Minimally Invasive Spine Lumbar Surgery in Obese Patients: A Systematic Review and Meta-Analysis

Background

Transforaminal lumbar interbody fusion (TLIF) is the treatment of choice for lumbar spinal stenosis and spondylolisthesis. The procedure can be performed through a traditional open approach (O-TLIF) or through minimally invasive techniques (MI-TLIF). Spinal surgeries in obese patients can pose risks, including increased rates of infection and thromboembolic events.

Questions/Purposes

We sought to systematically review the literature on the differences between MI-TLIF and O-TLIF in the obese patient in terms of complication rate, functional outcomes, blood loss, and length of hospital stay.

Methods

We used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to systematically search PubMed, Embase, Web of Science, and the Cochrane Library for studies published through February 2019 and identified those comparing the outcomes of O-TLIF and MI-TLIF in obese patients. The primary outcome was complication rate (total, infections, dural tears); secondary outcomes were blood loss, length of hospital stay, and functional scores. Two authors independently reviewed the studies using the Newcastle-Ottawa Scale, and data were pooled using the Mantel-Haenszel random-effects model.

Results

In the sample of 430 patients, the average age was 53.5 years, there were 153 men and 203 women, and the average body mass index was 33.6. Complications were significantly higher in O-TLIF than in MI-TLIF (OR?=?0.420 [95% CI: 0.199, 0.887]; I²?=?45.20%). No difference was detected between the two groups for visual analog scale back pain scores and Oswestry Disability Index scores between the pre-operative and last follow-up visits (SMD?=?–0.034 [95% CI –0.695, 0.627]; I²?=?62.14% and SMD?=?0.617 [95% CI: –1.082, 2.316]; I²?=?25%, respectively). Blood loss was significantly lower in MI-TLIF compared to O-TLIF (SMD?=?–426.736 [95% CI: –490.720, –362.752]; I²?=?70.53%), as was the duration of hospital stay (SMD?=?–1.079 [95% CI: –1.591, –0.208]; I²?=?84.3%).

Conclusion

MI-TLIF has equivalent efficacy to O-TLIF in obese patients at long-term follow-up. In addition, complication rate, blood loss, and length of hospital stay were lower in MI-TLIF than in O-TLIF.

     

Learning Curve With Minimally Invasive Unicompartmental Knee Arthroplasty

This study examined 445 consecutive minimally invasive unicompartmental knee arthroplasties (UKAs) from one institution to determine whether revision and reoperation rates would decrease as the number of cases performed increased, indicating the presence of a learning curve with this procedure. At a mean of 3.25 years, 26 knees required revision yielding an overall revision rate of 5.8%; survivorship at 2 years with revision as an end point was 96% ± 1.7%. Both revisions and reoperations decreased over time but not significantly. For the first half of UKA cases performed vs the second half, revision rates fell from 5.0% to 2.5%, and reoperation rates fell from 8.1% to 5.4%. These data demonstrate that despite modifications made to improve surgical technique across time, a substantial complication rate with this procedure persists.     

Perioperative Surgical Complications and Learning Curve Associated with Minimally Invasive Transforaminal Lumbar Interbody Fusion: A Single-Institute Experience

BackgroundAs surgical complications tend to occur more frequently in the beginning stages of a surgeon''s career, knowledge of perioperative complications is important to perform a safe procedure, especially if the surgeon is a novice. We sought to identify and describe perioperative complications and their management in connection with minimally invasive transforaminal lumbar interbody fusion (TLIF).MethodsWe performed a retrospective chart review of our first 124 patients who underwent minimally invasive TLIF. The primary outcome measure was adverse events during the perioperative period, including neurovascular injury, implant-related complications, and wound infection. Pseudarthroses and adjacent segment pathologies were not included in this review. Adverse events that were not specifically related to spinal surgery and did not affect recovery were also excluded.ResultsPerioperative complications occurred in 9% of patients (11/124); including three cases of temporary postoperative neuralgia, two deep wound infections, two pedicle screw misplacements, two cage migrations, one dural tear, and one grafted bone extrusion. No neurologic deficits were reported. Eight complications occurred in the first one-third of the series and only 3 complications occurred in the last two-thirds of the series. Additional surgeries were performed in 6% of patients (7/124); including four reoperations (two for cage migrations, one for a misplaced screw, and one for an extruded graft bone fragment) and three hardware removals (one for a misplaced screw and two for infected cages).ConclusionsWe found perioperative complications occurred more often in the early period of a surgeon''s experience with minimally invasive TLIF. Implant-related complications were common and successfully managed by additional surgeries in this series. We suggest greater caution should be exercised to avoid the potential complications, especially when surgeon is a novice to this procedure.     

Management of Distal Fibular Fractures With Minimally Invasive Technique: A Systematic Review

Ankle fractures are extremely common, with isolated distal fibular fractures being the most common variant. The current gold standard in treating unstable distal fibular fractures is open reduction internal fixation. However, with potential risk of wound complications, minimally invasive techniques have been introduced. This systematic review was performed to evaluate the clinical and functional outcomes of varying minimally invasive techniques including minimally invasive plate osteosynthesis, intramedullary (IM) nailing, and IM screw fixation. A comprehensive English literature search on PubMed was performed yielding 543 studies. With specific study selection criteria, a total of 13 articles were selected. After studying the reference of each of the 13 studies, an additional 7 articles were included, resulting in a total of 20 studies reviewed. A total of 8 articles reviewed used IM nailing as the fixation of choice with a total of 211 patients. Of the 211 patients, 33 experienced complications. Six articles using minimally invasive plate osteosynthesis were reviewed with a total of 264 patients. Of the 264 patients, 39 experienced complications. IM screw fixation was used in 6 articles reviewed with a total of 219 patients. There were 30 cases of complications from the 132 patients. Additionally, mean American Orthopedic Foot and Ankle Society hindfoot-ankle scores among all fixation types was 88.4 ± 3.40 whereas the mean Olerud and Molander Score among all fixation types was 76.7 ± 16.58. The results of this study indicate that minimally invasive techniques for fixation of distal fibular fractures can provide excellent functional results with low complication rates compared with traditional open reduction internal fixation.     

