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Minimally Invasive TLIF Using Tubular Retractor Versus Mini-Open TLIF: Which Procedure is Less Invasive?
124S
Proceedings of the NASS 28th Annual Meeting / The Spine Journal 13 (2013) 1S–168S
and/or C3-4 level. Nevertheless, in a validation study on the correlation of various hyperactive reflexes and the cervical myelopathic level, this particular reflex was not evaluated. The hyperactive pectoralis reflex was proposed to be present in patients with spinal cord compression at the C2-3 and/or C3-4 level. Nevertheless, in a validation study on the correlation of various hyperactive reflexes and the cervical myelopathic level, this particular reflex was not evaluated. PURPOSE: To validate the correlation between hyperactive pectoralis reflex and the level of cervical myelopathy. STUDY DESIGN/SETTING: A diagnostic study. PATIENT SAMPLE: All patients presenting with cervical myelopathy between August 2009 and June 2012 were included in this study. OUTCOME MEASURES: The hyperactive pectoralis reflex was reported in sensitivity, specificity, positive likelihood ratio, negative likelihood ratio for cervical myelopathy at the level of above C4. METHODS: All patients presenting with cervical myelopathy between August 2009 and June 2012 were included in this study. Each patient underwent neurological examination for cervical myelopathy focusing on the examination of pathological reflexes, including the hyperactive pectoralis reflex. We recorded the presence or absence of these reflexes and the level of cervical myelopathy as detected on MRI. We used the level of spinal cord compressiondie, cranial to C4 of the vertebral bodydas the reference level to validate a hyperactive pectoralis reflex. RESULTS: 95 cervical myelopathy patients were included in the study. 33 patients had most of their compressed cervical cord at a level above the C4 vertebral body. The hyperactive pectoralis reflex had 84.84% sensitivity, 96.77% specificity, 26.67 positive likelihood ratio, 0.16 negative likelihood ratio for cervical myelopathy at this level. CONCLUSIONS: Due to high sensitivity and specificity, the hyperactive pectoralis reflex is very useful for screening and diagnosis of the cervical myelopathic level when the level is above the C4 vertebral body. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs. http://dx.doi.org/10.1016/j.spinee.2013.07.323
P50. Minimally Invasive TLIF Using Tubular Retractor Versus Mini-Open TLIF: Which Procedure is Less Invasive? Akihito Wada1, Yasuhiro Inoue, MD2, Yuichiro Yokoyama, MD3, Terajima Fumiaki, MD3, Hiroshi Takahashi, MD3; 1Toho University School of Medicine, Tokyo, Japan; 2Toho University School of Medicine, Department of Orthopaedic Surgery, Tokyo, Japan; 3Toho University School of Medicine, Department of Orthopaedic Surgery, Tokyo, Japan BACKGROUND CONTEXT: The current approach technique of minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) is generally divided into two different procedures. One of them is using small tubular retractor (TR), and the other is mid-sagittal, or paraspinal mini-open (MO) approach. Most authors described the advantage of those procedures compared to conventional/open methods, but there remains controversy about which procedure is less invasive and easier between TR and MO. PURPOSE: The objective of this study is to clarify the less invasiveness on MI-TLIF between TR and MO. STUDY DESIGN/SETTING: A prospective clinical evaluation of patients who underwent MO-TLIF by a single surgeon for single-level symptomatic degenerative lumbar spondylolisthesis, and compared them to patients treated with TR-TLIF. PATIENT SAMPLE: A total of 482 consecutive surgically treated degenerative lumbar spondylolisthesis patients with low back pain and leg pain from 2004 at our institution, 75 (39 males, 36 females) patients that underwent TR-TLIF (42 cases) and MO-TLIF (33 cases) were included with minimum follow-up of 24 months. Mean follow-up duration was 60.1 months for TR and 55.2 months for MO. OUTCOME MEASURES: Clinical outcomes were evaluated according to the Japanese Orthopedic Association score (JOA score), visual analog
