- Email: [email protected]
Revision for Endoscopic Diskectomy: Is Lateral Lumbar Interbody Fusion an Option?
Original Article
Revision for Endoscopic Diskectomy: Is Lateral Lumbar Interbody Fusion an Option? Guangxi Qiao1, Min Feng2, Xiaodong Wang3, Jian Liu4, Miao Ge5, Bin Yang5, Bin Yue5
OBJECTIVE: This study aims to report the clinical outcome of stand-alone lateral lumbar interbody fusion (LLIF) on recurrent disk herniation and to compare the outcome of stand-alone LLIF to that of conventional transforaminal lumbar interbody fusion (TLIF).
-
METHODS: A retrospective study of 47 patients with recurrent disk herniation was included from January 2008 to October 2016. The inclusion criteria were 1) with recurrent disk herniation that needs revision surgery, 2) with only 1 previous percutaneous endoscopic lumbar diskectomy surgery, 3) underwent 1-level stand-alone LLIF or 1-level TLIF surgery, and 4) with follow-up more than 1 year. Patients were asked to complete the following questionnaires for outcome evaluation: visual analog scales (VAS) for both low back pain and leg pain, the Oswestry Disability Index (ODI), and the 12-item Short-Form Health Survey.
rates for patients with recurrent disk herniation after a previous percutaneous endoscopic lumbar diskectomy surgery. Compared with the TLIF procedure, LLIF could achieve a similar improvement of patient-reported outcome with a better VAS back pain score.
-
RESULTS: Eighteen patients underwent stand-alone LLIF, and 29 patients underwent TLIF surgery. Radiographic analysis revealed a similar baseline and postoperative lumbar lordosis in both the LLIF and TLIF groups. Two weeks after surgery, the ODI and VAS scores showed a significant decrease in both groups. The TLIF group showed significantly larger postoperative VAS back pain after surgery (P [ 0.03). For both VAS leg pain and ODI score during follow-up, no significance difference was found between the LLIF and TLIF groups.
-
CONCLUSIONS: Stand-alone LLIF is a safe and effective approach with low morbidity and acceptable complication
-
Key words Endoscopic diskectomy - Lateral lumbar interbody fusion (LLIF) - ODI score - Revision surgery - TLIF - VAS score -
Abbreviations and Acronyms LLIF: Lateral lumbar interbody fusion MCS: Mental component summary MED: Microendoscopic diskectomy MIS-TLIF: Minimally invasive transforaminal lumbar interbody fusion ODI: Oswestry Disability Index PELD: Percutaneous endoscopic lumbar diskectomy PCS: Physical component summary SF-12: 12-item Short-Form Health Survey
WORLD NEUROSURGERY -: e1-e5, - 2019
INTRODUCTION
P
ercutaneous endoscopic lumbar diskectomy (PELD) has become a feasible alternative to conventional open surgery for lumbar disk herniation. Despite the advantages of minimal invasiveness, the incidence of recurrent herniation has been reported as high as 8%. The majority of patients suffering from recurrent herniation required revision surgery if the conservative treatment fails to relieve the pain symptoms. Several surgical methods have been reported as safe and effective for revision surgery including transforaminal lumbar interbody fusion (TLIF), minimally invasive surgerytransforaminal lumbar interbody fusion (MIS-TLIF), microendoscopic diskectomy (MED), and PELD. However, each of them has disadvantages. TLIF and MIS-TLIF share the disadvantages of surgical invasiveness, and fusion, MED, and PELD have the limitations of recurrence and less satisfactory decompression due to adhesion of nerve roots. Therefore a new method for revision surgery of recurrent disk herniation is needed with less surgical invasiveness and better clinical outcome. Lumbar interbody fusion surgery is a common and effective treatment for lumbar degenerative disease. Lateral lumbar interbody fusion (LLIF) surgeries have been attempted recently to treat lumbar degenerative disease in addition to the conventional TLIF
TLIF: Transforaminal lumbar interbody fusion VAS: Visual analog scales From the 1The Affiliated Hospital of Qingdao University, Qingdao; 2Binzhou Medical University Hospital, Binzhou; 3People’s Hospital of Qingdao, West Coast District; 4Eighth People’s Hospital of Qingdao, Qingdao; and 5Department of Bone Tumor, the Affiliated Hospital of Qingdao University, Qingdao, Shandong, China To whom correspondence should be addressed: Bin Yue, M.D., Ph.D. [E-mail: [email protected]] Citation: World Neurosurg. (2019). https://doi.org/10.1016/j.wneu.2019.07.226 Journal homepage: www.journals.elsevier.com/world-neurosurgery Available online: www.sciencedirect.com 1878-8750/$ - see front matter ª 2019 Elsevier Inc. All rights reserved.
www.journals.elsevier.com/world-neurosurgery
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ORIGINAL ARTICLE GUANGXI QIAO ET AL.
LLIF FOR ENDOSCOPIC DISKECTOMY?
