Minimally invasive 360° instrumented lumbar fusion

A retrospective preliminary study was undertaken of combined minimally invasive instrumented lumbar fusion utilizing the BERG (balloon-assisted endoscopic retroperitoneal gasless) approach ¶anteriorly, and a posterior small-incision approach with translaminar screw fixation and posterolateral ¶fusion. The study aimed to quantify the clinical and radiological results using this combined technique. The traditional minimally invasive approach to the anterior lumbar spine involves gas insufflation and provides reliable access only to L5-S1 and in some cases L4-5. A gas-mediated approach yields many technical drawbacks to performing spinal surgery. A minimally invasive posterior approach involving suprafascial pedicle screw instrumentation has been developed, but without widespread use. Translaminar facet fixation may be a viable alternative to transpedicular fixation in a 360° instrumented fusion model. Past studies have shown open 360° instrumented lumbar fusion yields high arthrodesis rates. The study examined the cases of 46 patients who underwent successful 360° instrumented lumbar fusion using a combined minimally invasive approach. Anterior lumbar interbody fusion (ALIF) at one or two levels was performed through the BERG approach; a gasless retroperitoneal approach to the lumbar spine allowing the use ¶of standard anterior instrumentation. Posteriorly, all patients underwent successful decompression, translaminar fixation, and posterolateral fusion at one or two levels through ¶one small (2.5-5.0 cm) incision. Results showed mean hospital stay of 2.02 days; mean combined blood loss was 255 cc; and mean pain relief was 56%, with 75.5% of patients reporting good, excellent, or total pain relief. Forty-two of 46 patients (93.2%) achieved a solid fusion ¶24 months after surgery. A total of 47% of all patients working prior to surgery returned to work following surgery. The study showed that minimally invasive 360° instrumented lumbar fusion, when performed utilizing these approaches, yields a high rate of solid arthrodesis (93.3%), good pain relief, short hospital stays, low blood losses, accelerated rehabilitation, and a quick return to the workforce. The BERG approach offers technical advantages over the traditional gas-mediated laparoscopic approach to the anterior lumbar spine.     

Do silver-impregnated dressings limit infections after lumbar laminectomy with instrumented fusion?

BACKGROUND: Silver has been used to reduce infection for centuries. This study retrospectively analyzed whether the introduction of silver-impregnated dressing (SD; Silverlon, Argentum Medical, LLC, Lakefront, GA) rather than RD (iodine- or alcohol-based swab and dry 4 x 4 gauze) would reduce the risk of superficial or deep infection after lumbar laminectomy with instrumented fusion. METHODS: The first 128 patients had RD applied postoperatively, whereas the second population of 106 patients received SD. These dressings were used for the first 2 weeks after surgery. Other clinical, surgical, and outcome data were comparable for both groups. RESULTS: Three of 128 patients who underwent multilevel laminectomies with instrumented fusions receiving RD developed deep postoperative wound infections (culture confirmed). All were successfully managed with 6 weeks of postoperative antibiotics, and none required secondary surgery. In addition, 11 patients who had RD developed superficial infection/irritation; 7 required oral antibiotics (7-10 days) alone, whereas 4 were referred to plastic surgeons for superficial wound revision. Alternatively, there were neither deep nor superficial wound infections/irritation among the 106 patients who received SD. Although the number of cases in each series was small, there appeared to be a positive trend toward a reduction in postoperative wound infection using SD. CONCLUSIONS: Use of SD for application on lumbar wounds after laminectomies with instrumented fusions appeared to limit/reduce the incidence of both postoperative deep and superficial wound infections.     

Minimally invasive lumbar decompression—indications,surgical techniques,and outcomes

The treatment of lumbar spinal stenosis, which afflicts millions of patients annually, has greatly evolved to include alternative surgical procedures other than a total laminectomy. Open decompressive procedures have led to satisfactory outcomes in randomized controlled trials; however, recent subgroup analyses have demonstrated complications from this approach. In the properly selected patient, a minimally invasive decompression, which preserves midline structures and limits soft tissue destruction, can improve upon these complications and lead to excellent clinical outcomes. The proper indications, techniques, and published outcomes of a minimally invasive lumbar decompression for spinal stenosis will be reviewed.     

