Objective To review the latest comparative research of minimally invasive transforaminal lumbar interbody fusion (TLIF) and traditional open approach. Methods The domestic and foreign literature concerning the comparative research of minimally invasive TLIF and traditional open TLIF was reviewed, then intraoperative indicators, length of hospitalization, effectiveness, complication, fusion rate, and the effect on paraspinal muscles were analyzed respectively. Results Minimally invasive TLIF has less blood loss and shorter length of hospitalization, but with longer operation and fluoroscopic time. Minimally invasive surgery has the same high fusion rate as open surgery, however, its effectiveness is not superior to open surgery, and complication rate is relatively higher. In the aspect of the effect on paraspinal muscles, in creatine kinase, multifidus cross-sectional area, and atrophy grading, minimally invasive surgery has no significant reduced damage on paraspinal muscles. Conclusion Minimally invasive TLIF is not significantly superior to open TLIF, and it does not reduce the paraspinal muscles injury. But prospective double-blind randomized control trials are still needed for further study.
【Abstract】 Objective To investigate the effectiveness of surgical treatment for discogenic low back pain (DLBP) by minimally invasive transforaminal lumbar interbody fusion (TLIF) combined with unilateral pedicle screw fixation (UPSF). Methods Between March 2006 and July 2009, 57 patients with single-level DLBP were treated by minimally invasive TLIF combined with UPSF, including 27 males and 30 females with an average age of 45.6 years (range, 38-61 years) and a disease duration of 3.8 years (range, 9 months to 11 years). The involved segments included L2，3 in 2 cases, L3，4 in 5 cases, L4，5 in 29 cases, and L5, S1 in 21 cases. The operative time, incision length, intraoperative blood loss, postoperative drainage volume, hospitalization times, fusion rate, and complications were observed. The effectiveness were evaluated through Oswestry disability index (ODI) and visual analogue score (VAS), and the operative outcomes were compared in different groups classified according to various pressures of the contrast medium and sensitivities to discoblock after inducing consistent pain. Results The operation time, incision length, blood loss, postoperative drainage volume, and hospitalization times were (84.6 ± 37.4) minutes, (3.4 ± 0.6) cm, (132.5 ± 23.2) mL, (58.7 ± 21.4) mL, and (6.5 ± 0.8) days, respectively. All patients were followed up 2 years and 2 months to 5 years and 4 months (mean, 3.2 years). At last follow-up, ODI and VAS scores were significantly improved when compared with preoperative scores (P lt; 0.05). The effectiveness according to ODI were excellent in 27 cases, good in 22 cases, fair in 6 cases, and poor in 2 cases, with an excellent and good rate of 86.0%. All patients acquired b interbody fusion. At last follow-up according to ODI and VAS scores, better results were found in patients of low-pressure sensitive group and high-sensitive discoblock group (P lt; 0.05). Conclusion Minimally invasive TLIF combined with UPSF is reliable for DLBP with minimal surgical trauma, less paravertebral tissue injury, and fewer complications, but the indications for operation must be strictly followed. Patients being sensitive to low-pressure or high-sensitive to discoblock can achieve better surgical results.