or posterior interbody fusion. LLIF allows access to the intervertebral disk space without disrupting the anterior longitudinal ligament or posterior facets. After insertion of the cage, subsequent relief of pain and disability could be achieved due to indirect decompression. LLIF was initially performed for patients with stenosis, and then the indication extended to degenerative spondylolisthesis when combined with percutaneous posterior fixation. The satisfactory outcome of LLIF on degenerative lumbar disease has been extensively reported. In this study, we aim to report the clinical outcome of stand-alone LLIF on recurrent disk herniation and compare the outcome of stand-alone LLIF to that of conventional TLIF. MATERIAL AND METHODS Cohort This is a retrospective study. A total of 47 patients with recurrent disk herniation was included from our hospital from January 2008 to October 2016. The inclusion criteria were as follows: 1) with recurrent disk herniation that needs revision surgery, 2) with only 1 previous PELD surgery, 3) underwent 1-level stand-alone LLIF or 1-level TLIF surgery, 4) with follow-up more than 1 year. Recurrent disk herniation was defined as “pain-free for at least 1 month after initial PELD surgery and MRI confirmation of a reherniated fragment on the same level as the previous PELD surgery was achieved.” Patients were excluded if the recurrent level revealed spondylolisthesis, with active infection, with active malignancy, or with acute trauma. The protocol of this study has been approved by the ethics committee at our hospital. The selection of surgical procedures mainly depended on the surgeons. All surgeries were performed by 2 attending surgeons, 1 for stand-alone LLIF and 1 for conventional TLIF. In this study cohort, all LLIF surgery was stand-alone without posterior fixation. Outcome Evaluation Outcomes were collected preoperatively and at standard follow-up intervals: 2 weeks, 3, 6, and 12 months postoperatively, as applicable. Patients were asked to complete the following questionnaires for outcome evaluation: visual analog scales (VAS) for both low back pain and leg pain, the Oswestry Disability Index (ODI), and the 12-item Short-Form Health Survey (SF-12, consisting of a physical component summary [PCS] and a mental component summary [MCS]). Substantial clinical benefit thresholds for the ODI were defined as a 15-point improvement in the ODI score. The SF-12 is a multipurpose short-form survey with 12 questions, all selected from the SF-36 Health Survey. Any improvement in the components of the SF-12, which would be represented by a higher score, was considered significant. Radiographic assessments were made using standing lumbar lateral radiographs at preoperative evaluation and on the date of last clinical follow-up. Lumbar lordosis was measured as the angulation from the superior end plate of L1 to the superior end plate of S1 on Surgimap software (Nemaris, New York, New York, USA). Any cage subsidence or rod breakage was also recorded as a complication. Statistics The data are given as the means the standard deviations. Statistical analysis was performed using SPSS software (version
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20.0.0; SPSS Inc., Chicago, Illinois, USA). Independent Student’s t-test were used to compare outcome parameters between the 2 groups. P values <0.05 were considered significant. RESULTS A total of 47 patients were included into this study with an average age of 56.2 years at the time of surgery. Eighteen patients underwent stand-alone LLIF, and 29 patients underwent TLIF surgery. Regarding the surgical levels, 15 in the LLIF group and 20 in the TLIF group were at the L4/5 level (Figures 1 and 2); the other 3 patients in the LLIF group was operated at L3/4 levels; 3 patients underwent revision surgery at L3/4 level; and 6 were at the L5/S1 level in the TLIF group. The mean follow-up time was 14.2 months. The mean operative time was 87 minutes for LLIF and 145 minutes for TLIF group (P < 0.001). The mean estimated blood loss was 152 mL for LLIF and 360 mL for the TLIF group (P < 0.001). Complete demographic and treatment data are detailed in Table 1. Clinical Outcome Radiographic analysis revealed similar baseline and postoperative lumbar lordosis in both the LLIF and TLIF groups (both P > 0.05, Table 2). For clinical outcomes, generally, there were no significant differences in the preoperative pain levels or functional scores between the 2 groups (see Table 2). At 2 weeks after surgery, the ODI and VAS scores showed a significant decrease in both groups (all P < 0.05, see Table 2). ODI decreased from 28.3 at baseline to 14.5 at 2 weeks’ postoperative in the LLIF group (P < 0.001) and from 29.1 at baseline to 16.4 at 2 weeks’ postoperative in the TLIF group (P < 0.001). VAS back pain decreased from 6.4 at baseline to 2.2 at 2 weeks’ postoperative in the LLIF group (P < 0.001) and from 6.3 at baseline to 3.4 at 2 weeks’ postoperative in the TLIF group (P < 0.001). The TLIF group showed significantly larger postoperative VAS back pain after surgery (P ¼ 0.03). VAS leg pain decreased from 7.6 at baseline to 3.4 at 2 weeks’ postoperative in the LLIF group (P < 0.001) and from 7.1 at baseline to 3.1 at 2 weeks’ postoperative in the TLIF group (P < 0.001). Both SF-12 PCS and MCS scores also showed improvements in both groups (see Table 2). During follow-ups, slightly decreased back pain was found in the TLIF group while VAS back pain was stable in the LLIF group. For both VAS leg pain and ODI score during follow-up, no significance difference was found between the LLIF and TLIF groups. Complications There were no intraoperative complications. No patient required hospital readmission during the 90-day perioperative period. Postoperative complications occurred in 2 LLIF patients and 1 TLIF patient. The 2 LLIF patients both had thigh dysesthesia at the side of the incision after surgery, and both of them reported resolve at 2 weeks’ follow-up. The patients who underwent TLIF showed numbness of 1 leg after surgery and resolved at 6-month followup. There were no cases of hardware failure, cage subsidence, or pseudarthrosis that required additional surgical intervention in all patients.
WORLD NEUROSURGERY, https://doi.org/10.1016/j.wneu.2019.07.226
ORIGINAL ARTICLE GUANGXI QIAO ET AL.
LLIF FOR ENDOSCOPIC DISKECTOMY?
Figure 1. Recurrent L4/5 disk herniation treated with transforaminal lumbar interbody fusion. (A)
Preoperative radiograph. (B) Preoperative magnetic resonance imaging. (C) Postoperative radiograph.
Figure 2. Recurrent L4/5 disk herniation treated with lateral lumbar interbody fusion. (A) Preoperative
radiograph. (B) Preoperative magnetic resonance imaging. (C) Postoperative radiograph.
WORLD NEUROSURGERY -: e1-e5, - 2019
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ORIGINAL ARTICLE GUANGXI QIAO ET AL.
LLIF FOR ENDOSCOPIC DISKECTOMY?