Which procedure is better for lumbar interbody fusion: anterior lumbar interbody fusion or transforaminal lumbar interbody fusion?

Introduction

Both anterior lumbar interbody fusion (ALIF) and transforaminal lumbar interbody fusion (TLIF) surgeries are performed to obtain a solid fusion to treat lumbar spondylosis. This systematic review investigated whether surgical complications, nonfusion rate, radiographic outcome, and clinical outcome of ALIF were significantly different from those of TLIF.

Method

A computerized search of the electronic databases MEDLINE was conducted. Only therapeutic studies with a prospective or retrospective comparative design were considered for inclusion in the present investigation. Two reviewers independently extracted relevant data from each included study. Statistical comparisons were made when appropriate.

Results

Nine studies were determined to be appropriate for the systematic review, and all studies were retrospective comparative studies. Blood loss and operative time in ALIF was greater than in TLIF. There was no significant difference in the complication rate between ALIF and TLIF. The restoration of disc height, segmental lordosis, and whole lumbar lordosis in ALIF was superior to TLIF. However, clinical outcomes in ALIF were similar with TLIF, and there was no significant difference in nonfusion rate between the two techniques. Costs of ALIF were greater than those of TLIF.

Conclusion

Clinical outcomes and nonfusion rate in ALIF were similar to TLIF. However, the restoration of disc height, segmental lordosis, and whole lumbar lordosis in ALIF were superior to those in TLIF, while blood loss, operative time, and costs in ALIF were greater than in TLIF.     

One-stage posterior transforaminal lumbar debridement, 360° interbody fusion, and posterior instrumentation in treating lumbosacral spinal tuberculosis

Purpose

Retrospective analysis of the clinical study efficacy and feasibility of one-stage posterior transforaminal lumbar debridement, 360° interbody fusion, and posterior instrumentation in treating lumbosacral spinal tuberculosis.

Method

A total of 21 patients with lumbosacral tuberculosis (TB) collected from January 2004 to January 2010, underwent one-stage posterior transforaminal lumbar debridement, 360° interbody fusion, and posterior instrumentation. In addition, the clinical efficacy was evaluated based on the data on the lumbo-sacral angle, neuro-logical status that was recorded by American Spinal Injury Association (ASIA) Impairment Scale, erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP), which were collected at specific time points.

Results

All cases were followed up for 16–36 months (average 24.9 ± 6.44 months). 18 patients suffered from evident neurological deficits preoperatively, of which 16 patients returned to normal at the final follow-up. Two patients with neurological dysfunction aggravated postoperative, experienced significant partial neurological recovery. With an effective and standard anti-TB chemotherapy treated, the values of ESR and CRP returned to normal levels 3-month later postoperative and maintained till the final follow-up. Preoperative lumbosacral angle was 20.89 ± 2.32° and returned 29.62 ± 1.41° postoperative. During long-term follow-up, there was only 1–3° lumbosacral angle loss. There was a significant difference between preoperative and postoperative lumbosacral angles.

Conclusion

With effective and standard anti-TB chemotherapy, one-stage posterior transforaminal lumbar debridement, 360° interbody fusion, and posterior instrumentation for lumbosacral tuberculosis can effectively relieve pain symptoms, improve neurological function, and reconstruct the spinal stability.     

Is a drain tube necessary for minimally invasive lumbar spine fusion surgery?

Purpose

This study aimed to evaluate if closed suction wound drainage is necessary in minimally invasive surgery of transforaminal lumbar interbody fusion (MIS TLIF).

Methods

This is a prospective randomized clinical study. Fifty-six patients who underwent MIS TLIF were randomly divided into groups A (with a closed suction wound drainage) and B (without tube drainage). Surgical duration, intraoperative blood loss, timing of ambulation, length of hospital stay and complications were recorded. Patients were followed up for an average of 25.3 months. Clinical outcome was assessed using the Oswestry disability index and visual analogue scale (VAS). Fusion rate was classified with the Bridwell grading system, based on plain radiograph.

