Influence of Surgical Experience on the Efficiency of Discectomy in TLIF

Pumberger, Matthias; Hughes, Alexander P.; Girardi, Federico P.; Gogia, Jaspaul; Kotwal, Suhel; Thaler, Christoph; Sama, Andrew A.

doi:10.1097/bsd.0b013e318260dd0b

Cited by 10 publications

(10 citation statements)

References 10 publications

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“…Pumberger et al, in two separate cadaveric studies, also found that the posterior contralateral quadrant was the most difficult disc quadrant to prepare in a unilateral TLIF [14,15]. Although there was no difference in disc removed from the anterior ipsilateral quadrant compared with the posterior ipsilateral quadrant in the open approach, the MIS approach was slightly less effective at removing disc from the anterior ipsilateral quadrant compared with the posterior ipsilateral quadrant.…”

Section: Discussionmentioning

confidence: 96%

Disc Space Preparation in Transforaminal Lumbar Interbody Fusion: A Comparison of Minimally Invasive and Open Approaches

Rihn

Gandhi

Sheehan

et al. 2014

Clinical Orthopaedics &Amp; Related Research

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Background Minimally invasive surgical (MIS) approaches to transforaminal lumbar interbody fusion (TLIF) have been developed as an alternative to the open approach. However, concerns remain regarding the adequacy of disc space preparation that can be achieved through a minimally invasive approach to TLIF.Questions/purposes The purpose of this cadaver study is to compare the adequacy of disc space preparation through MIS and open approaches to TLIF. Specifically we sought to compare the two approaches with respect to (1) the time required to perform a discectomy and the number of endplate violations; (2) the percentage of disc removed; and (3) the anatomic location where residual disc would remain after discectomy. Methods Forty lumbar levels (ie, L1-2 to L5-S1 in eight fresh cadaver specimens) were randomly assigned to open and MIS groups. Both surgeons were fellowship-trained spine surgeons proficient in the assigned approach used. Time required for discectomy, endplate violations, and percentage of disc removed by volume and mass were recorded for each level. A digital imaging software program (ImageJ; US National Institutes of Health, Bethesda, MD, USA) was used to measure the percent disc removed by area for the total disc and for each quadrant of the endplate. Results The open approach was associated with a shorter discectomy time (9 versus 12 minutes, p = 0.01) and fewer endplate violations (one versus three, p = 0.04) when compared with an MIS approach, percent disc removed by volume (80% versus 77%, p = 0.41), percent disc removed by mass (77% versus 75%, p = 0.55), and percent total disc removed by area (73% versus 71%, p = 0.63) between the open and MIS approaches, respectively. The posterior contralateral quadrant was associated with the lowest percent of disc removed compared with the other three quadrants in both open and MIS groups (50% and 60%, respectively). Conclusions When performed by a surgeon experienced with MIS TLIF, MIS and open approaches are similar in regard to the adequacy of disc space preparation. The least amount of disc by percentage is removed from the posterior

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Section: Discussionmentioning

confidence: 96%

Disc Space Preparation in Transforaminal Lumbar Interbody Fusion: A Comparison of Minimally Invasive and Open Approaches

Rihn

Gandhi

Sheehan

et al. 2014

Clinical Orthopaedics &Amp; Related Research

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“…Pumberger et al, in 2 separate cadaveric studies, also found that the posterior-contralateral quadrant was the most difficult disc quadrant to prepare in a unilateral TLIF. 7,8 The study by Rihn et al had a substantially better endplate preparation rate than the current study, reporting an overall endplate preparation rate of 73% by surface area. 9 Our results were more consistent with those reported by Tatsumi et al, 10 who found a much lower preparation rate of 39.2% that was more consistent with our study.…”

Section: Discussionmentioning

confidence: 44%

An in vitro study examining a novel suction curette device for lumbar discectomy compared with standard manual discectomy

