e
PRIMARY RESEARCH
Transforaminal Lumbar Interbody Fusion in Degenerative Disk Disease and Spondylolisthesis Grade I Minimally Invasive Versus Open Surgery Giovanni B. Brodano, MD,* Konstantinos Martikos, MD,w Francesco Lolli, MD,w Alessandro Gasbarrini, MD,* Alfredo Cioni, MD,w Stefano Bandiera, MD,* Mario Di Silvestre, MD,w Stefano Boriani, MD,* and Tiziana Greggi, MDw
Background: Interbody fusion represents an efficient surgical treatment in degenerative lumbar disease, achieving satisfying outcome in >90% of cases. Various studies have affirmed the advantages of percutaneous and minimally invasive techniques with regard to minimized damage on soft tissues during surgical procedure, but their efficacy in comparison with the classic open surgical procedures has not yet been demonstrated. Materials and Methods: This is a retrospective study. We compared 30 consecutive patients affected by disk degenerative disease or grade I degenerative spondylolisthesis that were treated with minimally invasive transforaminal lumbar interbody fusion (miniTLIF) to a group of 34 consecutive patients presenting similar pathologic findings and demographic characteristics that underwent interbody fusion by traditional open approach (open-TLIF). All patients were treated between 2006 and 2010. Patients’ mean age was 46 years (min 28–max 56) and 51 years (min 32–max 58), respectively. Mean follow-up was 23 months (min 12–max 38) and 25 months (min 12–max 40), respectively. Clinical evaluation was performed by using Visual Analogue Scale (VAS) and Oswestry Disability Index (ODI) questionnaires. Radiographic evaluation was performed on standing and dynamic x-rays before operation and at final follow-up. Results: There was a statistically significant improvement in clinical scores (VAS and ODI) in both groups. Early postoperative VAS score was significantly lower in the mini-TLIF group. Mean hospital stay and mean blood loss were significantly higher in the open-TLIF group than in the mini-TLIF group (7.4 vs. 4.1 d and 620 vs. 230 mL, respectively). Surgical time length of the procedure was higher in the mini-TLIF group. There were no major neurological complications in any of the patients. At final follow-
Received for publication February 4, 2013; accepted October 3, 2013. From the Department of *Oncological and Degenerative Spine Surgery; and wSpinal Deformities Surgery, Rizzoli Orthopedic Institute, Bologna, Italy. G.B.B. and K.M. contributed equally. The authors declare no conflict of interest. Reprints: Giovanni B. Brodano, MD, Department of Oncological and Degenerative Spine Surgery, Rizzoli Orthopedic Institute, Via G.C. Pupilli, Bologna 1-40136, Italy. (e-mail: [email protected]). Copyright r 2013 Wolters Kluwer Health, Inc. All rights reserved.
J Spinal Disord Tech
Volume 28, Number 10, December 2015
up, radiographic evaluation showed good implant stability in both groups. Conclusions: Mini-TLIF is a safe and efficient procedure and, when correctly and carefully performed, can reach good results, similar to those obtained with traditional open surgical techniques, even though it may require a longer surgical time at least during the first stages of the learning curve. Reduced surgical invasiveness, short hospital stay, and limited blood loss represent the major advantages of minimally invasive technique. Key Words: transforaminal lumbar interbody fusion, degenerative lumbar spine, degenerative spondylolisthesis, minimally invasive approach, open approach, clinical outcomes (J Spinal Disord Tech 2015;28:E559–E564)
T
he need for interbody fusion is due to the importance of stabilization of the anterior vertebral body column that represents the anatomic segment where nearly 80% of compression, torsion, and distraction loads are transmitted. Interbody fusion offers a good primary stability to the motion segment and thus enhances the possibilities for late definitive segmental fusion.1,2 Transforaminal lumbar interbody fusion (TLIF) was first described and introduced in the early 1980s as an alternative interbody fusion procedure to earlier described PLIF procedures and claimed the advantage of exposing the surgeon to reduced risk of nerve root damage and dural lesions because of the fact that the interbody disk space is reached through a more lateral, transforaminal approach.3 TLIF also offers the possibility to achieve fusion of both anterior and posterior vertebral column. According to the original technique, transforaminal approach should be unilateral, preserving contralateral laminae, articular facets, and transverse processes that may be used as posterolateral arthrodesis surface. Theoretically, TLIF has also been accredited with an increased potential to achieve major segmental lordosis as the transforaminal approach consents cage positioning at the anterior-medial portion of the interbody space. For the aforementioned characteristics and because of good fusion rates that may reach 95% according www.jspinaldisorders.com |
Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved.