scale (VAS) of pain, and Oswestry disability questionnaire (ODQ). Data were collected pre- and postoperatively. Surgical time and estimated blood loss, duration of postoperative bed rest and hospital stay, postoperative data of blood chemistry (WBC, CRP, CPK) were assessed for parameters of surgical stress. METHODS: TR-TLIF was performed via a unilateral dorsal approach using METRx 22 mm tubular retractor system (Medtronic Sofamor Danek). With the use of surgical microscope and bayonetted special instruments, unilateral facetectomy and discectomy, contra-lateral laminotomy followed by bone grafting was achieved using local autologous bone with inerbody cage. Percutaneous pedicle screw fixation was added bilaterally with Sextant system (MSD). MO-TLIF was performed via a mid-sagittal dorsal spinous process splitting approach by 2 inches skin incision. Laminotomy, facetectomy and discectomy were performed, followed by bone graft was accomplished with interbody cage. Pedicle screws were applied using paraspinal approach as Wiltse et al. described. All devices in this study are FDA approved. RESULTS: Cohorts were well matched based on patient age (TR: 56.1yrs. MO: 58.9yrs.), duration of symptoms (TR: 18.8mo. MO: 22.1mo.), JOA score (TR: 14.5 points. MO: 15.3 points.), and ODQ (TR: 66. MO: 68.) before surgery. Mean operative time of TR (225 min.) is significantly longer than MO (167 min.). Mean estimated blood loss (TR: 141 ml. MO: 158 ml.), mean length of postoperative bed rest (TR: 2.1 days. MO: 2.3 days.), and hospital stay (TR: 7.5 days. MO: 9.1 days.) were similar in the two groups. The mean postoperative JOA scores in TR and MO were improved to 25.6 and 24.8 respectively at the latest follow-up. The mean postoperative ODQ in TR and MO were decreased to 15 and 17 at latest follow-up, respectively. There are no statistical differences on pre- and postoperative JOA score, VAS, and ODQ between the two groups. As for the postoperative blood chemistry, One day after surgery on serum CPK concentration in the TR is significantly higher than MO. CONCLUSIONS: Both of these procedures accomplish almost the same clinical results, and TR-TLIF has a steeper learning curve than MO-TLIF as from the results of longer surgical time and higher serum concentration of postoperative CPK. Results from this study suggested that MO-TLIF might be less invasive than TR-TLIF. FDA DEVICE/DRUG STATUS: METRx 22 mm tubular retractor system (Approved for this indication), CD Horizon Sextant system (Approved for this indication). http://dx.doi.org/10.1016/j.spinee.2013.07.324
P51. Relationship between Surgical Technique and the Incidence of Adjacent Level Pathology in Lumbar Spine Fusion: Open Traditional Approach (OTA) Versus Minimally Invasive Transforaminal Interbody Fusion and Percutaneous Screws (MIS TLIF/PPS) Hazem Nicola, MD1, Manuel Da Silva, MD2, Irwing J. Aranguren, RN2; 1 Hospital San Juan De Dias, Caracas, DC, Venezuela; 2Clinica Sanatrix, Caracas, Venezuela BACKGROUND CONTEXT: Large Skin incision, significant muscle retraction, and bone removal associated with traditional fusion procedure are known to lead to a long recovery time, postoperative complications. Adjacent Level disease (ALP) refers to the degeneration of the segment above and/or below the fused vertebrae. Many factors as disturb of the facet joints and posterior ligament complex lead to a biomechanical alterations. MIS procedures may decrease or prevent ALP from occurring. PURPOSE: To determine which surgical technique may be associated with lower risk of radiological or/and clinical ALP. STUDY DESIGN/SETTING: Prospective study to compare MIS TLIF and PPS and OTA. PATIENT SAMPLE: 173 patients with back pain and/or Leg pain due to DDD associated or not with low-grade instability were included. OUTCOME MEASURES: VAS, Oswestry Disability Index and radiographs at different time points.
Refer to onsite Annual Meeting presentations and postmeeting proceedings for possible referenced figures and tables. Authors are responsible for accurately reporting disclosures and FDA device/drug status at time of abstract submission.
