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1.  Minimally Invasive Versus Open Transforaminal Lumbar Interbody Fusion for Degenerative Spondylolisthesis Grades 1-2: Patient-Reported Clinical Outcomes and Cost-Utility Analysis 
The Ochsner Journal  2014;14(1):32-37.
Background
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.
Methods
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.
Results
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).
Conclusion
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.
PMCID: PMC3963049  PMID: 24688330
Costs and cost analysis; outcome assessment; pain measurement; spinal fusion; spinal instrumentation; spondylolisthesis; surgical procedures–minimally invasive
2.  Slip Reduction Rate between Minimal Invasive and Conventional Unilateral Transforaminal Interbody Fusion in Patients with Low-Grade Isthmic Spondylolisthesis 
Korean Journal of Spine  2013;10(4):232-236.
Objective
To compare the slip reduction rate and clinical outcomes between unilateral conventional transforaminal lumbar interbody fusion (conventional TLIF) and unilateral minimal invasive TLIF (minimal TLIF) with pedicle screw fixation for treatment of one level low-grade symptomatic isthmic spondylolisthesis.
Methods
Between February 2008 and April 2012, 25 patients with low-grade isthmic spondylolisthesis underwent conventional TLIF (12 patients) and minimal TLIF (13 patients) in single university hospital by a single surgeon. Lateral radiographs of lumbar spine were taken 12 months after surgery to analyze the degree of slip reduction and the clinical outcome. All measurements were performed by a single observer.
Results
The demographic data between conventional TLIF and minimal TLIF were not different. Slip percentage was reduced from 15.00% to 8.33% in conventional TLIF, and from 14.15% to 9.62% in minimal TLIF. In both groups, slip percentage was significantly improved postoperatively (p=0.002), but no significant intergroup differences of slip percentage in preoperative and postoperative were found. The reduction rate also not different between conventional TLIF (45.41±28.80%) and minimal TLIF (32.91±32.12%, p=0.318).
Conclusion
Conventional TLIF and minimal TLIF with pedicle screw fixation showed good slip reduction in patients with one level low-grade symptomatic isthmic spondylolisthesis. The slip percentage and reduction rate were similar in the conventional TLIF and minimal TLIF.
doi:10.14245/kjs.2013.10.4.232
PMCID: PMC4040640  PMID: 24891854
Slip percentage; Reduction rate; Conventional; Minimal invasive; Transforamenal lumbar interbody fusion
3.  Clinical and radiological outcomes of open versus minimally invasive transforaminal lumbar interbody fusion 
European Spine Journal  2012;21(11):2265-2270.
Study design
Prospective observational cohort study.
Objective
Comparison of clinical and radiological outcomes of single-level open versus minimally invasive (MIS) transforaminal lumbar interbody fusion (TLIF) at 6 months and 2-year follow-up.
Summary of background data
There is recognition that more data are required to ascertain the benefits and risks of MIS vis-a-vis open TLIF. This study aims to report on one of the largest currently available series comparing the clinical and radiological outcomes of the two procedures with a minimum follow-up of 2 years.
Methods
From January 2002 to March 2008, 144 single-level open and MIS TLIF were performed at our centre, with 72 patients in each group. Clinical outcomes were based on patient-reported outcome measures recorded at the Orthopaedic Diagnostic Centre by independent assessors before surgery, at 6 months and 2 years post-operatively. These were visual analogue scores (VAS) for back and leg pain, Oswestry disability index (ODI), short form-36 (SF-36), North American Spine Society (NASS) scores for neurogenic symptoms, returning to full function, and patient rating of the overall result of surgery. Radiological fusion based on the Bridwell grading system was also assessed at 6 months and 2 years post-operatively by independent assessors.
Results
In terms of demographics, the two groups were similar in terms of patient sample size, age, gender, body mass index (BMI), spinal levels operated, and all the clinical outcome measures (p > 0.05). Perioperative analysis revealed that MIS cases have comparable operative duration (open: 181.8 min, MIS: 166.4 min, p > 0.05), longer fluoroscopic time (open: 17.6 s, MIS: 49.0 s, p < 0.05), less intra-operative blood loss (open: 447.4 ml, MIS: 50.6 ml, p < 0.05) and no post-operative drainage (open: 528.9 ml, MIS: 0 ml, p < 0.05). MIS patients needed less morphine (open: 33.5 mg, MIS: 3.4 mg, p < 0.05) and were able to ambulate (open: 3.4 days, MIS: 1.2 days, p < 0.05) and be discharged from hospital earlier (open: 6.8 days, MIS: 3.2 days, p < 0.05).
At 6 months, clinical outcome analysis showed both groups improving significantly (>50.0 %) and similarly in terms of VAS, ODI, SF-36, return to full function and patient rating (p > 0.05). Radiological analysis showed similar grade 1 fusion rates (open: 52.2 %, MIS: 59.4 %, p > 0.05) with small percentage of patients developing asymptomatic cage migration (open: 8.7 %, MIS: 5.8 %, p > 0.05). One major complication (open: myocardial infarction, MIS: screw malpositioning requiring subsequent revision) and two minor complications in each group (open: pneumonia and post-surgery anemia, MIS: incidental durotomy and pneumonia) were noted.
