Superior Facet Joint Violations in Single Level Minimally Invasive and Open Transforaminal Lumbar Interbody Fusion: A Comparative Study

Abstract

To compare the incidence of iatrogenic superior facet joint violation (SFV) in minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) and open TLIF (OPEN-TLIF) at a single lower lumbar fusion level and to evaluate the patient and surgical factors influencing the outcome. Overview of Literature: Iatrogenic SFV is a significant risk factor for adjacent segment disease (ASD). Blind screw placement technique in MIS-TLIF contributes to the increasing incidence of iatrogenic SFV which can be influenced by several other potential factors. There are only limited studies comparing the incidence of iatrogenic SFV in MIS-TLIF and OPEN-TLIF. Methods: In total, 225 cases (450 top screws; MIS-TIFL, 120; OPEN-TILF, 105) undergoing single-level lower lumbar fusion were included in the study. Postoperative computed tomography grading system was used to evaluate iatrogenic SFV. Patient and surgical factors such as age, body mass index, top-screw level, side of the top screw, depth of the spine, and superior facet joint angle (SFA) were analyzed in iatrogenic SFV and non-violation groups to determine their influence on iatrogenic SFV. The clinical outcomes in both groups were assessed preoperatively and postoperatively. Results: The overall incidence of iatrogenic SFV and high-grade violations was higher in MIS-TLIF (41.25%) than in OPEN-TLIF (30.4%). In both groups, bivariate analysis showed a significantly greater incidence of the iatrogenic SFV in patients aged <60 years and those with obesity, top pedicle screws at L4, right-sided top screws, SFA >35°, and depth of the spine >50 mm. Conclusions: This study demonstrated that the incidence of iatrogenic SFV is greater in MIS-TLIF than in OPEN-TLIF at a single lower lumbar level. MIS-TLIF is effective for lumbar degenerative disease; however, the incidence of iatrogenic SFV was higher. Patient and surgical factors must be considered to protect the facet joints in both TLIF methods to avoid ASD.

Clinical and Radiographic Comparison Between Open Versus Minimally Invasive Transforaminal Lumbar Interbody Fusion With Bilateral Facetectomies

“…During MIS TLIF, when pedicle screws are placed percutaneously, careful attention needs to be paid to avoid iatrogenic superior facet joint violation, which is a known risk factor for ASD. 23 Whereas revision for pseudarthrosis was only seen in the open cohort in our study, pseudarthrosis is also a potential long-term complication of MIS TLIF. 17,24 In our study, there were statistically significant improvements in VAS and ODI after MIS and open TLIF.…”

Predictors of accurate intrapedicular screw placement in single-level lumbar (L4-5) fusion: robot-assisted pedicle screw, traditional pedicle screw, and cortical bone trajectory screw insertion

“…In addition, the present study revealed that a smaller facet angle and older age were significant risk factors independent of the surgical technique. Teles et al [ 39 ] and Patel et al [ 40 ] compared the incidence of FJVs between percutaneous and open screw placement and found that facet angle was an independent risk factor for FJVs. The morphology of the facet joint varies greatly among individuals.…”

Minimally Invasive Surgery (MIS) Versus Traditional Open Approach

“…27 In line with these findings, Hsiang et al 28 also report on a series of MIS TLIFs in which 5% of the cohort had an aberrant screw placement that not only presented as a new onset of leg pain but also required a surgical revision to correct the screw placement. Another recent study by Patel et al 29 looked at rates of superior facet joint violations in both MIS and open TLIF surgeries. They found that MIS had more superior facet joint violations overall.…”

“…This increased rate of superior facet violations places patients at increased risk of adjacent segment disease in the future. 29 The increased frequency of nerve root injuries and facet joint violations may be a direct result of limited visualization in MIS TLIFs, indicating that the technique itself leads to an increased number of surgical complications.…”