Proceedings of the NASS 28th Annual Meeting / The Spine Journal 13 (2013) 1S–168S
and/or C3-4 level. Nevertheless, in a validation study on the correlation of various hyperactive reflexes and the cervical myelopathic level, this particular reflex was not evaluated. The hyperactive pectoralis reflex was proposed to be present in patients with spinal cord compression at the C2-3 and/or C3-4 level. Nevertheless, in a validation study on the correlation of various hyperactive reflexes and the cervical myelopathic level, this particular reflex was not evaluated. PURPOSE: To validate the correlation between hyperactive pectoralis reflex and the level of cervical myelopathy. STUDY DESIGN/SETTING: A diagnostic study. PATIENT SAMPLE: All patients presenting with cervical myelopathy between August 2009 and June 2012 were included in this study. OUTCOME MEASURES: The hyperactive pectoralis reflex was reported in sensitivity, specificity, positive likelihood ratio, negative likelihood ratio for cervical myelopathy at the level of above C4. METHODS: All patients presenting with cervical myelopathy between August 2009 and June 2012 were included in this study. Each patient underwent neurological examination for cervical myelopathy focusing on the examination of pathological reflexes, including the hyperactive pectoralis reflex. We recorded the presence or absence of these reflexes and the level of cervical myelopathy as detected on MRI. We used the level of spinal cord compressiondie, cranial to C4 of the vertebral bodydas the reference level to validate a hyperactive pectoralis reflex. RESULTS: 95 cervical myelopathy patients were included in the study. 33 patients had most of their compressed cervical cord at a level above the C4 vertebral body. The hyperactive pectoralis reflex had 84.84% sensitivity, 96.77% specificity, 26.67 positive likelihood ratio, 0.16 negative likelihood ratio for cervical myelopathy at this level. CONCLUSIONS: Due to high sensitivity and specificity, the hyperactive pectoralis reflex is very useful for screening and diagnosis of the cervical myelopathic level when the level is above the C4 vertebral body. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs. http://dx.doi.org/10.1016/j.spinee.2013.07.323
P50. Minimally Invasive TLIF Using Tubular Retractor Versus Mini-Open TLIF: Which Procedure is Less Invasive? Akihito Wada1, Yasuhiro Inoue, MD2, Yuichiro Yokoyama, MD3, Terajima Fumiaki, MD3, Hiroshi Takahashi, MD3; 1Toho University School of Medicine, Tokyo, Japan; 2Toho University School of Medicine, Department of Orthopaedic Surgery, Tokyo, Japan; 3Toho University School of Medicine, Department of Orthopaedic Surgery, Tokyo, Japan BACKGROUND CONTEXT: The current approach technique of minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) is generally divided into two different procedures. One of them is using small tubular retractor (TR), and the other is mid-sagittal, or paraspinal mini-open (MO) approach. Most authors described the advantage of those procedures compared to conventional/open methods, but there remains controversy about which procedure is less invasive and easier between TR and MO. PURPOSE: The objective of this study is to clarify the less invasiveness on MI-TLIF between TR and MO. STUDY DESIGN/SETTING: A prospective clinical evaluation of patients who underwent MO-TLIF by a single surgeon for single-level symptomatic degenerative lumbar spondylolisthesis, and compared them to patients treated with TR-TLIF. PATIENT SAMPLE: A total of 482 consecutive surgically treated degenerative lumbar spondylolisthesis patients with low back pain and leg pain from 2004 at our institution, 75 (39 males, 36 females) patients that underwent TR-TLIF (42 cases) and MO-TLIF (33 cases) were included with minimum follow-up of 24 months. Mean follow-up duration was 60.1 months for TR and 55.2 months for MO. OUTCOME MEASURES: Clinical outcomes were evaluated according to the Japanese Orthopedic Association score (JOA score), visual analog