At 2 years, continued improvements were observed in both groups as compared to the preoperative state (p > 0.05), with 50.8 % of open and 58 % of MIS TLIF patients returning to full function (p > 0.05). Almost all patients have Grade 1 fusion (open: 98.5 %, MIS: 97.0 %, p > 0.05) with minimal new cage migration (open: 1.4 %, MIS: 0 %, p > 0.05).
Conclusions
MIS TLIF is a safe option for lumbar fusion, and when compared to open TLIF, has similar operative duration, good clinical and radiological outcomes, with additional significant benefits of less perioperative blood loss and pain, earlier rehabilitation, and a shorter hospitalization.
doi:10.1007/s00586-012-2281-4
PMCID: PMC3481101  PMID: 22453894
Lumbar fusion; Open; Minimally invasive; Clinical outcomes
4.  Radiographic Results of Minimally Invasive (MIS) Lumbar Interbody Fusion (LIF) Compared with Conventional Lumbar Interbody Fusion 
Korean Journal of Spine  2013;10(2):65-71.
Objective
To evaluate the radiographic results of minimally invasive (MIS) anterior lumbar interbody fusion (ALIF) and transforaminal lumbar interbody fusion (TLIF).
Methods
Twelve and nineteen patients who underwent MIS-ALIF, MIS-TLIF, respectively, from 2006 to 2008 were analyzed with a minimum 24-months' follow-up. Additionally, 18 patients treated with single level open TLIF surgery in 2007 were evaluated as a comparative group. X-rays and CT images were evaluated preoperatively, postoperatively, and at the final follow-up. Fusion and subsidence rates were determined, and radiographic parameters, including lumbar lordosis angle (LLA), fused segment angle (FSA), sacral slope angle (SSA), disc height (DH), and foraminal height (FH), were analyzed. These parameters were also compared between the open and MIS-TLIF groups.
Results
In the MIS interbody fusion group, statistically significant increases were observed in LLA, FSA, and DH and FH between preoperative and final values. The changes in LLA, FSA, and DH were significantly increased in the MIS-ALIF group compared with the MIS-TLIF group, but SSA and FH were not significantly different. No significant differences were seen between open and MIS-TLIF except for DH. The interbody subsidence and fusion rates of the MIS groups were 12.0±4% and 96%, respectively.
Conclusion
Radiographic results of MIS interbody fusion surgery are as favorable as those with conventional surgery regarding fusion, restoration of disc height, foraminal height, and lumbar lordosis. MIS-ALIF is more effective than MIS-TLIF for intervertebral disc height restoration and lumbar lordosis.
doi:10.14245/kjs.2013.10.2.65
PMCID: PMC3941727  PMID: 24757461
Minimally Invasive Interbody Fusion; Transforaminal Lumbar Interbody Fusion; Anterior Lumbar Interbody Fusion; Radiographic Results
5.  Minimally Invasive Transforaminal Lumbar Interbody Fusion Using a Single Interbody Cage and a Tubular Retraction System : Technical Tips, and Perioperative, Radiologic and Clinical Outcomes 
Objective
A minimally invasive transforaminal lumbar interbody fusion (MIS TLIF) has recently been introduced. However, MIS TLIF is a technically challenging procedure. The authors performed retrospective analysis about MIS TLIF using a single interbody cage.
Methods
Twenty-eight consecutive patients were treated by MIS TLIF. Of these 28 patients, 20 patients were included in this retrospective study. Perioperative, clinical, and radiologic outcomes were assessed. Clinical outcomes were assessed using Oswestry Disability Index (ODI) and Visual Analogue Scores (VAS). Fusion rates and cross-sections of operated spinal canals were assessed by CT.
Results
Twelve patients underwent MIS TLIF at one segment and 8 patients at two segments (L3/4: 4, L4/5: 17, L5/S1: 7). Operation time for a single segment was 131.7 min and for two segment was 201.4 min, and corresponding blood losses were 208.3 mL and 481.2 mL, respectively. ODI and VAS scores were significantly improved at 6 months postop (ODI from 30.32 to 15. 54, VAS from 7.80 to 2.20, p = 0.001). Twenty-two segments (78.6%) achieved grade I fusion, 4 segments (14.3%) achieved grade II, 2 segments (7.1%) achieved grade III and 0 segments achieved grade IV at 12 months. Postoperatively at 12 months, spinal canal cross sectional areas at disc spaces significantly increased from 157.5 to 294.3 mm2 (p = 0.012).
Conclusion
MIS TLIF achieved good clinical outcomes and high fusion rates. Our findings show that MIS TLIF performed with a single interbody cage and a tubular retractor system can be used as a standard MIS TLIF technique.
doi:10.3340/jkns.2010.48.3.219
PMCID: PMC2966722  PMID: 21082048
Minimally invasive; Spinal fusion; Lumbar vertebrae
6.  Biomechanical comparison of unilateral and bilateral pedicle screws fixation for transforaminal lumbar interbody fusion after decompressive surgery -- a finite element analysis 
Background
Little is known about the biomechanical effectiveness of transforaminal lumbar interbody fusion (TLIF) cages in different positioning and various posterior implants used after decompressive surgery. The use of the various implants will induce the kinematic and mechanical changes in range of motion (ROM) and stresses at the surgical and adjacent segments. Unilateral pedicle screw with or without supplementary facet screw fixation in the minimally invasive TLIF procedure has not been ascertained to provide adequate stability without the need to expose on the contralateral side. This study used finite element (FE) models to investigate biomechanical differences in ROM and stress on the neighboring structures after TLIF cages insertion in conjunction with posterior fixation.
