle screw fixation via small incision Wiltse approach for the lumbar spondylolisthesis has minimally invasive features, such as less trauma, fewer complications, and higher intervertebral fusion rate. It is a safe and effective method.

The efficacy and safety of multiple-dose intravenous tranexamic acid in reducing perioperative blood loss in patients with thoracolumbar burst fracture

OBJECTIVE

To evaluate the efficacy and safety of tranexamic acid (TXA) for single-segment thoracolumbar burst fracture without neurologic injury underwent pedicle screw fixation via Wiltse approach.

PATIENTS AND METHODS

We identified 264 patients with single-segment thoracolumbar burst fracture without neurologic injury underwent pedicle screw fixation via Wiltse approach (January 2016-June 2019) at a single center. The cohort was separated into three groups. Group A received 20 mg/kg TXA at 5 min before skin incision and 16 h after first dose; Group B received 20 mg/kg TXA at 5 min before skin incision; Group C received NS at each same time point. The outcomes were evaluated by hidden blood loss (HBL), total blood loss (TBL), intraoperative blood loss (IBL), transfusion rate, maximum hemoglobin (Hb) drop, prethrombotic state molecular markers, liver and renal function, coagulation function, inflammatory factor and adverse events.

RESULTS

The HBL, TBL and maximum Hb drop were significantly lower in Group A than those of Group B and Group C, while the difference between Group B and Group C was statistically significant. The IBL was significantly lower in Group A and Group B than that of Group C. However, there was no significantly difference among the three groups in live and renal function, coagulation function, prethrombotic state molecular markers, transfusion rate and complications during the perioperative period. There was significantly lower level of interleukin-6 (IL-6) in Group A than Group C at the day after surgery, and lower level of C-reactive protein (CRP) at the third day after surgery.

CONCLUSIONS

Intravenous TXA used in the treatment of thoracolumbar burst fracture underwent pedicle screw fixation via Wiltse approach is effective and safe in decreasing perioperative blood loss. The two-dose TXA regimen can further reduce blood loss and alleviate post-operative inflammation response, without affecting prethrombotic state molecular marks and without increasing the risk of complications.

Clinical Outcome of Minimally Invasive Decompression Without Discectomy in Contained Foraminal Disc Herniation: A Single-Center Study

BACKGROUND

Foraminal disc herniation is rare. When conservative treatment fails, it is often treated with discectomy via a paraspinal or Wiltse approach. In contained foraminal disc herniation, more symptoms arise from the foraminal compression of the exiting nerve root, including the dorsal root ganglion, than from the herniation itself. We aimed to evaluate the benefits of stand-alone decompression without discectomy for patients with contained foraminal disc herniation.

METHODS

This study included 17 patients with unilateral single-level foraminal disc herniation (14 women and 3 men; mean age, 62.8 ± 14.6 years, range, 37-86 years). Disc herniation was confirmed as contained by preoperative magnetic resonance imaging and/or computed tomography and by intraoperative exploration. All patients underwent thorough decompression without discectomy, via a paraspinal approach. Pain was evaluated preoperatively and at 3 and 12 months postoperatively using a visual analog scale (VAS). The Oswestry Disability Index (ODI) and Macnab criteria were used to evaluate final outcomes.

RESULTS

The most commonly affected level was L5-S1. All 17 patients showed significant improvements in VAS and ODI scores at 3 and 12 months postoperatively. According to the Macnab criteria, outcome results were excellent in 13 patients and good in 4. The mean duration of follow-up was 18.4 ± 2.4 months, with no recurrences or lumbar instability at the final follow-up.

CONCLUSIONS

Stand-alone decompression without discectomy is an effective method for relieving symptoms and preserving the disc in contained foraminal disc herniation. A minimally invasive approach with thorough decompression techniques yields good results.

Case presentation and short perspective on management of foraminal/far lateral discs and stenosis

Background

The management of lumbar foraminal/far lateral discs (FOR/FLD) with stenosis remains controversial. Operative choices should be based on each patient's preoperative dynamic X-ray findings, magnetic resonance (MR), and computed tomography (CT) studies. Here we reviewed several options for decompression alone vs. decompression with fusion.