Results

Both groups had similar patient demographics. The use of drains had no significant influence on perioperative parameters including operative time, estimated blood loss, length of stay and complications. Patients in group B started ambulation 1 day earlier than patients in group A (p < 0.001). Clinical outcomes were comparable between group A and group B.

Conclusion

A drain tube can lead to pain, anxiety and discomfort during the postoperative period. We conclude that drain tubes are not necessary for MIS TLIF. Patients without drains had the benefit of earlier ambulation than those with drains.

     

Minimally invasive ventriculo-atrial shunt for hydrocephalus

ntriculo atrialshuntisnowconsideredasaneffectivetherapymethodinthetreatmentofhydrocephalus.1Classicprocedurerequiresthatthecatheterisinsertedintotheatriumviafacialcommonveinandinternaljugularvein .Thedeeplocationoffacialcommonveinmakesitimpossibletoexposeitatbodysurface ,henceleadingtovariationsorevendefect,2 whichcancauseseveredamagestotissuesandalargeincision .Whentheveincannotbefoundout ,andtheinternaljugularveinmustbeinvolved ,theremustbemoredifficultiesandhigherriskstotheoperationalcomple…     

Lumbar plexopathy following instrumented posterior lumbar interbody fusion: a complication with use of Hohmann’s retractor

Introduction

A series of 12 patients in our centre following single level instrumented posterior lumbar interbody fusion at L4–L5 developed unexplainable motor weakness in the proximal lumbar nerve roots (L2, L3) and numbness of the whole limb, a clinical picture resembling lumbar plexopathy. Even though lumbar plexopathy has been reported following gynaecological procedures and in transpsoas interbody fusion surgeries, there is no literature reporting this complication following conventional instrumented posterior lumbar interbody fusions.

Study design

Retrospective observational study.

Objective

To find the possible mechanism of development of lumbar plexopathy in patients who underwent posterior lumbar interbody fusion surgeries in our centre.

Material and methods

We analyzed retrospectively the medical records, electrophysiological reports of the patients, literatures on the anatomy of lumbar plexus and other literature reporting similar complications. We also dissected lumbar plexus of three cadavers and simulated surgical technique on them to find the mechanism of development of this unusual complication.

Results

We found injury to lumbar plexus that probably occurred intraoperatively with Hohmann’s retractor that was used for retraction of the paraspinal muscles. This theory was favoured by many clinical factors and further confirmed by cadaveric dissections.

Conclusion

We conclude that surgical technique with improper use of Hohmann’s retractor causes traction and compression injury to the lumbar plexus resulting in this complication. We propose proper technique of insertion of Hohmann’s retractor and also recommend use of modified Hohmann’s retractor with shorter tips for spinal procedures to prevent such complication.     

Minimally invasive approach to Boerhaave’s syndrome

Background: Boerhaave's syndrome requires urgent thoracotomy, laparotomy, or both for esophageal repair and pleuromediastinal debridement. Minimally invasive techniques may be suitable alternatives. Material and methods: Over a period of 12 months, three patients with spontaneous esophageal perforations after forceful vomiting were treated by a combination of minimally invasive techniques including laparoscopy, thoracoscopy, mediastinoscopy, and endoscopic stenting. Results: Esophageal repair was performed transhiatally via laparoscopy using primary suture, primary suture reinforced by a fundic patch, and fundic patch alone in one patient each. One patient had a second perforation of the proximal esophagus, which was sutured through a cervical incision. This patient successfully underwent secondary endoscopic stenting for a persistent esophageal fistula. Mediastinal debridement was performed transhiatally and also by means of a mediastinoscope introduced via the cervical incision in one patient. One patient required secondary thoracoscopic debridement of a pleural empyema but died of sepsis after 1 month. The two other patients recovered and were discharged from the hospital after 2 and 8 weeks, respectively. Conlusions: Boerhaave's syndrome is amenable to minimally invasive techniques. Avoidance of a formal thoracotomy with its resulting morbidity could be of considerable benefit to these critically ill patients.     

Does loss of spondylolisthesis reduction impact clinical and radiographic outcomes after minimally invasive transforaminal lumbar interbody fusion?

