Clinical evaluation of minimally invasive transforaminal lumbar interbody fusion for severe lumbar spinal stenosis_Chinese Journal of Reparative and Reconstructive Surgery

Authors：

YUAN Chao , LIU Chao , SHEN Junhong , TIAN Huake , ZHENG Wenjie , ZHANG Chao , PAN Yong , HUANG Bo , JIANG Tao , ZHANG Zhengfeng , LI Changqing ,  WANG Jian , ZHOU Yue

Department of Orthopaedics, Xinqiao Hospital, Army Medical University, Chongqing, 400037, P.R.China;

Corresponding?author：

WANG Jian, Email: tonywjxq@aliyun.com

Keywords：

Lumbar spinal stenosis; minimally invasive transforaminal lumbar interbody fusion; complication

DOI：

10.7507/1002-1892.201903120

Video：

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Objective To investigate the clinical results and complication prevention of minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) in the treatment of single-segment severe lumbar spinal stenosis (LSS).Methods The clinical data of 112 patients with severe LSS treated with MIS-TLIF between January 2010 and January 2017 were retrospectively analyzed. There were 43 males and 69 females, aged 52-81 years, with an average age of 65.3 years. The disease duration ranged from 4 to 126 months, with an average of 10.5 months. Clinical manifestations: 104 cases of low back pain, 91 cases of nervous intermittent claudication of both lower limbs, 21 cases of unilateral nerve root pain and/or numbness, and 5 cases of cauda equina nerve injury. The 112 cases were all severe central spinal stenosis, including 32 cases with lateral recess stenosis, 20 cases with foramen stenosis, 9 cases with ossification of ligamentum flavum, 38 cases with disc herniation; 14 cases with two complications and 5 cases with three. Stenosis segment: L_{3, 4} in 6 cases, L_{4, 5} in 89 cases, and L₅, S₁ in 17 cases. Surgical methods included bilateral decompression through bilateral approach (60 cases), bilateral decompression through unilateral approach (15 cases), and unilateral decompression (37 cases). The operation time, intraoperative blood loss, visual analogue scale (VAS) score of low back pain and leg pain, Oswestry disability index (ODI) score, fusion rate, and surgical complications were recorded. At last follow-up, the lumbar fusion was evaluated by Bridwell method, grades Ⅰ and Ⅱ were expressed as fusion.Results The operation time was 83-186 minutes (mean, 126.8 minutes), and the intraoperative blood loss was 65-630 mL (mean, 163.1 mL). All the 112 patients were followed up 25-49 months, with an average of 35.1 months. The VAS score of low back pain and leg pain and ODI score at each time point after operation were significantly improved when compared with preoperative scores (P<0.05). There was no significant difference between the VAS score of low back pain and leg pain and ODI score at the other time points except 1 month after operation (P<0.05). At last follow-up, 2 cases of cauda equina nerve injury recovered and 3 cases partially recovered. According to Bridwell classification criteria, 58 cases were grade Ⅰ, 47 cases were grade Ⅱ, and 7 cases were grade Ⅲ. The fusion rate was 93.8%. Perioperative complications included 5 cases of incision complications (superficial infection in 3 cases, hematoma formation in 2 cases), 19 cases of internal fixator complications (intraoperative end plate fracture in 8 cases, fusion cage sinking in 11 cases at last follow-up), and 15 cases of neurological complications (dural sac tear in 10 cases, transient neurological symptoms of lower extremities aggravated in 5 cases). Conclusion MIS-TLIF treatment of single-level severe LSS can achieve good clinical results, while there is a risk of serious complications. Full understanding of the clinical and imaging features of the disease and reasonable and careful operation are helpful to control the occurrence of cauda equina nerve damage.

Citation： YUAN Chao, LIU Chao, SHEN Junhong, TIAN Huake, ZHENG Wenjie, ZHANG Chao, PAN Yong, HUANG Bo, JIANG Tao, ZHANG Zhengfeng, LI Changqing, WANG Jian, ZHOU Yue. Clinical evaluation of minimally invasive transforaminal lumbar interbody fusion for severe lumbar spinal stenosis. Chinese Journal of Reparative and Reconstructive Surgery, 2019, 33(7): 801-806. doi: 10.7507/1002-1892.201903120 Copy

