ObjectiveTo investigate the effectiveness of minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) assisted with microscope in treatment of lumbar spondylolisthesis. MethodsBetween January 2011 and June 2012, 52 patients with lumbar spondylolisthesis underwent MI-TLIF assisted with microscope. There were 29 males and 23 females with an average age of 46 years (range, 32-67 years). The median disease duration was 3.2 years (range, 3 months to 6 years). There were 38 cases of lumbar isthmic spondylolisthesis and 14 cases of degenerative spondylolisthesis; 12 cases had stenosis secondary to lumbar spondylolisthesis. The affected segments were L4, 5 (29 cases) and L5, S1 (23 cases). According to the Meyerding evaluating system, 24 cases were classified as degree I and 28 cases as degree Ⅱ. The visual analogue scale (VAS) score and Oswestry disability index (ODI)were used for clinical assessment, and the clinical effects were also analyzed by Macnab criterion at last follow-up. The radiographic data were used to evaluate reduction of spondylolisthesis, including slipping degree, slipping angle, and intervertebral space height. The fusion rate was assessed by Suk criterion. ResultsThe operations were performed successfully in all patients. No dural tear or cerebrospinal fluid leakage occurred during operation. The average operation time was 105 minutes; the average intraoperative blood loss was 225 mL; the average postoperative drainage volume was 75 mL; and the average hospitalization days were 5.5 days. Superficial infection of incision occurred in 1 case and was cured after change dressing, and primary healing of incision was obtained in the others. All patients were followed up 12-26 months (mean, 18 months). No loosening, breakage, and displacement of pedicle screw and no Cage dislocation occurred by X-ray films after operation. The lumbar spondylolisthesis all got good correction. The three-dimensional CT showed continuous bone trabecula between centrums. The VAS score, ODI, and the slipping degree, slipping angle, and intervertebral space height were significantly improved at last follow-up when compared with preoperative ones (P<0.05). According to Macnab criterion at last follow-up, the results were excellent in 20 cases, good in 29 cases, and fair in 3 cases; the excellent and good rate was 94.2%. According to Suk criterion for fusion, 49 cases obtained complete fusion and 3 cases got possible fusion. ConclusionAs long as indications are seized, MI-TLIF assisted with microscope is safe and reliable for treatment of lumbar spondylolisthesis (Meyerding dergee I or Ⅱ), and it has the advantage of less injury, less blood loss, less complications, and definite short-term effectiveness.
Objective To analyze the cl inical effects of modified transforaminal lumbar interbody fusion (TLIF) for the treatment of lumbar degenerative disease. Methods From October 2003 to December 2006, 33 patients with lumbar degenerative disease (L3-S1) were treated by modified TLIF. There were 14 males and 19 females with an average age of 52.2 years(33 to 70 years). The median disease course was 1.8 years (4 months to 15 years). A total of 42 levels were fused, including 24 cases of single level and 9 cases of double levels. The results of preoperative diagnosis were lumbar degenerative spondylol isthesis with stenosis (8 cases), isthmic spondylol isthesis (5 cases), degenerative lumbar stenosis (16 cases), huge herniated disc with segmental instabil ity (3 cases) and failed back surgery syndrome (1 case). During the modified TLIF procedure, total inferior facet process and inner half summit of superior facet process of TLIF side were resected to make the posterior wall of foramen opened partly. After the bone graft (3 to 5 mL) was placed into the interbody space, a single rectangle Cage was inserted obl iquely from 30° to 40° toward the midl ine. Combined with pedicle screw instrumentation, TLIF was accompl ished. Middle canal and opposite side nerve root decompression were performed simultaneously when necessary. Results Intraoperative dura mater rupture, postoperative cerebral spinal fluid leakage, deep wound infection and transient nerve root stimulation occurredin 1 case respectively, and were all recovered after treatment. No patients had permanent neurologic deficit or aggravation. All patients were followed up for 20 to 58 months (mean 27.2 months). At the follow-up after 1 year postoperatively, all the operated segments achieved fusion standard and no broken screw or Cage dislocation occurred. All 13 cases of spondylol isthesis were reduced thoroughly and maintained satisfactorily. Nineteen patients remained sl ight chronic back pain. There was significant difference (P lt; 0.05) in JOA score between preoperation (14.9 ± 5.1) and postoperation (25.9 ± 3.0). The rate of cl inical improvement was 80.5% (excellent in 24 cases, good in 7 cases, and fair in 2 cases). Conclusion The modified TLIF carries out the less invasive principles in opening operations, simpl ifies the manipulation and expands the indication of TLIF to some extent, and the cl inical results for the treatment of lumbar degenerative disease is satisfactory.
