Background Minimally invasive transpsoas or antepsoas lateral lumbar interbody fusion (MI-LLIF) has been reported as an effective surgical option for various lumbar diseases. Many researchers reported high fusion rate and clinical excellence of LLIF with the use of bone morphogenic protein (BMP). However, there have been paucity of studies regarding LLIF without the use of BMP. Therefore, this study aimed to analyze radiologic and clinical results of patients who underwent minimally invasive lateral lumbar interbody fusion without the use of BMP. Furthermore, a further analysis was conducted regarding the frequency of cage subsidence and its impact on the radiologic and clinical outcome.
Materials and Methods Fifty patients and 109 levels treated by MI-LLIF with postoperative follow-up of at least 2 years were included. Radiologic evaluation included intervertebral disc height, segmental lordosis, lumbar lordosis, fusion rate, cage subsidence grade, and the bone mineral density. Radiologic fusion was determined by modified Bridwell’s grade, and cage subsidence by Marchi’s grade. Clinical outcome was evaluated by VAS of low back pain (LBP) and leg pain, and ODI score. The above clinical and radiologic variables were analyzed statistically for comparison of cage subsidence and nonsubsidence groups.
Results There were 20 male and 30 female patients with the average age of 69 years. Average follow-up period was 29.6 months(24-42 months). Graft material used for PEEK cage was autogenous bone only in 9 levels, autogenous bone and DBM in 19 levels, and DBM only in 81 levels. Twelve patients received surgery on 1 level, 20 patients on 2 levels, 17 patients on 3 levels, and 1 patient on 4 levels, respectively. Operated levels were L1-2 in 7 cases, L2-3 in 27, L3-4 in 41, and L4-5 in 34, respectively. Mean low back pain (LBP) VAS decreased from preoperative 5.5 to 2.2 at the final follow-up, leg pain from 6.1 to 1.7, and ODI score from 25.6 to 13.7, with statistical significance (p<0.001). Mean disc height increased from preoperative 5.9 mm to postoperative 11.5 mm, and subsequently decreased to 9.6mm at the final follow-up. Average lumbar lordosis increased from preoperative 18.6 degrees to postoperative 37.0 degrees, and 35.9 degree at final follow-up. Radiologic union rate was 90.8%. Cage subsidence was observed in 6 levels (5.5%) on immediate postoperative radiographs; and in 20 levels (18.3%) at final follow-up. Comparison between cage subsidence and non-subsidence groups revealed no significant difference in age and BMD. Immediate postoperative segmental lordosis was considered as a risk factor of cage subsidence (p=0.005, odds ratio 0.813, CI 0.703~0.940). Furthermore, the preoperative and the final follow-up measurement of disc height, VAS score of LBP and leg pain, and ODI score were not different between the two groups. However, pseudoarthrosis rate was higher in subsidence group.
Conclusions Minimally invasive LLIF was an effective surgical option with high fusion rate even without the use of BMP.
Although cage subsidence also increases the frequency of pseudarthrosis, it does not significantly deteriorate the lumbar lordosis correction and clinical outcome.
Purpose To evaluate whether the contralateral radiating pain improved after unilateral decompression and minimally invasive transforaminal lumbar interbody fusion (TLIF) in the patients with bilateral radiating pain due to degenerative lumbar disease.
Materials and Methods Patients with the degenerative lumbar disease who underwent unilateral minimally invasive TLIF and were followed for more than 1 year were included. Clinically, low back pain and radiating pain on the dominant symptom side and the contralateral side were evaluated by the visual analogue score (VAS), and the Oswestry disability index (ODI) score was also evaluated.
Results ODI and VAS of low back pain and radiating pain were effectively reduced in a total of 57 cases. Thirty cases having bilateral radiating pain, among these patients, unilateral decompression was performed in 15 cases and bilateral decompression thru unilateral approach in 15 patients. In unilateral decompression group, radiating pain on the dominant symptom side, and radiating pain on the contralateral side were also improved at the final followup. In 15 cases who underwent bilateral decompression, radiating pain on the dominant symptom side and the contralateral side were improved at the final follow-up. There was no significant difference between the two groups in terms of preoperative ODI, VAS of low back and radiating pain.