1.	Machado GC, Ferreira PH, Harris IA, et al. Effectiveness of surgery for lumbar spinal stenosis: a systematic review and meta-analysis. PLoS One, 2015, 10(3): e0122800.
2.	Issack PS, Cunningham ME, Pumberger M, et al. Degenerative lumbar spinal stenosis: evaluation and management. J Am Acad Orthop Surg, 2012, 20(8): 527-535.
3.	Harms J, Rolinger H. A one-stager procedure in operative treatment of spondylolistheses: dorsal traction-reposition and anterior fusion (author’s transl). Z Orthop Ihre Grenzgeb, 1982, 120(3): 343-347.
4.	張磊, 方向前, 趙興, 等. 經椎間孔單側入路雙側減壓融合內固定術治療腰椎管狹窄癥的近期療效觀察. 中國修復重建外科雜志, 2017, 31(5): 519-526.
5.	Deyo RA, Mirza SK, Martin BI, et al. Trends, major medical complications, and charges associated with surgery for lumbar spinal stenosis in older adults. JAMA, 2010, 303(13): 1259-1265.
6.	Foley KT, Holly LT, Schwender JD. Minimally invasive lumbar fusion. Spine (Phila Pa 1976), 2003, 28(15 Suppl): S26-S35.
7.	Wang J, Zhou Y, Zhang ZF, et al. Comparison of one-level minimally invasive and open transforaminal lumbar interbody fusion in degenerative and isthmic spondylolisthesis grades 1 and 2. Eur Spine J, 2010, 19(10): 1780-1784.
8.	漆啟華, 肖強, 鄧亮, 等. 旁正中切口微創與開放經椎間孔腰椎椎體間融合術治療單節段腰椎退行性疾病的療效比較. 中國修復重建外科雜志, 2015, 29(10): 1253-1258.
9.	Schizas C, Theumann N, Burn A, et al. Qualitative grading of severity of lumbar spinal stenosis based on the morphology of the dural sac on magnetic resonance images. Spine (Phila Pa 1976), 2010, 35(21): 1919-1924.
10.	Wang J, Zhou Y, Zhang ZF, et al. Minimally invasive or open transforaminal lumbar interbody fusion as revision surgery for patients previously treated by open discectomy and decompression of the lumbar spine. Eur Spine J, 2011, 20(4): 623-628.
11.	Ogon M, Krismer M, S?llner W, et al. Chronic low back pain measurement with visual analogue scales in different settings. Pain, 1996, 64(3): 425-428.
12.	Fairbank JC, Pynsent PB. The Oswestry Disability Index. Spine (Phila Pa 1976), 2000, 25(22): 2940-2952.
13.	Bridwell KH, Lenke LG, McEnery KW, et al. Anterior fresh frozen structural allografts in the thoracic and lumbar spine. Do they work if combined with posterior fusion and instrumentation in adult patients with kyphosis or anterior column defects? Spine (Phila Pa 1976), 1995, 20(12): 1410-1418.
14.	Genevay S, Atlas SJ. Lumbar spinal stenosis. Best Pract Res Clin Rheumatol, 2010, 24(2): 253-265.
15.	Ishimoto Y, Yoshimura N, Muraki S, et al. Prevalence of symptomatic lumbar spinal stenosis and its association with physical performance in a population-based cohort in Japan: the Wakayama Spine Study. Osteoarthritis Cartilage, 2012, 20(10): 1103-1108.
16.	Weinstein JN, Tosteson TD, Lurie JD, et al. Surgical versus non-operative treatment for lumbar spinal stenosis four-year results of the spine patient outcomes research trial (SPORT). Spine (Phila Pa 1976), 2010, 35(14): 1329-1338.
17.	鄭揚, 李危石, 陳仲強, 等. 微創與開放經椎間孔椎體間融合術治療腰椎單節段退行性疾病的臨床療效比較. 中國脊柱脊髓雜志, 2014, 24(12): 1064-1071.
18.	Peng CW, Yue WM, Poh SY, et al. Clinical and radiological outcomes of minimally invasive versus open transforaminal lumbar interbody fusion. Spine (Phila Pa 1976), 2009, 34(13): 1385-1389.
19.	楊進, 孔清泉, 宋躍明, 等. 微創小切口與開放經椎間孔腰椎椎間融合術治療單節段腰椎退變疾患的近期療效比較. 中國修復重建外科雜志, 2013, 27(3): 262-267.
20.	Li XC, Huang CM, Zhong CF, et al. Minimally invasive procedure reduces adjacent segment degeneration and disease: New benefit-based global meta-analysis. PLoS One, 2017, 12(2): e0171546.
21.	Wang J, Zhou Y. Perioperative complications related to minimally invasive transforaminal lumbar fusion: evaluation of 204 operations on lumbar instability at single center. Spine J, 2014, 14(9): 2078-2084.