Objective To investigate the effectiveness of surgical treatment for single-level degenerative lumbar instabil ity (DLI) by comparing traditional open transforaminal lumbar interbody fusion (TLIF) with minimally invasive TLIF. Methods Between March 2007 and May 2009，87 patients with single-level DLI were treated by traditional open TLIF (group A, n=45) and by minimally invasive TLIF (group B, n=42), respectively. There was no significant difference in gender, age, disease duration, segment level, combined diseases of lumbar spine, or the proportion of uni- and bilateral symptom between 2groups (P gt; 0.05). The indexes of surgical trauma，systemic inflammatory response, cl inical outcomes, and aravertebral muscle injury were compared between 2 groups. Results Operation was performed successfully in all patients. The patients were followed up 2.9 years on average in group A and 2.8 years on average in group B. The incision, blood loss, and postoperative drainage in group B were significantly less than those in group A (P lt; 0.05), but the operation time in group B was significantly longer than that in group A (P lt; 0.05). There were significant differences (P lt; 0.05) in C-reactive protein, leucocyte count, and creatine kinase MM between 2 groups at 24 hours postoperatively as well as in C-reactive protein at 6 days postoperatively; group B was superior to group A. At last follow-up, the Oswestry disabil ity index (ODI) and visual analogue score (VAS) were significantly improved when compared with the preoperative scores in 2 groups (P lt; 0.05). There were significant differences in ODI and back pain VAS score (P lt; 0.05), but no significant difference in leg pain VAS score (P gt; 0.05) between 2 groups. At last follow-up, no low back pain occurred in 8 and 18 cases, mild in 25 and 18 cases, moderate in 9 and 6 cases, and severe in 3 and 0 cases in groups A and B, respectively, showing that low back pain was significantly l ighter in group B than in group A (Z= —2.574, P=0.010). At last follow-up, the atrophy ratio of multifidus muscle was 37% ± 13% in group A and was 15% ± 7% in group B, showing significant difference (t=12.674, P=0.000). The multifidus muscle atrophy was rated as grade I in 18 and 44 sides, as grade II in 42 and 32 sides, and as grade III in 30 and 8 sides in groups A and B, respectively, showing significant difference (Z= — 4.947, P=0.000). Conclusion Both traditional open TLIF and minimally invasive TLIF are the effective treatments for single-level DLI. Minimally invasive TLIF has less surgical trauma, sl ighter postoperative systemic inflammatory response, less paravertebral muscle injury, and lower incidence of postoperative back pain, but it has longer operation time.
ObjectiveTo investigate the effectiveness and safety of minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) for upper lumbar disc herniation. MethodsRetrospective analysis was made on the clinical data of 26 patients with upper lumbar disc herniation, who were in line with the selection criteria and underwent MIS-TLIF in 14 patients (MIS-TLIF group) and open transforaminal lumbar interbody fusion (OTLIF) in 12 patients (OTLIF group) between December 2007 and May 2012. There was no significant difference in gender, age, disease duration, level of disc herniation, side of disc herniation between 2 groups (P>0.05). The operation time, intraoperative blood loss, postoperative drainage volume, and complications were compared between 2 groups. The clinical outcome was assessed using the visual analogue scale (VAS) and the Oswestry disability index (ODI) scores. The fusion rate was determined by using CT three-dimensional reconstruction and dynamic lumbar radiography at last follow-up. ResultsPrimary healing of incisions was obtained in both groups. No difference was found in operation time between 2 groups (t=0.858, P=0.399), but MIS-TLIF group had less intraoperative blood loss and postoperative drainage volume than OTLIF group (P<0.05). The average follow-up duration was 34.1 months with a range of 12-50 months. No complication of dural tear, infection, spinal nerve trauma, and implant failure occurred. The VAS scores of lower back pain and radicular pain and ODI scores at preoperation showed no significant difference between 2 groups (P>0.05). The VAS score of lower back pain and ODI score at 1 day after operation in MIS-TLIF group were significantly lower than those in the OTLIF group (P<0.05), but no difference was found in VAS scores of radicular pain between 2 groups (P>0.05). Difference in all scores was not significant at last follow-up between 2 groups (P>0.05). The fusion rate was 92.8% (13/14) in MIS-TLIF group, and was 100% (12/12) in OTLIF group at last follow-up. ConclusionMIS-TLIF is a safe and effective procedure for upper lumbar disc herniation as an alternative to other techniques.
