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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.  The Multiple Benefits of Minimally Invasive Spinal Surgery: Results Comparing Transforaminal Lumbar Interbody Fusion and Posterior Lumbar Fusion 
Minimally invasive transforaminal lumbar interbody fusion (TLIF) offers equivalent postoperative fusion rates compared to posterior lumbar fusion (PLF) and minimizes the amount of iatrogenic injury to the spinal muscles. The objective of this study was to examine the difference in pain perception, stress, mood disturbance, quality of life, and immunological indices throughout the perioperative course among patients undergoing TLIF and PLF. A prospective, nonrandomized descriptive design was used to evaluate these measures among patients undergoing TLIF (n = 17) or PLF (n = 18) at 1 week prior to surgery (T1), the day of surgery (T2), 24 hours postoperatively (T3), and 6 weeks postoperatively (T4). Among TLIF patients, pain, stress, fatigue, and mood disturbance were significantly decreased at the 6-week follow-up visit (T4) compared to patients who underwent PLF. The TLIF group also demonstrated significantly higher levels (near baseline) of CD8 cells atT4 than the PLF group. Interleukin-6 levels were significantly higher in the TLIF group as well, which may be an indicator of ongoing nerve regeneration and healing. Knowledge concerning the effect of pain and the psychological experience on immunity among individuals undergoing spinal fusion can help nurses tailor interventions to improve outcomes, regardless of the approach used.
PMCID: PMC3714401  PMID: 18330408
3.  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
4.  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
5.  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
6.  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
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.  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
9.  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
10.  AxiaLIF system: minimally invasive device for presacral lumbar interbody spinal fusion 
Lumbar fusion is commonly performed to alleviate chronic low back and leg pain secondary to disc degeneration, spondylolisthesis with or without concomitant lumbar spinal stenosis, or chronic lumbar instability. However, the risk of iatrogenic injury during traditional anterior, posterior, and transforaminal open fusion surgery is significant. The axial lumbar interbody fusion (AxiaLIF) system is a minimally invasive fusion device that accesses the lumbar (L4–S1) intervertebral disc spaces via a reproducible presacral approach that avoids critical neurovascular and musculoligamentous structures. Since the AxiaLIF system received marketing clearance from the US Food and Drug Administration in 2004, clinical studies of this device have reported high fusion rates without implant subsidence, significant improvements in pain and function, and low complication rates. This paper describes the design and approach of this lumbar fusion system, details the indications for use, and summarizes the clinical experience with the AxiaLIF system to date.
doi:10.2147/MDER.S23606
PMCID: PMC3417883  PMID: 22915939
AxiaLIF; fusion; lumbar; minimally invasive; presacral
11.  Minimally Invasive Transforaminal Lumbar Interbody Fusion with Unilateral Pedicle Screw Fixation: Comparison between Primary and Revision Surgery 
BioMed Research International  2014;2014:919248.
Minimally invasive surgery with a transforaminal lumbar interbody fusion (MIS TLIF) is an important minimally invasive fusion technique for the lumbar spine. Lumbar spine reoperation is challenging and is thought to have greater complication risks. The purpose of this study was to compare MIS TLIF with unilateral screw fixation perioperative results between primary and revision surgeries. This was a prospective study that included 46 patients who underwent MIS TLIF with unilateral pedicle screw. The patients were divided into two groups, primary and revision MIS TLIF, to compare perioperative results and complications. The two groups were similar in age, sex, and level of operation, and were not significantly different in the length of follow-up or clinical results. Although dural tears were more common with the revision group (primary 1; revision 4), operation time, blood loss, total perioperative complication, and fusion rates were not significantly different between the two groups. Both groups showed substantial improvements in VAS and ODI scores one year after surgical treatment. Revision MIS TLIF performed by an experienced surgeon does not necessarily increase the risk of perioperative complication compared with primary surgery. MIS TLIF with unilateral pedicle screw fixation is a valuable option for revision lumbar surgery.
doi:10.1155/2014/919248
PMCID: PMC4053265  PMID: 24949483
12.  Minimally invasive versus open transforaminal lumbar interbody fusion: evaluating initial experience 
International Orthopaedics  2008;33(6):1683-1688.