E559
J Spinal Disord Tech
Brodano et al
to various reports, TLIF has gained increased popularity over the past 3 decades.4–8 Recently, with the advent of modern image guidance and sophisticated instrumentations, the TLIF procedure was adapted as the minimally invasive spinal surgery technique, which over the past years has been proven advantageous over traditional open surgery in terms of damage on spinal soft tissues.9–18 Although minimally invasive TLIF (mini-TLIF) has been reported to be a secure and efficient surgical treatment, its advantages over traditional open surgical procedure for the treatment of lumbar degenerative pathology have not yet been demonstrated, as currently there is limited evidence in the literature comparing the 2 techniques.19–25
MATERIALS AND METHODS This is a retrospective study comparing mini-TLIF and open-TLIF for the treatment of lumbar degenerative disk disease (DDD) or grade I degenerative spondylolisthesis. Patients were operated between 2006 and 2010 in a single institute by a single surgeon. Clinical and radiographic data were revised to identify patients that satisfied the following inclusion criteria: symptomatic and refractory to prior conservative treatment, low back pain with or without unilateral leg pain, single-level DDD or degenerative grade I spondylolisthesis documented with both x-ray and MRI of the lumbar spine, and minimum follow-up period of 6 months after operation. We excluded patients with DDD or degenerative spondylolisthesis at >1 level, patients with spinal stenosis with neurogenic claudication or bilateral leg pain, patients with isthmic spondylolisthesis, and patients with 0.05) (Table 2). At final radiographic follow-up, we did not observe any instrumentation breakage; there were no cases of cage migration, instrumentation loosening, or pseudoarthrosis in any of the 2 groups.
DISCUSSION Although in the literature there are sufficient reports that describe the advantages of minimally invasive lumbar spine surgery techniques, there is limited evidence directly comparing minimally invasive to traditional open approach TLIF. There is general consent that minimally invasive posterior interbody fusion provides statistically significant less intraoperative and postoperative blood loss, decreased need for blood transfusion, earlier ambulation, and shorter hospital stay and our study confirms these results.21–25 Statistically significant differences in favor of minimally invasive treatment were immediate postoperative pain (VAS at third day after operation 4.5 vs. 7.2, P < 0.001), short-term postoperative pain and function (VAS at 30th day after operation 3.2 vs. 5.6, P < 0.001 and ODI 18% vs. 32%, P < 0.001, respectively), hospital stay (4.1 vs. 7.4 d, respectively, P = 0.015), and total blood losses (230 vs. 620 mL, respectively, P < 0.0001). In contrast, there are findings in our study that divert from other evidence in the literature. Park and Ha22 as well as Shunwu et al25 report significantly higher surgical time with minimally invasive procedure. Although the results of our study concur with this finding when considering the TABLE 2. Results Mini-TLIF
Open-TLIF
Total blood loss (mL) 230 (min 150–max 350) 620 (min 350–max 800) Hospital stay (d) 4.1 (min 4–max 8) 7.4 (min 5–max 15) Surgical time (h) 2.4 (min 1.5–max 3.7) 1.7 (min 1.2–max 3.1) Dural lesions 1 (3.3%) 2 (5.8%) TLIF indicates transforaminal lumbar interbody fusion.