BACKGROUND CONTEXTMinimally invasive transforaminal lumbar interbody fusion (MI-TLIF) is a common operative approach to address degenerative lumbar stenosis and spondylolisthesis which has failed nonoperative care. Compared to open TLIF, MI-TLIF relies to a greater extent on indirect decompression resulting in a heightened awareness of spondylolisthesis reduction among MI surgeons. To what extent intraoperative reduction is achieved as well as the rate and clinical impact of loss or reduction and slip recurrence remain unknown.PURPOSETo determine the rate and clinical impact of slip recurrence after MI-TLIF with expandable cage technologySTUDY DESIGN/SETTINGRetrospective Cohort StudyPATIENT SAMPLEPatients undergoing MI-TLIF for degenerative spondylolisthesis using an articulating, expandable cageOUTCOME MEASURESPatient-reported outcome measures (PROMs), including the Oswestry Disability Index (ODI), visual analog scale (VAS) for back/leg pain, Short Form-12 (SF-12), and PROMIS Physical Function (PF)METHODSPatients undergoing MI-TLIF for degenerative spondylolisthesis using articulating, expandable cages from 2017 to 2019 were retrospectively studied. Lateral radiographs were reviewed and evaluated for the presence or absence of spondylolisthesis preoperatively, intraoperatively, and at follow-up times including 2 weeks, 6 weeks, 12 weeks, 6 months, and 1 year postoperatively. Spondylolisthesis was measured from the posterior inferior corner of the cephalad vertebra to the posterior superior corner of the caudal vertebra, with any measurement >1 mm classified as spondylolisthesis, and Meyerding grade was noted. Intraoperative reduction was measured, and loss of reduction was defined as >1 mm increase in spondylolisthesis comparing follow-up imaging to intraoperative films. PROMs were recorded at the preoperative and follow-up time points. Fusion was assessed at 1 year postoperatively via CT.RESULTSA total of 63 patients and 70 levels were included, with mean age 59.8 years (SD,13.8). 19 levels (27.1%) had complete reduction intraoperatively, 40 (57.1%) had partial reduction, and 11 (15.7%) had no reduction. Of the 30 levels with loss of reduction (50.8%), 20 (66.7%) occurred by 2 weeks postoperatively and 28 (93.3%) occurred by 12 weeks postoperatively. At 6 months, there were significant differences between those who had loss of reduction and those who did not in VAS back pain (3.0 vs. 0.9, p = .017) and SF-12 PCS (41.5 vs. 50.0, p = .035), but no differences were found between the groups for any instruments at any other time points. The overall fusion rate was 82.1% (32/39) at 1 year postoperatively. There was no significant difference in fusion rate between the loss of reduction (16/20) and no loss of reduction (20/23) groups. Patients with loss of reduction had no difference in reoperation rate (1/28) compared to those without loss of reduction (2/24).CONCLUSIONSWhile a majority of patients demonstrated reduction intraoperatively, 51% had loss of reduction, most commonly in the acute postoperative period. There were few differences in PROMs between patients who had loss of reduction and those who did not, suggesting that radiographic loss of reduction after MI-TLIF in the setting of degenerative spondylolisthesis may not be clinically meaningful.     

Lateral decubitus single position anterior–posterior (AP) fusion shows equivalent results to minimally invasive transforaminal lumbar interbody fusion at one-year follow-up

European Spine Journal - This study compares perioperative and 1-year outcomes of lateral decubitus single position circumferential fusion (L-SPS) versus minimally invasive transforaminal lumbar...     

Minimally invasive partial fasciectomy for Dupuytren’s contractures

Background

Numerous options exist for the treatment of Dupuytren’s contracture. This study describes the technique and early results of partial fasciectomy through a mini-incision approach as an additional treatment option for Dupuytren’s disease.

Methods

This procedure involves the excision of diseased Dupuytren’s tissue with the use of multiple 1 cm transverse incisions. Patient demographics, digit involvement, the number of incisions required to release each digit, and complications were recorded for all patients. Range of motion data was obtained from a subgroup of patients that had at least 6 months of follow-up. A paired t test was used to compare preoperative and postoperative contracture.