The aim of this study was to compare our experience with minimally invasive transforaminal lumbar interbody fusion (MITLIF) and open midline transforaminal lumbar interbody fusion (TLIF). A total of 36 patients suffering from isthmic spondylolisthesis or degenerative disc disease were operated with either a MITLIF (n = 18) or an open TLIF technique (n = 18) with an average follow-up of 22 and 24 months, respectively. Clinical outcome was assessed using the visual analogue scale (VAS) and the Oswestry disability index (ODI). There was no difference in length of surgery between the two groups. The MITLIF group resulted in a significant reduction of blood loss and had a shorter length of hospital stay. No difference was observed in postoperative pain, initial analgesia consumption, VAS or ODI between the groups. Three pseudarthroses were observed in the MITLIF group although this was not statistically significant. A steeper learning effect was observed for the MITLIF group.
doi:10.1007/s00264-008-0687-8
PMCID: PMC2899194  PMID: 19023571
13.  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
14.  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
15.  Minimally invasive one-level lumbar decompression and fusion surgery with posterior instrumentation using a combination of pedicle screw fixation and transpedicular facet screw construct 
Background:
Minimally invasive lumbar spine fusion surgery has gained popularity in recent years. Routinely, this technique requires bilateral parasagittal incisions for decompression, interbody fusion, and posterior instrumentation. The following study is a description of a new minimally invasive technique for one-level transforaminal lumbar interbody fusion (TLIF) using a unilateral parasagittal incision (Wiltse approach), with placement of pedicle screws and then a percutaneous transpedicular facet screw insertion on the contralateral side. The biomechanical stability of this posterior construct will be discussed while the efficacy and complications of this technique have been examined.
Methods:
Forty patients underwent this new technique of one-level TLIF with posterior instrumentation using unilateral pedicle screw fixation supplemented with contralateral percutaneous transpedicular facet screw construct. Data regarding surgical time, estimated blood loss (EBL), hospital length of stay (LOS), and complications related to the posterior instrumentation are recorded.
Results:
The average surgical time of this new procedure was 124 minutes; average EBL was 140 cc; average hospital LOS was 3 days. Two patients developed new leg pain on the side where the facet screw had been placed. Both patients had the facet screw removed.
Conclusion:
This novel technique of unilateral pedicle screw fixation combined with contralateral percutaneous transpedicular facet screw construct has further reduced the amount of normal tissue injury while maintaining the same biomechanical advantages of bilateral pedicle screw fixation. However, caution is needed during the placement of the percutaneous facet screw in order to avoid nerve root injury.
doi:10.4103/2152-7806.119007
PMCID: PMC3814991  PMID: 24255796
Minimally invasive spine surgery; percutaneous facet screw; transforaminal interbody fusion; Wiltse approach
16.  Durotomy repair in minimally invasive transforaminal lumbar interbody fusion by nonpenetrating clips 
Background:
Closure of the dura defect may be easy to perform in open lumbar surgery but could be difficult in minimally invasive transforaminal lumbar interbody fusions (MIS-TLIF) since MIS-TLIF was done through a small tube, which limited the use of standard dural repair instruments. We used nonpenetrating titanium clips that were originally designed for the vascular anastomoses to repair the dura defect, which is never described in the literature.
Methods:
We presented a case of spinal stenosis with incidental durotomy while performing MIS-TLIF. We closed the dura laceration with three medium-sized nonpenetrating titanium clips (AnastoClip Vessel Closure System, LeMaitre Vascular, Inc., Burlington, MA).
Results:
Nonpenetrating titanium clips have the benefits of being technically easy to use, reduced durotomy repair time, decreased bed rest due to related medical complications, superior postoperation with immediate hydrostatic strength, and better reapproximation if it fails to clip successfully. As for the postoperation follow up, clips are tiny and reveal no obvious artifact, especially in cases where the pedicle screws are already causing much artifact.
Conclusion:
Primary dural closure during MIS-TLIF with clips is an effective way in cases that involve limited tubular space.
doi:10.4103/2152-7806.129161
PMCID: PMC4014817  PMID: 24818043
Durotomy; minimally invasive lumbar fusion; nonpenetrating titanium clips
17.  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
18.  Complications in patients undergoing combined transforaminal lumbar interbody fusion and posterior instrumentation with deformity correction for degenerative scoliosis and spinal stenosis 
Background:
Utilization of the transforaminal lumbar interbody fusion (TLIF) approach for scoliosis offers the patients deformity correction and interbody fusion without the additional morbidity associated with more invasive reconstructive techniques. Published reports on complications associated with these surgical procedures are limited. The purpose of this study was to quantify the intra- and postoperative complications associated with the TLIF surgical approach in patients undergoing surgery for spinal stenosis and degenerative scoliosis correction.
Methods:
This study included patients undergoing TLIF for degenerative scoliosis with neurogenic claudication and painful lumbar degenerative disc disease. The TLIF technique was performed along with posterior pedicle screw instrumentation. The average follow-up time was 30 months (range, 15–47).
