Minimally invasive versus open transforaminal lumbar interbody fusion: comparison of clinical outcomes among obese patients

Abstract

<jats:sec> <jats:title>Object</jats:title> <jats:p>Minimally invasive (MI) transforaminal lumbar interbody fusion (TLIF) has been demonstrated in previous studies to offer improvement in pain and function comparable to those provided by the open surgical approach. However, comparative studies in the obese population are scarce, and it is possible that obese patients may respond differently to these two approaches. In this study, the authors compared the clinical benefit of open and MI TLIF in obese patients.</jats:p></jats:sec> <jats:sec> <jats:title>Methods</jats:title> <jats:p>The authors conducted a retrospective cohort study based on review of electronic medical records at a single institution. Eligible patients had a body mass index (BMI) ≥ 30 kg/m<jats:sup>2</jats:sup>, were ≥ 18 years of age, underwent single-level TLIF between 2007 and 2011, and outcome was assessed at a minimum 6 months postoperatively. The authors categorized patients according to surgical approach (open vs MI TLIF). Outcome measures included postoperative improvement in visual analog scale (VAS), Oswestry Disability Index (ODI), estimated blood loss (EBL), and hospital length of stay (LOS).</jats:p></jats:sec> <jats:sec> <jats:title>Results</jats:title> <jats:p>A total 74 patients (21 open and 53 MI TLIF) were studied. Groups had similar baseline characteristics. The median BMI was 34.4 kg/m<jats:sup>2</jats:sup> (interquartile range 31.6–37.5 kg/m<jats:sup>2</jats:sup>). The mean follow-up time was 30 months (range 6.5–77 months). The mean improvement in VAS score was 2.8 (95% CI 1.9–3.8) for the open group (n = 21) and 2.4 (95% CI 1.8–3.1) for the MI group (n = 53), which did not significantly differ (unadjusted, p = 0.49; adjusted, p = 0.51). The mean improvement in ODI scores was 13 (95% CI 3–23) for the open group (n = 14) and 15 (95% CI 8–22) for the MI group (n = 45), with no significant difference according to approach (unadjusted, p = 0.82; adjusted, p = 0.68). After stratifying by BMI (&lt; 35 kg/m<jats:sup>2</jats:sup> and ≥ 35 kg/m<jats:sup>2</jats:sup>), there was still no difference in either VAS or ODI improvement between the approaches (both unadjusted and adjusted, p &gt; 0.05). Complications and EBL were greater for the open group than for the MI group (p &lt; 0.05).</jats:p></jats:sec> <jats:sec> <jats:title>Conclusions</jats:title> <jats:p>Obese patients experienced clinically and statistically significant improvement in both pain and function after undergoing either open or MI TLIF. Patients achieved similar clinical benefit whether they underwent an open or MI approach. However, patients in the MI group experienced significantly decreased operative blood loss and complications than their counterparts in the open group.</jats:p></jats:sec>

Perioperative outcomes in minimally invasive lumbar spine surgery: A systematic review

