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      Total 3D Airo® Navigation for Minimally Invasive Transforaminal Lumbar Interbody Fusion

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          Abstract

          Introduction. A new generation of iCT scanner, Airo®, has been introduced. The purpose of this study is to describe how Airo facilitates minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF). Method. We used the latest generation of portable iCT in all cases without the assistance of K-wires. We recorded the operation time, number of scans, and pedicle screw accuracy. Results. From January 2015 to December 2015, 33 consecutive patients consisting of 17 men and 16 women underwent single-level or two-level MIS-TLIF operations in our institution. The ages ranged from 23 years to 86 years (mean, 66.6 years). We treated all the cases in MIS fashion. In four cases, a tubular laminectomy at L1/2 was performed at the same time. The average operation time was 192.8 minutes and average time of placement per screw was 2.6 minutes. No additional fluoroscopy was used. Our screw accuracy rate was 98.6%. No complications were encountered. Conclusions. Airo iCT MIS-TLIF can be used for initial planning of the skin incision, precise screw, and cage placement, without the need for fluoroscopy. “Total navigation” (complete intraoperative 3D navigation without fluoroscopy) can be achieved by combining Airo navigation with navigated guide tubes for screw placement.

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          Comparison of posterior and transforaminal approaches to lumbar interbody fusion.

          Andrea Covington, Joanna Humphreys, Michael Eck … (2001)
          A study of the transforaminal lumbar interbody fusion and the posterior lumbar interbody fusion techniques was performed. To describe the transforaminal lumbar interbody fusion technique, and to compare operative data, including blood loss and operative time, with data from posterior lumbar interbody fusion technique. The evolution of posterior lumbar fusion combined with anterior interbody fusion has resulted in increased fusion rates as well as improved reductions and stability. The transforaminal lumbar interbody fusion technique pioneered by Harms and Jeszensky offers potential advantages and provides a surgical alternative to more traditional methods. In 13 consecutive months, two spinal surgeons performed 40 transforaminal lumbar interbody fusions and 34 posterior lumbar interbody fusion procedures. Data regarding blood loss, operative times, and length of hospital stay were recorded. These data were analyzed using analysis of variance to show any significant differences between the two techniques. To determine whether differences in measured variables were dependent on patient gender or number of levels fused, epsilon(chi2) analysis was used. No significant differences were found between transforaminal and posterior lumbar interbody fusions in terms of blood loss, operative time, or duration of hospital stay when a single-level fusion was performed. Significantly less blood loss occurred when a two-level fusion was performed using the transforaminal approach instead of the posterior approach (P < 0.01). Differences in measured variables for the two procedures were independent of patient age, gender, and the number of levels fused. There were no complications with the transforaminal approach, but the posterior approach resulted in multiple complications. In this comparison of patients receiving transforaminal lumbar interbody fusion versus posterior lumbar interbody fusion, no complications occurred with the transforaminal approach, whereas multiple complications were associated with the posterior approach. Similar operative times, blood loss, and duration of hospital stay were obtained in single-level fusions, but significantly less blood loss occurred with the transforaminal lumbar interbody approach in two-level fusions. The transforaminal procedure preserves the interspinous ligaments of the lumbar spine and preserves the contralateral laminar surface as an additional surface for bone graft. It may be performed at all lumbar levels because it avoids significant retraction of the dura and conus medullaris.
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            Comparison of one-level posterior lumbar interbody fusion performed with a minimally invasive approach or a traditional open approach.

            Yung Park, J. Høie (2007)
            Prospective cohort study. To determine the statistical difference between the minimally invasive and traditional open approach for one-level instrumented posterior lumbar interbody fusion by comparing the perioperative data, clinical outcome, and radiographic result. Posterior lumbar fusion performed with mini-incision using tubular retractor has been advocated as a minimally invasive technique. Proponents have claimed that minimally invasive techniques reduce postoperative pain, blood loss, transfusion needs, and the length of hospital stay compared with the traditional open techniques. But there was no well-designed comparison study that supports these claims. We studied a consecutive series of 61 patients who underwent one-level PLIF procedure (32 cases performed with minimally invasive approach and 29 cases with traditional open approach) by one surgeon at one hospital, from October 2003 until October 2004. The following data were compared between the 2 groups with 1-year minimum follow-up: the clinical and radiographic results, surgical time, estimated blood loss, transfusion needs, postoperative back pain by visual analogue scale, time needed before ambulation, length of hospital stay, and complications. There was no significant difference between the 2 groups in the aspects of the clinical and radiographic results with 1-year minimum follow-up. The minimally invasive group was found to have a significantly less blood loss, less needs of transfusion, less postoperative back pain, shorter recovery time before ambulation, and shorter length of hospital stay. However, the minimally invasive group needed significantly longer surgical time and showed 2 cases of technical complications. The present study, which was based on the authors' initial experience with the minimally invasive approach, could confirm favorable results reported by previous uncontrolled cohort studies in the aspects of less blood loss, less transfusion need, less postoperative back pain, quicker recovery, and shorter hospital stay. It also showed the similar surgical efficacy of the minimally invasive approach with that of the traditional open technique. However, the minimally invasive technique needs longer surgical time and a prudent attention to lower the risk of technical complications. Further long-term, prospective studies involving a larger study group are needed to determine the benefits of this minimally invasive percutaneous procedure.
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              Clinical and radiological outcomes of open versus minimally invasive transforaminal lumbar interbody fusion.

              Gavin Tan, Tsin W Yeo, Jae K. Lee … (2012)
              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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                Author and article information

                Journal
                Journal ID (nlm-ta): Biomed Res Int
                Journal ID (iso-abbrev): Biomed Res Int
                Journal ID (publisher-id): BMRI
                Title: BioMed Research International
                Publisher: Hindawi Publishing Corporation
                ISSN (Print): 2314-6133
                ISSN (Electronic): 2314-6141
                Publication date (Print): 2016
                Publication date (Electronic): 27 July 2016
                Volume: 2016
                Electronic Location Identifier: 5027340
                Affiliations
                1Weill Cornell Brain and Spine Center, Department of Neurological Surgery, Weill Cornell Medical College, New York-Presbyterian Hospital, 525 East 68th Street, P.O. Box 99, New York City, NY 10065, USA
                2Spine Subdivision, Department of Orthopedics, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
                Author notes
                *Rodrigo Navarro-Ramirez: ron2006@ 123456med.cornell.edu

                Academic Editor: Panagiotis Korovessis

                Author information
                http://orcid.org/0000-0003-2543-9063
                http://orcid.org/0000-0002-6679-4910
                Article
                DOI: 10.1155/2016/5027340
                PMC ID: 4978816
                PubMed ID: 27529069
                SO-VID: 983f5f20-bec9-4ec5-8638-a3f8d765afbf
                Copyright © Copyright © 2016 Xiaofeng Lian et al.
                License:

                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
                Date received : 22 January 2016
                Date accepted : 8 May 2016
                Funding
                Funded by: AOSpine
                Funded by: DePuy Synthes Spine
                Funded by: Brainlab
                Funded by: Lanx
                Categories
                Subject: Research Article

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