Table 1. Baseline Demographic and Operative Parameters Characteristics
LLIF
TLIF
P
Number of patients
18
29
Gender, male/female
4/14
6/23
0.026*
Age
55.7 8.4
56.5 9.2
0.471
BMI
25.74 5.2
24.89 5.0
0.673
Follow-up time
15.7 5.6
13.3 5.5
0.252
Table 2. Comparison of Patient-Reported Outcome Parameters and Lumbar Lordosis Parameters
OR time
87.5 30.7
145.3 20.2
<0.001
EBL
152 95.4
360 120.8
0.014
LLIF, lateral lumbar interbody fusion; TLIF, transforaminal lumbar interbody fusion; BMI, body mass index; OR, operation time; EBL, estimated blood loss. *P < 0.05.
DISCUSSION Revision surgery is necessary for patients with a reherniated disk who fail to respond to conservative therapy. It has been acknowledged that recurrent disk herniation is a certain indication for interbody fusion. Currently, TLIF is one of the popular surgical procedures that were used for revision surgery of PELD. MIS-TLIF, a procedure with less surgical invasiveness, was also an alternative. However, few studies focused on the clinical outcome of stand-alone LLIF serving as a revision option for PELD. In this study, our results revealed that LLIF is a safe and effective treatment for patients with recurrent disk herniation after PELD. The use of this surgical approach provides a minimally invasive solution that offers favorable clinical and radiologic outcomes with low rates of postoperative complications. LLIF is a minimally invasive alternative to conventional fusion techniques that allows access to the intervertebral disk space. The main aim of LLIF surgery is to restore disk space height with subsequent reduction of pain and improvement in disability. This procedure has been successfully used for obtaining effective reduction and favorable alignment through a minimally disruptive approach and indirect decompression of the spinal canal and intervertebral foramen. The indication of LLIF has extended from mild stenosis to degenerative spondylolisthesis and degenerative scoliosis. Campbell et al1 concluded that LLIF was an effective technique for the treatment of grade 1 or 2 degenerative spondylolisthesis at L4e5. Louie et al2 also demonstrated that stand-alone LLIF is a safe and effective approach with low morbidity and acceptable complication rates for patients with symptomatic ASD after a previous lumbar fusion. In our study, we, for the first time, demonstrated that LLIF is an effective procedure for revision surgery after PELD. The significant improvements in patient-reported outcomes found in this study are in line with the improvement in patientreported outcomes in other studies evaluating the efficacy of an LLIF for multiple pathologies.3-6 Our results showed significant improvement after revision LLIF surgery. ODI showed an improvement of 13.8 in the LLIF group, and VAS back pain improved from 6.4 to 2.2 after LLIF surgery. Louie et al2 reported that ODI scores significantly improved from preoperative 46.6 to 30.4 at final follow-up and that VAS back pain scores improved
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LLIF
TLIF
P
Baseline
6.4 1.7
6.3 2.2
0.87
2-week post-op
2.2 0.4
3.4 0.7
0.03*
Last follow-up
2.3 0.4
3.1 0.6
0.07
7.6 2.3
7.1 2.3
0.72
VAS back
VAS leg Baseline 2-week post-op
3.4 1.4
3.1 1.3
0.55
Last follow-up
2.5 1.1
2.1 0.8
0.67
Baseline
28.3 12.6
29.1 12.2
0.71
2-week post-op
14.5 5.0
16.4 5.7
0.27
Last follow-up
13.7 4.6
14.9 5.1
0.33
ODI
SF-12 PCS Baseline
23.4 8.5
21.7 7.3
0.48
2-week post-op
42.2 10.7
38.5 11.5
0.04*
Last follow-up
43.7 10.6
41.7 10.2
0.62
Baseline
28.2 7.7
31.4 8.5
0.27
2-week postoperative
35.7 8.6
36.3 8.2
0.33
Last follow-up
38.9 8.5
38.4 8.6
0.75
SF-12 MCS
Lumbar lordosis ( ) Baseline
43.5 11.7
42.6 12.9
0.68
2-week post-op
48.4 12.4
44.7 10.3
0.12
Last follow-up
46.3 11.4
44.2 11.8
0.36
LLIF, lateral lumbar interbody fusion; TLIF, transforaminal lumbar interbody fusion; VAS, visual analog scales; ODI, Oswestry Disability Index; SF-12, 12-item Short-Form Health Survey; PCS, physical component summary; MCS, mental component summary. *P < 0.05.
from baseline 8.4 to 3.2 postoperative in after revision LLIF surgery for adjacent segmental degeneration. Park et al7 investigated LLIF surgery for adult spinal deformity and found that LLIF surgery showed similar improvement of patient-reported outcome compared with traditional posterior fusion surgery. A reduction of the ODI score of 15 points could reflect clinical improvement.8 The U.S. Food and Drug Administration standards identify good to excellent operative outcomes when there is a 15-point improvement in ODI, plus maintenance or improvement in the SF-36 score.9 Both the ODI and SF-12 PCS/MCS scores exhibited trends that were similar to that of the VAS scores, indicating that the clinical status and quality of life were highly involved with the pain level. In the current study, we confirm the attainment of good to excellent clinical outcomes at 12-month postoperative time points when treating the recurrent disk herniation after primary PELD surgery using FDA metrics.
WORLD NEUROSURGERY, https://doi.org/10.1016/j.wneu.2019.07.226
ORIGINAL ARTICLE GUANGXI QIAO ET AL.
LLIF FOR ENDOSCOPIC DISKECTOMY?