Objective To investigate the effectiveness of minimally invasive transforaminal lumbar interbody fusion (TLIF) assisted with microscope for lumbar degenerative disease. Methods Retrospective analysis was made on the clinical data of 82 patients with lumbar degenerative disease (minimally invasive group) undergoing minimally invasive TLIF assisted with microscope between January 2010 and June 2011, which was compared with those of 76 patients (traditional group) undergoing traditional open TLIF. There was no significant difference in age, gender, disease duration, disease type, lesion level, preoperative visual analogue scale (VAS), and preoperative Oswestry disability index (ODI) between 2 groups (P gt; 0.05). The perioperative related parameters, radiography index, and effectiveness were documented and compared. Results There was no significant difference in operation time and intraoperative radiological exposure time between 2 groups (P gt; 0.05), but intraoperative blood loss and postoperative drainage volume in the minimally invasive group were significantly less than those in the traditional group (P lt; 0.05). Dural tear occurred in 2 patients of the traditional group. Superficial infection of incision occurred in 1 case in each group, respectively; and primary healing of incision was obtained in the other patients. All patients were followed up 12-28 months (mean, 18 months). No failure of internal fixation occurred. Radiological analysis showed that the bone graft fusion rate was 96.1% (73/76) in the traditional group and 95.1% (78/82) in the minimally invasive group at last follow-up, showing no significant difference (χ2= 0.012 2, P= 0.912 0). The postoperative ODI and VAS score were significantly improved when compared with preoperative ones in 2 groups (P lt; 0.05); the ODI of the minimally invasive group were significantly better than those of the traditional group at 3 months (t= — 11.941 1, P=0.000 0), and the VAS score of the minimally invasive group was significantly lower than that of the traditional group at 1 day and 3 months (P lt; 0.05); but no significant difference was found in ODI and VAS score between 2 groups at 1 year and last follow-up (P gt; 0.05). Conclusion Minimally invasive TLIF is an effective method to treat lumbar degenerative disease. This procedure is safe and reliable because it has less injury, less blood loss, and milder pain than the traditional open TLIF, and the short-term effectiveness is comparable in 2 procedures.
