Both the paraspinal muscle sparing approach and percutaneous screw fixation are less traumatic procedures in comparison with the conventional midline approach. These techniques have been used with the goal of reducing muscle injury. The purpose of this study was to evaluate and to compare the safety and efficacy of the paraspinal muscle sparing technique and percutaneous screw fixation for the treatment of L5-S1 spondylolisthesis.
Twenty patients who had undergone posterior lumbar interbody fusion (PLIF) at the L5-S1 segment for spondylolisthesis were prospectively studied. They were divided into two groups by screw fixation technique (Group I : paraspinal muscle sparing approach and Group II: percutaneous screw fixation). Clinical outcomes were assessed by Low Back Outcome Score (LBOS) and Visual Analogue Scale (VAS) for back and leg pain at different times after surgery. In addition, modified MacNab's grading criteria were used to assess subjective patients' outcomes 6 months after surgery. Postoperative midline surgical scarring, intraoperative blood loss, mean operation time, and procedure-related complications were analyzed.
Excellent or good results were observed in all patients in both groups 6 months after surgery. Patients in both groups showed marked improvement in terms of LBOSs all over time intervals. Postoperative midline surgical scarring and intraoperative blood loss were lower in Group II compared to Group I although these differences were not statistically significant. Low back pain (LBP) and leg pain in both groups also showed significant improvement when compared to preoperative scores. However, at 7 days and 1 month after surgery, patients in Group II had significantly better LBP scores compared to Group I.
In terms of LBP during the early postoperative period, patients who underwent percutaneous screw fixation showed better results compared to ones who underwent screw fixation via the paraspinal muscle sparing approach. Our results indicate that the percutaneous screw fixation procedure is the preferable minimally invasive technique for reducing LBP associated with L5-S1 spondylolisthesis.
Spondylolisthesis; Paraspinal muscle sparing approach; Percutaneous screw fixation; Back pain
The conventional open pedicle screw fusion (PSF) requires an extensive detachment of the paraspinal muscle from the posterior aspect of the lumbar spine, which can cause muscle injury and subsequently lead to “approach-related morbidity”. The spinous process-splitting (SPS) approach for decompression, unilateral laminotomy for bilateral decompression, and the Wiltse approach for pedicle screw insertion are considered to be less invasive to the paraspinal musculature. We investigated whether SPS open PSF combined with the abovementioned techniques attenuates the paraspinal muscle damage and yields favorable clinical results, including alleviation in the low back discomfort, in comparison to the conventional open PSF.
We studied 53 patients who underwent single-level PSF for the treatment of degenerative spondylolisthesis (27 patients underwent SPS open PSF and the other 26 underwent the conventional open PSF). The clinical outcomes were assessed using the Japanese Orthopedic Association (JOA) score, the Roland–Morris disability questionnaire (RDQ), and the visual analog scale (VAS) for low back pain and low back discomfort (heavy feeling or stiffness). Postoperative multifidus (MF) atrophy was evaluated using MRI. Follow-up examinations were performed at 1 and 3 years after the surgery.
Although there was no significant difference in the JOA and RDQ score between the two groups, the VAS score for low back pain and discomfort after the surgery were significantly lower in the SPS open PSF group than in the conventional open PSF group. The extent of MF atrophy after SPS open PSF was reduced more significantly than after the conventional open PSF during the follow-up. The MF atrophy ratio was found to correlate with low back discomfort at the 1-year follow-up examination.
In conclusion, SPS open PSF was less damaging to the paraspinal muscle than the conventional open PSF and had a significant clinical effect, reducing low back discomfort over 1 year after the surgery.
Posterior lumbar fusion; Multifidus muscle; Wiltse approach; Minimally invasive; Conventionally open
Prospective controlled study.
The results of conventional open surgery was compared with those from minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) for lumbar fusion to determine which approach resulted in less postoperative paraspinal muscle degeneration.
Overview of Literature
MI TLIF is new surgical technique that appears to minimize iatrogenic injury. However, there aren't any reports yet that have quantitatively analyzed and proved whether there's difference in back muscle injury and degeneration between the minimally invasive surgery and conventional open surgery in more than 1 year follow-up after surgery.
This study examined a consecutive series of 48 patients who underwent lumbar fusion in our hospital during the period, March 2006 to March 2008, with a 1-year follow-up evaluation using MRI. There were 17 cases of conventional open surgery and 31 cases of MI-TLIF (31 cases of single segment fusion and 17 cases of multi-segment fusion). The digital images of the paravertebral back muscles were analyzed and compared using the T2-weighted axial images. The point of interest was the paraspinal muscle of the intervertebral disc level from L1 to L5. Picture archiving and communication system viewing software was used for quantitative analysis of the change in fat infiltration percentage and the change in cross-sectional area of the paraspinal muscle, before and after surgery.
A comparison of the traditional posterior fusion method with MI-TLIF revealed single segment fusion to result in an average increase in fat infiltration in the paraspinal muscle of 4.30% and 1.37% and a decrease in cross-sectional area of 0.10 and 0.07 before and after surgery, respectively. Multi-segment fusion showed an average 7.90% and 2.79% increase in fat infiltration and a 0.16 and 0.10 decrease in cross-sectional area, respectively. Both single and multi segment fusion showed less change in the fat infiltration percentage and cross-sectional area, particularly in multi segment fusion. There was no significant difference between the two groups in terms of the radiologic results.
A comparison of conventional open surgery with MI-TLIF upon degeneration of the paraspinal muscle with a 1 year follow-up evaluation revealed that both single and multi segment fusion showed less change in fat infiltration percentage and cross-sectional area in the MI-TLIF but there was no significant difference between the two groups. This suggests that as time passes after surgery, there is no significant difference in the level of degeneration of the paraspinal muscle between surgical techniques.