Copyright
r
2013 Wolters Kluwer Health, Inc. All rights reserved.
TLIF in Degenerative Disk Disease
minimally invasive group of patients in its totality (2.4 h for mini-TLIF vs. 1.7 h for open-TLIF, P < 0.05), there was a statistically significant difference in operation time length between the former 15 minimally invasive patients (mean time 3.2 h) and the latter 15 ones (mean time 1.8 h). We therefore believe that minimally invasive techniques require a certain learning curve, and that once adequate experience is gained, operation time length may equal that of respective open technique. In fact, our results showed that statistically significant shorter times were required for the latter half of the minimally invasive cases, than for the former half, statistically equaling the time needed for the open procedure group. Neurological complications rate was similar in the 2 groups. No permanent neurological deficits were registered and dural lesion rate was not statistically different between the 2 groups: 1 case in the mini-TLIF group and 2 cases in the open-TLIF group (P = 0.4). Our findings therefore do not match those of Villavicencio et al19 who report a higher rate of neurological complications (10.5% vs. 1.6%, respectively). At final radiographic follow-up, we did not observe any instrumentation breakage; there were no cases of cage migration, instrumentation loosening, or residual instability in any of the 2 groups. Because of the lack of CT scan in all patients at final evaluation, we could not retrieve precise homogenous information regarding qualitative and quantitative differences in terms of bone fusion between the 2 groups.
CONCLUSIONS The results of our retrospective study confirm that both mini-TLIF and open-TLIF achieved good or excellent results in terms of clinical improvement at final follow-up. The retrospective design and lack of CT scan at final follow-up represent the main limits of our study. We therefore undertook a comparison between mini-TLIF and open-TLIF based on patients’ subjective pain and physical ability criteria, objective variables related to surgical procedure, and final x-ray evaluation. On the basis of our findings we conclude that miniTLIF is a safe and efficient procedure in the treatment of DDD, with similar clinical outcomes to open-TLIF. The major advantages of mini-TLIF are represented by decreased postoperative pain, lower blood loss, and shorter hospitalization. Another major advantage of mini-TLIF, as our findings advocate, is represented by decreased postoperative pain and superior functional outcomes at short-term postoperative period, which may be suggestive of a faster return to routine daily activity and professional work. Final radiographic follow-up revealed good outcomes without any mechanical complications due to instrumentation failure or apparent pseudoarthrosis with residual instability (standing and dynamic x-rays). We firmly believe that the most important factor in improving minimally invasive surgical technique and reducing surgical time is the surgeon’s learning curve and continuity in www.jspinaldisorders.com |
Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved.
E563
J Spinal Disord Tech
Brodano et al
repeat technique execution. We believe that after at least 15 or 20 procedures, sufficient experience should be gained for reducing time length. Although time length represents the major disadvantage of mini-TLIF, we believe that when the technique is carefully and patiently performed with respect to precise anatomic landmarks, major complications such as screw malposition and permanent neurological damage can be avoided. REFERENCES 1. Evans JH. Biomechanics of lumbar fusion. Clin Orthop Relat Res. 1985;193:38–46. 2. Voor MJ, Mehta S, Wang M, et al. Biomechanical evaluation of posterior and anterior lumbar interbody fusion techniques. J Spinal Disord. 1998;11:328–334. 3. Harms J, Rolinger H. A one-stager procedure in operative treatment of spondylolistheses: dorsal traction-reposition and anterior fusion (author’s transl). Z Orthop Ihre Grenzgeb. 1982;120:343–347. 4. Humphreys SC, Hodges SD, Patwardhan AG, et al. Comparison of posterior and transforaminal approaches to lumbar interbody fusion. Spine (Phila Pa 1976). 2001;26:567–571. 5. Lowe TG, Tahernia AD, O’Brien MF, et al. Unilateral transforaminal posterior lumbar interbody fusion (TLIF): indications, technique, and 2-year results. J Spinal Disord Tech. 2002;15:31–38. 6. Rosenberg WS, Mummaneni PV. Transforaminal lumbar interbody fusion: technique, complications and early results. Neurosurgery. 2001;48:569–574. 7. Salehi SA, Tawk R, Ganju A, et al. Transforaminal lumbar interbody fusion: surgical technique and results in 24 patients. Neurosurgery. 2004;54:368–374. 8. Potter BK, Freedman BA, Verwiebe EG, et al. Transforaminal lumbar interbody fusion: clinical and radiographic results and complications in 100 consecutive patients. J Spinal Disord Tech. 2005;18:337–346. 9. Foley KT, Holly LT, Schwender JD. Minimally invasive lumbar fusion. Spine. 2003;28:S26–S35. 10. Schwender JD, Holly LT, Rouben DP, et al. Minimally invasive transforaminal lumbar interbody fusion (TLIF): technical feasibility and initial results. J Spinal Disord Tech. 2005;18:S1–S6. 11. Mummaneni PV, Rodts GE Jr. The mini-open transforaminal lumbar interbody fusion. Neurosurgery. 2005;57:256–261.