Lavelle

Ordway

Araghi

et al. 2017

SPI

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OBJECTIVE This purpose of this study was to objectively evaluate and assess the efficacy and efficiency of discectomy and endplate preparation during transforaminal lumbar interbody fusion (TLIF) using traditional manual instrumentation versus a novel suction discectomy curette. Transforaminal lumbar interbody fusion is the most widely used approach for lumbar arthrodesis, and its success depends on the ability to achieve fusion. Complete preparation of intervertebral disc space (removal of the nucleus, endplate cartilage, and margin of inner annulus) is the surgical goal. Performing an adequate discectomy requires numerous instrument passes, increasing surgical time and the risk of complications. METHODS Four experienced spinal surgeons performed transforaminal discectomies from T-12 to S-1 on 5 whole-body cadavers. Each level (n = 26) was randomly assigned to either a control group using traditional instruments (12 levels) or to a suction curette group (14 levels). The time required to perform the discectomy and the number of passes through the annulus were recorded. Motion segments were dissected and analyzed by digital photogrammetric analysis. The intervertebral disc and the discectomy cross-sectional areas were measured on both superior and inferior images of each dissected surgical level. Areas were divided into 4 quadrants based on a midsagittal and midcoronal axis and analyzed for regional efficiency. In addition, a cross-sectional area of bony endplate (the area still covered with cartilage) and an area of endplate perforation were evaluated. RESULTS There was no significant difference in surgical time between the techniques (7:51 ± 2:43 minutes in the manual discectomy [MD] group and 7:06 ± 3:33 minutes in the suction curette discectomy [SD] group). There were significantly fewer (p < 0.01) instrument passes in the SD group (13 passes) compared with the MD group (43 passes). For both techniques, the amount of disc removed depended upon the anatomical region, with the posterior-contralateral side having the least amount of disc material removed. There was significantly less (p < 0.01) disc material removed in the MD group (38%) compared with the SD group (48%). The amount of disc material removed was significantly more (p < 0.05) in each quadrant when comparing the SD and MD groups, with the anterior regions showing the largest difference. For both techniques, the preparation of the endplate within the discectomy area resulted in a mostly cartilaginous interface (50% MD, 48% SD); a smaller amount of bony interface area (31% MD, 38% SD); and a smaller amount of perforation to the interface area (19% MD, 13% SD). There were no significant differences between the groups in terms of endplate preparation. CONCLUSIONS The improved discectomy observed with the suction curette device could potentially improve the clinical fusion rate.

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“…Microscopic observation indicated that the veins around the nerve roots were well protected or coagulated, which further prevented blood loss. Therefore, blood loss in MMI-TLF patients (42 ml) was reduced, in comparison with values reported for MI-TLIF (81.5 ml) [26]. This represents an advantage over MI-TLIF and should be further explored in future studies.…”

Section: Resultsmentioning

confidence: 73%

Modified minimally invasive transforaminal lumbar interbody fusion using a trans-multifidus approach: a safe and effective alternative to open-TLIF

Zhang

Shang

et al. 2015

J Orthop Surg Res

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BackgroundApplication of minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) is limited by long fluoroscopy time and a steep learning curve. Herein, MI-TLIF was modified using a trans-multifidus approach, assisted by microscope, termed MMI-TLIF, and the clinical outcomes of MMI-TLIF and open-TLIF were compared.MethodsForty-nine patients treated with MMI-TLIF were matched with 49 subjects who underwent open-TLIF. Patients were assessed using the North American Spine Society Score (NASS), Oswestry Disability Index (ODI), Short Form-36 (SF-36), and Visual Analogue Score (VAS) before surgery and during follow-up (6 months and 2 years). The four-type Bridwell anterior fusion grading system was used to evaluate fusion rates at 2 years.ResultsThe median fluoroscopic time did not differ significantly between the MMI-TLIF and open-TLIF groups. MMI-TLIF surgery took significantly longer than open-TLIF (91.3 vs. 82.5 min; P < 0.05). Meanwhile, MMI-TLIF patients lost significantly less blood than open-TLIF patients (75.3 vs. 215.2 ml; P < 0.05), and MMI-TLIF patients were hospitalized for less long than open-TLIF patients (3.7 vs. 6.9 days; P < 0.05) and reported less pain, faster ambulation, and lower morphine intake than open-TLIF patients (all P < 0.05). The NASS, ODI, VAS, and SF-36 scores were significantly improved 6 months and 2 years postsurgery in both groups, compared with preoperative values, and similar values were obtained for both groups. Finally, fusion rates were similar in MMI-TLIF and open-TLIF patients.ConclusionsOverall, these findings strongly suggest the superiority of MMI-TLIF to open-TLIF. Therefore, MMI-TLIF could be a safe and effective alternative to MI-TLIF and open-TLIF.

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Influence of Surgical Experience on the Efficiency of Discectomy in TLIF

Abstract: Our results demonstrate that a satisfactory discectomy may be performed by surgeons with relatively less surgical experience in the transforaminal approach using a powered discectomy device.

Cited by 10 publications

References 10 publications

Disc Space Preparation in Transforaminal Lumbar Interbody Fusion: A Comparison of Minimally Invasive and Open Approaches

Disc Space Preparation in Transforaminal Lumbar Interbody Fusion: A Comparison of Minimally Invasive and Open Approaches

An in vitro study examining a novel suction curette device for lumbar discectomy compared with standard manual discectomy

Modified minimally invasive transforaminal lumbar interbody fusion using a trans-multifidus approach: a safe and effective alternative to open-TLIF

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