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      Clinical Outcomes of Posterior Lumbar Interbody Fusion versus Minimally Invasive Transforaminal Lumbar Interbody Fusion in Three-Level Degenerative Lumbar Spinal Stenosis

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          Abstract

          The aim of this study was to directly compare the clinical outcomes of posterior lumbar interbody fusion (PLIF) and minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) in three-level lumbar spinal stenosis. This retrospective study involved a total of 60 patients with three-level degenerative lumbar spinal stenosis who underwent MIS-TLIF or PLIF from January 2010 to February 2012. Back and leg visual analog scale (VAS), Oswestry Disability Index (ODI), and Short Form-36 (SF-36) scale were used to assess the pain, disability, and health status before surgery and postoperatively. In addition, the operating time, estimated blood loss, and hospital stay were also recorded. There were no significant differences in back VAS, leg VAS, ODI, SF-36, fusion condition, and complications at 12-month follow-up between the two groups ( P > 0.05). However, significantly less blood loss and shorter hospital stay were observed in MIS-TLIF group ( P < 0.05). Moreover, patients undergoing MIS-TLIF had significantly lower back VAS than those in PLIF group at 6-month follow-up ( P < 0.05). Compared with PLIF, MIS-TLIF might be a prior option because of noninferior efficacy as well as merits of less blood loss and quicker recovery in treating three-level lumbar spinal stenosis.

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          Most cited references27

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          Minimally invasive transforaminal lumbar interbody fusion (TLIF): technical feasibility and initial results.

          Forty-nine patients underwent minimally invasive transforaminal lumbar interbody fusion (TLIF) from October 2001 to August 2002 (minimum 18-month follow-up). The diagnosis was degenerative disc disease with herniated nucleus pulposus (HNP) in 26, spondylolisthesis in 22, and a Chance-type seatbelt fracture in 1. The majority of cases (n = 45) were at L4-L5 or L5-S1. A paramedian, muscle-sparing approach was performed through a tubular retractor docked unilaterally on the facet joint. A total facetectomy was then conducted, exposing the disc space. Discectomy and endplate preparation were completed through the tube using customized surgical instruments. Structural support was achieved with allograft bone or interbody cages. Bone grafting was done with local autologous or allograft bone, augmented with recombinant human bone morphogenetic protein-2 in some cases. Bilateral percutaneous pedicle screw-rod placement was accomplished with the Sextant system. There were no conversions to open surgery. Operative time averaged 240 minutes. Estimated blood loss averaged 140 mL. Mean length of hospital stay was 1.9 days. All patients presenting with preoperative radiculopathy (n = 45) had resolution of symptoms postoperatively. Complications included two instances of screw malposition requiring screw repositioning and two cases of new radiculopathy postoperatively (one from graft dislodgement, the other from contralateral neuroforaminal stenosis). Narcotic use was discontinued 2-4 weeks postoperatively. Improvements in average Visual Analogue Pain Scale and Oswestry Disability Index (preoperative to last follow-up) scores were 7.2-2.1 and 46-14, respectively. At last follow-up, all patients had solid fusions by radiographic criteria. Results of this study indicate that minimally invasive TLIF is feasible and offers several potential advantages over traditional open techniques.
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            Clinical and radiological outcomes of open versus minimally invasive transforaminal lumbar interbody fusion.