E564 | www.jspinaldisorders.com
Volume 28, Number 10, December 2015
12. Ozgur BM, Yoo K, Rodriguez G, et al. Minimally-invasive technique for transforaminal lumbar interbody fusion (TLIF). Eur Spine J. 2005;14:887–894. 13. Holly LT, Schwender JD, Rouben DP, et al. Minimally invasive transforaminal lumbar interbody fusion: indications, technique, and complications. Neurosurg Focus. 2006;20:E6. 14. Scheufler KM, Dohmen H, Vougioukas VI. Percutaneous transforaminal lumbar interbody fusion for the treatment of degenerative lumbar instability. Neurosurgery. 2007;60:203–213. 15. Kawaguchi Y, Matsui H, Tsuji H. Back muscle injury after posterior lumbar spine surgery. Spine. 1996;21:941–944. 16. Styf JR, Wille´n J. The effects of external compression by three different retractors on pressure in the erector spine muscles during and after posterior lumbar spine surgery in humans. Spine (Phila Pa 1976). 1998;23:354–358. 17. Gejo R, Matsui H, Kawaguchi Y, et al. Serial changes in trunk muscle performance after posterior lumbar surgery. Spine. 1999;24:1023–1028. 18. Sihvonen T, Herno A, Paljiarvi L, et al. Local denervation atrophy of paraspinal muscles in postoperative failed back syndrome. Spine. 1993;18:575–581. 19. Villavicencio AT, Burneikiene S, Roeca CM, et al. Minimally invasive versus open transforaminal lumbar interbody fusion. Surg Neurol Int. 2010;1:12. 20. Peng CW, Yue WM, Poh SY, et al. Clinical and radiological outcomes of minimally invasive versus open transforaminal lumbar interbody fusion. Spine (Phila Pa 1976). 2009;34:1385–1389. 21. Dhall SS, Wang My, Mummanenni PV. Clinical and radiographic comparison of mini-open transforaminal lumbar interbody fusion with open transforaminal lumbar interbody fusion in 42 patients with long-term follow up. J Neurosurg Spine. 2008;9:560–565. 22. Park Y, Ha YW. Comparison of one-level posterior lumbar interbody fusion performed with a minimally invasive approach or a traditional open approach. Spine. 2007;32:537–543. 23. Schizas C, Tzinieris N, Tsiridis E, et al. Minimally invasive versus open transforaminal lumbar interbody fusion: evaluating initial experience. Int Orthop. 2009;33:1683–1688. 24. Wang J, Zhou Y, Zheng Z, et al. Comparison of one-level minimally invasive and open transforaminal lumbar interbody fusion in degenerative and isthmic spondylolisthesis grades 1 and 2. Eur Spine J. 2010;19:1780–1784. 25. Shunwu F, Xing Z, Fengdong Z, et al. Minimally invasive transforaminal lumbar interbody fusion for the treatment of degenerative lumbar diseases. Spine. 2010;35:1615–1620.
Copyright
r
2013 Wolters Kluwer Health, Inc. All rights reserved.
Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved.