Interbody fusion has been reported to be an effective surgical procedure for revision surgery after PELD. Yao et al10 concluded that MIS-TLIF showed fewer recurrence rates for revision surgery but with higher costs compared with MED or PELD, and that all pain and functional scores were significantly improved after revision MIS-TLIF surgery. VAS back pain score showed a decrease of 2.65 and ODI showed an improvement of 12.92 after MIS-TLIF surgery. Our results also showed significant improvement after revision TLIF and LLIF surgery. ODI showed an improvement of 13.8 in the LLIF group and 12.7 in the TLIF group. In addition, the LLIF group had a better postoperative VAS back pain improvement compared with the TLIF group, which may be due to the relatively larger injury incurred during posterior dissection of the paraspinal muscle. Regarding VAS leg pain relief, the clinical improvement was similar between the TLIF and LLIF groups, demonstrating that the nerve could be decompressed from the herniated disk in both groups. Revision surgery after PELD surgery has been widely reported. Osterman et al11 found that patients with 1 reoperation had a 25.1% risk of further spinal surgery over the next 10 years. Cheng et al12 reported that more real recurrent herniation was found after minimally invasive endoscopic diskectomy than after open disk surgery. The reason that PELD presented with a higher revision rate may be due to the difficulty of thorough decompression with endoscopic surgery. In open diskectomy, it is convenient to make a thorough decompression and remove the hidden fragments under a wide view, while MED and PELD
CONCLUSION Stand-alone LLIF is a safe and effective approach with low morbidity and acceptable complication rates for patients with recurrent disk herniation after a previous PELD surgery. Compared with the TLIF procedure for revision surgery, LLIF could achieve similar improvement of patient-reported outcomes with better VAS back pain scores.
spinal deformity: clinical and radiological efficacy with minimum two years follow-up. Spine (Phila Pa 1976). 2018;43:E813-E821.
REFERENCES 1. Campbell PG, Nunley PD, Cavanaugh D, et al. Short-term outcomes of lateral lumbar interbody fusion without decompression for the treatment of symptomatic degenerative spondylolisthesis at L4-5. Neurosurg Focus. 2018;44:E6.
are performed under the endoscope with a bidimensional vision. Relatively less decompression is performed because the endoscope tube limits the scope of decompression instruments. Furthermore, it is difficult to remove hidden free fragments, which are located beyond the endoscopic channel.13-15 Similarly, the recurrence rate after limited diskectomy was reported to be higher than that after aggressive diskectomy.16 Therefore interbody fusion could avoid recurrent disk herniation due to total diskectomy and preparation of end plate in LLIF surgery. In our study, no reherniated disk was found during follow-up in both the LLIF and TLIF groups, similar to the report of Yao et al.17 This study had several limitations. A larger cohort with a diverse range of disk pathology may provide additional insight into the ability to adequately indirectly decompress the revision level. A prospective randomized controlled trial with a longer follow-up period is necessary to provide more helpful information about the assessments of these surgical procedures.
8. Deutsch H. The predictive value of the baseline Oswestry Disability Index in lumbar disc arthroplasty. Neurosurg Focus. 2010;28:E7.
lumbar micro-endoscopic discectomy. Eur Spine J. 2010;19:443-450. 15. Matsumoto M, Watanabe K, Hosogane N, et al. Recurrence of lumbar disc herniation after microendoscopic discectomy. J Neurol Surg A Cent Eur Neurosurg. 2013;74:222-227.
9. Glassman S, Gornet MF, Branch C, et al. MOS short form 36 and Oswestry Disability Index outcomes in lumbar fusion: a multicenter experience. Spine J. 2006;6:21-26.
16. McGirt MJ, Ambrossi GL, Datoo G, et al. Recurrent disc herniation and long-term back pain after primary lumbar discectomy: review of outcomes reported for limited versus aggressive disc removal. Neurosurgery. 2009;64:338-344.
3. Phillips FM, Isaacs RE, Rodgers WB, et al. Adult degenerative scoliosis treated with XLIF: clinical and radiographical results of a prospective multicenter study with 24-month follow-up. Spine (Phila Pa 1976). 2013;38:1853-1861.
10. Yao Y, Zhang H, Wu J, et al. Minimally invasive transforaminal lumbar interbody fusion versus percutaneous endoscopic lumbar discectomy: revision surgery for recurrent herniation after microendoscopic discectomy. World Neurosurg. 2017;99:89-95.
17. Yao Y, Zhang H, Wu J, et al. Comparison of three minimally invasive spine surgery methods for revision surgery for recurrent herniation after percutaneous endoscopic lumbar discectomy. World Neurosurg. 2017;100:641-647.
4. Youssef JA, McAfee PC, Patty CA, et al. Minimally invasive surgery: lateral approach interbody fusion: results and review. Spine (Phila Pa 1976). 2010;35(suppl 26):S302-311.
11. Osterman H, Sund R, Seitsalo S, Keskimaki I. Risk of multiple reoperations after lumbar discectomy: a population-based study. Spine (Phila Pa 1976). 2003;28:621-627.
Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
5. Rodgers WB, Gerber EJ, Patterson J. Intraoperative and early postoperative complications in extreme lateral interbody fusion: an analysis of 600 cases. Spine (Phila Pa 1976). 2011;36:26-32.
12. Cheng J, Wang H, Zheng W, et al. Reoperation after lumbar disc surgery in two hundred and seven patients. Int Orthop. 2013;37:1511-1517.
6. Castro C, Oliveira L, Amaral R, Marchi L, Pimenta L. Is the lateral transpsoas approach feasible for the treatment of adult degenerative scoliosis? Clin Orthop Relat Res. 2014;472:1776-1783.
13. Kim JM, Lee SH, Ahn Y, Yoon DH, Lee CD, Lim ST. Recurrence after successful percutaneous endoscopic lumbar discectomy. Minim Invasive Neurosurg. 2007;50:82-85.
7. Park HY, Ha KY, Kim YH, et al. Minimally invasive lateral lumbar interbody fusion for adult
14. Teli M, Lovi A, Brayda-Bruno M, et al. Higher risk of dural tears and recurrent herniation with
2. Louie PK, Varthi AG, Narain AS, et al. Stand-alone lateral lumbar interbody fusion for the treatment of symptomatic adjacent segment degeneration following previous lumbar fusion. Spine J. 2018;18: 2025-2032.