Objective To compare the therapeutic effect of conventional discectomy, posterior lumbar interbody fusion (PLIF), and transforaminal lumbar interbody fusion (TLIF) on the recurrent lumbar disc protrusion (RLDP). Methods From January 2000 to January 2008, 65 patients with RLDP underwent different surgical procedures, namely conventional discectomy (group A, 25 cases), PLIF (group B, 22 cases), and TLIF (group C, 18 cases). There were 44 males and 21 females aged 26-65 years old (average 41 years old). All the patients were single-level protrusion, including 33 cases at the L4, 5 level and 32 cases at the L5, S1 level. The primary procedure included laminectomy discectomy in 39 patients, unilateral hemilaminectomy discectomy in 15 patients, and bilateral laminectomy and total laminectomy discectomy in 11patients. The recurrent time to the primary operation was 13-110 months (average 64 months). The location of recurrent disc protrusion was at the ipsilateral side in 47 cases and the contralateral side in 18 cases. No significant differences among three groups were evident in terms of basel ine data (P gt; 0.05). Results The incision all healed by first intention. The incidence of perioperative compl ication in group A (24.0%) and group B (22.3%) was significantly higher than that of group C (5.6%) (P lt; 0.05), and there was no significant difference between group A and group B (P gt; 0.05). The operation time and bleed loss during operation of group B were obviously higher than that of group A and group C (P lt; 0.05), and there was no significant difference between group A and group C (P gt; 0.05). There were no significant differences among three groups in terms of the length of hospital ization (P gt; 0.05). Six-one patients were followed up for 12-36 months (average 20 months). At 1 week after operation, the satisfied rate of patients was 84.0% in group A, 81.8% in group B, and 88.9% in group C (P gt; 0.05). All the patients in group B and group C achieved fusion uneventfully. There were no significant differences among three groups in terms of visual analogue scale (VAS) and Oswestry disabil ity index (ODI) when compared the preoperative value with the final follow-up value (P gt; 0.05). There was significant difference within group A, B, and C in terms of VAS and ODI when compared the preoperative value with the final follow-up value (P lt; 0.05), but there were no significant differences among three groups in the improvement rate (P gt; 0.05). The intervertebral space grading method proposed by Roberts et al. was adopted to evaluate the intervertebral space height (ISH), the preoperative value was 2.04 ± 0.93 in group A, 2.18 ± 0.91 in group B, and 2.11 ± 0.90 in group C, andat the final follow-up, the value was 2.64 ± 0.58 in group A, 1.05 ± 0.59 in group B, and 1.06 ± 0.42 in group C. There were significant differences among three groups in the ISH when compared the properative value with the final follow-up value (P lt; 0.05). Conclusion All of the three surgical procedures are effective for RLDP, but conventional discectomy and PLIF have more compl ications than TLIF. Conventional discectomy may result in the further narrow of the intervertebral space and the occurrence of segment instabil ity, whereas TLIF is safer, more effective, and one of the ideal methods to treat RLDP.
Objective To investigate the effectiveness of surgical treatment for single-level degenerative lumbar instabil ity (DLI) by comparing traditional open transforaminal lumbar interbody fusion (TLIF) with minimally invasive TLIF. Methods Between March 2007 and May 2009，87 patients with single-level DLI were treated by traditional open TLIF (group A, n=45) and by minimally invasive TLIF (group B, n=42), respectively. There was no significant difference in gender, age, disease duration, segment level, combined diseases of lumbar spine, or the proportion of uni- and bilateral symptom between 2groups (P gt; 0.05). The indexes of surgical trauma，systemic inflammatory response, cl inical outcomes, and aravertebral muscle injury were compared between 2 groups. Results Operation was performed successfully in all patients. The patients were followed up 2.9 years on average in group A and 2.8 years on average in group B. The incision, blood loss, and postoperative drainage in group B were significantly less than those in group A (P lt; 0.05), but the operation time in group B was significantly longer than that in group A (P lt; 0.05). There were significant differences (P lt; 0.05) in C-reactive protein, leucocyte count, and creatine kinase MM between 2 groups at 24 hours postoperatively as well as in C-reactive protein at 6 days postoperatively; group B was superior to group A. At last follow-up, the Oswestry disabil ity index (ODI) and visual analogue score (VAS) were significantly improved when compared with the preoperative scores in 2 groups (P lt; 0.05). There were significant differences in ODI and back pain VAS score (P lt; 0.05), but no significant difference in leg pain VAS score (P gt; 0.05) between 2 groups. At last follow-up, no low back pain occurred in 8 and 18 cases, mild in 25 and 18 cases, moderate in 9 and 6 cases, and severe in 3 and 0 cases in groups A and B, respectively, showing that low back pain was significantly l ighter in group B than in group A (Z= —2.574, P=0.010). At last follow-up, the atrophy ratio of multifidus muscle was 37% ± 13% in group A and was 15% ± 7% in group B, showing significant difference (t=12.674, P=0.000). The multifidus muscle atrophy was rated as grade I in 18 and 44 sides, as grade II in 42 and 32 sides, and as grade III in 30 and 8 sides in groups A and B, respectively, showing significant difference (Z= — 4.947, P=0.000). Conclusion Both traditional open TLIF and minimally invasive TLIF are the effective treatments for single-level DLI. Minimally invasive TLIF has less surgical trauma, sl ighter postoperative systemic inflammatory response, less paravertebral muscle injury, and lower incidence of postoperative back pain, but it has longer operation time.