Methods
A validated finite-element (FE) model of L1-S1 was established to implant three types of cages (TLIF with a single moon-shaped cage in the anterior or middle portion of vertebral bodies, and TLIF with a left diagonally placed ogival-shaped cage) from the left L4-5 level after unilateral decompressive surgery. Further, the effects of unilateral versus bilateral pedicle screw fixation (UPSF vs. BPSF) in each TLIF cage model was compared to analyze parameters, including stresses and ROM on the neighboring annulus, cage-vertebral interface and pedicle screws.
Results
All the TLIF cages positioned with BPSF showed similar ROM (<5%) at surgical and adjacent levels, except TLIF with an anterior cage in flexion (61% lower) and TLIF with a left diagonal cage in left lateral bending (33% lower) at surgical level. On the other hand, the TLIF cage models with left UPSF showed varying changes of ROM and annulus stress in extension, right lateral bending and right axial rotation at surgical level. In particular, the TLIF model with a diagonal cage, UPSF, and contralateral facet screw fixation stabilize segmental motion of the surgical level mostly in extension and contralaterally axial rotation. Prominent stress shielded to the contralateral annulus, cage-vertebral interface, and pedicle screw at surgical level. A supplementary facet screw fixation shared stresses around the neighboring tissues and revealed similar ROM and stress patterns to those models with BPSF.
Conclusions
TLIF surgery is not favored for asymmetrical positioning of a diagonal cage and UPSF used in contralateral axial rotation or lateral bending. Supplementation of a contralateral facet screw is recommended for the TLIF construct.
doi:10.1186/1471-2474-13-72
PMCID: PMC3503692  PMID: 22591664
Transforaminal lumbar interbody fusion; Pedicle screw fixation; Contralateral facet screw; Finite element analysis
7.  Lumbar degenerative spinal deformity: Surgical options of PLIF, TLIF and MI-TLIF 
Indian Journal of Orthopaedics  2010;44(2):159-162.
Degenerative disease of the lumbar spine is common in ageing populations. It causes disturbing back pain, radicular symptoms and lowers the quality of life. We will focus our discussion on the surgical options of posterior lumbar interbody fusion (PLIF) and transforaminal lumbar interbody fusion (TLIF) and minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) for lumbar degenerative spinal deformities, which include symptomatic spondylolisthesis and degenerative scoliosis. Through a description of each procedure, we hope to illustrate the potential benefits of TLIF over PLIF. In a retrospective study of 53 ALIF/PLIF patients and 111 TLIF patients we found reduced risk of vessel and nerve injury in TLIF patients due to less exposure of these structures, shortened operative time and reduced intra-operative bleeding. These advantages could be translated to shortened hospital stay, faster recovery period and earlier return to work. The disadvantages of TLIF such as incomplete intervertebral disc and vertebral end-plate removal and potential occult injury to exiting nerve root when under experienced hands are rare. Hence TLIF remains the mainstay of treatment in degenerative deformities of the lumbar spine. However, TLIF being a unilateral transforaminal approach, is unable to decompress the opposite nerve root. This may require contralateral laminotomy, which is a fairly simple procedure. The use of minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) to treat degenerative lumbar spinal deformity is still in its early stages. Although the initial results appear promising, it remains a difficult operative procedure to master with a steep learning curve. In a recent study comparing 29 MI-TLIF patients and 29 open TLIF, MI-TLIF was associated with longer operative time, less blood loss, shorter hospital stay, with no difference in SF-36 scores at six months and two years. Whether it can replace traditional TLIF as the surgery of choice for degenerative lumbar deformity remains unknown and more studies are required to validate the safety and efficiency.
doi:10.4103/0019-5413.62066
PMCID: PMC2856390  PMID: 20419002
Degenerative spine; lumbar spine fusion; minimally invasive transforaminal fusion
8.  Comparing Miniopen and Minimally Invasive Transforaminal Interbody Fusion in Single-Level Lumbar Degeneration 
BioMed Research International  2015;2015:168384.