WORLD NEUROSURGERY -: e1-e5, - 2019
Received 5 May 2019; accepted 30 July 2019 Citation: World Neurosurg. (2019). https://doi.org/10.1016/j.wneu.2019.07.226 Journal homepage: www.journals.elsevier.com/worldneurosurgery Available online: www.sciencedirect.com 1878-8750/$ - see front matter ª 2019 Elsevier Inc. All rights reserved.
www.journals.elsevier.com/world-neurosurgery
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Revision for Endoscopic Diskectomy: Is Lateral Lumbar Interbody Fusion an Option? Guangxi Qiao1, Min Feng2, Xiaodong Wang3, Jian Liu4, Miao Ge5, Bin Yang5, Bin Yue5
OBJECTIVE: This study aims to report the clinical outcome of stand-alone lateral lumbar interbody fusion (LLIF) on recurrent disk herniation and to compare the outcome of stand-alone LLIF to that of conventional transforaminal lumbar interbody fusion (TLIF).
-
METHODS: A retrospective study of 47 patients with recurrent disk herniation was included from January 2008 to October 2016. The inclusion criteria were 1) with recurrent disk herniation that needs revision surgery, 2) with only 1 previous percutaneous endoscopic lumbar diskectomy surgery, 3) underwent 1-level stand-alone LLIF or 1-level TLIF surgery, and 4) with follow-up more than 1 year. Patients were asked to complete the following questionnaires for outcome evaluation: visual analog scales (VAS) for both low back pain and leg pain, the Oswestry Disability Index (ODI), and the 12-item Short-Form Health Survey.
rates for patients with recurrent disk herniation after a previous percutaneous endoscopic lumbar diskectomy surgery. Compared with the TLIF procedure, LLIF could achieve a similar improvement of patient-reported outcome with a better VAS back pain score.
-
RESULTS: Eighteen patients underwent stand-alone LLIF, and 29 patients underwent TLIF surgery. Radiographic analysis revealed a similar baseline and postoperative lumbar lordosis in both the LLIF and TLIF groups. Two weeks after surgery, the ODI and VAS scores showed a significant decrease in both groups. The TLIF group showed significantly larger postoperative VAS back pain after surgery (P [ 0.03). For both VAS leg pain and ODI score during follow-up, no significance difference was found between the LLIF and TLIF groups.
-
CONCLUSIONS: Stand-alone LLIF is a safe and effective approach with low morbidity and acceptable complication
-
Key words Endoscopic diskectomy - Lateral lumbar interbody fusion (LLIF) - ODI score - Revision surgery - TLIF - VAS score -
Abbreviations and Acronyms LLIF: Lateral lumbar interbody fusion MCS: Mental component summary MED: Microendoscopic diskectomy MIS-TLIF: Minimally invasive transforaminal lumbar interbody fusion ODI: Oswestry Disability Index PELD: Percutaneous endoscopic lumbar diskectomy PCS: Physical component summary SF-12: 12-item Short-Form Health Survey
WORLD NEUROSURGERY -: e1-e5, - 2019
INTRODUCTION
P
ercutaneous endoscopic lumbar diskectomy (PELD) has become a feasible alternative to conventional open surgery for lumbar disk herniation. Despite the advantages of minimal invasiveness, the incidence of recurrent herniation has been reported as high as 8%. The majority of patients suffering from recurrent herniation required revision surgery if the conservative treatment fails to relieve the pain symptoms. Several surgical methods have been reported as safe and effective for revision surgery including transforaminal lumbar interbody fusion (TLIF), minimally invasive surgerytransforaminal lumbar interbody fusion (MIS-TLIF), microendoscopic diskectomy (MED), and PELD. However, each of them has disadvantages. TLIF and MIS-TLIF share the disadvantages of surgical invasiveness, and fusion, MED, and PELD have the limitations of recurrence and less satisfactory decompression due to adhesion of nerve roots. Therefore a new method for revision surgery of recurrent disk herniation is needed with less surgical invasiveness and better clinical outcome. Lumbar interbody fusion surgery is a common and effective treatment for lumbar degenerative disease. Lateral lumbar interbody fusion (LLIF) surgeries have been attempted recently to treat lumbar degenerative disease in addition to the conventional TLIF
TLIF: Transforaminal lumbar interbody fusion VAS: Visual analog scales From the 1The Affiliated Hospital of Qingdao University, Qingdao; 2Binzhou Medical University Hospital, Binzhou; 3People’s Hospital of Qingdao, West Coast District; 4Eighth People’s Hospital of Qingdao, Qingdao; and 5Department of Bone Tumor, the Affiliated Hospital of Qingdao University, Qingdao, Shandong, China To whom correspondence should be addressed: Bin Yue, M.D., Ph.D. [E-mail: [email protected]] Citation: World Neurosurg. (2019). https://doi.org/10.1016/j.wneu.2019.07.226 Journal homepage: www.journals.elsevier.com/world-neurosurgery Available online: www.sciencedirect.com 1878-8750/$ - see front matter ª 2019 Elsevier Inc. All rights reserved.
www.journals.elsevier.com/world-neurosurgery
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ORIGINAL ARTICLE GUANGXI QIAO ET AL.
LLIF FOR ENDOSCOPIC DISKECTOMY?