Methods

Safe excision of FOR/FLD with stenosis should begin at the level above the disc herniation, as identification of the superior, foraminally, and far laterally exiting nerve root is critical. Performing an undercutting laminectomy and utilizing an operating microscope usually preserves the facet joints, and in many cases, avoids the need for fusion. Other decompressive techniques include; the intertransverse (ITT), and Wiltse approaches. Fusions following complete unilateral full facetectomy may be; noninstrumented (e.g., older, osteoporotic patients) vs. instrumented (e.g., posterolateral fusion or occasionally transforaminal lumbar interbody fusion). Here we present a patient with L2-L5 stenosis, and a left L3-L4 FOR/FLD, and multiple synovial cysts who was successfully managed with an l2-L5 laminecotmy, left L34 FOR/FLD diksectomy without fusion.

Results

Postoperatively, the patient was neurologically intact, and stability was maintained. Adjunctive measures for FOR/FLD diksectomy should include; intraoperative monitoring, use of the operating microscope, and an intraoperative film with a radiopaque marker in the correct disc space to confirm the correct level of diskectomy.

Conclusions

There are multiple approaches to the excision of FOR/FLD with stenosis. These include; decompression alone vs. decompression with non-instrumented vs. instrumented fusion. Surgical choices must be based on individual patient's X-ray, MR, and CT findings. The aim should be to maximize the safety of disc excision with decompression of stenosis, and to preserve stability, reducing the need for fusion, while minimizing morbidity.

How to perform the Wiltse posterolateral spinal approach: Technical note

Background:

The paraspinal, posterolateral, or Wiltse approach is an old technique that observes the principles of an MIS procedure. The aim of this study was to provide a step-by-step description from the literature of the Wiltse paraspinal approach and analyze its main advantages and limitations.

Methods:

Here, we provide a step-by-step description of the Wiltse approach. Utilizing PubMed and Lilacs and the Mesh terms “Wiltse approach,” “paraspinal approach,” “muscle sparing approach,” and “lumbar spine,” we identified 10 papers. We then put together, based on these publications, a step-by-step analysis of the preparation, patient positioning, skin incision, fascial opening, dissection, bone identification, retractors, deperiostization, decompression, discectomy, instrumentation, arthrodesis, and closure for the Wiltse technique.

Results:

Most papers underscored the minimally invasive aspects of the typical Wiltse approach. Advantages included minimal intraoperative bleeding, a shorter hospital length of stay, and a low infection rate.

Conclusion:

The classical approach described by Wiltse is essentially minimally invasive, sparing both the muscle planes and soft tissues, allowing for ample far lateral lumbar decompression, including discectomy and fusion, with a low complication rate.

Effectiveness of Transpedicular Dynamic Stabilization in Treating Discogenic Low Back Pain

PURPOSE

To assess clinical outcomes after dynamic stabilization in discogenic low back pain.

METHODS

From April 2012 to January 2015, 23 patients with discogenic low back pain were treated with dynamic stabilization via the Wiltse approach. Main clinical assessments included visual analog scale, Oswestry Disability Index, and complications. Radiographs were evaluated for lumbar range of motion and intervertebral height. The Woodend classification was determined by magnetic resonance imaging.

RESULTS

There were 23 cases evaluated with a mean follow-up time of 39 months. At last follow-up, visual analog scale and Oswestry Disability Index scores improved significantly compared with preoperatively (P < 0.05). At the stabilized segments, the height of intervertebral discs was increased significantly after surgery (P < 0.05). At last follow-up, the height was reduced to the preoperative level. At the operated segment, 47.4% of the flexion/extension range of motion was retained. Six discs showed rehydration with 1 grade improvement on the Woodend classification.

CONCLUSIONS

Dynamic stabilization was a safe and effective treatment in carefully selected groups of patients with discogenic low back pain and promoted disc regeneration to some extent.

Comparison of pedicle fixation by the Wiltse approach and the conventional posterior open approach for thoracolumbar fractures, using MRI, histological and electrophysiological analyses of the multifidus muscle

PURPOSE

To use imaging, histology and electrophysiological assessment to compare the Wiltse approach to pedicle fixation with the conventional posterior open approach for thoracolumbar fractures.

METHODS

We analyzed clinical and histopathological information of consecutive patients with thoracolumbar fractures who underwent short-segment pedicle fixation using either the Wiltse approach or the posterior open approach. Seventy-five patients were enrolled between June 2010 and August 2014 (Wiltse group 35 cases; posterior open group 40 cases). The two groups were compared for MRI appearance, histological and electrophysiological changes in multifidus muscle.