ObjectiveTo analyze the restoration of intervertebral height and lordosis of fusion segment after open-transforaminal lumbar interbody fusion (Open-TLIF) and minimally invasive-TLIF (MIS-TLIF).MethodsBetween January 2013 and February 2016, patients who treated with TLIF due to lumbar degenerative diseases and met the selection criteria were selected as the study objects. Among them, 41 patients were treated with open-TLIF (Open-TLIF group), 34 patients were treated with MIS-TLIF (MIS-TLIF group). There was no significant difference between the two groups (P>0.05) in gender, age, body mass index, disease type, disease duration, pathological segment, and other general data. The intraoperative bleeding volume, hospital stay, visual analogue scale (VAS) score of waist and leg, and Oswestry disability index (ODI) were recorded before and after operation. The anterior disc height (ADH), posterior disc height (ADH), and segmental lordosis (SL) of fusion segment were measured by X-ray film before and at 6 months after operation. The differences of ADH, PDH, and SL between pre- and post-operation were calculated.ResultsThe intraoperative bleeding volume and hospital stay in Open-TLIF group were significantly higher than those in MIS-TLIF group (t=14.619, P=0.000; t=10.021, P=0.000). All incisions healed by first intention without early complications. All patients were followed up 6-24 months (mean, 12.6 months) in Open-TLIF group and 6-24 months (mean, 11.5 months) in MIS-TLIF group. The preoperative VAS scores of waist and leg and ODI of the two groups significantly improved (P<0.05). There was no significant difference in VAS scores and ODI between the two groups before operation and at 2 weeks and 6 months after operation (P>0.05). Imaging examination showed the good intervertebral fusion. There was no significant difference in ADH, PDH, and SL between the two groups before operation and at 6 months after operation (P>0.05). The differences of ADH, PDH, and SL between the two groups were not significant (P>0.05). The ADH, PDH, and SL after operation significantly increased in the two groups (P<0.05).ConclusionOpen-TLIF and MIS-TLIF show similar effectiveness and radiological change in the treatment of single lumbar degenerative diseases and the improved intervertebral height and lordosis, but MIS-TLIF can significantly reduce hospital stay and intraoperative blood loss.
Objective To investigate the effectiveness of minimally invasive transforaminal lumbar interbody fusion (TLIF) assisted with microscope for lumbar degenerative disease. Methods Retrospective analysis was made on the clinical data of 82 patients with lumbar degenerative disease (minimally invasive group) undergoing minimally invasive TLIF assisted with microscope between January 2010 and June 2011, which was compared with those of 76 patients (traditional group) undergoing traditional open TLIF. There was no significant difference in age, gender, disease duration, disease type, lesion level, preoperative visual analogue scale (VAS), and preoperative Oswestry disability index (ODI) between 2 groups (P gt; 0.05). The perioperative related parameters, radiography index, and effectiveness were documented and compared. Results There was no significant difference in operation time and intraoperative radiological exposure time between 2 groups (P gt; 0.05), but intraoperative blood loss and postoperative drainage volume in the minimally invasive group were significantly less than those in the traditional group (P lt; 0.05). Dural tear occurred in 2 patients of the traditional group. Superficial infection of incision occurred in 1 case in each group, respectively; and primary healing of incision was obtained in the other patients. All patients were followed up 12-28 months (mean, 18 months). No failure of internal fixation occurred. Radiological analysis showed that the bone graft fusion rate was 96.1% (73/76) in the traditional group and 95.1% (78/82) in the minimally invasive group at last follow-up, showing no significant difference (χ2= 0.012 2, P= 0.912 0). The postoperative ODI and VAS score were significantly improved when compared with preoperative ones in 2 groups (P lt; 0.05); the ODI of the minimally invasive group were significantly better than those of the traditional group at 3 months (t= — 11.941 1, P=0.000 0), and the VAS score of the minimally invasive group was significantly lower than that of the traditional group at 1 day and 3 months (P lt; 0.05); but no significant difference was found in ODI and VAS score between 2 groups at 1 year and last follow-up (P gt; 0.05). Conclusion Minimally invasive TLIF is an effective method to treat lumbar degenerative disease. This procedure is safe and reliable because it has less injury, less blood loss, and milder pain than the traditional open TLIF, and the short-term effectiveness is comparable in 2 procedures.