Paraspainal muscle; Fat degeneration; MRI; Posterior fusion
Paraspinal muscle damage is inevitable during conventional posterior lumbar fusion surgery. Minimal invasive surgery is postulated to result in less muscle damage and better outcome. The aim of this study was to monitor metabolic changes of the paraspinal muscle and to evaluate paraspinal muscle damage during surgery using microdialysis (MD). The basic interstitial metabolisms of the paraspinal muscle and the deltoid muscle were monitored using the MD technique in eight patients, who underwent posterior lumbar fusion surgery (six male and two female, median age 57.7 years, range 37–74) and eight healthy individuals for different positions (five male and three female, age 24.1 ± 0.8 years). Concentrations of glucose, glycerol, and lactate pyruvate ratio (L/P) in both tissues were compared. In the healthy group, the glucose and glycerol concentrations and L/P were unchanged in the paraspinal muscle when the body position changed from prone to supine. The glucose concentration and L/P were stable in the paraspinal muscle during the surgery. Glycerol concentrations increased significantly to 243.0 ± 144.1 μM in the paraspinal muscle and 118.9 ± 79.8 μM in the deltoid muscle in the surgery group. Mean glycerol concentration difference (GCD) between the paraspinal muscle and the deltoid tissue was 124.1 μM (P = 0.003, with 95% confidence interval 83.4–164.9 μM). The key metabolism of paraspinal muscle can be monitored by MD during the conventional posterior lumbar fusion surgery. The glycerol concentration in the paraspinal muscle is markedly increased compared with the deltoid muscle during the surgery. It is proposed that GCD can be used to evaluate surgery related paraspinal muscle damage. Changing body position did not affect the paraspinal muscle metabolism in the healthy subjects.
Glucose; Lactate pyruvate ratio; Glycerol; Paraspinal muscle; Microdialysis
The goal of a fusion of the lumbar spine is to obtain a primary solid arthrodesis thus to alleviate pain. Different circumferential fusion techniques have been described such as combined anterior–posterior fusion (APF), instrumented posterior lumbar interbody fusion (PLIF) and transforaminal lumbar interbody fusion (TLIF). The TLIF procedure has rapidly gained popularity; because of its posterolateral extracanalar discectomy and fusion, it has been reported as a safe technique, without the potential complications described when using combined APF and PLIF techniques. A retrospective clinical and radiographic study was performed. The database of our Center was interrogated in a retrospective way to extract data from patients that underwent a one or two level lumbar fusion with TLIF approach. All patients had symptomatic disc degeneration of the lumbar spine. One hundred and fourteen levels fused from 2003 to 2008. All patients were operated in the same center. All the patients were operated by the same surgical team. Patients were evaluated preoperatively and postoperatively at 1 and 3 months and 1 and 2 years follow-up. The spine was approached through a classic posterior midline incision and subperiosteal muscular detachment. The side of facetectomy was chosen according to the subject’s symptoms of leg pain if present. A posterolateral annulotomy was made and subtotal discectomy was performed and the hyaline cartilage of endplates was removed. Once the surgeon was satisfied with endplate preparation, a banana shaped allograft spacer was inserted through the annulotomy and placed anteriorly. Additional autograft locally harvested from decompression was packed behind the allograft spacer in all cases. Laminae and the remaining contralateral facet joint were decorticated, and packed with bone graft (local autologous and allograft chips in some cases). The posterior fusion was instrumented with pedicle screws and titanium rods. The TLIF procedure had led to shortened surgical times, less neurologic injury, and improved overall outcomes. The introduction of the TLIF procedure has allowed surgeons to achieve successful fusion without the risk of nerve root tethering that is seen so frequently with standard PLIF techniques.
TLIF; Minimal invasive fusion; Degenerative disc disease; Interbody fusion
On the basis of the experiences gained from conventional open spinal procedures, a long list of desirable objectives have emerged with the evolution of the lesser invasive spinal procedures. At the top of that list is the desire to minimize the trauma of surgery. The rest of the objectives, which include reductions of operating time, surgical blood loss, hospital stay, postoperative narcotic medication, convalescence, complication rates, and escalating health care costs, as well as the desire of elderly patients to continue rigorous physical activities, largely depend on the ability to minimize the trauma of surgery. The purpose of this study was to investigate the feasibility of the least invasive lumbar decompression, interbody fusion and percutaneous pedicle screw implantation, to minimize surgical trauma without compromising the quality of the treatment outcome, as well as to minimize risk of complications.
In this case series, 60 patients with diagnoses of degenerative disc disease, degenerative motion segments with stenosis, and spondylolisthesis, in whom nonoperative treatments failed, were treated with endoscopic transforaminal decompression and interbody fusion by 1 surgeon in 2 centers. The outcome measures were as follows: operating time, intraoperative blood loss, hospital stay, Visual Analogue Scale (VAS) scores for back and leg pain, scores on the Roland-Morris Disability Questionnaire, and postoperative imaging studies. A consecutive series of patients who met the treatment criteria completed VAS forms and Roland-Morris questionnaires preoperatively. Surgical procedures included arthroscopic decompression of the foramina and the discs; endplate preparation and implantation of allograft bone chips and bone morphogenetic protein 2 on absorbable collagen sponge into the disc space; and percutaneous implantation of pedicle screws. Postoperatively, the patients again completed the VAS forms and Roland-Morris questionnaires. Their charts were reviewed for office notes, operative notes, hospital stay, medications, and imaging studies. The latest X-ray and computed tomography scan films were reviewed and analyzed. Patients were followed up for a minimum of 6 months. The literature was reviewed for comparison of outcomes.
Sixty patients met the inclusion criteria. The mean age was 52.8 years. The duration of illness averaged 5 years. Follow-up ranged from 6 to 25 months, with a mean of 12 months. Preoperative diagnoses included degenerative disc disease, degenerative motion segments with stenosis, and spondylolisthesis. The mean time in the operating room was 2 hours 54 minutes. Estimated blood loss averaged 57.6 mL. The duration of the hospital stay averaged 2.6 days. Preoperative back pain and leg pain were significantly reduced (P < .005). Forty-seven imaging studies obtained at the last visit, including X-ray and computed tomography scans, showed solid fusion in 28 patients (59.6%), stable fixation in 17 (36.2%), and osteolysis around the pedicle screws in 2 (4.2%). All patients had improvement of motor function, whereas 2 patients complained of residual numbness. In addition, 8 patients (13%) complained of residual discomfort on extension of the lumbar spine. Two patients had pedicle screw–related complications requiring surgery. A review of the literature showed that endoscopic transforaminal decompression and interbody fusion performed better than open transforaminal lumbar interbody fusion/posterior lumbar interbody fusion, minimally invasive transforaminal lumbar interbody fusion, and extreme lateral lumbar interbody fusion, with regard to most parameters studied.
