Clinical outcomes of transforaminal lumbar interbody fusion using a modified posterior spinous process–splitting approach for lumbar degenerative or isthmic spondylolisthesis: a prospective cohort study

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Abstract

In the conventional posterior approach to the lumbar spine for transforaminal lumbar interbody fusion (TLIF), the paravertebral muscles are stripped from the spinous process. The authors developed a novel surgical procedure in which TLIF was performed via a modified spinous process–splitting (SPS) approach that enabled the preservation of the attachment of the paravertebral muscles to the spinous process. The SPS TLIF group comprised 52 patients with lumbar degenerative or isthmic spondylolisthesis who underwent surgery using a modified SPS TLIF technique, whereas the control group comprised 54 patients who underwent conventional TLIF. Compared with the control group, the SPS TLIF group had a significantly shorter operation time, smaller intra- and postoperative blood loss volumes, and shorter hospital stay and time to ambulation (p < 0.05). The SPS TLIF group had a lower mean visual analog scale score for back pain than the control group on both postoperative day 3 and at 2 years postoperatively (p < 0.05). Follow-up MRI showed changes in the paravertebral muscles in 46 of 54 patients (85%) in the control group and 5 of 52 patients (10%) in the SPS TLIF group (p < 0.001). This novel technique may be a useful alternative to the conventional posterior approach for TLIF.

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Minimally invasive lumbar fusion.

Kevin T. Foley, Langston T. Holly, James D. Schwender (2003)

Review article. To provide an overview of current techniques for minimally invasive lumbar fusion. Minimally invasive techniques have revolutionized the management of pathologic conditions in various surgical disciplines. Although these same principles have been used in the treatment of lumbar disc disease for many years, minimally invasive lumbar fusion procedures have only recently been developed. The goals of these procedures are to reduce the approach-related morbidity associated with traditional lumbar fusion, yet allow the surgery to be performed in an effective and safe manner. The authors' clinical experience with minimally invasive lumbar fusion was reviewed, and the pertinent literature was surveyed. Minimally invasive approaches have been developed for common lumbar procedures such as anterior and posterior interbody fusion, posterolateral onlay fusion, and internal fixation. As with all new surgical techniques, minimally invasive lumbar fusion has a learning curve. As well, there are benefits and disadvantages associated with each technique. However, because these techniques are new and evolving, evidence to support their potential benefits is largely anecdotal. Additionally, there are few long-term studies to document clinical outcomes. Preliminary clinical results suggest that minimally invasive lumbar fusion will have a beneficial impact on the care of patients with spinal disorders. Outcome studies with long-term follow-up will be necessary to validate its success and allow minimally invasive lumbar fusion to become more widely accepted.

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Serial changes in trunk muscle performance after posterior lumbar surgery.

R Gejo, Y Kawaguchi, H Matsui … (1999)

Serial changes in trunk muscle performance were prospectively studied in 20 patients who underwent posterior lumbar surgery. To evaluate the influence of back muscle injury on postoperative trunk muscle performance and low back pain, to clarify the significance of minimization of back muscle injury during surgery. The current investigators have reported examination of iatrogenic back muscle injury in an animal model and in humans. However, definite impairment caused by such back muscle injury has not been clarified. The patients were divided into a short-retraction-time group ( or = 80 minutes; n = 8). Before surgery and 3 and 6 months after surgery, the degree of back muscle injury was estimated by magnetic resonance imaging, and trunk muscle strength was measured. In addition, the incidence and severity of low back pain were serially analyzed. Back muscle injury was directly related to the muscle retraction time during surgery. The damage to the multifidus muscle was more severe, and the recovery of extensor muscle strength was delayed in the long-retraction-time group. In addition, the incidence of postoperative low back pain was significantly higher in the long-retraction-time group. Postoperative trunk muscle performance is dependent on the muscle retraction time. Thus, it is beneficial to shorten the retraction time to minimize back muscle injury and subsequent postoperative low back pain.

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Back muscle injury after posterior lumbar spine surgery. Part 2: Histologic and histochemical analyses in humans.

Y Kawaguchi, H Matsui, H Tsuji (1994)

The histologic and histochemical changes in back muscle were studied in virgin surgery patients with lumbar spine disorders and in patients who underwent repeat posterior lumbar surgery. The results were correlated to provide the evidences of histologic changes of back muscle after posterior lumbar surgery. Back muscles were examined histologically and histochemically after posterior lumbar surgery. No previous study has assessed these changes. Back muscles were obtained before and after retraction from 18 virgin surgery cases with lumbar spine disorders. In four patients, the retraction pressure was monitored and the retraction pressure-time products ([P][T]) were calculated. In 21 repeat lumbar surgery cases, muscle samples were obtained before muscle retraction. Samples were evaluated by histologic and histochemical methods. Abnormal findings were slight in virgin surgery cases. Early back muscle injury tended to depend on operation time and [P][T] products. Late back muscle injury in reoperated patients was marked. Various types of neurogenic changes were observed more than 10 months after the first operation. Histologic damages of back muscle due to previous surgical intervention were long-lasting. To avoid permanent muscle injury, the retraction time and pressure should be shortened or the pressure on the back muscle should be monitored during posterior surgery.