PRIMARY RESEARCH
Transforaminal Lumbar Interbody Fusion in Degenerative Disk Disease and Spondylolisthesis Grade I Minimally Invasive Versus Open Surgery Giovanni B. Brodano, MD,* Konstantinos Martikos, MD,w Francesco Lolli, MD,w Alessandro Gasbarrini, MD,* Alfredo Cioni, MD,w Stefano Bandiera, MD,* Mario Di Silvestre, MD,w Stefano Boriani, MD,* and Tiziana Greggi, MDw
Background: Interbody fusion represents an efficient surgical treatment in degenerative lumbar disease, achieving satisfying outcome in >90% of cases. Various studies have affirmed the advantages of percutaneous and minimally invasive techniques with regard to minimized damage on soft tissues during surgical procedure, but their efficacy in comparison with the classic open surgical procedures has not yet been demonstrated. Materials and Methods: This is a retrospective study. We compared 30 consecutive patients affected by disk degenerative disease or grade I degenerative spondylolisthesis that were treated with minimally invasive transforaminal lumbar interbody fusion (miniTLIF) to a group of 34 consecutive patients presenting similar pathologic findings and demographic characteristics that underwent interbody fusion by traditional open approach (open-TLIF). All patients were treated between 2006 and 2010. Patients’ mean age was 46 years (min 28–max 56) and 51 years (min 32–max 58), respectively. Mean follow-up was 23 months (min 12–max 38) and 25 months (min 12–max 40), respectively. Clinical evaluation was performed by using Visual Analogue Scale (VAS) and Oswestry Disability Index (ODI) questionnaires. Radiographic evaluation was performed on standing and dynamic x-rays before operation and at final follow-up. Results: There was a statistically significant improvement in clinical scores (VAS and ODI) in both groups. Early postoperative VAS score was significantly lower in the mini-TLIF group. Mean hospital stay and mean blood loss were significantly higher in the open-TLIF group than in the mini-TLIF group (7.4 vs. 4.1 d and 620 vs. 230 mL, respectively). Surgical time length of the procedure was higher in the mini-TLIF group. There were no major neurological complications in any of the patients. At final follow-
Received for publication February 4, 2013; accepted October 3, 2013. From the Department of *Oncological and Degenerative Spine Surgery; and wSpinal Deformities Surgery, Rizzoli Orthopedic Institute, Bologna, Italy. G.B.B. and K.M. contributed equally. The authors declare no conflict of interest. Reprints: Giovanni B. Brodano, MD, Department of Oncological and Degenerative Spine Surgery, Rizzoli Orthopedic Institute, Via G.C. Pupilli, Bologna 1-40136, Italy. (e-mail: [email protected]). Copyright r 2013 Wolters Kluwer Health, Inc. All rights reserved.
J Spinal Disord Tech
Volume 28, Number 10, December 2015
up, radiographic evaluation showed good implant stability in both groups. Conclusions: Mini-TLIF is a safe and efficient procedure and, when correctly and carefully performed, can reach good results, similar to those obtained with traditional open surgical techniques, even though it may require a longer surgical time at least during the first stages of the learning curve. Reduced surgical invasiveness, short hospital stay, and limited blood loss represent the major advantages of minimally invasive technique. Key Words: transforaminal lumbar interbody fusion, degenerative lumbar spine, degenerative spondylolisthesis, minimally invasive approach, open approach, clinical outcomes (J Spinal Disord Tech 2015;28:E559–E564)
T
he need for interbody fusion is due to the importance of stabilization of the anterior vertebral body column that represents the anatomic segment where nearly 80% of compression, torsion, and distraction loads are transmitted. Interbody fusion offers a good primary stability to the motion segment and thus enhances the possibilities for late definitive segmental fusion.1,2 Transforaminal lumbar interbody fusion (TLIF) was first described and introduced in the early 1980s as an alternative interbody fusion procedure to earlier described PLIF procedures and claimed the advantage of exposing the surgeon to reduced risk of nerve root damage and dural lesions because of the fact that the interbody disk space is reached through a more lateral, transforaminal approach.3 TLIF also offers the possibility to achieve fusion of both anterior and posterior vertebral column. According to the original technique, transforaminal approach should be unilateral, preserving contralateral laminae, articular facets, and transverse processes that may be used as posterolateral arthrodesis surface. Theoretically, TLIF has also been accredited with an increased potential to achieve major segmental lordosis as the transforaminal approach consents cage positioning at the anterior-medial portion of the interbody space. For the aforementioned characteristics and because of good fusion rates that may reach 95% according www.jspinaldisorders.com |
Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved.