“…Although EBL differences across randomized studies did not reach clinically meaningful levels of ≥ 750 mL, one of the randomized studies did find a significantly 1002 WJO|www.wjgnet.com [43] 168. [44] 159.2 ± 21.7 142.8 ± 22.5 399.8 ± 125.8 517.0 ± 147.8 0% 0% 9.3 ± 2.6 12.5 ± 1.8 Wang et al [45] 139.0 ± 27.0 143.0 ± 35.0 291.0 ± 86.0 652.0 ± 150.0 12% 19% --Cohort studies Wong et al [46] 173 309 115 485 12% 13% 2.8 4.4 Zhang et al [47] 120 ± 35 115 ± 28 250 ± 75 650 ± 150 0% 3% --Villavicencio et al [48] 223 ± 68 215 ± 60 163 ± 131 367 ± 298 11% 13% 3.0 ± 2.3 4.2 ± 3.5 Lee et al [49] 166 ± 52 182 ± 45 161 ± 51 447 ± 519 1% 0% 3.2 ± 2.9 6.8 ± 3.4 Terman et al [50] --100 450 --2.0 3.0 Cheng et al [51] 245 ± 73 279 ± 15 393 ± 284 536 ± 324 0% 12% 4.8 ± 1.8 6.1 ± 1.8 Liang et al [52] 127 ± 60 96 ± 46 194 ± 86 357 ± 116 ----Yang et al [53] 175 ± 35 177 ± 30 362 ± 177 720 ± 171 7% 2% 4.0 ± 1.3 7.1 ± 1.0 Gu et al [54] 196 ± 28 187 ± 23 248 ± 94 576 ± 176 5% 3% 9.3 ± 3.7 12.1 ± 3.6 Wang et al [55] 145 ± 27 156 ± 32 264 ± 89 673 ± 145 10% 7% 10.6 ± 2.5 14.6 ± 3.8 Zairi et al [56] 170 186 148 486 3% 3% 4.5 5.5 Seng et al [57] 185 ± 9 166 ± 7 127 ± 46 405 ± 80 ----Pelton et al [58] 112 ± 33 185 ± 34 125 ± 76 275 ± 99 --2.0 ± 0.7 3.0 ± 1.1 Singh et al [59] 116 ± 28 186 ± 31 124 ± 92 380 ± 191 --2.3 ± 1.2 2.9 ± 1.1 Brodano et al [60] 144 102 230 620 3% 9% 4.1 7.4 Zou et al [61] 150 ± 41 175 ± 37 131 ± 74 318 ± 177 0% 0% 7.5 ± 2.7 9.3 ± 4.2 Peng et al [62] 216 171 150 681 --4.0 6.7 Archavlis et al [63] 220 ± 48 190 ± 65 185 ± 140 255 ± 468 13% 4% 7.0 11.0 Dhall et al [64] 199 237 194 505 0% 5% 3.0 5.5 Schizas et al [65] --456 961 17% 6% 6.1 8.2 Adogwa et al [66] 300 210 200 295 0% 0% 3.0 5.0 Niesche et al [67] 140 130 150 380 0% 11% 5.0 10.0 Lau et al [68] reduced transfusion need between MIS and open TLIF [44] . LOS was found to be significantly reduced in MIS TLIF by almost three days, however all of the studies originated from Chinese hospitals.…”

“…Although decompressive lumbar laminectomy is a relatively straightforward spinal operation, there exists a steep learning curve associated with microscopeassisted tubular spinal surgery [68] , which could be one important factor accounting for the differences in operative times between the two techniques. With the growing popu larity of minimally invasive approaches and the growing number of younger surgeons performing minimally 1001 WJO|www.wjgnet.com [43] 2011 TLIF LSS, herniation, spondylolisthesis 41 38 Shunwu et al [44] 2010 TLIF Degenerative lumbar disease 32 30 Wang et al [45] 2011 TLIF Failed discectomy and decompression 25 27 Cohort studies Wong et al [46] 2014 TLIF FBSS, DDD, spondylolisthesis 144 54 Zhang et al [47] 2013 TLIF DDD 82 76 Villavicencio et al [48] 2010 TLIF LSS, DDD ± herniation, spondylolisthesis 76 63 Lee et al [49] 2012 TLIF LSS, DDD, herniation, spondylolisthesis 72 72 Terman et al [50] 2014 TLIF DDD, LSS, spondylolisthesis, herniation 53 21 Cheng et al [51] 2013 TLIF Spondylosis/listhesis, foraminal stenosis 50 25 Liang et al [52] 2011 TLIF Degenerative lumbar instability 45 42 Yang et al [53] 2013 TLIF Lumbar degenerative diseases 43 104 Gu et al [54] 2014 TLIF Degenerative conditions 43 38 Wang et al [55] 2010 TLIF Spondylolisthesis 42 43 Zairi et al [56] 2013…”

Standard versus Minimally Invasive Transforaminal Lumbar Interbody Fusion: A Prospective Randomized Study

“…Wong et al [10] compared 144 MI TLIF with 54 standard TLIF patients and found statistically significant benefits for MI TLIF in operating room time, blood loss, primary infection rates, secondary medical complications, LOS, transfusion need, hospital costs, short-term and long-term pain outcomes, and short-term and long-term ODI scores. Terman et al [8] retrospectively reviewed his results at a single institution in obese patients undergoing MI TLIF ( n = 53) and S TLIF ( n = 21) and concluded that both procedures had good results, similar to those in nonobese patients. Other studies with fewer patients enrolled had results generally favoring the MI TLIF technique.…”

The effect of obesity on patient-reported outcome measures after minimally invasive transforaminal lumbar interbody fusion

“…Initial studies comparing open TLIF to MI-TLIF in obese patients have demonstrated comparable short-term outcomes regarding pain relief and functional improvement [19,20]. Furthermore, MI-TLIF has been reported to be associated with either decreased or equivalent rates of perioperative complications when compared to open TLIF [21][22][23].…”