The endoscopic transforaminal lumbar decompression, interbody fusion, and percutaneous pedicle screw instrumentation consistently produced satisfactory results in all demographics. It performed better than the alternative procedures for most parameters studied.
ETDIF; Arthroscopic; Posterolateral; Interbody; Percutaneous; BMP-2
We set out to determine whether a minimally invasive approach for one-level instrumented posterior lumbar interbody fusion reduced undesirable changes in the multifidus muscle, compared to a conventional open approach. We also investigated associations between muscle injury during surgery (creatinine kinase levels), clinical outcome and changes in the multifidus at follow-up. We studied 59 patients treated by one team of surgeons at a single institution (minimally invasive approach in 28 and conventional open approach in 31, voluntarily chosen by patients). More than 1 year postoperatively, all the patients were followed up with the visual analogue scale (VAS) and Oswestry disability index (ODI), and 16 patients from each group were evaluated using MRI. This enabled the cross-sectional area (CSA) of lean multifidus muscle, and the T2 signal intensity ratio of multifidus to psoas muscle, to be compared at the operative and adjacent levels. The minimally invasive group had less postoperative back pain (P < 0.001) and lower postoperative ODI scores (P = 0.001). Multifidus atrophy was less in the minimally invasive group (P < 0.001), with mean reductions in CSA of 12.2% at the operative and 8.5% at the adjacent levels, compared to 36.8% and 29.3% in the conventional open group. The increase in the multifidus:psoas T2 signal intensity ratio was similarly less marked in the minimally invasive group where values increased by 10.6% at the operative and 8.3% at the adjacent levels, compared to 34.4 and 22.7% in the conventional open group (P < 0.001). These changes in multifidus CSA and T2 signal intensity ratio were significantly correlated with postoperative creatinine kinase levels, VAS scores and ODI scores (P < 0.01). The minimally invasive approach caused less change in multifidus, less postoperative back pain and functional disability than conventional open approach. Muscle damage during surgery was significantly correlated with long-term multifidus muscle atrophy and fatty infiltration. Furthermore these degenerative changes of multifidus were also significantly correlated with long-term clinical outcome.
Minimally invasive; Lumbar spine; Multifidus muscle; Interbody fusion
Spinal manipulation (SM) is a form of manual therapy used clinically to treat patients with low back and neck pain. The most common form of this maneuver is characterized as a high velocity (duration < 150ms), low amplitude (segmental translation < 2mm, rotation < 4°, and applied force 220-889N) impulse thrust (HVLA-SM). Clinical skill in applying an HVLA-SM lies in the practitioner's ability to control the duration and magnitude of the load (i.e., the rate of loading), the direction in which the load is applied, and the contact point at which the load is applied. Control over its mechanical delivery presumably related to its clinical effects. Biomechanical changes evoked by an HVLA-SM are thought to have physiological consequences caused, at least in part, by changes in sensory signaling from paraspinal tissues.
If activation of afferent pathways does contribute to the effects of an HVLA-SM, it seems reasonable to anticipate that neural discharge might increase or decrease in a non-linear fashion as the thrust duration thrust approaches a threshold value. We hypothesized that the relationship between the duration of an impulsive thrust to a vertebra and paraspinal muscle spindle discharge would be non-linear with an inflection near the duration of an HVLA-SM delivered clinically (<150ms). In addition, we anticipated that muscle spindle discharge would be more sensitive to larger amplitude thrusts.
A neurophysiological study of spinal manipulation using the lumbar spine of a feline model.
Impulse thrusts (duration: 12.5, 25, 50, 100, 200, and 400 ms; amplitude 1 or 2mm posterior to anterior) were applied to the spinous process of the L6 vertebra of deeply anesthetized cats while recording single unit activity from dorsal root filaments of muscle spindle afferents innervating the lumbar paraspinal muscles. A feedback motor was used in displacement control mode to deliver the impulse thrusts. The motor's drive arm was securely attached to the L6 spinous process via a forceps.
As thrust duration became shorter the discharge of the lumbar paraspinal muscle spindles increased in a curvilinear fashion. A concave up inflection occurred near the 100ms duration eliciting both a higher frequency discharge compared to the longer durations and a substantially faster rate of change as thrust duration was shortened. This pattern was evident in paraspinal afferents with receptive fields both close and far from the midline. Paradoxically, spindle afferents were almost twice as sensitive to the 1mm compared to the 2mm amplitude thrust (6.2 vs 3.3 spikes/s/mm/s). This latter finding may be related to the small vs large signal range properties of muscle spindles.
. The results indicate that the duration and amplitude of a spinal manipulation elicits a pattern of discharge from paraspinal muscle spindles different from slower mechanical inputs. Clinically, these parameters may be important determinants of an HVLA-SM's therapeutic benefit.
lumbar spine; spinal manipulation; chiropractic; osteopathy; paraspinal muscles; muscle spindle
The use of minimally invasive surgical (MIS) techniques represents the most recent modification of methods used to achieve lumbar interbody fusion. The advantages of minimally invasive spinal instrumentation techniques are less soft tissue injury, reduced blood loss, less postoperative pain and shorter hospital stay while achieving clinical outcomes comparable with equivalent open procedure. The aim was to study the clinicoradiological outcome of minimally invasive transforaminal lumbar interbody fusion.
Materials and Methods:
This prospective study was conducted on 23 patients, 17 females and 6 males, who underwent MIS-transforaminal lumbar interbody fusion (TLIF) followed up for a mean 15 months. The subjects were evaluated for clinical and radiological outcome who were manifested by back pain alone (n = 4) or back pain with leg pain (n = 19) associated with a primary diagnosis of degenerative spondylolisthesis, massive disc herniation, lumbar stenosis, recurrent disc herniation or degenerative disc disease. Paraspinal approach was used in all patients. The clinical outcome was assessed using the revised Oswestry disability index and Macnab criteria.