Results:
A total of 29 patients with an average age of 65.9 years (range, 49–83) were evaluated. TLIFs were performed at 2.2 levels on average (range, 1–4) in addition to 6.0 (range, 4–9) levels of posterolateral instrumented fusion. The preoperative mean lumbar lordosis was 37.6° (range, 16°–55°) compared to 40.5° (range, 26°–59.2°) postoperatively. The preoperative mean coronal Cobb angle was 32.3° (range, 15°–55°) compared to 15.4° (range, 1°–49°) postoperatively. The mean operative time was 528 min (range, 276–906), estimated blood loss was 1091.7 mL (range, 150–2500), and hospitalization time was 8.0 days (range, 3–28). A baseline mean Visual Analog Scale (VAS) score of 7.6 (range, 4–10) decreased to 3.6 (range, 0–8) postoperatively. There were a total of 14 (49%) hardware and/or surgical technique related complications, and 8 (28%) patients required additional surgeries. Five (17%) patients developed pseudoarthrosis. The systemic complications (31%) included death (1), cardiopulmonary arrest with resuscitation (1), myocardial infarction (1), pneumonia (5), and pulmonary embolism (1).
Conclusion:
This study suggests that although the TLIF approach is a feasible and effective method to treat degenerative adult scoliosis, it is associated with a high rate of intra- and postoperative complications and a long recovery process.
doi:10.4103/2152-7806.92933
PMCID: PMC3307239  PMID: 22439116
Adult scoliosis; complications; degenerative spine; lumbar stenosis; transforaminal lumbar interbody fusion
19.  Clinical and radiological outcome of anterior–posterior fusion versus transforaminal lumbar interbody fusion for symptomatic disc degeneration: a retrospective comparative study of 133 patients 
European Spine Journal  2009;18(2):203-211.
Abundant data are available for direct anterior/posterior spine fusion (APF) and some for transforaminal lumbar interbody fusion (TLIF), but only few studies from one institution compares the two techniques. One-hundred and thirty-three patients were retrospectively analyzed, 68 having APF and 65 having TLIF. All patients had symptomatic disc degeneration of the lumbar spine. Only those with one or two-level surgeries were included. Clinical chart and radiologic reviews were done, fusion solidity assessed, and functional outcomes determined by pre- and postoperative SF-36 and postoperative Oswestry Disability Index (ODI), and a satisfaction questionnaire. The minimum follow-up was 24 months. The mean operating room time and hospital length of stay were less in the TLIF group. The blood loss was slightly less in the TLIF group (409 vs. 480 cc.). Intra-operative complications were higher in the APF group, mostly due to vein lacerations in the anterior retroperitoneal approach. Postoperative complications were higher in the TLIF group due to graft material extruding against the nerve root or wound drainage. The pseudarthrosis rate was statistically equal (APF 17.6% and TLIF 23.1%) and was higher than most published reports. Significant improvements were noted in both groups for the SF-36 questionnaires. The mean ODI scores at follow-up were 33.5 for the APF and 39.5 for the TLIF group. The patient satisfaction rate was equal for the two groups.
doi:10.1007/s00586-008-0845-0
PMCID: PMC2899330  PMID: 19125304
Symptomatic lumbar disc degeneration; Anterior–posterior fusion; Transforaminal lumbar interbody fusion
20.  Minimally invasive transforaminal lumber interbody fusion and degenerative lumbar spine disease 
European Spine Journal  2012;21(11):2300-2305.
Objective
The purpose of this study was to assess the clinical and radiological outcomes of minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) surgery for degenerative lumbar spine disease.
Methods
A prospective analysis of 34 consecutive patients who underwent a MI-TLIF using image guidance between July 2008 and November 2010. The patient group comprised 19 males and 15 females (mean age 56), 23 of whom had undergone additional reduction of spondylolisthesis. All patients underwent post-operative CT imaging to assess pedicle screw, cage placement and fusion at 6 months. Oswestry Disability Index (ODI) scores were recorded pre-operatively and at 6-month follow up.
Results
33/34 (97.1 %) patients showed evidence of fusion at 6 months with a mean improvement of 27 on ODI scores. The mean length of hospital stay was 4 days. The mean operative time was 173 min.
Complications observed
1/34 (2.9 %) suffered a pulmonary embolism and 1/34 (2.9 %) patients developed transient nerve root pain post-operatively. There were no occurrences of infection and no post-operative CSF leaks.