Conclusions Minimally invasive TLIF via unilateral approach with or without contralateral decompression showed good clinical results in patients having unilateral or bilateral radiating pain. Minimally invasive TLIF could be an useful option even if there is bilateral radiating pain in degenerative lumbar disease.
Background Oblique and anterior lumbar interbody fusion have been widely performed in the lumbar spinal disease but we cannot get a direct decompression effect with these procedure.
Objective: The purpose of this study is to report clinical and imaging outcomes of microscope assisted direct decompression combined with oblique lumbar interbody fusion (OLIF) or anterior lumbar interbody fusion (ALIF).
Methods Twelve patients who received microscope assisted direct decompression during OLIF or ALIF for lumbar spinal stenosis were enrolled. The OLIF was performed for the lesion upper than the L4-5 or in the case of multisegmental disease. The ALIF was performed for the lesion at the L5-S1. After anterior-approaching surgery, percutaneous fixation of pedicle screw was performed and we did not perform an additional decompression posteriorly in all cases. For the clinical outcomes, we evaluated short form 36 (SF-36), Oswestry disability index (ODI) score and visual analog scale (VAS) pain score. For the imaging outcomes, we obtained postoperative lumbar magnetic resonance imaging (MRI).
Results The OLIF was performed for 9 patients and the ALIF was performed for 3 patients. In the clinical outcomes, SF-36 was improved from 25.40 to 69.83 and ODI score was also improved from 69.83 to 16.50. VAS pain score of back was improved from 4.3 to 1.6 and VAS pain score of leg was improved from 7.5 to 2.2. In the imaging outcomes, all patients had severe stenosis before surgery. After surgery the severity of the stenosis was reduced to mild state in 9 cases and moderate state in 3 cases postoperatively.
Conclusions We could obtain the good clinical outcomes and effective decompression through microscope assisted direct decompression during OLIF or ALIF.
Purpose Spinal fusion is useful method of treatment of degenerative lumbar diseases, and is divided into anterior and posterior surgery. Each approach has advangages and disadvantages. Recently, minimally invasive lateral lumbar interbody fusion (LLIF) supplemented disadvantages of anterior and posterior surgery is interested. We introduce LLIF and present about application and indication of LLIF.
Materials and Methods A 76-year-old female was diagnosed by degenerative disc disease on L2-3. A 66-year-old male was diagnosed by central spinal stenosis on L2-3-4-5. A 86-year-old female was diagnosed by foraminal stenosis on L3-4-5 and degenerative scoliosis. A 73-year-old male was diagnosed by spinal stenosis on L3-4-5 and spondylolisthesis. A 70-year-old male was diagnosed nonunion on L4-5. On past history, the patient was operated by fusion because of L2 burst fracture. A 75-year-old female was diagnosed by infective spondylodiscitis on L3-4.
Results Degenerative disc disease, severe central and foraminal spinal stenosis, degenerative scoliosis, spondylolisthesis and infective spondylodiscitis were application and indication of LLIF.
Conclusions LLIF merges the advantages and covers the disadvantages of anterior and posterior surgery. However, approach-related lumbar plexus injury and L5-S1 approach were remained obstacles.
Introduction A spondylitis developed after a surgery has been usually treated with drainage and curettage through anterior approach and autoiliac strut bone graft. However, anterior support with titanium cage combined with posterior pedicle screw fixation has been attempted. Implanting a foreign material is usually prohibited at an active pyogenic infection site. We tried to prove the usefulness of chip bone graft with metal cages in surgical treatment of spondylitis developed in posterior lumbar intebody fusion cases.
Materials and Methods This is a retrospective study. The patients who received posterior lumbar interbody fusion (PLIF) between Jan. 2007 and Dec 2017 and had a spondylitis around the cage were reviewed. There were 1,831 PLIFs during the study period. There were 32 cases of surgical site infection and 20 of them were spondylitis around the cage. Ten out of the 20 cases had a revision surgery. All implants removal, drainage and curettage were done and interbody bone graft and pedicle screw re-fixation was done simultaneously. Five cases used autoiliac strut bone (Group I) and the other 5 cases used titanium cage and autoiliac chip bone (Group II) as interbody graft materials.