Objective To analyze the effectiveness of transforaminal lumbar interbody fusion (TLIF) for failed back surgery syndrome (FBSS). Methods Between October 2003 and December 2007, 36 patients with FBSS were treated with TLIF. There were 19 males and 17 females with an average age of 52.6 years (range, 46-68 years) and an average disease duration of 1.6 years (range, 3 months-15 years). Of 36 patients, reoperation was performed in 25, 10 received 3 operations,and 1 had 5 operations. A total of 50 segments were involved in fusion, including L4, 5 in 12 cases, L5, S1 in 10 cases, L3, 4 and L4, 5 double segments in 8 cases, and L4, 5 and L5, S1 double segments in 6 cases. According to X-ray films, CT, and MRI examination, 12 patients were diagnosed as having lumbar instabil ity secondary to total laminectomy, 18 as having recurrence of lumbar disc protrusion, and 6 as having recurrence of lumbar spondylol isthesis. Results Dural rupture occurred in 1 case and was repaired by suturing without cerebrospinal fluid leakage was observed; 1 had deep incision infection of Staphylococcus; and 1 had transient single irritation sign because of hematoma formation and was cured after symptomatic treatment. The other incisions healed by first intention. No patients had permanent nerve injury or deterioration. Thirty-three cases were followed up 18-72 months (mean, 35.2 months). At 12 months, all the operated segments reached interbody fusion, and no breakage of screw or Cage dislocation occurred. Japanese Orthopaedic Association (JOA) scores showed significant difference (t=2.45, P=0.01) between before operation (14.2 ± 4.1) and 18 months after operation (23.9 ± 2.6). The rate of cl inical improvement was 90.9% (23 cases of excellent, 7 cases of good, 3 cases of acceptable). Conclusion The TLIF simpl ifies the manipulation of lumbar revision surgery and decreases the operation risk and the operative compl ications for the treatment of FBSS.
ObjectiveTo investigate the effectiveness of minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) assisted with microscope in treatment of lumbar spondylolisthesis. MethodsBetween January 2011 and June 2012, 52 patients with lumbar spondylolisthesis underwent MI-TLIF assisted with microscope. There were 29 males and 23 females with an average age of 46 years (range, 32-67 years). The median disease duration was 3.2 years (range, 3 months to 6 years). There were 38 cases of lumbar isthmic spondylolisthesis and 14 cases of degenerative spondylolisthesis; 12 cases had stenosis secondary to lumbar spondylolisthesis. The affected segments were L4, 5 (29 cases) and L5, S1 (23 cases). According to the Meyerding evaluating system, 24 cases were classified as degree I and 28 cases as degree Ⅱ. The visual analogue scale (VAS) score and Oswestry disability index (ODI)were used for clinical assessment, and the clinical effects were also analyzed by Macnab criterion at last follow-up. The radiographic data were used to evaluate reduction of spondylolisthesis, including slipping degree, slipping angle, and intervertebral space height. The fusion rate was assessed by Suk criterion. ResultsThe operations were performed successfully in all patients. No dural tear or cerebrospinal fluid leakage occurred during operation. The average operation time was 105 minutes; the average intraoperative blood loss was 225 mL; the average postoperative drainage volume was 75 mL; and the average hospitalization days were 5.5 days. Superficial infection of incision occurred in 1 case and was cured after change dressing, and primary healing of incision was obtained in the others. All patients were followed up 12-26 months (mean, 18 months). No loosening, breakage, and displacement of pedicle screw and no Cage dislocation occurred by X-ray films after operation. The lumbar spondylolisthesis all got good correction. The three-dimensional CT showed continuous bone trabecula between centrums. The VAS score, ODI, and the slipping degree, slipping angle, and intervertebral space height were significantly improved at last follow-up when compared with preoperative ones (P<0.05). According to Macnab criterion at last follow-up, the results were excellent in 20 cases, good in 29 cases, and fair in 3 cases; the excellent and good rate was 94.2%. According to Suk criterion for fusion, 49 cases obtained complete fusion and 3 cases got possible fusion. ConclusionAs long as indications are seized, MI-TLIF assisted with microscope is safe and reliable for treatment of lumbar spondylolisthesis (Meyerding dergee I or Ⅱ), and it has the advantage of less injury, less blood loss, less complications, and definite short-term effectiveness.