Conclusion
MI-TLIF offers patients a safe and effective surgical treatment option to treat degenerative lumbar spine disease.
doi:10.1007/s00586-012-2376-y
PMCID: PMC3481093  PMID: 22692557
Transforaminal lumbar interbody fusion; Minimally invasive spine surgery
21.  Surgical Outcomes of Minimally Invasive Transforaminal Lumbar Interbody Fusion for the Treatment of Spondylolisthesis and Degenerative Segmental Instability 
Asian Spine Journal  2011;5(4):228-236.
Study Design
This is a retrospective case study.
Purpose
This study was designed to analyze the surgical outcomes of patients who underwent minimally invasive transforaminal lumbar interbody fusion (TLIF) for the treatment of spondylolisthesis and degenerative segmental instability.
Overview of Literature
If the surgical outcomes of a procedure are evaluated together with multiple indications, it is not clear how the procedure helped each subgroup of patients. For the reason that some indications achieve better outcomes than the others, we performed a subgroup analysis using validated outcome measures to demonstrate the optimal indications and the treatment results of TLIF.
Methods
We conducted subgroup analyses by comparing the prospectively collecting data from the consecutive patients who underwent single-level minimally invasive TLIF for the treatment of the following 3 subgroups of indications: 23 cases of low-grade spondylolytic spondylolisthesis, 24 cases of degenerative spondylolisthesis, and 19 cases of degenerative segmental instability.
Results
The average duration of follow up was 36.1 ± 9.9 months (range, 24 to 63 months). The preoperative pain and disability scores were significantly improved at final postoperative follow-up in all the subgroups (all measurements: p < 0.0001). The 3 subgroups exhibited an equivalent improvement of the pain and disability scores at the final follow-up. The rates of radiographic solid fusion and complications were also similar among the 3 groups.
Conclusions
Our data suggests that minimally invasive TLIF optimally and equivalently alleviates all of the associated symptoms and disabilities from low-grade spondylolisthesis and degenerative segmental instability. Furthermore, these patients seem to have optimal surgical indications for minimally invasive TLIF, while maintaining favorable surgical outcomes.
doi:10.4184/asj.2011.5.4.228
PMCID: PMC3230650  PMID: 22164317
Spondylolisthesis; Transforaminal lumbar interbody fusion; Minimally invasive; Surgical outcome; Optimal indication
22.  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
23.  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
24.  Comparison of low back fusion techniques: transforaminal lumbar interbody fusion (TLIF) or posterior lumbar interbody fusion (PLIF) approaches 
The authors review and compare posterior lumbar interbody fusion (PLIF) with transforaminal lumbar interbody fusion (TLIF). A review of the literature is performed wherein the history, indications for surgery, surgical procedures with their respective biomechanical advantages, potential complications, and grafting substances are presented. Along with the technical advancements and improvements in grafting substances, the indications and use of PLIF and TLIF have increased. The rate of arthrodesis has been shown to increase given placement of bone graft along the weight-bearing axis. The fusion rate across the disc space is further enhanced with the placement of posterior pedicle screw–rod constructs and the application of an osteoinductive material. The chief advantages of the TLIF procedure compared with the PLIF procedure included a decrease in potential neurological injury, improvement in lordotic alignment given graft placement within the anterior column, and preservation of posterior column integrity through minimizing lamina, facet, and pars dissection.
doi:10.1007/s12178-009-9053-8
PMCID: PMC2697340  PMID: 19468868
Posterior lumbar interbody fusion; Transforaminal lumbar interbody fusion; Degenerative disc disease; Low back pain; History; Fusion; Complications
25.  Comparison of low back fusion techniques: transforaminal lumbar interbody fusion (TLIF) or posterior lumbar interbody fusion (PLIF) approaches 
The authors review and compare posterior lumbar interbody fusion (PLIF) with transforaminal lumbar interbody fusion (TLIF). A review of the literature is performed wherein the history, indications for surgery, surgical procedures with their respective biomechanical advantages, potential complications, and grafting substances are presented. Along with the technical advancements and improvements in grafting substances, the indications and use of PLIF and TLIF have increased. The rate of arthrodesis has been shown to increase given placement of bone graft along the weight-bearing axis. The fusion rate across the disc space is further enhanced with the placement of posterior pedicle screw–rod constructs and the application of an osteoinductive material. The chief advantages of the TLIF procedure compared with the PLIF procedure included a decrease in potential neurological injury, improvement in lordotic alignment given graft placement within the anterior column, and preservation of posterior column integrity through minimizing lamina, facet, and pars dissection.
doi:10.1007/s12178-009-9053-8
PMCID: PMC2697340  PMID: 19468868
Posterior lumbar interbody fusion; Transforaminal lumbar interbody fusion; Degenerative disc disease; Low back pain; History; Fusion; Complications

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