1. Machado GC, Ferreira PH, Harris IA, et al. Effectiveness of surgery for lumbar spinal stenosis: a systematic review and meta-analysis. PLoS One, 2015, 10(3): e0122800.
2. Issack PS, Cunningham ME, Pumberger M, et al. Degenerative lumbar spinal stenosis: evaluation and management. J Am Acad Orthop Surg, 2012, 20(8): 527-535.
3. Harms J, Rolinger H. A one-stager procedure in operative treatment of spondylolistheses: dorsal traction-reposition and anterior fusion (author’s transl). Z Orthop Ihre Grenzgeb, 1982, 120(3): 343-347.
4. 張磊, 方向前, 趙興, 等. 經椎間孔單側入路雙側減壓融合內固定術治療腰椎管狹窄癥的近期療效觀察. 中國修復重建外科雜志, 2017, 31(5): 519-526.
5. Deyo RA, Mirza SK, Martin BI, et al. Trends, major medical complications, and charges associated with surgery for lumbar spinal stenosis in older adults. JAMA, 2010, 303(13): 1259-1265.
6. Foley KT, Holly LT, Schwender JD. Minimally invasive lumbar fusion. Spine (Phila Pa 1976), 2003, 28(15 Suppl): S26-S35.
7. Wang J, Zhou Y, Zhang ZF, et al. Comparison of one-level minimally invasive and open transforaminal lumbar interbody fusion in degenerative and isthmic spondylolisthesis grades 1 and 2. Eur Spine J, 2010, 19(10): 1780-1784.
8. 漆啟華, 肖強, 鄧亮, 等. 旁正中切口微創與開放經椎間孔腰椎椎體間融合術治療單節段腰椎退行性疾病的療效比較. 中國修復重建外科雜志, 2015, 29(10): 1253-1258.
9. Schizas C, Theumann N, Burn A, et al. Qualitative grading of severity of lumbar spinal stenosis based on the morphology of the dural sac on magnetic resonance images. Spine (Phila Pa 1976), 2010, 35(21): 1919-1924.
10. Wang J, Zhou Y, Zhang ZF, et al. Minimally invasive or open transforaminal lumbar interbody fusion as revision surgery for patients previously treated by open discectomy and decompression of the lumbar spine. Eur Spine J, 2011, 20(4): 623-628.
11. Ogon M, Krismer M, S?llner W, et al. Chronic low back pain measurement with visual analogue scales in different settings. Pain, 1996, 64(3): 425-428.
12. Fairbank JC, Pynsent PB. The Oswestry Disability Index. Spine (Phila Pa 1976), 2000, 25(22): 2940-2952.
13. Bridwell KH, Lenke LG, McEnery KW, et al. Anterior fresh frozen structural allografts in the thoracic and lumbar spine. Do they work if combined with posterior fusion and instrumentation in adult patients with kyphosis or anterior column defects? Spine (Phila Pa 1976), 1995, 20(12): 1410-1418.
14. Genevay S, Atlas SJ. Lumbar spinal stenosis. Best Pract Res Clin Rheumatol, 2010, 24(2): 253-265.
15. Ishimoto Y, Yoshimura N, Muraki S, et al. Prevalence of symptomatic lumbar spinal stenosis and its association with physical performance in a population-based cohort in Japan: the Wakayama Spine Study. Osteoarthritis Cartilage, 2012, 20(10): 1103-1108.
16. Weinstein JN, Tosteson TD, Lurie JD, et al. Surgical versus non-operative treatment for lumbar spinal stenosis four-year results of the spine patient outcomes research trial (SPORT). Spine (Phila Pa 1976), 2010, 35(14): 1329-1338.
17. 鄭揚, 李危石, 陳仲強, 等. 微創與開放經椎間孔椎體間融合術治療腰椎單節段退行性疾病的臨床療效比較. 中國脊柱脊髓雜志, 2014, 24(12): 1064-1071.
18. Peng CW, Yue WM, Poh SY, et al. Clinical and radiological outcomes of minimally invasive versus open transforaminal lumbar interbody fusion. Spine (Phila Pa 1976), 2009, 34(13): 1385-1389.
19. 楊進, 孔清泉, 宋躍明, 等. 微創小切口與開放經椎間孔腰椎椎間融合術治療單節段腰椎退變疾患的近期療效比較. 中國修復重建外科雜志, 2013, 27(3): 262-267.
20. Li XC, Huang CM, Zhong CF, et al. Minimally invasive procedure reduces adjacent segment degeneration and disease: New benefit-based global meta-analysis. PLoS One, 2017, 12(2): e0171546.
21. Wang J, Zhou Y. Perioperative complications related to minimally invasive transforaminal lumbar fusion: evaluation of 204 operations on lumbar instability at single center. Spine J, 2014, 14(9): 2078-2084.

Chinese Journal of Reparative and Reconstructive Surgery

Clinical evaluation of minimally invasive transforaminal lumbar interbody fusion for severe lumbar spinal stenosis

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