Degenerative diseases of the lumbar spine, which are common among elderly people, cause back pain and radicular symptoms and lead to a poor quality of life. Lumbar spinal fusion is a standardized and widely accepted surgical procedure used for treating degenerative lumbar diseases; however, the classical posterior approach used in this procedure is recognized to cause vascular and neurologic damage of the lumbar muscles. Various studies have suggested that using the minimally invasive transforaminal interbody fusion (TLIF) technique provides long-term clinical outcomes comparable to those of open TLIF approaches in selected patients. In this study, we compared the perioperative and short-term advantages of miniopen, MI, and open TLIF. Compared with open TLIF, MI-TLIF and miniopen TLIF were associated with less blood loss, shorter hospital stays, and longer operative times; however, following the use of these procedures, no difference in quality of life was measured at 6 months or 1 year. Whether miniopen TLIF or MI-TLIF can replace traditional TLIF as the surgery of choice for treating degenerative lumbar deformity remains unclear, and additional studies are required for validating the safety and efficiency of these procedures.
doi:10.1155/2015/168384
PMCID: PMC4299488  PMID: 25629037
9.  Same-day Discharge After Minimally Invasive Transforaminal Lumbar Interbody Fusion: A Series of 808 Cases 
Background
The versatility of transforaminal lumbar interbody fusion (TLIF) allows fusion at any level along with any necessary canal decompression. Unilateral TLIF with a single interbody device and unilateral pedicle fixation has proven effective, and minimally invasive techniques have shortened hospital stays. Reasonable questions have been raised, though, about whether same-day discharge is feasible and safe after TLIF surgery.
Questions/purposes
We determined, in a high-volume spine practice, what proportion of patients having one- or two-level minimally invasive unilateral TLIF go home on the day of surgery or stay longer and compared the two groups in terms of outcome scores (VAS scores for back and leg pain, Waddell-Main Disability Index), complications, and hospital readmissions.
Methods
We retrospectively studied all 1005 patients who underwent 1114 minimally invasive unilateral TLIF procedures by one surgeon between March 18, 2003, and April 12, 2013. For the first 43 months, Medicare patients (65 years or older) were not offered same-day discharge. All other patients were offered the chance to be discharged home on the same day if they felt well enough. Followup data were for 3 months. VAS scores for back and leg pain and Waddell-Main Disability Index were recorded in a prospectively maintained database and readmissions were ascertained by chart review. Data were available on 100% of discharges, 95% of preoperative outcome scores, and 81% of outcome scores out to 3 months.
Results
Of the 1114 procedures, 808 went home the day of surgery, resulting in a 73% same-day discharge rate. Mean differences in outcome scores from preoperatively to 3 months were similar between groups, except for a difference in VAS lower leg pain in hospital stay patients, which was of borderline statistical and unlikely clinical significance (3.3 versus 2.7, p = 0.05). The only important differences between groups were slightly more medical complications and readmissions for patients 65 years and older who stayed in hospital overnight (3.9% versus 0%, p < 0.01); however, some self-selection bias toward staying overnight among patients with higher self-rated disability and pain scores likely accounted for this difference.
Conclusions
Surgeons experienced in minimally invasive spine surgery can consider same-day discharge for patients having minimally invasive unilateral TLIF procedures.
Level of Evidence
Level III, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.
doi:10.1007/s11999-013-3366-z
PMCID: PMC4016463  PMID: 24272414
10.  Minimally invasive versus open transforaminal lumbar interbody fusion 
Background
Available clinical data are insufficient for comparing minimally invasive (MI) and open approaches for transforaminal lumbar interbody fusion (TLIF). To date, a paucity of literature exists directly comparing minimally invasive (MI) and open approaches for transforaminal lumbar interbody fusion (TLIF). The purpose of this study was to directly compare safety and effectiveness for these two surgical approaches.
Materials and Methods
Open or minimally invasive TLIF was performed in 63 and 76 patients, respectively. All consecutive minimally invasive TLIF cases were matched with a comparable cohort of open TLIF cases using three variables: diagnosis, number of spinal levels, and history of previous lumbar surgery. Patients were treated for painful degenerative disc disease with or without disc herniation, spondylolisthesis, and/or stenosis at one or two spinal levels. Clinical outcome (self-report measures, e.g., visual analog scale (VAS), patient satisfaction, and MacNab's criteria), operative data (operative time, estimated blood loss), length of hospitalization, and complications were assessed. Average follow-up for patients was 37.5 months.
Results:
The mean change in VAS scores postoperatively was greater (5.2 vs. 4.1) in theopen TLIF patient group (P = 0.3). MacNab's criteria score was excellent/good in 67% and 70% (P = 0.8) of patients in open and minimally invasive TLIF groups, respectively. The overall patient satisfaction was 72.1% and 64.5% (P = 0.4) in open and minimally invasive TLIF groups, respectively. The total mean operative time was 214.9 min for open and 222.5 min for minimally invasive TLIF procedures (P = 0.5). The mean estimated blood loss for minimally invasive TLIF (163.0 ml) was significantly lower (P < 0.0001) than the open approach (366.8 ml). The mean duration of hospitalization in the minimally invasive TLIF (3 days) was significantly shorter (P = 0.02) than the open group (4.2 days). The total rate of neurological deficit was 10.5% in the minimally invasive TLIF group compared to 1.6% in the open group (P = 0.02).
Conclusions:
Minimally invasive TLIF technique may provide equivalent long-term clinical outcomes compared to open TLIF approach in select population of patients. The potential benefit of minimized tissue disruption, reduced blood loss, and length of hospitalization must be weighted against the increased rate of neural injury-related complications associated with a learning curve.
doi:10.4103/2152-7806.63905
PMCID: PMC2908364  PMID: 20657693
Clinical outcomes; Complications; Degenerative lumbar spine; Lumbar fusion; Minimally invasive approach; Open approach; Transforaminal lumbar interbody fusion
11.  Minimally invasive or open transforaminal lumbar interbody fusion as revision surgery for patients previously treated by open discectomy and decompression of the lumbar spine 
European Spine Journal  2010;20(4):623-628.
