An updated meta-analysis of clinical outcomes comparing minimally invasive with open transforaminal lumbar interbody fusion in patients with degenerative lumbar diseases

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Abstract

Background & Aims:

Open-transforaminal lumbar interbody fusion (O-TLIF) is regarded as the standard (S) approach which is currently available for patients with degenerative lumbar diseases patients. In addition, minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) has proposed and gradually obtained popularity compared with O-TLIF procedures due to its beneficial outcomes in minimized tissue injury and quicker recovery. Nonetheless, debates exist concerning the use of MI-TLIF with its conflicting outcomes of clinical effect and safety in several publications. The purpose of the current study is to conduct an updated meta-analysis to provide eligible and systematical assessment available for the evaluation of the efficacy and safety of MI-TLIF in comparison with O-TLIF.

Methods:

Publications on the comparison of O-TLIF and MI-TLIF in treating degenerative lumbar diseases in last 5 years were collected. After rigorous reviewing on the eligibility of publications, the available data was further extracted from qualified trials. All trials were conducted with the analysis of the summary hazard ratios (HRs) of the interest endpoints, including intraoperative and postoperative outcomes.

Results:

Admittedly, it is hard to run a clinical RCT to compare the prognosis of patients undergoing O-TLIF and MI-TLIF. A total of 10 trials including non-randomized trials in the current study were collected according to our inclusion criteria. The pooled results of surgery duration indicated that MI-TLIF was highly associated with shorter length of hospital stay, less blood loss, and less complications. However, there were no remarkable differences in the operate time, VAS-BP, VAS-LP, and ODI between the 2 study groups.

Conclusion:

The quantitative analysis and combined results of our study suggest that MI-TLIF may be a valid and alternative method with safe profile in comparison of O-TLIF, with reduced blood loss, decreased length of stay, and complication rates. While, no remarkable differences were found or observed in the operate time, VAS-BP, VAS-LP, and ODI. Considering the limited available data and sample size, more RCTs with high quality are demanded to confirm the role of MI-TLIF as a standard approach in treating degenerative lumbar diseases.

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Most cited references 44

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[A one-stager procedure in operative treatment of spondylolistheses: dorsal traction-reposition and anterior fusion (author's transl)].

J Harms, H Rolinger (1982)

On account of 41 cases of spondylolisthesis a one-stage operation for repositioning and stabilisation using Harrington's instrumentation with anterior intercorporal spine fusion is recommended. The advantage of this procedure is a secure fusion and a short hospitalisation. After 6 months the patient usually is rehabilitated.

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

David Rouben, Langston T. Holly, James D. Schwender … (2005)

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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2001 Volvo Award Winner in Clinical Studies: Lumbar fusion versus nonsurgical treatment for chronic low back pain: a multicenter randomized controlled trial from the Swedish Lumbar Spine Study Group.

, A Nordwall, O Hägg … (2001)