Comparative Outcomes of Minimally Invasive Surgery for Posterior Lumbar Fusion: A Systematic Review

Background

Although minimally invasive surgical (MIS) approaches to the lumbar spine for posterior fusion are increasingly being utilized, the comparative outcomes of MIS and open posterior lumbar fusion remain unclear.

Questions/purposes

In this systematic review, we compared MIS and open transforaminal or posterior lumbar interbody fusion (TLIF/PLIF), specifically with respect to (1) surgical end points (including blood loss, surgical time, and fluoroscopy time), (2) clinical outcomes (Oswestry Disability Index [ODI] and VAS pain scores), and (3) adverse events.

Methods

We performed a systematic review of MEDLINE^®, Embase, Web of Science, and Cochrane Library. Reference lists were manually searched. We included studies with 10 or more patients undergoing MIS compared to open TLIF/PLIF for degenerative lumbar disorders and reporting on surgical end points, clinical outcomes, or adverse events. Twenty-six studies of low- or very low-quality (GRADE protocol) met our inclusion criteria. No significant differences in patient demographics were identified between the cohorts (MIS: n = 856; open: n = 806).

Results

Equivalent operative times were observed between the cohorts, although patients undergoing MIS fusion tended to lose less blood, be exposed to more fluoroscopy, and leave the hospital sooner than their open counterparts. Patient-reported outcomes, including VAS pain scores and ODI values, were clinically equivalent between the MIS and open cohorts at 12 to 36 months postoperatively. Trends toward lower rates of surgical and medical adverse events were also identified in patients undergoing MIS procedures. However, in the absence of randomization, selection bias may have influenced these results in favor of MIS fusion.

Conclusions

Current evidence examining MIS versus open TLIF/PLIF is of low to very low quality and therefore highly biased. Results of this systematic review suggest equipoise in surgical and clinical outcomes with equivalent rates of intraoperative surgical complications and perhaps a slight decrease in perioperative medical complications. However, the quality of the current literature precludes firm conclusions regarding the comparative effectiveness of MIS versus open posterior lumbar fusion from being drawn and further higher-quality studies are critically required.     

Complications of Minimally Invasive Surgery and Their Management

Minimally invasive surgery, including both traditional laparoscopic and robot-assisted laparoscopic approaches, has increasingly become the standard of care for urologic abdominal and pelvic surgery. This is a comprehensive review of the contemporary literature regarding complications of laparoscopic and robotic urologic surgery. The review highlights pertinent studies with the goal of providing the minimally invasive urologic surgeon with an up-to-date overview of general and procedure-specific complications and their management.     

The Registration of Complications in Surgery: A Learning Curve

Registration of complications in surgery is an important method used for quality improvement. Unfortunately many different definitions and classification systems have been used, which influences the interpretation and the outcome of complication registration. Since 1986 complications have been registered on a daily basis in our surgical department. We focus in this article on the influence of changes in interpretation of the definition and registration methods used on the incidence of registered complications. Between 1986 and 1993 complications registered were strictly related to surgical procedures. In the second period, between 1993 and 2001, the interpretation of the definition changed and all adverse events were registered in a patient-centred way, not only related to the surgical procedure. The definition used in both periods did not change. In 1993 we started with the implementation of a fully automated registration system in our surgical department. In the first period 1699 (7%) complications in 24,201 surgical procedures were registered and in the second period 8335 (27%) complications were registered in 31,161 surgical procedures. A dramatic increase in the total number of registered complications was seen with the implementation of a fully automated registration system and a patient-centred way of registering complications. In the context of the evolving discussion of quality of care, a uniform definition and registration system has to be used to assure reliable outcome data in surgery and to form a basis for comparison.     

Systematic Review of Minimally Invasive Pancreatic Resection

Background  Pancreatic resection is associated with a significant morbidity. Efforts to reduce hospital stay and enhance recovery have seen the introduction of minimally invasive surgical techniques. This article reviews the current published literature on the safety and efficacy of minimally invasive surgery of the pancreas. Methods  An electronic search of the PubMed and Embase databases was performed from 1996 to May 2008 to identify all relevant publications; studies meeting predefined inclusion criteria were retrieved and analyzed using a standardized protocol. Data on the safety and efficacy of minimally invasive surgery of the pancreas were recorded and analyzed. Results  Of 565 abstracts reviewed, 39 studies were identified as eligible for inclusion. There were 37 case series and two case control studies. Compared with open pancreatic surgery, minimally invasive pancreatic resection is similar in terms of morbidity and mortality. Blood loss and length of stay are decreased. Conclusions  Laparoscopic distal pancreatic resection and enucleation of insulinoma appear to be safe procedures with reduced hospital stay, though morbidity remains significant. The evidence for laparoscopic pancreaticoduodenectomy is in its infancy, but the authors feel it is unlikely that many centers will achieve sufficient case load to make the introduction of minimally invasive resection feasible.