Minimally invasive lumbar fusion techniques have been developed in recent 20 years. The goals of these procedures are to reduce approach-related soft tissue injury, postoperative pain, and disability while allowing the surgery to be conducted in an effective manner. There have been no prospective clinical reports published on the comparison of minimally invasive transforaminal lumbar interbody fusion as revision surgery for patients previously treated by open discectomy and decompression or a traditional open approach. A prospective clinical study was performed by evaluating the clinical and radiographic results of minimally invasive transforaminal lumbar interbody fusion as an alternative new technique in the revision surgery for patients previously treated by open procedure. 52 patients (28 M, 24 F) with an average age of 55.7 (31–76) were prospectively evaluated. All patients who had previous discectomy (n = 13), hemilaminectomy (n = 16), laminectomy (n = 12) and facetectomy (n = 11) underwent monosegmental and bisegmental minimally invasive transforaminal lumbar interbody fusion (MiTLIF) (n = 25) or open transforaminal lumbar interbody fusion (OTLIF) (n = 27) by two experienced surgeons at one hospital, from March 2006 to October 2008 (minimum 12-month follow-up). The following data were compared between the two groups: the clinical and radiographic results, operative time, blood loss, X-ray exposure time, postoperative back pain, and complications. Clinical outcome was assessed using the visual analogue scale and the Oswestry disability index (ODI). The operative time and clinical and radiographic results were basically identical in both groups. Comparing with the OTLIF group, the MiTLIF group had significantly less blood loss and less postoperative back pain at the second day postoperatively. The radiation time was significantly longer in the MiTLIF group. Complications included three cases of small dural tear in the MiTLIF group. There were five cases of dural tear and two cases of superficial wound infection in the OTLIF group. One case of nonunion was observed from each group. Minimally invasive TLIF is a safe and effective procedure for treatment of selected revision patients previously treated by open surgery with some potential advantages. However, this technique needs longer X-ray exposure time.
doi:10.1007/s00586-010-1578-4
PMCID: PMC3065602  PMID: 20927557
Comparison; Revision spine surgery; Minimally invasive transforaminal lumbar interbody fusion; Failed lumbar surgery
12.  Comparison of one-level minimally invasive and open transforaminal lumbar interbody fusion in degenerative and isthmic spondylolisthesis grades 1 and 2 
European Spine Journal  2010;19(10):1780-1784.
Minimally invasive lumbar fusion techniques have only recently been developed. The goals of these procedures are to reduce approach-related soft tissue injury, postoperative pain and disability while allowing the surgery to be conducted in an effective manner. There have been no prospective clinical reports published on the comparison of one-level transforaminal lumbar interbody fusion in low-grade spondylolisthesis performed with an independent blade retractor system or a traditional open approach. A prospective clinical study of 85 consecutive cases of degenerative and isthmic lower grade spondylolisthesis treated by minimally invasive transforaminal lumbar interbody fusion (MiTLIF) or open transforaminal lumbar interbody fusion (OTLIF) was done. A total of 85 patients suffering from degenerative spondylolisthesis (n = 46) and isthmic spondylolisthesis (n = 39) underwent one-level MiTLIF (n = 42) and OTLIF (n = 43) by two experienced surgeons at one hospital, from June 2006 to March 2008 (minimum 13-month follow-up). The following data were compared between the two groups: the clinical and radiographic results, operative time, blood loss, transfusion needs, X-ray exposure time, postoperative back pain, length of hospital stay, and complications. Clinical outcome was assessed using the visual analog scale (VAS) and the Oswestry disability index. The operative time, clinical and radiographic results were basically identical in both groups. Comparing with the OTLIF group, the MiTLIF group had significantly lesser blood loss, lesser need for transfusion, lesser postoperative back pain, and shorter length of hospital stay. The radiation time was significantly longer in MiTLIF group. One case of nonunion was observed from each group. Minimally invasive TLIF has similar surgical efficacy with the traditional open TLIF in treating one-level lower grade degenerative or isthmic spondylolisthesis. The minimally invasive technique offers several potential advantages including smaller incisions, less tissue trauma and quicker recovery. However, this technique needs longer X-ray exposure time.
doi:10.1007/s00586-010-1404-z
PMCID: PMC2989221  PMID: 20411281
Comparison; Minimally invasive surgery; Transforaminal lumbar interbody fusion; Isthmic and degenerative spondylolisthesis
13.  Clinical outcomes of minimally invasive versus open approach for one-level transforaminal lumbar interbody fusion at the 3- to 4-year follow-up 
European Spine Journal  2013;22(12):2857-2863.