The demographic, diagnostic and microbiological characteristics were investigated and the results of treatment were compared between the two groups.
Results The diagnosis of infection was made at 282.0±106.1 (180~410) days in group I and 209±118.4 (75~335) days in group II after the PLIF. All cases had neither general fever nor local manifestations like heating and redness etc.
All patients had back pain, however, only 2 cases of group II had neurological symptoms. C-reactive protein (CRP) level was elevated at 2 weeks from the PLIF in all cases (p<0.001). All cases had implant loosening at the time of their diagnosis. There was no failure of infection control. All cases showed normalization of CRP and radiological interbody fusion. The final Oswestry disability index (ODI) showed no difference between the two groups. ODI improved from 54.6±11.5 to 42.2±6.8 in group I (p=0.095) and from 63.6±6.9 to 44.8±11.7 in group II (p=0.025).
Conclusion For the surgical treatment of spondylitis that were developed in PLIF, a comprehensive one stage operation that comprised all implants removal, drainage and curettage followed by simultaneous intebody bone graft with metal cages and pedicle screw re-fixation was useful to control the infection.
Lumbar fusion surgery for lumbar degenerative diseases has increased in the past several decades and many techniques for fusion surgery have been introduced. Recently lateral lumbar interbody fusion with minimally invasive technique was introduced and accepted as a useful method for various lumbar degenerative disease. It can produce good correction for sagittal and coronal imbalance with relatively decreased morbidity. The advantage of lateral lumbar interbody fusion is that it can avoid injury to the abdominal large vessels and neural structures which is more common during posterior approaches. However various complications had been reported. Complications related with lateral lumbar interbody fusion include neurologic complications including thigh pain and numbness, vascular complications including arterial injury, cage related complication such as cage subsidence and vertebral body fractures. Therefore special care should be taken to avoid possible complications in lateral lumbar interbody fusion surgery.
Purpose of Study: Purpose of this study is to summarize the technique of UBE surgery in lumbar interbody fusion and review the clinical outcomes and complications of UBE surgery in lumbar interbody fusion.
Materials and Methods Medical databases were searched for the key words of unilateral biportal endoscopic surgery and lumbar spinal stenosis using PubMed from 2005 to the present.
Conclusion UBE spinal surgery is a new technique that can be a feasible alternative and an effective treatment modality for spinal degenerative diseases and can achieve the necessary surgical skills for experienced microscopic surgeons, which is still expanding the indications for lumbar spinal surgery.
Objectives We report the new minimally invasive technique and its clinical results of oblique lumbar interbody fusion (OLIF) combined with central decompression using biportal endoscopic spinal surgery (BESS).
Summary of Literature Review: The OLIF procedure is one of the minimally invasive spine surgeries and is being frequently attempted recently to treat lumbar degenerative disease. It has been reported that it effectively decompresses foraminal stenotic lesions indirectly by inserting a large cage anteriorly, which reduces spondylolisthesis and widens the disc space. However, OLIF has limited effect for severe central canal stenosis, since it cannot achieve direct decompression. Therefore, authors report a new minimally invasive technique of OLIF combined with direct central decompression using BESS for severe central stenosis along with its clinical results as a pilot study.
Materials and Methods For patients who were candidate for fusion surgery due to spondylolisthesis (more than one segment) or foraminal stenosis, authors performed OLIF and central decompression using BESS simultaneously, when the patients had concomitant severe central canal stenosis. From June to December, 2017, 8 patients (16 levels) were enrolled, the operative time, blood loss, complications and clinical results have been evaluated. The clinical results were analyzed by Visual analog scale (VAS) scores, Oswestry disability index (ODI) and Roland Morris Disability Questionnaire (RMDQ) of preoperative, 1month, 3month postoperative and final follow-up.
Results Mean operative time and blood loss were 238.4 minutes and 173.3ml, respectively. In all cases, there were no operative complications, and mean follow-up period was 7.1 months. The mean back VAS, lower extremity VAS, ODI, and RMDQ at the final follow-up were improved from 5.4±2.4 to 2.0±0.9, 7.0±1.1 to 1.6±1.7, 64.2±11.8 to 44.2±10.6, and from 17.5±4.2 to 12.9±4.0.
