Objectives: To evaluate clinical, radiological outcomes of mini-open transforaminal lumbar interbody fusion (TLIF) for treatment of lumbar spondylolisthesis. Subjects and methods: A prospective study included 62 patients with mini-open TLIF. Clinical outcomes were assessed using Oswestry Disability Index (ODI), Visual Analogue Scores (VAS) and Macnab. Intervertebral height and fusion status were evaluated on CT-scanner.
Trang 1THE MINI-OPEN TRANSFORAMINAL LUMBAR INTERBODY
FUSION FOR TREATMENT OF SINGLE LEVEL
SPONDYLOLISTHESIS
Pham Vo Ky*; Vu Van Hoe**
Nguyen Hung Minh**; Nguyen Van Hung**
SUMMARY
Objectives: To evaluate clinical, radiological outcomes of mini-open transforaminal lumbar interbody fusion (TLIF) for treatment of lumbar spondylolisthesis Subjects and methods: A prospective study included 62 patients with mini-open TLIF Clinical outcomes were assessed using Oswestry Disability Index (ODI), Visual Analogue Scores (VAS) and Macnab Intervertebral height and fusion status were evaluated on CT-scanner Results: Sixty-two patients underwent mini-open TLIF The average age was 48.85 years The mean follow-up period was 18.31 months Operation time was 157.34 min and estimated blood losses were 158.55 mL VAS back was significantly improved from 6.98 to 1.27, VAS leg from 7.24 to 1.11, ODI from 52.48 to 11.24 (p < 0.001) Macnab: exellent (91.9%), good (5.4%) and fair (2.7%) The fusion rate was 100% at the final follow-up Postoperative intervertebral height was significantly improved from 6.97 to 11.30 (p < 0.001) Conclusions: Mini-open TLIF is a safe and effective method for achieving good clinical outcomes and high fusion rates This procedure is particularly useful in restoring intervertebral height
* Keywords: Transforaminal lumbar interbody fusion; Mini-open; Spondylolisthesis
INTRODUCTION
In 1982, Harms and Rolinger [1]
described the open transforaminal lumbar
interbody fusion (TLIF) technique The
advantages of the TLIF procedure include
the circumferential fusion via a single
posterolateral approach, less retraction of
the thecal sac and nerve root, lower
incidence of neural injury
The traditional open TLIF causes vascular
and neurologic damage of the lumbar
muscles On the other hand, minimally
invasive approaches can be used to
diminish soft-tissue injury In 2003, Foley [2] first introduced minimally invasive TLIF (MI-TLIF) The advantages of MI-TLIF include reduced blood loss, less postoperative pain, and earlier ambulation It has become extensively used in the treatment of lumbar spondylolisthesis all over the world [3, 4] However, minimally invasive TLIF has not yet become common in Vietnam The aim
of this study was to evaluate clinical, radiological outcomes of mini-open TLIF for treatment of lumbar spondylolisthesis
* Kiengiang Hospital
** 103 Military Hospital
Corresponding author: Pham Vo Ky (phamvoky9999@gmail.com)
Date received: 06/06/2017 Date accepted: 15/08/2017
Trang 2SUBJECTS AND METHODS
1 Sbjects
From April, 2012 to December, 2016,
sixty-two patients underwent mini-open
TLIF for single level lumbar spondylolisthesis
at Kiengiang General Hospital
* Inclusion criteria:
- The patients with meyerding grade I
and II spondylolisthesis that evident on
plain radiography; patient with a significant
neurological deficits or failed to respond
to conservative treatment
- Single level lumbar spondylolisthesis
* Exclusion criteria:
- The patients with grade III and IV
spondylolisthesis
- More than one level spondylolisthesis
- Severe osteoporosis
2 Methods
* Study design: A prospective study
* Surgical procedure: Decompression
and mini-open TLIF with Caspar retractor
system
* Assessment of results: The radiographic
follow-up was evaluated at the time of
6 months, 12 months and the last follow-up Clinical outcomes were assessed using Oswestry Disability Index (ODI), Visual Analogue Scores (VAS) and Macnab Intervertebral height (IH) and fusion status were assessed on CT-scanner Postoperative complications such as dura tear, nerve root injury, infection were recorded
* Statistical analysis: All statistical
analyses were performed using SPSS 16.0 software for Windows (SPSS, Inc.,
Chicago IL) A p-value < 0.05 was
considered to be statistically significant
RESULTS AND DISCUSSION