The mean age of subjects was 55.45 years. L4-L5 level was operated in 14 subjects, L5-S1 in 7 subjects; L3-L4 and double level was fixed in 1 patient each. L4-L5 degenerative listhesis was the most common indication (n = 12). Average operative time was 3 h. Fourteen patients had excellent results, a good result in 5 subjects, 2 subjects had fair results and 2 had poor results. Three patients had persistent back pain, 4 patients had residual numbness or radiculopathy. All patients had a radiological union except for 1 patient.
The study demonstrates a good clinicoradiological outcome of minimally invasive TLIF. It is also superior in terms of postoperative back pain, blood loss, hospital stay, recovery time as well as medication use.
Degenerative spine; lumbar fusion; minimally invasive transforaminal lumbar interbody fusion; spondylolisthesis; Spinal arthritis; spondyloarthritis; spondylolisthesis; minimally invasive; spinal fusion
Cross-sectional study with repeated measures design.
To compare the myosin heavy chain isoform distribution within and between paraspinal muscles and to test the theory that fiber type gradients exist as a function of paraspinal muscle depth.
Summary of Background Data
There is still uncertainty regarding the fiber type distributions within different paraspinal muscles. It has been previously proposed that deep fibers of the multifidus muscle may contain a higher ratio of type I to type II fibers, because, unlike superficial fibers, they primarily stabilize the spine, and may therefore have relatively higher endurance. Using a minimally invasive surgical approach, utilizing tubular retractors that are placed within anatomic inter-muscular planes, it was feasible to obtain biopsies from the multifidus, longissimus, iliocostalis and psoas muscles at specific predefined depths.
Under an IRB approved protocol, muscle biopsies were obtained from 15 patients who underwent minimally invasive spinal surgery, using the posterior paramedian (Wiltse) approach or the minimally invasive lateral approach. Myosin heavy chain (MyHC) isoform distribution was analyzed using SDS-PAGE electrophoresis. Since multiple biopsies were obtained from each patient, MyHC distribution was compared using both within- and between-muscle repeated measures analyses.
The fiber type distribution was similar among the posterior paraspinal muscles and was composed of relatively high percentage of type I (63%), compared to type IIA (19%) and type IIX (18%) fibers. In contrast, the psoas muscle was found to contain a lower percentage of type I fibers (42%) and a higher percentage of type IIA (33%) and IIX fibers (26%; P<0.05). No significant difference was found for fiber type distribution among three different depths of the multifidus and psoas muscles.
Fiber type distribution between the posterior paraspinal muscles is consistent and is composed of relatively high percentage of type I fibers, consistent with a postural function. The psoas muscle, on the other hand, is composed of a higher percentage of type II fibers such as in the appendicular muscles. Our data do not support the idea of a fiber type gradient as a function of depth for any muscle studied.
Lumbar multifidus; Muscle mechanics; Lumbar spine
Transforaminal lumbar interbody fusion (TLIF) is the standard surgical treatment for patients with lumbar degenerative spondylolisthesis who do not respond to a 6-week course of conservative therapy. A number of morbidities are associated with the conventional open-TLIF method, so minimally invasive surgery (MIS) techniques for TLIF (MIS-TLIF) have been introduced to reduce the trauma to paraspinal muscles and hasten postoperative recovery. Because providing cost-effective medical treatment is a core initiative of healthcare reforms, a comparison of open-TLIF and MIS-TLIF must include a cost-utility analysis in addition to an analysis of clinical effectiveness.
We compared patient-reported clinical functional outcomes and hospital direct costs in age-matched patients treated surgically with either open-TLIF or MIS-TLIF. Patients were followed for at least 1 year, and patient scores on the Oswestry Disability Index (ODI) and visual analog scale (VAS) were analyzed at 6 weeks, 6 months, and ≥1 year postoperatively in the 2 treatment groups.
Compared to their preoperative scores, patients in both the open-TLIF and MIS-TLIF groups had significant improvements in the ODI and VAS scores at each follow-up point, but no significant difference in functional outcome occurred between the open-TLIF and MIS-TLIF groups (P=0.46). However, open-TLIF is significantly more costly compared to MIS-TLIF (P=0.0002).
MIS-TLIF is a more cost-effective treatment than open-TLIF for patients with degenerative spondylolisthesis and is equally effective as the conventional open-TLIF procedure, although further financial analysis—including an analysis of indirect costs—is needed to better understand the full benefit of MIS-TLIF.
Costs and cost analysis; outcome assessment; pain measurement; spinal fusion; spinal instrumentation; spondylolisthesis; surgical procedures–minimally invasive
Degenerative lumbar spinal stenosis (DLSS) has become increasingly common and is characterized by multilevel disc herniation and lumbar spondylolisthesis, which are difficult to treat. The current study aimed to evaluate the short-term clinical outcomes and value of the combined use of microendoscopic discectomy (MED) and minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) for the treatment of multilevel DLSS with spondylolisthesis, and to compare the combination with traditional posterior lumbar interbody fusion (PLIF). A total of 26 patients with multilevel DLSS and spondylolisthesis underwent combined MED and MI-TLIF surgery using a single cage and pedicle rod-screw system. These cases were compared with 27 patients who underwent traditional PLIF surgery during the same period. Data concerning incision length, surgery time, blood loss, time of bed rest and Oswestry Disability Index (ODI) score prior to and following surgery were analyzed statistically. Statistical significance was reached in terms of incision length, blood loss and the time of bed rest following surgery (P<0.05), but there was no significant difference between the surgery time and ODI scores of the two groups. The combined use of MED and MI-TLIF has the advantages of reduced blood loss, less damage to the paraspinal soft tissue, shorter length of incision, shorter bed rest time, improved outcomes and shorter recovery times and has similar short-term clinical outcomes to traditional PLIF.
microendoscopic discectomy; minimally invasive transforaminal lumbar interbody fusion; posterior lumbar interbody fusion; lumbar spinal stenosis; lumbar spondylolisthesis
We attempted to identify changes in back muscle atrophy occurring in multilevel minimally invasive transforaminal interbody fusion (MITLIF) and the impact of these changes on clinical outcomes.