Objective To compare the therapeutic effect of conventional discectomy, posterior lumbar interbody fusion (PLIF), and transforaminal lumbar interbody fusion (TLIF) on the recurrent lumbar disc protrusion (RLDP). Methods From January 2000 to January 2008, 65 patients with RLDP underwent different surgical procedures, namely conventional discectomy (group A, 25 cases), PLIF (group B, 22 cases), and TLIF (group C, 18 cases). There were 44 males and 21 females aged 26-65 years old (average 41 years old). All the patients were single-level protrusion, including 33 cases at the L4, 5 level and 32 cases at the L5, S1 level. The primary procedure included laminectomy discectomy in 39 patients, unilateral hemilaminectomy discectomy in 15 patients, and bilateral laminectomy and total laminectomy discectomy in 11patients. The recurrent time to the primary operation was 13-110 months (average 64 months). The location of recurrent disc protrusion was at the ipsilateral side in 47 cases and the contralateral side in 18 cases. No significant differences among three groups were evident in terms of basel ine data (P gt; 0.05). Results The incision all healed by first intention. The incidence of perioperative compl ication in group A (24.0%) and group B (22.3%) was significantly higher than that of group C (5.6%) (P lt; 0.05), and there was no significant difference between group A and group B (P gt; 0.05). The operation time and bleed loss during operation of group B were obviously higher than that of group A and group C (P lt; 0.05), and there was no significant difference between group A and group C (P gt; 0.05). There were no significant differences among three groups in terms of the length of hospital ization (P gt; 0.05). Six-one patients were followed up for 12-36 months (average 20 months). At 1 week after operation, the satisfied rate of patients was 84.0% in group A, 81.8% in group B, and 88.9% in group C (P gt; 0.05). All the patients in group B and group C achieved fusion uneventfully. There were no significant differences among three groups in terms of visual analogue scale (VAS) and Oswestry disabil ity index (ODI) when compared the preoperative value with the final follow-up value (P gt; 0.05). There was significant difference within group A, B, and C in terms of VAS and ODI when compared the preoperative value with the final follow-up value (P lt; 0.05), but there were no significant differences among three groups in the improvement rate (P gt; 0.05). The intervertebral space grading method proposed by Roberts et al. was adopted to evaluate the intervertebral space height (ISH), the preoperative value was 2.04 ± 0.93 in group A, 2.18 ± 0.91 in group B, and 2.11 ± 0.90 in group C, andat the final follow-up, the value was 2.64 ± 0.58 in group A, 1.05 ± 0.59 in group B, and 1.06 ± 0.42 in group C. There were significant differences among three groups in the ISH when compared the properative value with the final follow-up value (P lt; 0.05). Conclusion All of the three surgical procedures are effective for RLDP, but conventional discectomy and PLIF have more compl ications than TLIF. Conventional discectomy may result in the further narrow of the intervertebral space and the occurrence of segment instabil ity, whereas TLIF is safer, more effective, and one of the ideal methods to treat RLDP.
Objective To compare the difference of traumatic related index in serum and its significance between minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) and open TLIF. Methods Sixty patients were enrolled by the entry criteria between May and November 2012, and were divided into MIS-TLIF group (n=30) and open TLIF group (n=30). There was no significant difference in gender, age, type of lesions, disease segment, and disease duration between 2 groups (P gt; 0.05). The operation time, intraoperative blood loss, and postoperative hospitalization time were recorded, and the pain severity of incision was evaluated by visual analog scale (VAS). The serum levels of C-reactive protein (CRP) and creatine kinase (CK) were measured at preoperation and at 24 hours postoperatively. The levels of interleukin 6 (IL-6), IL-10, and tumor necrosis factor α (TNF-α) in serum were measured at preoperation and at 2, 4, 8, and 24 hours after operation. Results The operation time, intraoperative blood loss, and postoperative hospitalization time of MIS-TLIF group were significantly smaller than those of open TLIF group (P lt; 0.05), and the VAS score for incision pain in MIS-TLIF group was significantly lower than that of open TLIF group at 1, 2, and 3 days after operation (P lt; 0.05). The levels of CRP, CK, IL-6, and IL-10 in MIS-TLIF group were significantly lower than those in open TLIF group at 24 hours after operation (P lt; 0.05), but there was no significant difference between 2 groups before operation (P gt; 0.05). No significant difference was found in TNF-α level between 2 groups at pre- and post-operation (P gt; 0.05). Conclusion Compared with the open-TLIF, MIS-TLIF may significantly reduce tissue injury and systemic inflammatory reactions during the early postoperative period.