scale (VAS) of pain, and Oswestry disability questionnaire (ODQ). Data were collected pre- and postoperatively. Surgical time and estimated blood loss, duration of postoperative bed rest and hospital stay, postoperative data of blood chemistry (WBC, CRP, CPK) were assessed for parameters of surgical stress. METHODS: TR-TLIF was performed via a unilateral dorsal approach using METRx 22 mm tubular retractor system (Medtronic Sofamor Danek). With the use of surgical microscope and bayonetted special instruments, unilateral facetectomy and discectomy, contra-lateral laminotomy followed by bone grafting was achieved using local autologous bone with inerbody cage. Percutaneous pedicle screw fixation was added bilaterally with Sextant system (MSD). MO-TLIF was performed via a mid-sagittal dorsal spinous process splitting approach by 2 inches skin incision. Laminotomy, facetectomy and discectomy were performed, followed by bone graft was accomplished with interbody cage. Pedicle screws were applied using paraspinal approach as Wiltse et al. described. All devices in this study are FDA approved. RESULTS: Cohorts were well matched based on patient age (TR: 56.1yrs. MO: 58.9yrs.), duration of symptoms (TR: 18.8mo. MO: 22.1mo.), JOA score (TR: 14.5 points. MO: 15.3 points.), and ODQ (TR: 66. MO: 68.) before surgery. Mean operative time of TR (225 min.) is significantly longer than MO (167 min.). Mean estimated blood loss (TR: 141 ml. MO: 158 ml.), mean length of postoperative bed rest (TR: 2.1 days. MO: 2.3 days.), and hospital stay (TR: 7.5 days. MO: 9.1 days.) were similar in the two groups. The mean postoperative JOA scores in TR and MO were improved to 25.6 and 24.8 respectively at the latest follow-up. The mean postoperative ODQ in TR and MO were decreased to 15 and 17 at latest follow-up, respectively. There are no statistical differences on pre- and postoperative JOA score, VAS, and ODQ between the two groups. As for the postoperative blood chemistry, One day after surgery on serum CPK concentration in the TR is significantly higher than MO. CONCLUSIONS: Both of these procedures accomplish almost the same clinical results, and TR-TLIF has a steeper learning curve than MO-TLIF as from the results of longer surgical time and higher serum concentration of postoperative CPK. Results from this study suggested that MO-TLIF might be less invasive than TR-TLIF. FDA DEVICE/DRUG STATUS: METRx 22 mm tubular retractor system (Approved for this indication), CD Horizon Sextant system (Approved for this indication). http://dx.doi.org/10.1016/j.spinee.2013.07.324
P51. Relationship between Surgical Technique and the Incidence of Adjacent Level Pathology in Lumbar Spine Fusion: Open Traditional Approach (OTA) Versus Minimally Invasive Transforaminal Interbody Fusion and Percutaneous Screws (MIS TLIF/PPS) Hazem Nicola, MD1, Manuel Da Silva, MD2, Irwing J. Aranguren, RN2; 1 Hospital San Juan De Dias, Caracas, DC, Venezuela; 2Clinica Sanatrix, Caracas, Venezuela BACKGROUND CONTEXT: Large Skin incision, significant muscle retraction, and bone removal associated with traditional fusion procedure are known to lead to a long recovery time, postoperative complications. Adjacent Level disease (ALP) refers to the degeneration of the segment above and/or below the fused vertebrae. Many factors as disturb of the facet joints and posterior ligament complex lead to a biomechanical alterations. MIS procedures may decrease or prevent ALP from occurring. PURPOSE: To determine which surgical technique may be associated with lower risk of radiological or/and clinical ALP. STUDY DESIGN/SETTING: Prospective study to compare MIS TLIF and PPS and OTA. PATIENT SAMPLE: 173 patients with back pain and/or Leg pain due to DDD associated or not with low-grade instability were included. OUTCOME MEASURES: VAS, Oswestry Disability Index and radiographs at different time points.
Refer to onsite Annual Meeting presentations and postmeeting proceedings for possible referenced figures and tables. Authors are responsible for accurately reporting disclosures and FDA device/drug status at time of abstract submission.