This study was conducted on 92 patients who underwent unilateral MITLIF between 2006 and 2013, had been tracked with a follow-up for at least 1 year, and had been assessed by pre- and postoperative computed tomography (CT). For the clinical evaluation, a pre- and postoperative visualized analog scale (VAS) of the back and legs, and Oswestry Disability Index (ODI) were measured. CT was used for the evaluation of back muscle atrophy and a cross-sectional area (CSA) of the multifidus was measured at the level below a fused segment, excluding metal artifacts.
There was no significant difference in the reduction of CSA between groups with one-, two-, or three-plus-segment fusion. In addition, no statistically significant differences were found in the pre- and postoperative VAS of the back, VAS of the legs, and ODI between the three groups. The reduction of CSA showed a statistically significant positive correlation with preoperative VAS of the back (p = 0.025, r = 0.562). On the other hand, no significant difference was found in VAS of the leg (p = 0.437, r = 0.082) and ODI (p = 0.106, r = 0.017).
When performing unilateral multilevel MITLIF, significant difference was not found in the atrophy of the multifidus according to the number of fused segments. The clinical outcomes also showed no significant difference. Therefore, unilateral MITLIF can be considered to be an effective surgical method to minimize lumbar muscle damage, even at multiple levels.
Spinal fusion; Minimally invasive surgery; Unilateral approach; Contralateral indirect decompression
To investigate the changes of cross sectional area (CSA) in paraspinal muscles upon magnetic resonance imaging (MRI) and bone mineral density (BMD) in postmenopausal osteoporotic spinal compression fractures.
We reviewed 81 postmenopausal women with osteoporosis, who had underwent MRI examination. The patients were divided into 51 patients who had osteoporotic spinal compression fractures (group I), and 30 patients who without fractures (group II). Group I were subdivided into IA and IB, based on whether they were younger (IA) of older (IB) than 70 years of age. We additionally measured body mass index and BMD. The CSA of multifidus, erector spinae, paraspinal muscles, psoas major (PT), and intervertebral (IV) discs were measured. The degree of fatty atrophy was estimated using three grades.
The BMD and T-score of group I were significantly lower than those of group II. The CSA of erector spinae, paraspinal muscles, and PT in the group I was significantly smaller than that of group II. The CSA of paraspinal muscles in group IB were significantly smaller than those of group IA. The CSA of erector spinae, mutifidus, and PT in group IB were smaller than those of group IA, but the difference was not statistically significant. Group 1 exhibited greater fat infiltration in the paraspinal muscle than group II.
Postmenopausal osteoporotic spinal compression fracture is associated with profound changes of the lumbar paraspinal muscle, reduction of CSA, increased CSA of IV disc, and increased intramuscular fat infiltration.
Cross-sectional area; Fractures compression; Paraspinal muscles; Postmenopause
The original description of the paraspinal posterior approach to the lumbar spine was for spinal fusion, especially regarding lumbosacral spondylolisthesis treatment. In spite of the technical details described by Wiltse, exact location of the area where the sacrospinalis muscle has to be split remains somewhat unclear. The goal of this study was to provide topographic landmarks to facilitate this surgical approach. Thirty cadavers were dissected in order to precisely describe the anatomy of the trans-muscular paraspinal approach. The level of the natural cleavage plane between the multifidus and the longissimus part of the sacrospinalis muscle was noted and measurements were done between this level and the midline at the level of the spinous process of L4. A natural cleavage plane between the multifidus and the longissimus part of the sacrospinalis muscle was present in all cases. There was a fibrous separation between the two muscular parts in 55 out of 60 cases. The mean distance between the level of the cleavage plane and the midline was 4 cm (2.4–5.5 cm). In all cases, small arteries and veins were present, precisely at the level of the cleavage plane. We found it possible to easily localize the anatomical cleavage plane between the multifidus part and the longissimus part of the sacrospinalis muscle. First the superficial muscular fascia is opened near the midline, exposing the posterior aspect of the sacrospinalis muscle. Then, the location of the muscular cleft can be found by identifying the perforating vessels leaving the anatomical inter-muscular space.
Paraspinal approach; Lumbar spine; Lumbosacral spondylolisthesis; Sacrospinalis muscle; Minimally invasive approach
We retrospectively evaluated 488 percutaneous pedicle screws in 110 consecutive patients that had undergone minimally invasive transforaminal lumbar interbody fusion (MITLIF) to determine the incidence of pedicle screw misplacement and its relevant risk factors. Screw placements were classified based on postoperative computed tomographic findings as “correct”, “cortical encroachment” or as “frank penetration”. Age, gender, body mass index, bone mineral density, diagnosis, operation time, estimated blood loss (EBL), level of fusion, surgeon’s position, spinal alignment, quality/quantity of multifidus muscle, and depth to screw entry point were considered to be demographic and anatomical variables capable of affecting pedicle screw placement. Pedicle dimensions, facet joint arthritis, screw location (ipsilateral or contralateral), screw length, screw diameter, and screw trajectory angle were regarded as screw-related variables. Logistic regression analysis was conducted to examine relations between these variables and the correctness of screw placement. The incidence of cortical encroachment was 12.5% (61 screws), and frank penetration was found for 54 (11.1%) screws. Two patients (0.4%) with medial penetration underwent revision for unbearable radicular pain and foot drop, respectively. The odds ratios of significant risk factors for pedicle screw misplacement were 3.373 (95% CI 1.095–10.391) for obesity, 1.141 (95% CI 1.024–1.271) for pedicle convergent angle, 1.013 (95% CI 1.006–1.065) for EBL >400 cc, and 1.003 (95% CI 1.000–1.006) for cross-sectional area of multifidus muscle. Although percutaneous insertion of pedicle screws was performed safely during MITLIF, several risk factors should be considered to improve placement accuracy.
Risk factor; Percutaneous; Pedicle screw; Minimally invasive; TLIF
Various modalities of treatment from standard discectomy, microdiscectomy, percutaneous discectomy, and transforaminal endoscopic discectomy have been in use for lumbar intervertebral disc prolapse. The access to spine is kept to a minimum without stripping paraspinal muscles minimizing muscle damage by posterior interlaminar endoscopic approach. The aim of this study was to evaluate technical problems, complications, and overall initial results of microendoscopic discectomy.
