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.
Journal of military pharmaco-medicine THE 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 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 176 Journal of military pharmaco-medicine SUBJECTS AND METHODS 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 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 - Single level lumbar spondylolisthesis RESULTS AND DISCUSSION * Exclusion criteria: - The patients with grade III and IV spondylolisthesis - More than one level spondylolisthesis - Severe osteoporosis 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 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 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 Surgical outcomes * Improved postoperative VAS, ODI and IH: Table 1: Perioperative change of VAS, ODI and IH Mean ± SD p-value Pre op months 12 months 18 months 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 ODI (%) 52.48 ± 8.07 21.94 ± 4.79 14.96 ± 2.72 11.24 ± 3.35 < 0.001 IH (mm) 6.97 ± 2.20 11.37 ± 0.61 11.35 ± 0.67 11.30 ± 0.66 < 0.001 177 Journal of military pharmaco-medicine Table 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 followup 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 (%) months 12 months 18 months Grade 56.7 84.8 100.0 Grade 33.3 13.0 0.0 Grade 10.0 2.2 0.0 Table showed that fusion rate was observed radiologically in 90% at 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 months, 87.5% at 12 months and 100% at the final follow-up, study by Kepler [6], 178 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% Clinical outcome with Macnab Table 3: Postoperative outcomes with Macnab Clinical outcomes with Macnab (%) months 12 months 18 months Excellent 40.3 82.6 91.9 Good 53.2 13.0 5.4 Fair 6.5 4.4 2.7 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 - 14 months (average 11 months) The clinical results were excellent in 16 cases, good in 22 cases and fair in 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% 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 Journal of military pharmaco-medicine Two patients (3.2%) developed superficial surgical site infections and were successfully treated with antibiotics; one case had nerve root injury (1.6%) Lee H.J, Kim J.S, Ryu K.S Minimally invasive TLIF using unilateral approach and single cage at single level in patients over 65 BioMed Research International 2016, pp.1-10 Rosenberg [11] conducted the study on 22 patients with grade or 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] Kepler C.K, Rihn J.A, Radcliff K.E Restoration of lordosis and disk height after single-level transforaminal lumbar interbody fusion Orthopaedic Surgery 2012, (1), pp.15-20 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 REFERENCES Harms J, Rolinger H A one-stage procedure in operative treatment of spondylolisthesis: Dorsal traction-reposition and anterior fusion J Orthop 1982, 120, pp.343-347 Foley K.T, Holly L.T, Schwender J.D Minimally invasive lumbar fusion Spine 2003, 28, S26-S35 Chang K.L, Jeong Y.P, Ho Y.Z Minimally invasive transforaminal lumbar interbody fusion using a single interbody cage and a tubular retraction system: Technical Tips and Perioperative, Radiologic and Clinical Outcomes J Korean Neurosurg Soc 2010, 48, pp.219-224 Praveen V.M, Gerald E.R The miniopen transforaminal lumbar interbody fusion Neurosurgery 2005, 57, pp.256-261 Bevevino A.J, Kang D.G, Lehman R.A Systematic review and meta-analysis of minimally invasive transforaminal lumbar interbody fusion rates performed without posterolateral fusion Journal of Clinical Neuroscience 2014, 21, pp.1686-1690 Gu G.F, Zhang H.L, He S.S The clinical results of minimally invasive transforaminal lumbar interbody fusion for lumbar spinal stenosis with lumbar instability Zhonghua Wai Ke Za Zhi 2011, 49 (12), pp.1081-1085 Sakeb N., Ahsan K Comparison of the early results of transforaminal lumbar interbody fusion and posterior lumbar interbody fusion in symptomatic lumbar instability Indian J Orthop 2013, 47, pp.255-236 10 Torres J, James A, Alimi M Screw placement accuracy for minimally invasive transforaminal lumbar interbody fusion surgery: A study on 3-D neuronavigationguided surgery Global Spine J 2012, 2, pp.143-152 11 Rosenberg W.S, Mummaneni P.V Transforaminal lumbar interbody fusion: Technique, complications, and early results Neurosurgery 2001, 48, pp.569-574 12 McGirt M.J, Parker S.L, Lerner J Comparative analysis of perioperative surgical site infection after minimally invasive versus open posterior/transforaminal lumbar interbody fusion: analysis of hospital billing and discharge data from 5.170 patients J Neurosurg Spine 2011, 14, pp.771-778 179 ... Restoration of lordosis and disk height after single- level transforaminal lumbar interbody fusion Orthopaedic Surgery 2012, (1), pp.15-20 CONCLUSION Mini-open TLIF is a safe and effective method for. .. invasive transforaminal lumbar interbody fusion for lumbar spinal stenosis with lumbar instability Zhonghua Wai Ke Za Zhi 2011, 49 (12), pp.1081-1085 Sakeb N., Ahsan K Comparison of the early... Sakeb N., Ahsan K Comparison of the early results of transforaminal lumbar interbody fusion and posterior lumbar interbody fusion in symptomatic lumbar instability Indian J Orthop 2013, 47, pp.255-236