            Prospective observational cohort study. Comparison of clinical and radiological outcomes of single-level open versus minimally invasive (MIS) transforaminal lumbar interbody fusion (TLIF) at 6 months and 2-year follow-up. There is recognition that more data are required to ascertain the benefits and risks of MIS vis-a-vis open TLIF. This study aims to report on one of the largest currently available series comparing the clinical and radiological outcomes of the two procedures with a minimum follow-up of 2 years. From January 2002 to March 2008, 144 single-level open and MIS TLIF were performed at our centre, with 72 patients in each group. Clinical outcomes were based on patient-reported outcome measures recorded at the Orthopaedic Diagnostic Centre by independent assessors before surgery, at 6 months and 2 years post-operatively. These were visual analogue scores (VAS) for back and leg pain, Oswestry disability index (ODI), short form-36 (SF-36), North American Spine Society (NASS) scores for neurogenic symptoms, returning to full function, and patient rating of the overall result of surgery. Radiological fusion based on the Bridwell grading system was also assessed at 6 months and 2 years post-operatively by independent assessors. In terms of demographics, the two groups were similar in terms of patient sample size, age, gender, body mass index (BMI), spinal levels operated, and all the clinical outcome measures (p > 0.05). Perioperative analysis revealed that MIS cases have comparable operative duration (open: 181.8 min, MIS: 166.4 min, p > 0.05), longer fluoroscopic time (open: 17.6 s, MIS: 49.0 s, p 50.0%) and similarly in terms of VAS, ODI, SF-36, return to full function and patient rating (p > 0.05). Radiological analysis showed similar grade 1 fusion rates (open: 52.2%, MIS: 59.4%, p > 0.05) with small percentage of patients developing asymptomatic cage migration (open: 8.7%, MIS: 5.8%, p > 0.05). One major complication (open: myocardial infarction, MIS: screw malpositioning requiring subsequent revision) and two minor complications in each group (open: pneumonia and post-surgery anemia, MIS: incidental durotomy and pneumonia) were noted. At 2 years, continued improvements were observed in both groups as compared to the preoperative state (p > 0.05), with 50.8% of open and 58% of MIS TLIF patients returning to full function (p > 0.05). Almost all patients have Grade 1 fusion (open: 98.5 %, MIS: 97.0%, p > 0.05) with minimal new cage migration (open: 1.4 %, MIS: 0%, p > 0.05). MIS TLIF is a safe option for lumbar fusion, and when compared to open TLIF, has similar operative duration, good clinical and radiological outcomes, with additional significant benefits of less perioperative blood loss and pain, earlier rehabilitation, and a shorter hospitalization.
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              Complications associated with single-level transforaminal lumbar interbody fusion.

              The transforaminal lumbar interbody fusion (TLIF) procedure has become an increasingly popular means of obtaining a circumferential fusion while avoiding the morbidity of the anterior approach. Concerns remain, however, regarding the clinical efficacy and safety of its use. The purpose of this study was to evaluate the complications of the single-level TLIF procedure. The difference in complications observed with the use of iliac crest autograft compared with rhBMP-2 will be assessed. Retrospective cohort study; a review of complications. Patients who underwent a single-level TLIF between January 2004 to May 2007 with either autograft iliac crest or rhBMP-2 were identified. A retrospective review of these patients included operative reports, pre- and postoperative medical records, most recent postoperative dynamic and static lumbar radiographs, and computed tomography scans (when available). A total of 130 patients met the study criteria; 119 patients were available for follow-up, with an average radiographic follow-up of 19.1 months and an average clinical follow-up of 27.6 months. Thirty-three patients received iliac crest autograft and 86 patients received rhBMP-2. Complications occurred in 40 of the 119 study patients (33.6%). The autograft group had a higher complication rate (45.5% vs. 29.1%), but the difference was not statistically significant (p=.09). Complications in the autograft group included persistent donor-site pain (30.3%), donor-site infection (3.1%), lumbar wound infection (6.1%), and postoperative radiculitis (3.0%). Complications in the rhBMP-2 group included postoperative radiculitis (14.0%), vertebral osteolysis (5.8%), ectopic bone formation (2.3%), and lumbar wound infection (3.5%). A hydrogel sealant (Duraseal; Confluent Surgical Inc., Waltham, MA, USA) was used in 37 out of 86 patients in the rhBMP-2 group. The use of this sealant decreased the rate of postoperative radiculitis in the rhBMP-2 group from 20.4% to 5.4% (p=.047). The radiographic nonunion rate at most recent follow-up was 3.0% in the autograft group and 3.5% (p=.90) in the rhBMP-2 group. The most common complications in the autograft group were related to the donor site. The most common complication in the rhBMP-2 group was postoperative radiculitis, the incidence of which is reduced by the use of a hydrogel sealant.
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                Author and article information

                Journal
                Biomed Res Int
                Biomed Res Int
                BMRI
                BioMed Research International
                Hindawi Publishing Corporation
                2314-6133
                2314-6141
                2016
                26 September 2016
                : 2016
                : 9540298
                Affiliations
                Orthopedic Department, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
                Author notes

                Academic Editor: William B. Rodgers

                Author information
                http://orcid.org/0000-0002-9088-2486
                http://orcid.org/0000-0002-5040-886X
                Article
                10.1155/2016/9540298
                5056235
                27747244
                2fc5f975-625a-4416-bb84-e0366a432c4e
                Copyright © 2016 Guoxin Fan et al.

                This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                : 9 July 2016
                : 5 September 2016
                Funding
                Funded by: Tongji University
                Award ID: 1501219103
                Categories
                Clinical Study

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