ObjectiveTo investigate the advantage and short- and medium-term effectivenesses of paramedian incision minimally invasive transforaminal lumbar interbody fusion (mini-TLIF) by comparing with open TLIF. MethodsA retrospective analysis was made on the clinical data of 54 patients with single segmental lumbar degenerative disease who accorded with the inclusion criteria between January 2012 and March 2014. Open TLIF was performed in 26 patients (open group), mini-TLIF in 28 cases (minimally invasive group). There was no significant difference in gender, age, disease duration, etiology, and affected segments between 2 groups (P>0.05). The indexes of surgical trauma, systemic inflammatory response, clinical outcome, and interbody fusion rate were compared between 2 groups. ResultsDural rupture occurred in 1 case of open group, L5 nerve root injury in 1 case of minimally invasive group. All patients obtained primary healing of incision. The operation time, intraoperative blood loss, and postoperative drainage of minimally invasive group were significantly lower than those of open group (P<0.05). C-reactive protein, leucocyte count, and creatine kinase-MM (CK-MM) of open group were significantly higher than those of minimally invasive group at 24 hours after operation (P<0.05). At 7 days after operation, the CK-MM of minimally invasive group was significantly lower than that of open group (P<0.05), but no significant difference was found in C-reactive protein and leucocyte count between 2 groups (P>0.05). The follow-up time was 1.2-3.1 years in open group and 1.4-2.9 years in minimally invasive group. At 1 year after operation, the Oswestry disability index (ODI) and visual analogue scale (VAS) scores were significantly improved in 2 groups (P<0.05). Minimally invasive group was better than open group in ODI and VAS score of back pain (P<0.05), but VAS score of leg pain showed no significant difference (P>0.05). According to the Suk interbody fusion standard, solid fusion was obtained in 18 cases, probable fusion in 4 cases, and nonunion in 4 cases, and the fusion rate was 84.61% in open group; solid fusion was obtained in 21 cases, probable fusion in 3 cases, and nonunion in 4 cases, and the fusion rate was 85.71% in minimally invasive group; and the interbody fusion rates showed no significant difference between 2 groups (χ2=0.072, P=0.821). ConclusionCompared with open TLIF, paramedian incision mini-TLIF has advantages of minimal surgical trauma and little blood loss for single-level lumbar degenerative disease. The short- and medium-term effectivenesses are satisfactory.
Objective To compare the short-term effectiveness of minimally invasive surgery-transforaminal lumbar interbody fusion (MIS-TLIF) versus open-TLIF in treatment of single-level lumbar degenerative disease. Methods Between February 2010 and February 2011, 147 patients with single-level lumbar degenerative diseases underwent open-TLIF in 104 cases (open-TLIF group) and MIS-TLIF in 43 cases (MIS-TLIF group), and the clinical data were analyzed retrospectively. There was no significant difference in gender, age, disease type, lesion level, disease duration, preoperative visual analogue scale (VAS), and preoperative Oswestry disability index (ODI) between 2 groups (P gt; 0.05). The operation time, intraoperative radiological exposure time, intra- and post-operative blood loss, postoperative hospitalization time, and postoperative complications were compared between 2 groups. The VAS score and ODI were observed during follow-up. The imaging examination was done to observe the bone graft fusion and the locations of internal fixator and Cage. Results There was no significant difference in operation time between 2 groups (t=0.402, P=0.688); MIS-TLIF group had a decreased intra- and post-operative blood loss, shortened postoperative hospitalization time, and increased intraoperative radiological exposure time, showing significant differences when compared with open-TLIF group (P lt; 0.05). Cerebrospinal fluid leakage (2 cases) and superficial infection of incision (2 cases) occurred after operation in open-TLIF group, with a complication incidence of 3.8% (4/104); dorsal root ganglion stimulation symptom (3 cases) occurred in MIS-TLIF group, with a complication incidence of 7.0% (3/43); there was no significant difference in the complication incidence between 2 groups (χ2=0.657, P=0.417). The patients were followed up 18-26 months (mean, 21 months) in MIS-TLIF group, and 18-28 months (mean, 23 months) in open-TLIF group. The VAS scores and ODI of 2 groups at each time point after operation were significantly improved when compared with those before operation (P lt; 0.05). There was no significant difference in VAS score between 2 groups at discharge and 3 months after operation (P gt; 0.05); VAS score of MIS-TLIF group was significantly lower than that of open-TLIF group at last follow-up (t= — 2.022, P=0.047). At 3 months and last follow-up, no significant difference was found in the ODI between 2 groups (P gt; 0.05). The imaging examination showed good positions of Cage and internal fixator, and bone graft fusion in 2 groups. Conclusion The short-term effectiveness of MIS-TLIF and open-TLIF for single-level degenerative lumbar diseases was similar. MIS-TLIF has the advantages of less invasion and quick recovery, but the long-term effectiveness needs more observation.