E559
J Spinal Disord Tech
Brodano et al
to various reports, TLIF has gained increased popularity over the past 3 decades.4–8 Recently, with the advent of modern image guidance and sophisticated instrumentations, the TLIF procedure was adapted as the minimally invasive spinal surgery technique, which over the past years has been proven advantageous over traditional open surgery in terms of damage on spinal soft tissues.9–18 Although minimally invasive TLIF (mini-TLIF) has been reported to be a secure and efficient surgical treatment, its advantages over traditional open surgical procedure for the treatment of lumbar degenerative pathology have not yet been demonstrated, as currently there is limited evidence in the literature comparing the 2 techniques.19–25
MATERIALS AND METHODS This is a retrospective study comparing mini-TLIF and open-TLIF for the treatment of lumbar degenerative disk disease (DDD) or grade I degenerative spondylolisthesis. Patients were operated between 2006 and 2010 in a single institute by a single surgeon. Clinical and radiographic data were revised to identify patients that satisfied the following inclusion criteria: symptomatic and refractory to prior conservative treatment, low back pain with or without unilateral leg pain, single-level DDD or degenerative grade I spondylolisthesis documented with both x-ray and MRI of the lumbar spine, and minimum follow-up period of 6 months after operation. We excluded patients with DDD or degenerative spondylolisthesis at >1 level, patients with spinal stenosis with neurogenic claudication or bilateral leg pain, patients with isthmic spondylolisthesis, and patients with 0.05) (Table 2). At final radiographic follow-up, we did not observe any instrumentation breakage; there were no cases of cage migration, instrumentation loosening, or pseudoarthrosis in any of the 2 groups.
DISCUSSION Although in the literature there are sufficient reports that describe the advantages of minimally invasive lumbar spine surgery techniques, there is limited evidence directly comparing minimally invasive to traditional open approach TLIF. There is general consent that minimally invasive posterior interbody fusion provides statistically significant less intraoperative and postoperative blood loss, decreased need for blood transfusion, earlier ambulation, and shorter hospital stay and our study confirms these results.21–25 Statistically significant differences in favor of minimally invasive treatment were immediate postoperative pain (VAS at third day after operation 4.5 vs. 7.2, P < 0.001), short-term postoperative pain and function (VAS at 30th day after operation 3.2 vs. 5.6, P < 0.001 and ODI 18% vs. 32%, P < 0.001, respectively), hospital stay (4.1 vs. 7.4 d, respectively, P = 0.015), and total blood losses (230 vs. 620 mL, respectively, P < 0.0001). In contrast, there are findings in our study that divert from other evidence in the literature. Park and Ha22 as well as Shunwu et al25 report significantly higher surgical time with minimally invasive procedure. Although the results of our study concur with this finding when considering the TABLE 2. Results Mini-TLIF
Open-TLIF
Total blood loss (mL) 230 (min 150–max 350) 620 (min 350–max 800) Hospital stay (d) 4.1 (min 4–max 8) 7.4 (min 5–max 15) Surgical time (h) 2.4 (min 1.5–max 3.7) 1.7 (min 1.2–max 3.1) Dural lesions 1 (3.3%) 2 (5.8%) TLIF indicates transforaminal lumbar interbody fusion.