RESULTS

On MRI, multifidus cross-sectional area (CSA) in the Wiltse group decreased by only 7.6% between pre-op and the last follow-up, compared to 35.4% in the posterior open group, and less fatty infiltration was found in the Wiltse group. Histologically, post-op (removal of internal fixation) tissue from the posterior open group showed disordered myofibrils, with diameter and CSA decreased by 11.6 and 24.3%, respectively; also, the myofibril gap became larger with fat deposition and scar formation. The Wiltse group had no such significant changes. Electrophysiologically, in the posterior open group, median frequency slope (MFs) significantly increased by 67.6% with average amplitude (AA) significantly decreased by 17.5% between pre-op and 12 months post-op. No significant changes were found in the Wiltse group. At 12 months post-op, AA was significantly lower and MFs was higher in the posterior open group than the Wiltse group.

CONCLUSION

The Wiltse approach showed a lower incidence of multifidus atrophy and denervation, and less fatty infiltration. It is an effective and minimally invasive approach for thoracolumbar fractures.

Mini-invasive Transforaminal Lumbar Interbody Fusion through Wiltse Approach to Treating Lumbar Spondylolytic Spondylolisthesis

OBJECTIVE

To assess the clinical efficacy of mini-invasive transforaminal lumbar interbody fusion (TLIF) through the Wiltse approach for treating lumbar spondylolytic spondylolisthesis.

METHODS

In this retrospective controlled study, 69 cases with lumbar spondylolytic spondylolisthesis treated in Qilu hospital from April to November 2014 were randomly assigned to Wiltse approach (31 cases, 16 male, 15 female; mean age 45.1 years) and traditional approach groups (38 cases, 21 male, 17 female; 47.2 years. In the Wiltse approach group, the affected level was L4, 5 in 19 cases and L5 S1 in 12, 9 of whom had low back pain (LBP) only and 21 both LBP and leg pain. There were 17 cases of I degree and 14 of II degree spondylolisthesis. Pre-operative Japanese Orthopedic Association (JOA) score was 13.1 ± 2.6; visual analog scale (VAS) for LBP 7.4 ± 1.2; VAS for leg pain 6.1 ± 2.0 and Oswestry disability index (ODI) score 42.2% ± 1.2%. In the traditional approach group, the affected level was L4, 5 in 22 cases and L5 S1 in 16, 11 of whom had LBP only and 27 both LBP and leg pain. There were 21 cases of I degree and 17 of II degree spondylolisthesis. Pre-operative JOA score was 12.8 ± 1.2; VAS for LBP 6.9 ± 1.1; VAS for leg pain 7.1 ± 2.0 and ODI score 41.2% ± 2.0%. The JOA score, VAS for LBP and leg pain, ODI dynamic X-rays, CT and/or MR were evaluated 3 and 6 months and 1 year postoperatively.

RESULTS

There were no differences in sex, age, affected levels, spondylolisthesis degree, pre-operative JOA score, VAS for LBP or leg pain and ODI score between the two groups (P > 0.05). The incision length, blood loss and time to achieving exposure were better in the Wiltse approach than the traditional approach group (P < 0.05). The VAS for LBP and muscle atrophy MRI scores were significantly lower in the Wiltse approach than the traditional approach group on Days 1 and 14 and at 1 year follow-up (P < 0.05). The VAS for leg pain, JOA recovery rate and JOA and ODI scores tended to be lower in the Wiltse approach than the traditional approach group at 1 year follow-up examinations (no differences statistically significant, P > 0.05). The interbody fusion rate was not significantly different between the groups (P > 0.05). There were no complications of internal fixation in either group.

CONCLUSION

TLIF via both approaches has satisfactory clinical efficacy. TLIF through the Wiltse approach significantly reduces the damage of multifidus and postoperative incidence of chronic LBP.

Clinical outcomes of two minimally invasive transforaminal lumbar interbody fusion (TLIF) for lumbar degenerative diseases

BACKGROUND

There are two modified TLIF, including MIS-TLIF and TLIF through Wiltse approach (W-TLIF). Although both of the two minimally invasive surgical procedures can be effective in the treatment for lumbar degenerative diseases, no comparative analysis has been made so far regarding their clinical outcomes.