Purpose
Supporters of minimally invasive approaches for transforaminal lumbar interbody fusion (TLIF) have reported short-term advantages associated with a reduced soft tissue trauma. Nevertheless, mid- and long-term outcomes and specifically those involving physical activities have not been adequately studied. The aim of this study was to compare the clinical outcomes of mini-open versus classic open surgery for one-level TLIF, with an individualized evaluation of the variables used for the clinical assessment.
Methods
A prospective cohort study was conducted of 41 individuals with degenerative disc disease who underwent a one-level TLIF from January 2007 to June 2008. Patients were randomized into two groups depending on the type of surgery performed: classic open (CL-TLIF) group and mini-open approach (MO-TLIF) group. The visual analog scale (VAS), North American Spine Society (NASS) Low Back Pain Outcome instrument, Oswestry Disability Index (ODI) and the Short Form 36 Health Survey (SF-36) were used for clinical assessment in a minimum 3-year follow-up (36–54 months).
Results
Patients of the MO-TLIF group presented lower rates of lumbar (p = 0.194) and sciatic pain (p = 0.427) and performed better in daily life activities, especially in those requiring mild efforts: lifting slight weights (p = 0.081), standing (p = 0.097), carrying groceries (p = 0.033), walking (p = 0.069) and dressing (p = 0.074). Nevertheless, the global scores of the clinical questionnaires showed no statistical differences between the CL-TLIF and the MO-TLIF groups.
Conclusions
Despite an improved functional status of MO-TLIF patients in the short term, the clinical outcomes of mini-open TLIF at the 3- to 4-year follow-up showed no clinically relevant differences to those obtained with open TLIF.
doi:10.1007/s00586-013-2853-y
PMCID: PMC3843777  PMID: 23764765
Minimally invasive; TLIF; Lumbar fusion; Degenerative disc disease; Prospective
14.  Microdialysis of paraspinal muscle in healthy volunteers and patients underwent posterior lumbar fusion surgery 
European Spine Journal  2009;18(11):1604-1609.
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.
doi:10.1007/s00586-009-1021-x
PMCID: PMC2899392  PMID: 19418074
Glucose; Lactate pyruvate ratio; Glycerol; Paraspinal muscle; Microdialysis
15.  Spinous process-splitting open pedicle screw fusion provides favorable results in patients with low back discomfort and pain compared to conventional open pedicle screw fixation over 1 year after surgery 
European Spine Journal  2012;21(4):745-753.
Introduction
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.
Methods
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.
Results
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.
Conclusion
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.
doi:10.1007/s00586-011-2146-2
PMCID: PMC3326135  PMID: 22237851
Posterior lumbar fusion; Multifidus muscle; Wiltse approach; Minimally invasive; Conventionally open
16.  Paraspinal Muscle Sparing versus Percutaneous Screw Fixation : A Prospective and Comparative Study for the Treatment of L5-S1 Spondylolisthesis 
Objective
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.
Methods
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.
Results
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.
Conclusion
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.
doi:10.3340/jkns.2011.49.3.163
PMCID: PMC3085812  PMID: 21556236
Spondylolisthesis; Paraspinal muscle sparing approach; Percutaneous screw fixation; Back pain
17.  Extent of intraoperative muscle dissection does not affect long-term outcomes after minimally invasive surgery versus open-transforaminal lumbar interbody fusion surgery: A prospective longitudinal cohort study 
Surgical Neurology International  2012;3(Suppl 5):S355-S361.
Background:
Minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) versus open TLIF, addressing lumbar degenerative disc disease (DDD) or grade I spondylolisthesis (DS), are associated with shorter hospital stays, decreased blood loss, quicker return to work, and equivalent short- and long-term outcomes. However, no prospective study has assessed whether the extent of intraoperative muscle trauma utilizing creatinine phosphokinase levels (CPK) differently impacts long-term outcomes.
Methods:
Twenty-one patients underwent MIS-TLIF (n = 14) versus open-TLIF (n = 7) for DDD or DS. Serum CPK levels were measured at baseline, and postoperatively (days 1, 7, and 1.5, 3 and 6 months). The correlation between the extent of intraoperative muscle trauma and two-year improvement in functional disability was evaluated (multivariate regression analysis). Additionally, baseline and two-year changes in Visual Analog Scale (VAS)-leg pain (LP), VAS-back pain (BP), Oswestry Disability Index (ODI), Short-Form-36 (SF-36) Physical Component Score (PCS) and SF-36 Mental Component Score (MCS), and postoperative satisfaction with surgical care were assessed.
Results:
Although the mean change from baseline in the serum creatine phosphokinase level on POD 1 was greater for MIS-TLIF (628.07) versus open-TLF (291.42), this did not correlate with lesser two-year improvement in functional disability. Both cohorts also showed similar two-year improvement in VAS-LP, ODI, and SF-36 PCS/MCS.
Conclusion:
Increased intraoperative muscle trauma unexpectedly observed in higher postoperative CPK levels for MIS-TLIF versus open-TLIF did not correlate with any differences in two-year improvement in pain and functional disability.
doi:10.4103/2152-7806.103868
PMCID: PMC3520077  PMID: 23248754
Long-term outcomes; minimally invasive transforaminal lumbar interbody fusion; Open-transforaminal lumbar interbody fusion; Serum creatine phosphokinase
18.  An investigation into the use of MR imaging to determine the functional cross sectional area of lumbar paraspinal muscles 
European Spine Journal  2005;15(6):764-773.