or posterior interbody fusion. LLIF allows access to the intervertebral disk space without disrupting the anterior longitudinal ligament or posterior facets. After insertion of the cage, subsequent relief of pain and disability could be achieved due to indirect decompression. LLIF was initially performed for patients with stenosis, and then the indication extended to degenerative spondylolisthesis when combined with percutaneous posterior fixation. The satisfactory outcome of LLIF on degenerative lumbar disease has been extensively reported. In this study, we aim to report the clinical outcome of stand-alone LLIF on recurrent disk herniation and compare the outcome of stand-alone LLIF to that of conventional TLIF. MATERIAL AND METHODS Cohort This is a retrospective study. A total of 47 patients with recurrent disk herniation was included from our hospital from January 2008 to October 2016. The inclusion criteria were as follows: 1) with recurrent disk herniation that needs revision surgery, 2) with only 1 previous PELD surgery, 3) underwent 1-level stand-alone LLIF or 1-level TLIF surgery, 4) with follow-up more than 1 year. Recurrent disk herniation was defined as “pain-free for at least 1 month after initial PELD surgery and MRI confirmation of a reherniated fragment on the same level as the previous PELD surgery was achieved.” Patients were excluded if the recurrent level revealed spondylolisthesis, with active infection, with active malignancy, or with acute trauma. The protocol of this study has been approved by the ethics committee at our hospital. The selection of surgical procedures mainly depended on the surgeons. All surgeries were performed by 2 attending surgeons, 1 for stand-alone LLIF and 1 for conventional TLIF. In this study cohort, all LLIF surgery was stand-alone without posterior fixation. Outcome Evaluation Outcomes were collected preoperatively and at standard follow-up intervals: 2 weeks, 3, 6, and 12 months postoperatively, as applicable. Patients were asked to complete the following questionnaires for outcome evaluation: visual analog scales (VAS) for both low back pain and leg pain, the Oswestry Disability Index (ODI), and the 12-item Short-Form Health Survey (SF-12, consisting of a physical component summary [PCS] and a mental component summary [MCS]). Substantial clinical benefit thresholds for the ODI were defined as a 15-point improvement in the ODI score. The SF-12 is a multipurpose short-form survey with 12 questions, all selected from the SF-36 Health Survey. Any improvement in the components of the SF-12, which would be represented by a higher score, was considered significant. Radiographic assessments were made using standing lumbar lateral radiographs at preoperative evaluation and on the date of last clinical follow-up. Lumbar lordosis was measured as the angulation from the superior end plate of L1 to the superior end plate of S1 on Surgimap software (Nemaris, New York, New York, USA). Any cage subsidence or rod breakage was also recorded as a complication. Statistics The data are given as the means the standard deviations. Statistical analysis was performed using SPSS software (version
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20.0.0; SPSS Inc., Chicago, Illinois, USA). Independent Student’s t-test were used to compare outcome parameters between the 2 groups. P values <0.05 were considered significant. RESULTS A total of 47 patients were included into this study with an average age of 56.2 years at the time of surgery. Eighteen patients underwent stand-alone LLIF, and 29 patients underwent TLIF surgery. Regarding the surgical levels, 15 in the LLIF group and 20 in the TLIF group were at the L4/5 level (Figures 1 and 2); the other 3 patients in the LLIF group was operated at L3/4 levels; 3 patients underwent revision surgery at L3/4 level; and 6 were at the L5/S1 level in the TLIF group. The mean follow-up time was 14.2 months. The mean operative time was 87 minutes for LLIF and 145 minutes for TLIF group (P < 0.001). The mean estimated blood loss was 152 mL for LLIF and 360 mL for the TLIF group (P < 0.001). Complete demographic and treatment data are detailed in Table 1. Clinical Outcome Radiographic analysis revealed similar baseline and postoperative lumbar lordosis in both the LLIF and TLIF groups (both P > 0.05, Table 2). For clinical outcomes, generally, there were no significant differences in the preoperative pain levels or functional scores between the 2 groups (see Table 2). At 2 weeks after surgery, the ODI and VAS scores showed a significant decrease in both groups (all P < 0.05, see Table 2). ODI decreased from 28.3 at baseline to 14.5 at 2 weeks’ postoperative in the LLIF group (P < 0.001) and from 29.1 at baseline to 16.4 at 2 weeks’ postoperative in the TLIF group (P < 0.001). VAS back pain decreased from 6.4 at baseline to 2.2 at 2 weeks’ postoperative in the LLIF group (P < 0.001) and from 6.3 at baseline to 3.4 at 2 weeks’ postoperative in the TLIF group (P < 0.001). The TLIF group showed significantly larger postoperative VAS back pain after surgery (P ¼ 0.03). VAS leg pain decreased from 7.6 at baseline to 3.4 at 2 weeks’ postoperative in the LLIF group (P < 0.001) and from 7.1 at baseline to 3.1 at 2 weeks’ postoperative in the TLIF group (P < 0.001). Both SF-12 PCS and MCS scores also showed improvements in both groups (see Table 2). During follow-ups, slightly decreased back pain was found in the TLIF group while VAS back pain was stable in the LLIF group. For both VAS leg pain and ODI score during follow-up, no significance difference was found between the LLIF and TLIF groups. Complications There were no intraoperative complications. No patient required hospital readmission during the 90-day perioperative period. Postoperative complications occurred in 2 LLIF patients and 1 TLIF patient. The 2 LLIF patients both had thigh dysesthesia at the side of the incision after surgery, and both of them reported resolve at 2 weeks’ follow-up. The patients who underwent TLIF showed numbness of 1 leg after surgery and resolved at 6-month followup. There were no cases of hardware failure, cage subsidence, or pseudarthrosis that required additional surgical intervention in all patients.
WORLD NEUROSURGERY, https://doi.org/10.1016/j.wneu.2019.07.226
ORIGINAL ARTICLE GUANGXI QIAO ET AL.
LLIF FOR ENDOSCOPIC DISKECTOMY?
Figure 1. Recurrent L4/5 disk herniation treated with transforaminal lumbar interbody fusion. (A)
Preoperative radiograph. (B) Preoperative magnetic resonance imaging. (C) Postoperative radiograph.
Figure 2. Recurrent L4/5 disk herniation treated with lateral lumbar interbody fusion. (A) Preoperative
radiograph. (B) Preoperative magnetic resonance imaging. (C) Postoperative radiograph.
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Table 1. Baseline Demographic and Operative Parameters Characteristics
LLIF
TLIF
P
Number of patients
18
29
Gender, male/female
4/14
6/23
0.026*
Age
55.7 8.4
56.5 9.2
0.471
BMI
25.74 5.2
24.89 5.0
0.673
Follow-up time
15.7 5.6
13.3 5.5
0.252
Table 2. Comparison of Patient-Reported Outcome Parameters and Lumbar Lordosis Parameters
OR time
87.5 30.7
145.3 20.2
<0.001
EBL
152 95.4
360 120.8
0.014
LLIF, lateral lumbar interbody fusion; TLIF, transforaminal lumbar interbody fusion; BMI, body mass index; OR, operation time; EBL, estimated blood loss. *P < 0.05.