OBJECTIVE

To compare the clinical outcomes of MIS-TLIF and W-TLIF for the treatment for single-segment degenerative lumbar diseases.

METHODS

Ninety-seven patients with single-segment degenerative lumbar disorders were included in this study. Forty-seven underwent MIS-TLIF surgery (group A). For group B, fifty patients underwent W-TLIF. The Japanese Orthopedic Association (JOA) score, the visual analog scale (VAS) of low back pain (LBP) and leg pain, MRI score and atrophy rate of CSA, interbody fusion rate were assessed during the postoperative follow-up.

RESULTS

Incision length, blood loss, operative time, CPK, and postoperative incision pain VAS were better in group A (P < 0.05). The seconds of intraoperative fluoroscopy in groups A and B were 76 ± 9 and 7 ± 2, respectively (P < 0.05). In group B, The blood loss and CPK at L5-S1 were significantly higher than those at L4-5. Postoperative JOA scores, VAS of leg pain, and fusion rate were statistically the same between the two groups. VAS of LBP, MRI score, and atrophy rate of CSA was better in group A than in group B (P < 0.05).

CONCLUSION

Both methods are effective in the treatment for lumbar degenerative disease. MIS-TLIF has less blood loss, shorter surgical incision, and less lower postoperative back pain, while W-TLIF is less expensive for hospital stay with lower exposure to X-rays.

Surgical outcomes of mini-open Wiltse approach and conventional open approach in patients with single-segment thoracolumbar fractures without neurologic injury

This study aimed to introduce a novel mini-open pedicle screw fixation technique via Wiltse approach, and compared it with the traditional posterior open method. A total of 72 cases of single-segment thoracolumbar fractures without neurologic injury underwent pedicle screw fixation via two different approaches. Among them, 37 patients were treated using posterior open surgery, and 35 patients received mini-open operation via Wiltse approach. Crew placement accuracy rate, operative time, blood loss, postoperative drainage, postoperative hospitalization time, radiation exposure time, postoperative improvement in R value, Cobb's angle and visual analog scale (VAS) scores of the two methods were compared. There were no significant differences in the accuracy rate of pedicle screw placement, radiation exposure and postoperative R value and Cobb's angle improvement between the two groups. However, the mini-open method had obvious advantages over the conventional open method in operative time, blood loss, postoperative drainage, postoperative hospitalization time, and postoperative improvement in VAS. The mini-open pedicle screw technique could be applied in treatment of single-segment thoracolumbar fracture without neurologic injury and had advantages of less tissue trauma, short operative and rehabilitative time on the premise of guaranteed accuracy rate and no increased radiation exposure.

Minimally invasive one-level lumbar decompression and fusion surgery with posterior instrumentation using a combination of pedicle screw fixation and transpedicular facet screw construct

Background:

Minimally invasive lumbar spine fusion surgery has gained popularity in recent years. Routinely, this technique requires bilateral parasagittal incisions for decompression, interbody fusion, and posterior instrumentation. The following study is a description of a new minimally invasive technique for one-level transforaminal lumbar interbody fusion (TLIF) using a unilateral parasagittal incision (Wiltse approach), with placement of pedicle screws and then a percutaneous transpedicular facet screw insertion on the contralateral side. The biomechanical stability of this posterior construct will be discussed while the efficacy and complications of this technique have been examined.

Methods:

Forty patients underwent this new technique of one-level TLIF with posterior instrumentation using unilateral pedicle screw fixation supplemented with contralateral percutaneous transpedicular facet screw construct. Data regarding surgical time, estimated blood loss (EBL), hospital length of stay (LOS), and complications related to the posterior instrumentation are recorded.

Results:

The average surgical time of this new procedure was 124 minutes; average EBL was 140 cc; average hospital LOS was 3 days. Two patients developed new leg pain on the side where the facet screw had been placed. Both patients had the facet screw removed.

Conclusion:

This novel technique of unilateral pedicle screw fixation combined with contralateral percutaneous transpedicular facet screw construct has further reduced the amount of normal tissue injury while maintaining the same biomechanical advantages of bilateral pedicle screw fixation. However, caution is needed during the placement of the percutaneous facet screw in order to avoid nerve root injury.