Copyright
r
2013 Wolters Kluwer Health, Inc. All rights reserved.
TLIF in Degenerative Disk Disease
minimally invasive group of patients in its totality (2.4 h for mini-TLIF vs. 1.7 h for open-TLIF, P < 0.05), there was a statistically significant difference in operation time length between the former 15 minimally invasive patients (mean time 3.2 h) and the latter 15 ones (mean time 1.8 h). We therefore believe that minimally invasive techniques require a certain learning curve, and that once adequate experience is gained, operation time length may equal that of respective open technique. In fact, our results showed that statistically significant shorter times were required for the latter half of the minimally invasive cases, than for the former half, statistically equaling the time needed for the open procedure group. Neurological complications rate was similar in the 2 groups. No permanent neurological deficits were registered and dural lesion rate was not statistically different between the 2 groups: 1 case in the mini-TLIF group and 2 cases in the open-TLIF group (P = 0.4). Our findings therefore do not match those of Villavicencio et al19 who report a higher rate of neurological complications (10.5% vs. 1.6%, respectively). At final radiographic follow-up, we did not observe any instrumentation breakage; there were no cases of cage migration, instrumentation loosening, or residual instability in any of the 2 groups. Because of the lack of CT scan in all patients at final evaluation, we could not retrieve precise homogenous information regarding qualitative and quantitative differences in terms of bone fusion between the 2 groups.
CONCLUSIONS The results of our retrospective study confirm that both mini-TLIF and open-TLIF achieved good or excellent results in terms of clinical improvement at final follow-up. The retrospective design and lack of CT scan at final follow-up represent the main limits of our study. We therefore undertook a comparison between mini-TLIF and open-TLIF based on patients’ subjective pain and physical ability criteria, objective variables related to surgical procedure, and final x-ray evaluation. On the basis of our findings we conclude that miniTLIF is a safe and efficient procedure in the treatment of DDD, with similar clinical outcomes to open-TLIF. The major advantages of mini-TLIF are represented by decreased postoperative pain, lower blood loss, and shorter hospitalization. Another major advantage of mini-TLIF, as our findings advocate, is represented by decreased postoperative pain and superior functional outcomes at short-term postoperative period, which may be suggestive of a faster return to routine daily activity and professional work. Final radiographic follow-up revealed good outcomes without any mechanical complications due to instrumentation failure or apparent pseudoarthrosis with residual instability (standing and dynamic x-rays). We firmly believe that the most important factor in improving minimally invasive surgical technique and reducing surgical time is the surgeon’s learning curve and continuity in www.jspinaldisorders.com |
Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved.
E563
J Spinal Disord Tech
Brodano et al
repeat technique execution. We believe that after at least 15 or 20 procedures, sufficient experience should be gained for reducing time length. Although time length represents the major disadvantage of mini-TLIF, we believe that when the technique is carefully and patiently performed with respect to precise anatomic landmarks, major complications such as screw malposition and permanent neurological damage can be avoided. REFERENCES 1. Evans JH. Biomechanics of lumbar fusion. Clin Orthop Relat Res. 1985;193:38–46. 2. Voor MJ, Mehta S, Wang M, et al. Biomechanical evaluation of posterior and anterior lumbar interbody fusion techniques. J Spinal Disord. 1998;11:328–334. 3. Harms J, Rolinger H. A one-stager procedure in operative treatment of spondylolistheses: dorsal traction-reposition and anterior fusion (author’s transl). Z Orthop Ihre Grenzgeb. 1982;120:343–347. 4. Humphreys SC, Hodges SD, Patwardhan AG, et al. Comparison of posterior and transforaminal approaches to lumbar interbody fusion. Spine (Phila Pa 1976). 2001;26:567–571. 5. Lowe TG, Tahernia AD, O’Brien MF, et al. Unilateral transforaminal posterior lumbar interbody fusion (TLIF): indications, technique, and 2-year results. J Spinal Disord Tech. 2002;15:31–38. 6. Rosenberg WS, Mummaneni PV. Transforaminal lumbar interbody fusion: technique, complications and early results. Neurosurgery. 2001;48:569–574. 7. Salehi SA, Tawk R, Ganju A, et al. Transforaminal lumbar interbody fusion: surgical technique and results in 24 patients. Neurosurgery. 2004;54:368–374. 8. Potter BK, Freedman BA, Verwiebe EG, et al. Transforaminal lumbar interbody fusion: clinical and radiographic results and complications in 100 consecutive patients. J Spinal Disord Tech. 2005;18:337–346. 9. Foley KT, Holly LT, Schwender JD. Minimally invasive lumbar fusion. Spine. 2003;28:S26–S35. 10. Schwender JD, Holly LT, Rouben DP, et al. Minimally invasive transforaminal lumbar interbody fusion (TLIF): technical feasibility and initial results. J Spinal Disord Tech. 2005;18:S1–S6. 11. Mummaneni PV, Rodts GE Jr. The mini-open transforaminal lumbar interbody fusion. Neurosurgery. 2005;57:256–261.