DISCUSSION Revision surgery is necessary for patients with a reherniated disk who fail to respond to conservative therapy. It has been acknowledged that recurrent disk herniation is a certain indication for interbody fusion. Currently, TLIF is one of the popular surgical procedures that were used for revision surgery of PELD. MIS-TLIF, a procedure with less surgical invasiveness, was also an alternative. However, few studies focused on the clinical outcome of stand-alone LLIF serving as a revision option for PELD. In this study, our results revealed that LLIF is a safe and effective treatment for patients with recurrent disk herniation after PELD. The use of this surgical approach provides a minimally invasive solution that offers favorable clinical and radiologic outcomes with low rates of postoperative complications. LLIF is a minimally invasive alternative to conventional fusion techniques that allows access to the intervertebral disk space. The main aim of LLIF surgery is to restore disk space height with subsequent reduction of pain and improvement in disability. This procedure has been successfully used for obtaining effective reduction and favorable alignment through a minimally disruptive approach and indirect decompression of the spinal canal and intervertebral foramen. The indication of LLIF has extended from mild stenosis to degenerative spondylolisthesis and degenerative scoliosis. Campbell et al1 concluded that LLIF was an effective technique for the treatment of grade 1 or 2 degenerative spondylolisthesis at L4e5. Louie et al2 also demonstrated that stand-alone LLIF is a safe and effective approach with low morbidity and acceptable complication rates for patients with symptomatic ASD after a previous lumbar fusion. In our study, we, for the first time, demonstrated that LLIF is an effective procedure for revision surgery after PELD. The significant improvements in patient-reported outcomes found in this study are in line with the improvement in patientreported outcomes in other studies evaluating the efficacy of an LLIF for multiple pathologies.3-6 Our results showed significant improvement after revision LLIF surgery. ODI showed an improvement of 13.8 in the LLIF group, and VAS back pain improved from 6.4 to 2.2 after LLIF surgery. Louie et al2 reported that ODI scores significantly improved from preoperative 46.6 to 30.4 at final follow-up and that VAS back pain scores improved
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LLIF
TLIF
P
Baseline
6.4 1.7
6.3 2.2
0.87
2-week post-op
2.2 0.4
3.4 0.7
0.03*
Last follow-up
2.3 0.4
3.1 0.6
0.07
7.6 2.3
7.1 2.3
0.72
VAS back
VAS leg Baseline 2-week post-op
3.4 1.4
3.1 1.3
0.55
Last follow-up
2.5 1.1
2.1 0.8
0.67
Baseline
28.3 12.6
29.1 12.2
0.71
2-week post-op
14.5 5.0
16.4 5.7
0.27
Last follow-up
13.7 4.6
14.9 5.1
0.33
ODI
SF-12 PCS Baseline
23.4 8.5
21.7 7.3
0.48
2-week post-op
42.2 10.7
38.5 11.5
0.04*
Last follow-up
43.7 10.6
41.7 10.2
0.62
Baseline
28.2 7.7
31.4 8.5
0.27
2-week postoperative
35.7 8.6
36.3 8.2
0.33
Last follow-up
38.9 8.5
38.4 8.6
0.75
SF-12 MCS
Lumbar lordosis ( ) Baseline
43.5 11.7
42.6 12.9
0.68
2-week post-op
48.4 12.4
44.7 10.3
0.12
Last follow-up
46.3 11.4
44.2 11.8
0.36
LLIF, lateral lumbar interbody fusion; TLIF, transforaminal lumbar interbody fusion; VAS, visual analog scales; ODI, Oswestry Disability Index; SF-12, 12-item Short-Form Health Survey; PCS, physical component summary; MCS, mental component summary. *P < 0.05.
from baseline 8.4 to 3.2 postoperative in after revision LLIF surgery for adjacent segmental degeneration. Park et al7 investigated LLIF surgery for adult spinal deformity and found that LLIF surgery showed similar improvement of patient-reported outcome compared with traditional posterior fusion surgery. A reduction of the ODI score of 15 points could reflect clinical improvement.8 The U.S. Food and Drug Administration standards identify good to excellent operative outcomes when there is a 15-point improvement in ODI, plus maintenance or improvement in the SF-36 score.9 Both the ODI and SF-12 PCS/MCS scores exhibited trends that were similar to that of the VAS scores, indicating that the clinical status and quality of life were highly involved with the pain level. In the current study, we confirm the attainment of good to excellent clinical outcomes at 12-month postoperative time points when treating the recurrent disk herniation after primary PELD surgery using FDA metrics.
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ORIGINAL ARTICLE GUANGXI QIAO ET AL.
LLIF FOR ENDOSCOPIC DISKECTOMY?