ObjectiveTo compare the biomechanical differences between the kidney-shaped nano-hydroxyapatite/polyamide 66 (n-HA/PA66) Cage and the bullet-shaped n-HA/PA66 Cage. MethodsL2-L5 spinal specimens were selected from 10 adult male pigs. L2, L3 and L4, L5 served as a motor unit respectively, 20 motor units altogether. They were divided into 4 groups (n=5):no treatment was given as control group (group A); nucleus pulposus resection was performed (group B); bullet-shaped Cage (group C), and kidney-shaped Cage (group D) were used in transforaminal lumbar interbody fusion (TLIF) through left intervertebral foramen and supplemented by posterior pedicle screw fixation. The intervertebral height (IH) and the position of Cages were observed on the X-ray films. The range of motion (ROM) was measured. ResultsThere was no significant difference in the preoperative IH among 4 groups (F=0.166, P=0.917). No significant change was found in IH between at pre- and post-operation in group B (P>0.05); it increased after operation in groups C and D, but difference was not statistically significant (P>0.05). There was no significant difference in the postoperative IH among groups B, C, and D (P>0.05). The distance from Cage to the left margin was (3.06±0.51) mm in group C (close to the left) and (5.68±0.69) mm in group D (close to the middle), showing significant difference (t=6.787, P=0.000). The ROM in all directions were significantly lower in groups C and D than in groups A and B (P<0.05), and in group A than in group B (P<0.05). The right bending and compression ROM of group C were significantly higher than those of group D (P<0.05), but no statistically significant difference was found in the other direction ROM (P>0.05). ConclusionThe bullet-shaped and kidney-shaped Cages have similar results in restoring IH and maintaining the stability of the spine assisted by internal fixation. Kidney-shaped Cage is more stable than bullet-shaped Cage in the axial compression and the bending load opposite implant, it can be placed in the middle and back of the vertebral body more ideally.
Objective To review the latest comparative research of minimally invasive transforaminal lumbar interbody fusion (TLIF) and traditional open approach. Methods The domestic and foreign literature concerning the comparative research of minimally invasive TLIF and traditional open TLIF was reviewed, then intraoperative indicators, length of hospitalization, effectiveness, complication, fusion rate, and the effect on paraspinal muscles were analyzed respectively. Results Minimally invasive TLIF has less blood loss and shorter length of hospitalization, but with longer operation and fluoroscopic time. Minimally invasive surgery has the same high fusion rate as open surgery, however, its effectiveness is not superior to open surgery, and complication rate is relatively higher. In the aspect of the effect on paraspinal muscles, in creatine kinase, multifidus cross-sectional area, and atrophy grading, minimally invasive surgery has no significant reduced damage on paraspinal muscles. Conclusion Minimally invasive TLIF is not significantly superior to open TLIF, and it does not reduce the paraspinal muscles injury. But prospective double-blind randomized control trials are still needed for further study.
ObjectiveTo investigate the role of 1,25-dihydroxyvitamin D3 in the posterior transforaminal lumbar interbody fusion (TLIF) for patients with osteoporosis and lumbar degenerative disease. MethodsBetween November 2011 and October 2012,44 patients with osteoporosis and lumbar degenerative disease were treated with TLIF and the clinical data were retrospectively analyzed.The patients were divided into 2 groups based on the administration of 1,25-dihydroxyvitamin D3.After TLIF operation,1,25-dihydroxyvitamin D3 was used in 21 patients (trial group),and was not used in 23 patients (control group).There was no significant difference in gender,age,etiology,affected segment,and disease duration between 2 groups (P>0.05).Lumbar interbody fusion was observed by X-ray and thin-section CT scan reconstruction of lumbar spine according to Brantigan assessment system at 6 months after operation and last follow-up.Clinical outcome was evaluated by Oswestry disability index (ODI) before and after operation. ResultsThe patients of 2 groups were followed up 12-27 months (mean,14.5 months).No fixation loosening or breaking occurred during follow-up.ODI scores in both groups were significantly improved at 6 months after operation and last follow-up (P<0.05) when conpared with preoperative value.Although at preoperation there was no significant difference in ODI score between 2 groups (P>0.05),ODI score of trial group was significantly lower than that of control group at 6 months after operation and last follow-up (P<0.05).At 6 months after operation,the interbody fusion rate was 76.19% (16/21) in trial group and 43.48% (10/23) in control group,showing significant difference (χ2=3.60,P=0.03); at last follow-up,the fusion rate was 95.24% (20/21) in trial group and 65.22% (15/23) in control group,showing significant difference (χ2=4.38,P=0.02). Conclusion1,25-dihydroxyvitamin D3 can improve the lumbar interbody fusion rate and general conditions in the patients with osteoporosis and lumbar degenerative disease.