The purpose of this study was to investigate the use of magnetic resonance (MR) imaging and image processing software to determine the functional cross-sectional area (FCSA) (the area of muscle isolated from fat) of the lumbar paraspinal muscles. The measurement of the morphology of the lumbar paraspinal muscles has become the focus of several recent investigations into the aetiology of low back pain. However, the reliability and validity of determining the FCSA of the lumbar paraspinal muscles using MR imaging are yet to be reported. T2 axial MR scans at the L1-S1 spinal levels of six subjects were obtained using identical MR systems and scanning parameters. Lean paraspinal muscle, vertebral body bone and intermuscular fat were manually segmented using image analysis software to assign a grey scale range to the MR signal intensity emitted by each tissue type. The resultant grey scale range for muscle was used to determine FCSA measurements for each of the paraspinal muscles, psoas, quadratus lumborum, erector spinae and lumbar multifidus on each scan slice. As various biological, instrument and measurement factors can affect MR signal intensity, a sensitivity analysis was conducted to determine the error associated in calculating FCSA for paraspinal muscle using a discrete grey scale range. Cross-sectional area and FCSA measurements were repeated three times and reliability indices for the FCSA measurements were obtained, showing excellent reliability, intra class correlation coefficient (mean=0.97, range 0.90–0.99) and %SEM (mean=2.6%, range 0.7–4.8%). In addition, the error associated with miscalculation of the grey scale range for the MR signal intensity of muscle was calculated and found to be low with an error of 20 grey scale units at the upper end of the muscle’s grey scale range resulting in a very small error in the measured muscle FCSA. The method presented in this paper has a variety of practical applications in areas such as evidence-based rehabilitation, biomechanical modelling and the determination of segmental inertial parameters.
doi:10.1007/s00586-005-0909-3
PMCID: PMC3489434  PMID: 15895259
Lumbar spine; Magnetic resonance imaging; Cross sectional area; Low back pain; Muscle morphology
19.  Minimally Invasive Transforaminal Lumbar Interbody Fusion: A Perspective on Current Evidence and Clinical Knowledge 
Minimally Invasive Surgery  2012;2012:657342.
This paper reviews the current published data regarding open transforaminal lumbar interbody fusion (TLIF) in relation to minimally invasive transforaminal lumbar interbody fusion (MI-TLIF). Introduction. MI-TLIF, a modern method for lumbar interbody arthrodesis, has allowed for a minimally invasive method to treat degenerative spinal pathologies. Currently, there is limited literature that compares TLIF directly to MI-TLIF. Thus, we seek to discuss the current literature on these techniques. Methods. Using a PubMed search, we reviewed recent publications of open and MI-TLIF, dating from 2002 to 2012. We discussed these studies and their findings in this paper, focusing on patient-reported outcomes as well as complications. Results. Data found in 14 articles of the literature was analyzed. Using these reports, we found mean follow-up was 20 months. The mean patient study size was 52. Seven of the articles directly compared outcomes of open TLIF with MI-TLIF, such as mean duration of surgery, length of post-operative stay, blood loss, and complications. Conclusion. Although high-class data comparing these two techniques is lacking, the current evidence supports MI-TLIF with outcomes comparable to that of the traditional, open technique. Further prospective, randomized studies will help to further our understanding of this minimally invasive technique.
doi:10.1155/2012/657342
PMCID: PMC3420139  PMID: 22928099
20.  Treatment of multilevel degenerative lumbar spinal stenosis with spondylolisthesis using a combination of microendoscopic discectomy and minimally invasive transforaminal lumbar interbody fusion 
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.
doi:10.3892/etm.2012.812
PMCID: PMC3570089  PMID: 23403827
microendoscopic discectomy; minimally invasive transforaminal lumbar interbody fusion; posterior lumbar interbody fusion; lumbar spinal stenosis; lumbar spondylolisthesis
21.  Multifidus muscle changes and clinical effects of one-level posterior lumbar interbody fusion: minimally invasive procedure versus conventional open approach 
European Spine Journal  2009;19(2):316-324.
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.
doi:10.1007/s00586-009-1191-6
PMCID: PMC2899808  PMID: 19876659
Minimally invasive; Lumbar spine; Multifidus muscle; Interbody fusion
22.  Comparative study of PILF and TLIF treatment in adult degenerative spondylolisthesis 
European Spine Journal  2008;17(10):1311-1316.