A randomized controlled multicenter study with a 2-year follow-up by an independent observer. To determine whether fusion of the lower lumbar spine could reduce pain and diminish disability more effectively when compared with nonsurgical treatment in patients with severe chronic low back pain (CLBP). The reported results after fusion surgery on patients with CLBP vary considerably, and the evidence of treatment efficacy is weak in the absence of randomized controlled studies. A total of 294 patients referred to 19 spinal centers from 1992 through 1998 were randomized blindly into four treatment groups. Patients aged 25-65 years with CLBP for at least 2 years and with radiologic evidence of disc degeneration at L4-L5, L5-S1, or both were eligible to participate in the study. The surgical group (n=222) included three different fusion techniques, not analyzed separately in this study. Patients in the nonsurgical group (n=72) were treated with different kinds of physical therapy. The surgical group comprised 49.5% men, and the mean age was 43 years. The corresponding figures for the nonsurgical group were 48.6% and 44 years. The patients had suffered from low back pain for a mean of 7.8 and 8.5 years and been on sick leave due to back pain for a mean of 3.2 and 2.9 years, respectively. The Visual Analogue Scale (VAS) was used to measure pain. The Oswestry Low Back Pain Questionnaire, the Million Score and the General Function Score (GFS) were used to measure disability. The Zung Depression Scale was used to measure depressive symptoms. The overall result was assessed by the patient and by an independent observer. Records from the Swedish Social Insurance were used to evaluate work disability. Patients who changed groups were included in the analyses of significance according to the intention-to-treat principle. At the 2-year follow-up 289 of 294 (98%) patients, including 25 who had changed groups, were examined. Back pain was reduced in the surgical group by 33% (64 to 43), compared with 7% (63 to 58) in the nonsurgical group (P=0.0002). Pain improved most during the first 6 months and then gradually deteriorated. Disability according to Oswestry was reduced by 25% (47 to 36) compared with 6% (48 to 46) among nonsurgical patients (P=0.015), according to Million by 28% (64 to 46) compared with 8% (66 to 60) (P=0.004), and accordingtoGFS by 31% (49 to 34) compared with 4% (48 to 46) (P=0.005). The depressive symptoms, according to Zung, were reduced by 20% (39 to 31) in the surgical group compared with 7% (39 to 36) in the nonsurgical group (P=0.123). In the surgical group 63% (122/195) rated themselves as "much better" or "better" compared with 29% (18/62) in the nonsurgical group (P<0.0001). The "net back to work rate" was significantly in favor of surgical treatment, or 36% vs. 13% (P=0.002). The early complication rate in the surgical group was 17%. Lumbar fusion in a well-informed and selected group of patients with severe CLBP can diminish pain and decrease disability more efficiently than commonly used nonsurgical treatment.

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Author and article information

Journal

Journal ID (nlm-ta): Medicine (Baltimore)

Journal ID (iso-abbrev): Medicine (Baltimore)

Journal ID (publisher-id): MEDI

Title: Medicine

Publisher: Wolters Kluwer Health

ISSN (Print): 0025-7974

ISSN (Electronic): 1536-5964

Publication date Collection: October 2019

Publication date (Electronic): 25 October 2019

Volume: 98

Issue: 43

Electronic Location Identifier: e17420

Affiliations

Department of Spine Surgery, Beijing Shijitan Hospital, Capital Medical University, Beijing, China.

Author notes

[∗ ]Correspondence: Ying-Chun Chen, Department of Spine Surgery, Beijing Shijitan Hospital, Capital Medical University, No.10 Tieyi Road, Yangfangdian, Beijing, 100038, China (e-mail: yingchun.chen.bj@ 123456gmail.com ).

Article

Publisher ID: MD-D-19-00107 Accession ID: 17420

DOI: 10.1097/MD.0000000000017420

PMC ID: 6824700

PubMed ID: 31651845

SO-VID: 9bda085e-af61-4739-b1a0-a0e57449347c

License:

This is an open access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. http://creativecommons.org/licenses/by-nc-nd/4.0

History

Date received : 5 January 2019

Date revision received : 9 August 2019

Date accepted : 10 September 2019

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Keywords: degenerative lumbar diseases,meta-analysis,minimally invasive,transforaminal lumbar interbody fusion

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Keywords: degenerative lumbar diseases, meta-analysis, minimally invasive, transforaminal lumbar interbody fusion

An updated meta-analysis of clinical outcomes comparing minimally invasive with open transforaminal lumbar interbody fusion in patients with degenerative lumbar diseases

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Most cited references 44

[A one-stager procedure in operative treatment of spondylolistheses: dorsal traction-reposition and anterior fusion (author's transl)].

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

2001 Volvo Award Winner in Clinical Studies: Lumbar fusion versus nonsurgical treatment for chronic low back pain: a multicenter randomized controlled trial from the Swedish Lumbar Spine Study Group.

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