Interbody fusion has been reported to be an effective surgical procedure for revision surgery after PELD. Yao et al10 concluded that MIS-TLIF showed fewer recurrence rates for revision surgery but with higher costs compared with MED or PELD, and that all pain and functional scores were significantly improved after revision MIS-TLIF surgery. VAS back pain score showed a decrease of 2.65 and ODI showed an improvement of 12.92 after MIS-TLIF surgery. Our results also showed significant improvement after revision TLIF and LLIF surgery. ODI showed an improvement of 13.8 in the LLIF group and 12.7 in the TLIF group. In addition, the LLIF group had a better postoperative VAS back pain improvement compared with the TLIF group, which may be due to the relatively larger injury incurred during posterior dissection of the paraspinal muscle. Regarding VAS leg pain relief, the clinical improvement was similar between the TLIF and LLIF groups, demonstrating that the nerve could be decompressed from the herniated disk in both groups. Revision surgery after PELD surgery has been widely reported. Osterman et al11 found that patients with 1 reoperation had a 25.1% risk of further spinal surgery over the next 10 years. Cheng et al12 reported that more real recurrent herniation was found after minimally invasive endoscopic diskectomy than after open disk surgery. The reason that PELD presented with a higher revision rate may be due to the difficulty of thorough decompression with endoscopic surgery. In open diskectomy, it is convenient to make a thorough decompression and remove the hidden fragments under a wide view, while MED and PELD
CONCLUSION Stand-alone LLIF is a safe and effective approach with low morbidity and acceptable complication rates for patients with recurrent disk herniation after a previous PELD surgery. Compared with the TLIF procedure for revision surgery, LLIF could achieve similar improvement of patient-reported outcomes with better VAS back pain scores.
spinal deformity: clinical and radiological efficacy with minimum two years follow-up. Spine (Phila Pa 1976). 2018;43:E813-E821.
REFERENCES 1. Campbell PG, Nunley PD, Cavanaugh D, et al. Short-term outcomes of lateral lumbar interbody fusion without decompression for the treatment of symptomatic degenerative spondylolisthesis at L4-5. Neurosurg Focus. 2018;44:E6.
are performed under the endoscope with a bidimensional vision. Relatively less decompression is performed because the endoscope tube limits the scope of decompression instruments. Furthermore, it is difficult to remove hidden free fragments, which are located beyond the endoscopic channel.13-15 Similarly, the recurrence rate after limited diskectomy was reported to be higher than that after aggressive diskectomy.16 Therefore interbody fusion could avoid recurrent disk herniation due to total diskectomy and preparation of end plate in LLIF surgery. In our study, no reherniated disk was found during follow-up in both the LLIF and TLIF groups, similar to the report of Yao et al.17 This study had several limitations. A larger cohort with a diverse range of disk pathology may provide additional insight into the ability to adequately indirectly decompress the revision level. A prospective randomized controlled trial with a longer follow-up period is necessary to provide more helpful information about the assessments of these surgical procedures.
8. Deutsch H. The predictive value of the baseline Oswestry Disability Index in lumbar disc arthroplasty. Neurosurg Focus. 2010;28:E7.
lumbar micro-endoscopic discectomy. Eur Spine J. 2010;19:443-450. 15. Matsumoto M, Watanabe K, Hosogane N, et al. Recurrence of lumbar disc herniation after microendoscopic discectomy. J Neurol Surg A Cent Eur Neurosurg. 2013;74:222-227.
9. Glassman S, Gornet MF, Branch C, et al. MOS short form 36 and Oswestry Disability Index outcomes in lumbar fusion: a multicenter experience. Spine J. 2006;6:21-26.
16. McGirt MJ, Ambrossi GL, Datoo G, et al. Recurrent disc herniation and long-term back pain after primary lumbar discectomy: review of outcomes reported for limited versus aggressive disc removal. Neurosurgery. 2009;64:338-344.
3. Phillips FM, Isaacs RE, Rodgers WB, et al. Adult degenerative scoliosis treated with XLIF: clinical and radiographical results of a prospective multicenter study with 24-month follow-up. Spine (Phila Pa 1976). 2013;38:1853-1861.
10. Yao Y, Zhang H, Wu J, et al. Minimally invasive transforaminal lumbar interbody fusion versus percutaneous endoscopic lumbar discectomy: revision surgery for recurrent herniation after microendoscopic discectomy. World Neurosurg. 2017;99:89-95.
17. Yao Y, Zhang H, Wu J, et al. Comparison of three minimally invasive spine surgery methods for revision surgery for recurrent herniation after percutaneous endoscopic lumbar discectomy. World Neurosurg. 2017;100:641-647.
4. Youssef JA, McAfee PC, Patty CA, et al. Minimally invasive surgery: lateral approach interbody fusion: results and review. Spine (Phila Pa 1976). 2010;35(suppl 26):S302-311.
11. Osterman H, Sund R, Seitsalo S, Keskimaki I. Risk of multiple reoperations after lumbar discectomy: a population-based study. Spine (Phila Pa 1976). 2003;28:621-627.
Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
5. Rodgers WB, Gerber EJ, Patterson J. Intraoperative and early postoperative complications in extreme lateral interbody fusion: an analysis of 600 cases. Spine (Phila Pa 1976). 2011;36:26-32.
12. Cheng J, Wang H, Zheng W, et al. Reoperation after lumbar disc surgery in two hundred and seven patients. Int Orthop. 2013;37:1511-1517.
6. Castro C, Oliveira L, Amaral R, Marchi L, Pimenta L. Is the lateral transpsoas approach feasible for the treatment of adult degenerative scoliosis? Clin Orthop Relat Res. 2014;472:1776-1783.
13. Kim JM, Lee SH, Ahn Y, Yoon DH, Lee CD, Lim ST. Recurrence after successful percutaneous endoscopic lumbar discectomy. Minim Invasive Neurosurg. 2007;50:82-85.
7. Park HY, Ha KY, Kim YH, et al. Minimally invasive lateral lumbar interbody fusion for adult
14. Teli M, Lovi A, Brayda-Bruno M, et al. Higher risk of dural tears and recurrent herniation with
2. Louie PK, Varthi AG, Narain AS, et al. Stand-alone lateral lumbar interbody fusion for the treatment of symptomatic adjacent segment degeneration following previous lumbar fusion. Spine J. 2018;18: 2025-2032.
WORLD NEUROSURGERY -: e1-e5, - 2019
Received 5 May 2019; accepted 30 July 2019 Citation: World Neurosurg. (2019). https://doi.org/10.1016/j.wneu.2019.07.226 Journal homepage: www.journals.elsevier.com/worldneurosurgery Available online: www.sciencedirect.com 1878-8750/$ - see front matter ª 2019 Elsevier Inc. All rights reserved.
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