Materials and Methods:
First 100 consecutive cases aged 19-65 years operated by microendoscopic dissectomy between August 2002 – December 2005 are reported. All patients with single nerve root lesions including sequestrated or migrated and selected central disc at L4-5 and L5-S1 were included. The patients with bilateral radiculopathy were excluded. All patients had preoperative MRI and first 11 patients had postoperative MRI to check the adequacy of decompression. Diagnostic selective nerve root blocks were done in selective cases to isolate the single root lesion when MRI was inconclusive (n=7). All patients were operated by a single surgeon with the Metrx system (Medtronics). 97 were operated by 18-mm ports, and only three patients were operated by 16-mm ports. Postoperatively, all patients were mobilized as soon as the pain subsided and discharged within 24–48 h postsurgery. Patients were evaluated for technical problems, complications, and overall results by modified Macnab criteria. Patients were followed up at 2, 6, and 12 weeks.
The mean follow up was 12 months (range 3 months – 4 years). Open conversion was required in one patient with suspected root damage. Peroperatively single facet removal was done in 5 initial cases. Minor dural punctures occurred in seven cases and root damage in one case. The average surgical time was 70 min (range 25-210 min). Average blood loss was 20-30 ml. Technical difficulties encountered in initial 25 cases were insertion of guide pin, image orientation, peroperative dissection and bleeding problems, and reaching wrong levels suggestive of a definitive learning curve. Postoperative MRI (n=11) showed complete decompression. Overall 91% of patients had good-to-excellent results, with four patients having recurrence of whom three were reoperated. Four patients had postoperative discitis. One of the patients required fusion for discitis and rest were managed conservatively. One patient had root damage to L5 root that had paresthesia in L5 region even on 4 years of follow-up.
Microendoscopic discectomy is minimally invasive procedure for discectomy with early encouraging results. Once definite learning curve was over and expertise is acquired, the results of this procedure are acceptable safe and effective.
Lumbar discectomy; microendo system; endoscopic lumbar discectomy
Transforaminal lumbar interbody fusion (TLIF) is commonly used procedure for spinal fusion. However, there are no reports describing anterior cage dislodgement after surgery. This report is a rare case of anterior dislodgement of fusion cage after TLIF for the treatment of isthmic spondylolisthesis with lumbosacral transitional vertebra (LSTV). A 51-year-old man underwent TLIF at L4-5 with posterior instrumentation for the treatment of grade 1 isthmic spondylolisthesis with LSTV. At 7 weeks postoperatively, imaging studies demonstrated that banana-shaped cage migrated anteriorly and anterolisthesis recurred at the index level with pseudoarthrosis. The cage was removed and exchanged by new cage through anterior approach, and screws were replaced with larger size ones and cement augmentation was added. At postoperative 2 days of revision surgery, computed tomography (CT) showed fracture on lateral pedicle and body wall of L5 vertebra. He underwent surgery again for paraspinal decompression at L4-5 and extension of instrumentation to S1 vertebra. His back and leg pains improved significantly after final revision surgery and symptom relief was maintained during follow-up period. At 6 months follow-up, CT images showed solid fusion at L4-5 level. Careful cage selection for TLIF must be done for treatment of spondylolisthesis accompanied with deformed LSTV, especially when reduction will be attempted. Banana-shaped cage should be positioned anteriorly, but anterior dislodgement of cage and reduction failure may occur in case of a highly unstable spine. Revision surgery for the treatment of an anteriorly dislodged cage may be effectively performed using an anterior approach.
Cage; Transforaminal lumbar interbody fusion; Spondylolisthesis; Lumbosacral spine; Transitional vertebra
Context: Although poor paraspinal muscle endurance has been associated with less quadriceps activation (QA) in persons with a history of low back pain, no authors have addressed the acute neuromuscular response after lumbar paraspinal fatiguing exercise.
Objective: To compare QA after lumbar paraspinal fatiguing exercise in healthy individuals and those with a history of low back pain.
Design: A 2 × 4 repeated-measures, time-series design.
Setting: Exercise and Sport Injury Laboratory.
Patients or Other Participants: Sixteen volunteers participated (9 males, 7 females; 8 controls and 8 with a history of low back pain; age = 24.1 ± 3.1 years, height = 173.4 ± 7.1 cm, mass = 72.4 ± 12.1 kg).
Intervention(s): Subjects performed 3 sets of isometric lumbar paraspinal fatiguing muscle contractions. Exercise sets continued until the desired shift in lumbar paraspinal electromyographic median power frequency was observed. Baseline QA was compared with QA after each exercise set.
Main Outcome Measure(s): An electric burst was superimposed while subjects performed a maximal quadriceps contraction. We used the central activation ratio to calculate QA = (FMVIC/[FMVIC + FBurst])* 100, where F = force and MVIC = maximal voluntary isometric contractions. Quadriceps electromyographic activity was collected at the same time as QA measurements to permit calculation of median frequency during MVIC.
Results: Average QA decreased from baseline (87.4% ± 8.2%) after the first (84.5% ± 10.5%), second (81.4% ± 11.0%), and third (78.2% ± 12.7%) fatiguing exercise sets. On average, the group with a history of low back pain showed significantly more QA than controls. No significant change in quadriceps median frequency was noted during the quadriceps MVICs.
Conclusions: The quadriceps muscle group was inhibited after lumbar paraspinal fatiguing exercise in the absence of quadriceps fatigue. This effect may be different for people with a history of low back pain compared with healthy controls.
superimposed burst technique; quadriceps muscle inhibition; low back pain
Percutaneous pedicle screw fixation is commonly used for upper lumber burst fractures. The direct decompression remains challenging with this minimally invasive surgery. The objective was to evaluate a novel paraspinal erector approach for effective and direct decompression in patients with canal compromise and neurologic deficit.
Patients (n = 21) with neurological deficiency and Denis B type upper lumbar burst fracture were enrolled in the study, including 14 cases in the L1 and 7 cases in the L2. The patients underwent removal of bone fragments from the spinal canal through intervertebral foramen followed by short-segment fixation. Evaluations included surgery-related, such as duration of surgery and blood loss, and 12-month follow-up, such as the kyphotic angle, the height ratio of the anterior edge of the vertebra, the ratio of sagittal canal compromise, visual analog scale (VAS), Oswestry Disability Index (ODI), and Frankel scores.