Conclusion A new combination technique of OLIF and BESS for direct decompression can be regarded as effective alternative procedure to treat the foraminal and central stenotic lesions of lumbar degenerative disease.
Many techniques have been introduced and performed, with different strengths and benefits. The lateral lumbar interbody fusion techniques (direct lateral lumbar interbody fusion [DLIF] and oblique lateral interbody fusion [OLIF]) have yielded good results for elderly patients. These are useful options for elderly patients with high risk of complications with traditional approaches.
A 77-year-old female suffering from severe degenerative scoliosis, spinal stenosis and lumbar disc herniation underwent Direct lateral lumbar interbody fusion (DLIF) at L2-4. On the 3rd postoperative day, she complained of severe back pain without any trauma history. Simple radiograph revealed L3 vertebral fracture and cage subsidence.
Pain was subsided after conservative treatment including TLSO and medication. Radiographic union was achieved at fractured vertebra after 3 months. Solid fusion was observed at operated level after 6 months. Patient has visited our clinic without any pain. DLIF is one of novel minimally invasive spine procedures available today. It is designed to maximize benefits and minimize risks of other traditional techniques such as anterior approach and posterior approach. However, there can be some risk of cage subsidence and vertebral fracture after DLIF. Therefore, care should be taken to avoid cage subsidence during the operation.
Minimally invasive TLIF has been reported to be a useful treatment option for the patients with various degenerative lumbar diseases. Many studies have reported the favorable clinical results of MIS TLIF. However it remains technically demanding, leading to higher complication rates and longer operative times during the early period of the learning curve. It showed some potential complications due to small working space and visual field. In this study, authors tried to find out various possible complications and some tips avoiding these complications through the review of various articles and authors’ clinical experiences. In many studies, the general complication fusion rates of MIS TLIF have been reported to be similar to that of open fusion. The technical difficulty of the procedure, combined with inadequate training, is evident in initial studies of MIS TLIF. A difficult learning curve of MIS TLIF demands that surgeons have sufficient preclinical training, and education is obtained before the application of MIS TLIF in clinical practice.
Purpose To assess the volume of fusion mass after posterior lumbar interbody fusion (PLIF) using Hounsfield units methods.
Methods The present study was within the frame work about a prospective observational cohort study to compare the surgical outcomes of a single-level PLIF for LSS between the local bone (LbG) and local bone plus hydroxyapatite groups (LbHa). The fusion material for each case was determined by the amount of available local bone. After the fusion material was chosen, patients were assigned to either the LbG group (n=20) or the LbHa group (n=20). The primary outcome was the assessment of fusion mass volume in each group.
Results We used the new method using Hounsfield units for volumetric assessments of interbody fusion mass. There was no difference in fusion rates or volume of the fusion mass between the 2 groups.
Conclusions Hounsfield unit method, that is the CT-based summation method using a cross-sectional slice, can be applied usefully to other areas of orthopaedics.
Objectives The aim of this study was to monitor the quality control of pedicle screw fixation using a cumulative summation test (CUSUM).
Overview of Literature: CUSUM test has already been used in several different surgical settings including the assessment of outcomes in transplant, laparoscopic, and total hip replacement surgeries. However, there has been no data regarding CUSUM analysis for spine surgery.
Methods Patients with lumbar spinal stenosis who underwent lumbar fusion surgery were included in this study.
The primary outcome was the CUSUM analysis for monitoring the quality control of the accuracy of pedicle screw insertion.
Results Seven screws of the 100 pedicle screw insertions were considered to have failed in the lumbar fusion surgery, respectively. Throughout the monitoring period, there was no indication by the CUSUM test that the quality of performance of the pedicle screw fixation procedure was inadequate.
Conclusions Thisstudy demonstrates the CUSUM test can be a useful tool for monitoring of the quality of procedures related with spine surgery.
Introduction Recently, minimally invasive lateral approach for the lumbar spine is revived and getting popularity under the name of XLIF or DLIF by modification of mini-open method using sequential tubular dilator and special expandable retractor system.