E564 | www.jspinaldisorders.com
Volume 28, Number 10, December 2015
12. Ozgur BM, Yoo K, Rodriguez G, et al. Minimally-invasive technique for transforaminal lumbar interbody fusion (TLIF). Eur Spine J. 2005;14:887–894. 13. Holly LT, Schwender JD, Rouben DP, et al. Minimally invasive transforaminal lumbar interbody fusion: indications, technique, and complications. Neurosurg Focus. 2006;20:E6. 14. Scheufler KM, Dohmen H, Vougioukas VI. Percutaneous transforaminal lumbar interbody fusion for the treatment of degenerative lumbar instability. Neurosurgery. 2007;60:203–213. 15. Kawaguchi Y, Matsui H, Tsuji H. Back muscle injury after posterior lumbar spine surgery. Spine. 1996;21:941–944. 16. Styf JR, Wille´n J. The effects of external compression by three different retractors on pressure in the erector spine muscles during and after posterior lumbar spine surgery in humans. Spine (Phila Pa 1976). 1998;23:354–358. 17. Gejo R, Matsui H, Kawaguchi Y, et al. Serial changes in trunk muscle performance after posterior lumbar surgery. Spine. 1999;24:1023–1028. 18. Sihvonen T, Herno A, Paljiarvi L, et al. Local denervation atrophy of paraspinal muscles in postoperative failed back syndrome. Spine. 1993;18:575–581. 19. Villavicencio AT, Burneikiene S, Roeca CM, et al. Minimally invasive versus open transforaminal lumbar interbody fusion. Surg Neurol Int. 2010;1:12. 20. Peng CW, Yue WM, Poh SY, et al. Clinical and radiological outcomes of minimally invasive versus open transforaminal lumbar interbody fusion. Spine (Phila Pa 1976). 2009;34:1385–1389. 21. Dhall SS, Wang My, Mummanenni PV. Clinical and radiographic comparison of mini-open transforaminal lumbar interbody fusion with open transforaminal lumbar interbody fusion in 42 patients with long-term follow up. J Neurosurg Spine. 2008;9:560–565. 22. Park Y, Ha YW. Comparison of one-level posterior lumbar interbody fusion performed with a minimally invasive approach or a traditional open approach. Spine. 2007;32:537–543. 23. Schizas C, Tzinieris N, Tsiridis E, et al. Minimally invasive versus open transforaminal lumbar interbody fusion: evaluating initial experience. Int Orthop. 2009;33:1683–1688. 24. Wang J, Zhou Y, Zheng Z, et al. Comparison of one-level minimally invasive and open transforaminal lumbar interbody fusion in degenerative and isthmic spondylolisthesis grades 1 and 2. Eur Spine J. 2010;19:1780–1784. 25. Shunwu F, Xing Z, Fengdong Z, et al. Minimally invasive transforaminal lumbar interbody fusion for the treatment of degenerative lumbar diseases. Spine. 2010;35:1615–1620.
Copyright
r
2013 Wolters Kluwer Health, Inc. All rights reserved.
Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved.