All patients achieved direct spinal canal decompression using the paraspinal erector approach followed by percutaneous pedicle screw fixation. The mean operation time (SD) was 173 (23) min, and the mean (SD) blood loss was 301 (104) ml. Significant improvement was noted in the kyphotic angle, 26.2 ± 8.7 prior to operation versus 9.1 ± 4.7 at 12 months after operation (p <0.05); the height ratio of the anterior edge of the injured vertebra, 60 ± 16% versus 84 ± 9% (p <0.05); and the ratio of sagittal canal compromise, 46.5 ± 11.4% versus 4.3 ± 3.6% (p <0.05). Significant improvements in VAS (7.3 ± 1.2 vs. 1.9 ± 0.7, p <0.05), ODI (86.7 ± 5.8 vs. 16.7 ± 5.1, p <0.05), and Frankel scores were also noted.
The paraspinal erector approach was effective for direct spinal canal decompression with minimal injury in the paraspinal muscles or spine. Significant improvements in spinal function and prognostics were achieved after the percutaneous pedicle screw fixation.
Erector spinae; Direct spinal canal decompression; Minimally invasive spine surgery; Surgical approach; Upper lumber burst fractures
No consensus exists on how rehabilitation programs for lumbar discectomy patients with persistent complaints after surgery should be composed. A better understanding of normal and abnormal postoperative trunk muscle condition might help direct the treatment goals.
A three-dimensional CT scan of the lumbar spine was obtained in 18 symptomatic and 18 asymptomatic patients who had undergone a lumbar discectomy 42 months to 83 months (median 63 months) previously. The psoas muscle (PS), the paraspinal muscle mass (PA) and the multifidus muscle (MF) were outlined at the L3, L4 and L5 level. Of these muscles, fat free Cross Sectional Area (CSA) and fat CSA were determined. CSA of the lumbar erector spinae (LES = longissimus thoracis + iliocostalis lumborum) was calculated by subtracting MF CSA from PA CSA. Mean muscle CSA of the left and right sides was calculated at each level. To normalize the data for interpersonal comparison, the mean CSA was divided by the CSA of the L3 vertebral body (mCSA = normalized fat-free muscle CSA; fCSA = normalized fat CSA). Differences in CSA between the pain group and the pain free group were examined using a General Linear Model (GLM). Three levels were examined to investigate the possible role of the level of operation.
In lumbar discectomy patients with pain, the mCSA of the MF was significantly smaller than in pain-free subjects (p = 0.009) independently of the level. The mCSA of the LES was significantly smaller in pain patients, but only on the L3 slice (p = 0.018). No significant difference in mCSA of the PS was found between pain patients and pain-free patients (p = 0.462). The fCSA of the MF (p = 0.186) and of the LES (p = 0.256) were not significantly different between both populations. However, the fCSA of the PS was significantly larger in pain patients than in pain-free patients. (p = 0.012).
The level of operation was never a significant factor.
CT comparison of MF, LES and PS muscle condition between lumbar discectomy patients without pain and patients with protracted postoperative pain showed a smaller fat-free muscle CSA of the MF at all levels examined, a smaller fat- free muscle CSA of the LES at the L3 level, and more fat in the PS in patients with pain. The level of operation was not found to be of importance. The present results suggest a general lumbar muscle dysfunction in the pain group, in particular of the deep stabilizing muscle system.
The most common causes of failed back surgery are residual or recurrent herniation, foraminal fibrosis and foraminal stenosis that is ignored, untreated, or undertreated. Residual back ache may also be from facetal causes or denervation and scarring of the paraspinal muscles.1–6 The original surgeon may advise his patient that nothing more can be done on the basis of his opinion that the nerve was visually decompressed by the original surgery, supported by improved post-op imaging and follow-up studies such as EMG and conduction velocity studies. Post-op imaging or electrophysiological assessment may be inadequate to explain all the reasons for residual or recurrent symptoms. Treatment of Failed back surgery by repeat traditional open revision surgery usually incorporates more extensive decompression causing increased instability and back pain, therefore necessitating fusion. The authors, having limited their practice to endoscopic MIS surgery over the last 15-20 years, report on their experience gained during that period to relieve pain by endoscopically visualizing and treating unrecognized causative patho-anatomy in FBSS.7
Thirty consecutive patients with FBSS presenting with back and leg pain that had supporting imaging diagnosis of lateral stenosis and /or residual / recurrent disc herniation, or whose pain complaint was supported by relief from diagnostic and therapeutic injections (Figure 1), were offered percutaneous transforaminal endoscopic discectomy and foraminoplasty over a repeat open procedure. Each patient sought consultation following a transient successful, partially successful or unsuccessful open translaminar surgical treatment for disc herniation or spinal stenosis. Endoscopic foraminoplasty was also performed to either decompress the bony foramen for foraminal stenosis, or foraminoplasty to allow for endoscopic visual examination of the affected traversing and exiting nerve roots in the axilla, also known as the “hidden zone” of Macnab (Figure 2).8, 9 The average follow up time was, average 40 months, minimum 12 months. Outcome data at each visit included Macnab, VAS and ODI.
A diagnostic and therapeutic epidural gram may help identify unrecognized lateral recess stenosis underestimated by MRI. An excellent result from a therapeutic block lends excellent prognosis for a more lasting and “permanent” result from transforaminal endoscopic lateral recess decompression.
Kambin's Triangle provides access to the “hidden zone” of Macnab by foraminoplasty. The foramen and lateral recess is decompressed by removing the ventral aspect and tip of the superior articular process to gain access to the axilla between the traversing and exiting nerve. FBSS contains patho-anatomy in the axilla between the traversing and exiting nerve that hides the pain generators of FBSS.
The average pre-operative VAS improved from 7.2 to 4.0, and ODI 48% to 31%. While temporary dysesthesia occurred in 4 patients in the early post-operative period, all were happy, as all received additional relief of their pre-op symptoms. They were also relieved to be able to avoid “open” decompression or fusion surgery.