Purposes: The purposes of this study were to introduce the mini-open lateral approach for the anterior lumbar interbody fusion (ALIF), and to investigate the advantages, technical pitfalls and complications & to provide basic knowledge on XLIF or DLIF
Materials and Methods Seventy-four patients who underwent surgery by the mini-open lateral approach from September 2000 to April 2008 with various disease entities were included. Blood loss, operation time, incision size, postoperative time to mobilization, length of hospital stay, technical problems and complications were analyzed.
Results With this approach, we can reach form T12 to L5 subdiaphragmatically. The blood loss and operation time of patients who underwent simple ALIF were 61.2 ml and 86 minutes for one level, 107 ml and 106 minutes for two levels, 250 ml and 142.8 minutes for three levels, and 400 ml and 190 minutes for four levels of fusion, respectively.
The incision sizes were on average 4.5cm for one level, 6.3 cm for two levels, 8.5 cm for three levels and 10.0 cm for four levels of fusion. The complications were retroperitoneal hematoma in two cases, pneumonia in one case and transient lumbosacral plexus palsy in three cases.
Conclusion The mini-open lateral approach is simpler & safer than XLIF or DLIF with very short learning curve. Trial of mini-open lateral approach would be helpful before trial of XLIF or DLIF. However, special attention is required to complications such as transient lumbosacral plexus palsy.
Purpose Anterior lumbar interbody fusion (ALIF) is widely accepted surgical technique in the treatment of lumbar degenerative disc disease, especially with foraminal stenosis. But many surgeons suspect the effectiveness of ALIF in one or multi-level lumbar degenerative disease. The aim of this study is to evaluate the effectiveness of the two-level ALIF in lumbar degenerative disease.
Materials and Methods Included were the patients who had foraminal stenosis or spinal stenosis with segmental instability (e.g. spondylolisthesis). All patients were studied with plain radiographs and MRI before surgery and plain radiographs at 1 week, 6, 12 and 24 months after surgery. Radiographic measurements included disc height, global lumbar lordosis and existence of lateral fusion mass. To investigate the changes in lumbar global lordosis, the Cobb angle was evaluated on pre- and postoperative standing lateral radiographs from L1 superior endplate to S1 endplate.
Union was defined as the presence of trabecular osseous continuity and/or less than 4° mobility between the segments on a flexion and extension radiograph. Details of blood loss, operative time, transfusions during hospitalization, hospital day, and perioperative complications were evaluated. Clinical outcomes were assessed using Visual Analogue Scale (VAS) scores for leg and back pain and Oswestry disability index (ODI) before surgery and at 6, 12 and 24 months after surgery. Paired t-test was used for statistical analysis.
Results 37 patients (10 men and 27 women; age 33-76 years, mean 61.1 years) who had undergone ALIF combined with PLF or percutaneous pedicle screw fixation (PPF) during January 2007 and January 2009 were studied retrospectively. The mean follow-up period was 34.2 months (48-25 months). The affected levels were L3-4-5 in 14 cases and L4-5-S1 in 23 cases. The average hospital days are 10.7 days, showing no difference between PLF and PPF surgery. The average operation time is 286 minutes. Blood loss was variable from 130 mL to 1200 mL (average 621.2 mL). But Blood loss during the ALIF operation was minimal. (220 mL ; range 120-540 mL). Global lumbar lordosis was improved from 29.2 to 37.8. Postoperatively all patients had relief of sciatic pain, and there were no techniqueassociated complications. Complications included sensory deficit (hypo/dysesthesia) in 4 patients, DVT in one patient, ileus in one patient and transient sympathetic symptom in 11 patients. Two patients had wound problem but were treated easily. The VAS score in leg pain was improved from 6.9 to 2.3 with statistical significance at 24 months after surgery. Also, ODI score was decreased from 30.8 to 9.2 significantly at 24 months after surgery. Radiologic evidence of solid fusion was observed in all patients on the basis of motion and screw loosening. The lateral bone mass was observed bilaterally in 26 of the 28 patients (92%). Radiologic ASD was found in 10/37(27%), but only one patient showed symptom and had minor surgery.
Conclusion ALIF is an effective surgical strategy for the treatment of two-level lumbar degenerative disease and could be a useful alternative to posterior fusion surgery.
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