transforaminal_lumbar_interbody_fusion_case_series [Operative Neurosurgery]

Patients ≥50-year-old who underwent MTLIF for degenerative lumbar spine conditions were analyzed. Ninety-day complications and patient-reported outcomes (PRO) (baseline, 90-d, 1-y, 2-y) were queried using the Michigan Spine Surgery Improvement Collaborative database. PROs were measured by back & leg visual analog scale (VAS), Patient-reported Outcomes Measurement Information System (PROMIS), EuroQol-5D (EQ-5D), and North American Spine Society (NASS) Patient Satisfaction Index. Univariate analyses were used to compare among elderly and complication cohorts. A generalized estimating equation (GEE) was used to identify predictors of complications and PROs.

A total of 3120 patients analyzed with 961 (31%) ≥ 70-y-o and 2159 (69%) between 50-69. A higher proportion of elderly experienced postoperative complications (P = .003) including urinary retention (P = <.001) and urinary tract infection (P = .002). Multivariate analysis demonstrated that age was not independently associated with complications. Number of operative levels was associated with any (P = .001) and minor (P = .002) complication. Incurring a complication was independently associated with worse leg VAS and PROMIS scores (P = <.001). Preoperative independent ambulation was independently associated with improved PROMIS, and EQ5D (P = <.001). Within the elderly, preoperative independent ambulation and lower BMI were associated with improved PROMIS (P = <.001). Complications had no significant effect on PROs in the elderly.

Age was not associated with complications nor predictive of functional outcomes in patients who underwent MTLIF. Age alone, therefore, may not be an appropriate surrogate for risk. Furthermore, baseline preoperative independent ambulation was associated with better clinical outcomes and should be considered during preoperative surgical counseling. Level of Evidence: 3 ¹⁾.

Under computed tomography (CT) guided spinal navigation the TLIF procedure was performed. Clinical outcome scores visual analog scale (VAS), Oswestry disability index (ODI) and short form-36 health survey questionnaire (SF-36) were obtained preoperatively, 6 and 12 months after surgery. Radiological data were acquired preoperatively, after 6 weeks, as well as 6 and 12 postoperatively and included measurements for disc height (anterior/posterior), foraminal height, segmental and global lumbar lordosis.

71% of the included patients have undergone previous lumbar surgery. In total, 80 SYNCHRO® cages have been implanted. The clinical results revealed a highly significant improvement of VAS, ODI and SF-36 after 6 and 12 months, compared to baseline levels (p < 0.05). Radiological analysis revealed a significant increase in anterior and posterior disc height, foraminal height, segmental and global lumbar lordosis postoperatively (p < 0.05). 47 out 49 patients (96%) showed evidence for fusion at the 12 months follow-up. Cage dislocation was found in 1 of 80 implanted cages (1%), which required revision surgery. Two dural tears occurred intraoperatively, which have been fixed. Another two patients needed surgical revision due to infection. The overall complication rate was 10% (n = 5/49).

The current study delineates satisfactory clinical and radiological results by using a novel articulating TLIF-cage. The implant-related complication rate was acceptable with low revision rate ²⁾.

2015

A retrospective review was performed on 125 consecutive patients who underwent minimally invasive transforaminal lumbar interbody fusion and transpedicular screws placement between the levels of T-12 and S-1. Screw accuracy was evaluated using a postoperative computed tomography by three independent observers. Pedicle breach was documented when there was a violation in any direction of the pedicle. Inter-observer agreement was assessed with the Kappa coefficient.

A total of 470 transpedicular screws were evaluated between the levels of T-12 and S-1. In 57 patients the instrumentation was bilateral and in 68 unilateral. A substantial degree of agreement was found between the observers AB (κ=0.769) and A-C (κ=0.784) and almost perfect agreement between observers B-C (κ=0.928). There were a total of 427.33 (90.92%) screws without breach, 39.33 (8.37%) minor breach pedicles and 3.33 (0.71%) major breach pedicles. The pedicle breach rate was 9.08% Trajectory pedicle breach percentages were as follows: minor medial pedicle breach 4.68%, minor lateral pedicle breach 3.47%, minor inferior pedicle breach 0.22%, and major medial breach 0.70%. No intraoperative instrumentation-related or postoperative clinical complications were encountered and no surgical revision was needed.

The study demonstrated a high accuracy (90.2%) for 2-D fluoroscopy-guided pedicle screw using electromonitoring. Only 0.71% of the 470 screws had a major breach. Knowing the radiological spine pedicle anatomy and the correct interpretation of EMG are the key factors for this technique ³⁾.

¹⁾

Claus CF, Tong D, Lytle E, Bahoura M, Garmo L, Li C, Park P, Carr DA, Easton R, Abdulhak M, Chang V, Houseman C, Bono P, Richards B, Soo TM. Age as a Predictor for Complications and Patient-reported Outcomes in Multilevel Transforaminal Lumbar Interbody Fusions: Analyses From the Michigan Spine Surgery Improvement Collaborative (MSSIC). Spine (Phila Pa 1976). 2021 Mar 15;46(6):356-365. doi: 10.1097/BRS.0000000000003792. PMID: 33620179.

²⁾

Ishak B, Steil M, Arroteia IF, Unterberg AW, Kiening KL. Safety and performance of a novel articulating cage for transforaminal lumbar interbody fusion in the setting of intraoperative spinal navigation. Clin Neurol Neurosurg. 2019 Jun 20;183:105391. doi: 10.1016/j.clineuro.2019.105391. [Epub ahead of print] PubMed PMID: 31254909.

³⁾

Soriano-Sánchez JA, Ortega-Porcayo LA, Gutiérrez-Partida CF, Ramírez-Barrios LR, Ortíz-Leyva RU, Rodríguez-García M, Sánchez-Escandón O. Fluoroscopy-guided pedicle screw accuracy with a mini-open approach: a tomographic evaluation of 470 screws in 125 patients. Int J Spine Surg. 2015 Oct 23;9:54. eCollection 2015. PubMed PMID: 26609509.