Results

Sixty-seven patients underwent 75 procedures that involved 119 digits. The mean patient age at the time of surgery was 63 years (range, 33–95 years). A total of 32 digits (47 joints) were available for range of motion analysis. After a mean of 2.2 years following surgery, metacarpophalangeal joint contractures maintained correction (34° preoperatively, 19° postoperatively, p = 0.008). After a mean postoperative duration of 2.0 years, proximal interphalangeal joint contractures trended worse than preoperative levels (39° preoperatively, 45° postoperatively, p = 0.319). There was one major complication, which consisted of a nerve laceration that was identified and repaired intraoperatively.

Conclusions

Partial fasciectomy through the described mini-incision approach provides an additional surgical option for patients who desire a less invasive surgical procedure than traditional fascietomy. Although this procedure is safe and effective at achieving immediate cord release, maintenance of correction for proximal interphalangeal joint contractures remains problematic.     

Is the use of minimally invasive fusion technologies associated with improved outcomes after elective interbody lumbar fusion? Analysis of a nationwide prospective patient-reported outcomes registry

Background Context

Over the last decade, clinical investigators and biomedical industry groups have used significant resources to develop advanced technologies that enable less invasive spine fusions. These minimally invasive surgery (MIS) technologies often require increased expenditures by hospitals and payers. Although several small single center studies have suggested MIS technologies decrease surgical morbidity and reduce hospital stay, evidence documenting benefit from a patient perspective remains limited. Furthermore, MIS outcomes have yet to be evaluated from the perspective of multiple practice types representing the broad spectrum of US spine surgery.

Is laparoscopic approach to lumbar spine fusion worthwhile?

BACKGROUND: Laparoscopic lumbar spine fusion has been recently described. The aim of this study is to evaluate the safety and efficacy of this procedure for single- and multiple-level degenerative disc disease. METHODS: Twenty-four consecutive laparoscopic interbody lumbar fusions were evaluated prospectively (18 single-level were compared with 6 multiple-level procedures). Results of the laparoscopic multiple-level procedures were further compared with 12 open multiple-level operations. RESULTS: Twenty procedures were completed laparoscopically. The conversions were related to iliac vein lacerations (3 cases) and a mesenteric tear. Single-level cases had lower morbidity (22% versus 83%), shorter hospital stay (2 versus 10 days), and higher fusion rate (88% versus 50%) than multiple-level procedures. Overall results in the latter group were worse than in the matched open group. CONCLUSIONS: Laparoscopic single-level fusion (L5-S1) is safe and carries the benefits of minimal access surgery. Morbidity after multiple level approach is high, and this procedure cannot be advocated at this time.     

微创腰椎360°固定术

目的评估微创腰椎360°固定术的疗效。方法从2002年5月至2005年5月,应用微创腰椎360°固定术治疗患者25例,其中男11例,女14例;年龄45~67岁,平均56岁。腰椎滑脱16例,其中Ⅰ度13例、Ⅱ度3例;腰椎不稳7例;椎间盘源性腰痛2例。行L4,5节段融合14例,L5~S111例。功能评估采用Oswestry D isab ility Index(OD I),统计患者术前、术后2周、3、6、12个月的OD I评分。术后即刻、3、6、12个月摄X线片,观察椎体的融合情况和融合器(cage)有无下沉。结果手术时间从110~180 m in。术中发生1例下腔静脉破裂出血。术后全部病例获得随访,随访时间12~35个月,平均22.3个月。OD I评分手术前为34.15±5.17,术后2周为43.27±10.43,术后3个月为46.14±6.85,术后6个月为44.97±3.65,术后12个月为46.38±4.48,与术前相比有显著差异(P<0.05)。25例植骨手术后3个月融合。1例患者术后3个月X线片显示相邻椎体滑移2 mm,6个月时融合。2例患者发生椎间高度丢失1 mm。无一例发生内置物松动、滑落及逆向射精等并发症。结论微创腰椎360°固定术适用于腰椎不稳、局限节段椎间盘变性及Ⅱ度以下腰椎滑脱伴神经根管狭窄患者。手术出血少、损伤小,但操作时应特别注意大血管的暴露和牵开。