This study is to compare the therapeutic effect of posterior lumbar interbody fusion (PLIF) and transforaminal lumbar interbody fusion (TLIF) with pedicle screw fixation on treatment in adult degenerative spondylolisthesis. A retrospective analysis of 187 patients to compare the complications and associated predictive factors of the two techniques of one level lumbar fusion. Ninety-one had PLIF with two cages and pedicle fixation (group 1), and ninety-six had TLIF with one cage and pedicle fixation (group 2). The two groups had similar age and sex distribution, and level of pain. Inclusion criteria and outcome measurements were identical in both groups. The two groups were operated on with autograft and cage with pedicle fixation. Before surgery and at the 2-year follow-up, pain (VAS) and functional disability (JOA) were quantified. The results showed there were no intraoperative deaths in our study. In the end 176 cases had 2-year follow-up while 11 cases were lost to follow-up. The follow-up rate was 93.4% (85/91) in the PLIF group and 94.8% (91/96) in the TLIF group. All patients had bone fusion, and there were no cases of cage extrusion. The pain index improved from 7.08 ± 1.13 to 2.84 ± 0.89 in PLIF patients and improved from 7.18 ± 1.09 to 2.84 ± 0.91 in TLIF patients (P < 0.001). There were 42 cases of excellent, 29 cases of good, 11 cases of general, and 3 cases of poor results in PLIF group. There were 46 cases of excellent, 31 case of good, 12 case of general, and 2 cases of poor results in TLIF group. The JOA score in all patients was 84.1% of good or excellent (83.5% in PLIF and 84.6% in TLIF, P > 0.05). The average preoperative slip was 30.1 ± 7.2% in PLIF group while in the TLIF it was 31.4 ± 8.3%. Immediately post operatively it was reduced to 7.3 ± 2.1% and 7.4 ± 2.7% and at last F/U it was 8.1 ± 2.8% and 8.2 ± 2.6%, respectively. The average of reduction rate was 75.2 ± 6.4% in PLIF and 75.4 ± 6.2 in TLIF on the initial post operatively X-ray, and 72.6 ± 5.2% and 72.4 ± 5.4% on the follow-up. The percentage rate, reduction rate and lost of reduction rate between the two groups was similar (P > 0.05). The average pre operative disk and foramen height in the PLIF group improved from 6.8 ± 2.3 and 14.2 ± 1.7 preoperatively to 11.6 ± 1.5 and 18.7 ± 1.8 post operatively, respectively. At last follow up there was minimal lost of correction down to 11.24 ± 1.2 and 18.1 ± 1.8, respectively. Similarly in the TLIF group, pre operative disk and foramen height were improved from 6.7 ± 1.7 and 14.1 ± 1.8 to 11.4 ± 1.6 and 18.5 ± 1.6 immediately post operative. At last follow up minimal lost of correction was noted with average disc height of 11.3 ± 1.4 and 18.2 ± 1.7. Both techniques achieve statistical significance in restoration of disc and foraminal (P < 0.01); however, there was no statistical difference between the two techniques. In conclusion, interbody fusion with either a PLIF technique or a TLIF technique provides good outcomes in the treatment of adult degenerative spondylolisthesis. The TLIF procedure is simpler and is as safe and effective as the PLIF technique.
doi:10.1007/s00586-008-0739-1
PMCID: PMC2556474  PMID: 18685873
Spondyolisthesis; Interverterbral fusion; Internal fixation
23.  Minimally invasive transforaminal lumbar interbody fusion 
Indian Journal of Orthopaedics  2014;48(6):562-567.
Background:
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.
Results:
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.
Conclusion:
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.
doi:10.4103/0019-5413.144217
PMCID: PMC4232824  PMID: 25404767
Degenerative spine; lumbar fusion; minimally invasive transforaminal lumbar interbody fusion; spondylolisthesis; Spinal arthritis; spondyloarthritis; spondylolisthesis; minimally invasive; spinal fusion
24.  Anterior Dislodgement of a Fusion Cage after Transforaminal Lumbar Interbody Fusion for the Treatment of Isthmic Spondylolisthesis 
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.
doi:10.3340/jkns.2013.54.2.128
PMCID: PMC3809439  PMID: 24175028
Cage; Transforaminal lumbar interbody fusion; Spondylolisthesis; Lumbosacral spine; Transitional vertebra
25.  Postoperative Changes in Paraspinal Muscle Volume: Comparison between Paramedian Interfascial and Midline Approaches for Lumbar Fusion 
Journal of Korean Medical Science  2007;22(4):646-651.
In this study, we compared the paramedian interfascial approach (PIA) and the traditional midline approach (MA) for lumbar fusion to determine which approach resulted in the least amount of postoperative back muscle atrophy. We performed unilateral transforaminal posterior lumbar interbody fusion via MA on the symptomatic side and pedicle screw fixation via PIA on the other side in the same patient. We evaluated the damage to the paraspinal muscle after MA and PIA by measuring the preoperative and postoperative paraspinal muscle volume in 26 patients. The preoperative and postoperative cross-sectional area, thickness, and width of the multifidus muscle were measured by computed tomography. The degree of postoperative paraspinal muscle atrophy was significantly greater on the MA side than on the contralateral PIA side (-20.7% and -4.8%, respectively, p<0.01). In conclusion, the PIA for lumbar fusion yielded successful outcomes for the preservation of paraspinal muscle in these 26 patients. We suggest that the success of PIA is due to less manipulation and retraction of the paraspinal muscle and further studies on this technique may help confirm whether less muscle injury has positive effects on the long-term clinical outcome.
doi:10.3346/jkms.2007.22.4.646
PMCID: PMC2693813  PMID: 17728503
Paraspinal Muscle; Paramedian Approach; Muscle Atrophy; Lumbar Spine

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