Conclusions / Level of Evidence 3
The transforaminal endoscopic approach is effective for FBSS due to residual/recurrent HNP and lateral stenosis. Failed initial index surgery may involve failure to recognize patho-anatomy in the axilla of the foramen housing the traversing and the exiting nerve, including the DRG, which is located cephalad and near the tip of SAP.10 The transforaminal endoscopic approach effectively decompresses the foramen and does not further destabilize the spine needing stabilization.11 It also avoids going through the previous surgical site.
Disc narrowing as a consequence of translaminar discectomy and progressive degenerative narrowing and spondylolisthesis (Figure 3) as a natural history of degenerative disc disease can lead to central and lateral stenosis. The MRI may underestimate the degree of stenosis from a bulging or a foraminal disc protrusion and residual lateral recess stenosis. Pain can be diagnosed and confirmed by evocative discography and by clinical response to transforaminal diagnostic and therapeutic steroid injections.12 Foraminal endoscopic decompression of the lateral recess is a MIS technique that does not “burn bridges” for a more conventional approach and it adds to the surgical armamentarium of FBSS.
Cadaver Illustration of Foraminal Stenosis (courtesy of Wolfgang Rauschning). As the disc narrows, the superior articular process impinges on the exiting nerve and DRG, creating lateral recess stenosis, lumbar spondylosis, and facet arthrosis.
Failed Back Surgery Syndrome(FBSS); Hidden zone; Foraminal decompression; Recurrent herniation; Lateral stenosis; Foraminal osteophyte
Retrospective case series.
The objectives of this study were to determine and discuss the surgical planning of patients who underwent operations following diagnoses of thoracal and lumbar spinal schwannomas. We also aimed to discuss the application of unilateral hemilaminectomy for the microsurgery of schwannomas.
Overview of Literature
Schwannomas are located in different regions and sites. These differences require several surgical approaches. Unilateral laminectomy without stabilization of the spine provides a more minimally invasive removal of the tumor.
In this retrospective study, 15 patients with spinal schwannomas were evaluated with regards to age, sex, onset history, neurological findings, tumor locations, McCormick scale, surgical procedure, and operational results. The lateral approach provides exposure of intradural structures and posterior paraspinal regions. Extensions of tumors cause problem for the surgeon in terms of approach, resectability of the tumor, and stability of the spine. Gross total resection was achieved in all cases, and none of the patients necessary required a fusion procedure.
Five patients were males and 10 were females. The age interval was 29-65 years. The tumor was located in the lumbar region in 9 patients, in the thoracic region in 2 patients, and in the thoracolumbar junction in 4 patients. The intradural lesions were removed by laminectomy and the extradural lesions were resected with hemilaminectomy. The paramedian route was used to explore the extraspinal part of the tumor. Costotransversectomy was for the thoracic region. Subtotal resection was performed in 1 patient. Patient symptoms recovered gradually in the postoperative period.
Resection of giant schwannomas is challenging and usually requires a different approach. We describe the complete resection of complex dumbbell or paraspinal schwannomas of the thoracic and lumbar spine by unilateral hemilaminectomy.
Thoracolumbar Schwannoma; Unilateral approach; Instability; Management
Transpedicular screw fixation has some disadvantages such as postoperative back pain through wide muscle dissection, long operative time, and cephalad adjacent segmental degeneration (ASD). The purposes of this study are investigation and comparison of radiological and clinical results between interspinous fusion device (IFD) and pedicle screw.
From Jan. 2008 to Aug. 2009, 40 patients underwent spinal fusion with IFD combined with posterior lumbar interbody fusion (PLIF). In same study period, 36 patients underwent spinal fusion with pedicle screw fixation as control group. Dynamic lateral radiographs, visual analogue scale (VAS), and Korean version of the Oswestry disability index (K-ODI) scores were evaluated in both groups.
The lumbar spine diseases in the IFD group were as followings; spinal stenosis in 26, degenerative spondylolisthesis in 12, and intervertebral disc herniation in 2. The mean follow up period was 14.24 months (range; 12 to 22 months) in the IFD group and 18.3 months (range; 12 to 28 months) in pedicle screw group. The mean VAS scores was preoperatively 7.16±2.1 and 8.03±2.3 in the IFD and pedicle screw groups, respectively, and improved postoperatively to 1.3±2.9 and 1.2±3.2 in 1-year follow ups (p<0.05). The K-ODI was decreased significantly in an equal amount in both groups one year postoperatively (p<0.05). The statistics revealed a higher incidence of ASD in pedicle screw group than the IFD group (p=0.029).
Posterior IFD has several advantages over the pedicle screw fixation in terms of skin incision, muscle dissection and short operative time and less intraoperative estimated blood loss. The IFD with PLIF may be a favorable technique to replace the pedicle screw fixation in selective case.
Degenerative; Fusion device; Interspinous; Lumbar disease; Posterior; Adjacent segmental degeneration
Decompressive laminectomy is one of the most commonly used surgical methods for the treatment of spinal stenosis. We retrospectively examined the risk factors that induce spinal instability, including slippage (spondylolisthesis) and/or segmental angulation after decompressive laminectomy on the lumbar spine.
From January 1, 2006 to June 30, 2010, 94 consecutive patients underwent first-time single level decompressive laminectomy without fusion and discectomy. Of these 94 patients, 42 with a follow-up period of at least 2 years were selected. We measured the segmental angulation and slippage in flexion and extension dynamic lumbar radiographs. We analyzed the following contributing factors to spinal instability: age/sex, smoking history, disc space narrowing, body mass index (kg/m2), facet joint tropism, effect of the lordotic angle on lumbar spine, asymmetrical paraspinal muscle volume, and surgical method and level.
Female patients, normal lordotic angle, and asymmetrical paraspinal muscle volume were factors more significantly associated with spondylolisthesis (p-value=0.026, 0.015, <0.01). Statistical results indicated that patients with facet tropism were more likely to have segmental angulation (p-value=0.046). Facet tropism and asymmetry of paraspinal muscle volume were predisposing factors to spinal instability (p-value=0.012, <0.01).
Facet joint tropism and asymmetry of paraspinal muscle volume are the most important factors associated with spinal instability; therefore, careful follow-up after decompressive laminectomy in affected patients is necessary.
Spinal stenosis; Facet tropism; Paraspinal muscle; Instability