1 Demographic characteristics of the patients
A total of 62 patients (23 males and 39 females) with average age of 48.85 years (ranged from 20 - 73 years) were treated
with surgical fixation, neural decompression
and mini-open TLIF with Caspar retractor system All patients were followed up for
at least 6 months with a mean follow-up of 18.31 ± 12.54 months Operation time was 157.34 mins and estimated blood losses were 158.55 mL
2 Surgical outcomes
* Improved postoperative VAS, ODI and IH:
Table 1: Perioperative change of VAS, ODI and IH
VAS
Back
Leg
6.98 ± 0.78 7.24 ± 1.07
1.97 ± 0.44 1.15 ± 0.40
1.33 ± 0.47 0.85 ± 0.47
1.27 ± 0.45 1.11 ± 0.39
< 0.001
< 0.001
Trang 3Table 1 showed perioperative change
of VAS, ODI and IH VAS back and leg
were significantly improved at the final
follow-up, from 6.98 ± 0.78 to 1.27 ± 0.45
and from 7.24 ± 1.07 to 1.11 ± 0.39,
respectively (both p < 0.001) ODI was
significantly improved at the final
follow-up from 52.48 ± 8.07 to 11.24 ± 3.35
(p < 0.001) IH was significantly increased
from 6.97 ± 2.20 mm to 11.30 ± 0.66 mm
postoperatively (p < 0.001)
In the study by Lee [5] on 38 patients
with MI-TLIF who were followed for a
mean of 15.5 months, recognized that
ODI was significantly improved at the final
follow-up, from 44.59 ± 11.9 to 21.5 ±
15.18 Back and leg pain were improved
from 4.24 ± 1.85 to 0.71 ± 0.76 and from
6.79 ± 1.28 to 0.86 ± 1.21 at the final
follow-up Kepler [6] showed preoperative
IH averaged 5.3 mm Postoperative IH
averaged 10.3 mm at immediate
postoperative and 9.8 mm at the final
follow-up That was indirect foraminal
decompression with distraction across the
disk space IH reconstruction is important
for achieving good surgical results
* Fusion status:
Table 2: Fusion rate
Postoperative fusion rate (%)
Table 2 showed that fusion rate was
observed radiologically in 90% at 6
months and 97.8% at 12 months after
surgery and 100% at the final follow-up In
Lee’s study [5], fusion was 64.71% at 6
months, 87.5% at 12 months and 100% at
the final follow-up, study by Kepler [6],
forty-five patients who had undergone a single-level TLIF procedure, follow-up averaged 21.2 months Final follow-up 96% of patients had achieved spinal fusion
A systematic review and meta-analysis of minimally invasive transforaminal lumbar interbody fusion rates, Bevevino [7] showed that overall fusion rate, confirmed
by bridging trabecular interbody bone on CT-scanner was 94.7%
3 Clinical outcome with Macnab
Table 3: Postoperative outcomes with
Macnab
Clinical outcomes with Macnab (%)
The excellent and good outcomes with Macnab in this study were 97.3% at the final follow-up
Gu’s retrospective study [8] was done
on 42 patients with MI-TLIF, followed for 6
- 14 months (average 11 months) The clinical results were excellent in 16 cases, good in 22 cases and fair in 4 cases to the Macnab criteria at the final follow-up
In Sakeb’s study [9], fifty cases underwent TLIF The clinical results with excellent and good were 96% Torres [10] carried out a retrospective review on 52 patients who had MIS-TLIF with mean clinical follow-up
of 11.3 months Excellent/good Macnab outcomes were recorded for 84.6%
4 Complications
Four perioperative complications were recorded, representing a complication rate
of 6.4% (4/62) There was one dural tear (1.6%), which was repaired intraoperatively
Trang 4Two patients (3.2%) developed superficial
surgical site infections and were successfully
treated with antibiotics; one case had
nerve root injury (1.6%)
Rosenberg [11] conducted the study
on 22 patients with grade 1 or 2
spondylolisthesis who underwent
transforaminal lumbar interbody fusion
There was one intraoperative complication
with dura tear (4.5%) McGirt’s study on
848 patients with MI-TLIF, the author
recognized that the incidence of surgical
site infection was 4.5% Risk of surgical
site infection increases due to the
extended operation time and tissue
damage, increased blood loss, and foreign
materials in the interbody space [12]
CONCLUSION
Mini-open TLIF is a safe and effective
method for achieving good clinical
outcomes with low complication and high
fusion rates This procedure is particularly
useful in restoring intervertebral height
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