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

Study Design. A cross-sectional observational study. Objective. This study aims to determine the diagnostic accuracy, sensitivity, and specificity of the Xpert MTB/RIF assay (Mycobacterium Tuberculosis/Rifampicin resistance) for the detection of spinal Tuberculosis (TB) and rifampicin (RIF) resistance. Summary of Background Data. The Spinal TB is often a paucibacillary extra pulmonary tuberculosis which gives a major challenge in early diagnosis and initializing the correct anti-tubercular treatment (ATT). Due to its rapidity and sensitivity, the dependence and reliability on the Xpert MTB/RIF assay has increased in the last few years. The studies describing accuracy of the Xpert MTB/RIF assay in spinal TB are scanty. Methods. This institutional review board-approved study included 360 diagnosed spinal TB patients. To determine the accuracy of the Xpert MTB/RIF assay, it was compared with other diagnostic tests like histopathology, acid fast bacilli (AFB) smear, culture, and drug sensitivity testing (DST). Results. The Xpert MTB/RIF assay showed 86.3% sensitivity and 85.3% specificity when compared with culture for the diagnosis of Spinal TB and showed 75.86% sensitivity, 96.12% specificity for RIF resistance when compared to DST. Four cases were false positive and 11 cases were false negative for RIF resistance on the Xpert MTB/RIF assay. Conclusion. The Xpert MTB/RIF assay is an efficient technique for the rapid diagnosis of spinal TB; however, a clinician should not solely rely on it for starting ATT. As there are false results also with this test which should be read cautiously and be well correlated with culture and DST pattern to guide the start of sensitive drug regimen only. The purpose is to prevent exposure of the second line drugs to false cases found on the Xpert MTB/RIF assay and avoid emergence of new acquired drug resistance. Level of Evidence: 4

The purpose of this study was to compare the clinical-radiological outcome and incidence of perioperative complications of MIS-TLIF at lower lumbar levels for elderly (Age >65 years) and younger patients (Age<65 years). Methods: A retrospective cohort study performed from 2011 to 2017. A total 138 patients who underwent MIS-TLIF were divided into two groups based on age (group A>65 years and group B<65 years). Perioperative clinical (co-morbidities, surgical time, blood loss, hospital stay, fusion level, VAS, ODI), radiological parameters (fusion, cage subsidence, implant failure), postoperative complications and satisfactory outcomes in the form of Wang's criteria were evaluated in both the groups. A statistical analysis between two matched groups was done with logistic regression analysis, chisquare and student t-test. Results: There was no statistical difference in blood loss, surgical time, mobilization and hospital stay between two groups however elderly patients took longer time to become pain free (p=0.001). Both groups showed significant improvement in ODI, VAS and Wang's outcome score however, no statistically significant difference noted in outcome between two groups at final follow up. General complications not affecting outcome were common in elderly group but no statistically significant difference noted among neurological events between both groups. Conclusion: MISS-TLIF surgery in elderly can produce successful clinical outcome and satisfaction after surgery in judiciously selected patients with proper preoperative risk assessment and optimization of medical co-morbidities. Elder age does not prove deterrent to outcome and should not be a contraindication to perform MISS-TLIF in lumbar degenerative diseases.

Study Design: A prospective study. Objectives: We present a largest study until date performed over a period of 10 years assessing the perioperative complications. The primary aim of this study was to review the incidence of perioperative complications of minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) in single-level lumbar degenerative diseases. Methods: A prospective study performed over a period of 10 years involving 560 patients who underwent single-level lumbar MI-TLIF. Perioperative clinical and radiological parameters, postoperative complications, and satisfactory outcomes in the form of Wang’s criteria were evaluated. All patients were scrutinized into 5 different categories based on the descriptive classification for perioperative complications suggested by the authors. Results: The mean age was 61.8 ± 12.7 years and male to female ratio was 0.8:1. The overall incidence of the perioperative complication was 25.5%. In all, 19.64% patients developed single complication, 4.64% patients were with 2 complications, and 1.25% patients developed 3 complications from the described categories. A total of 16.78% patients developed early (<6 months postsurgery) and 8.75% patients developed late (>6 months postsurgery) complications. Conclusion: This study showed 25.5% incidence of perioperative complications in MI-TLIF for degenerative lumbar disease over a period of 10 years with a higher incidence rate during the initial 3 years of practice. The described classification for perioperative complications is helpful to record, to evaluate and to understand the etiology based on its duration of occurrence in the perioperative period. MI-TLIF is an effective procedure with substantial clinical benefits in the form of excellent to good clinical-radiological outcomes.

This is a prospective cohort study involving patients who were followed for 2 years after total knee replacement (TKR) to determine changes in lumbar spine and knee symptoms. Purpose: The objectives of this study were to determine the percentage of patients undergoing bilateral TKR who present with coexisting lumbar spine problems and determine if TKR relieves lumbar spine symptoms. Overview of Literature: No studies quantify the percentage of TKR patients who experience relief of lumbar spine symptoms after TKR surgery. Methods: The study included 200 patients (164 females, 36 males) undergoing primary TKR. Follow-up was performed at 4 weeks, 3, 6, 12, and 24 months. Lumbar spine and knee symptom improvements were assessed using the Oswestry Disability Index (ODI) and Oxford Knee Score, respectively. Results: All 200 patients undergoing bilateral TKR presented with radiographic lumbar spine degenerative pathology; 60% (n=120) of the patients presented with moderate to severe clinical symptoms of lumbar spondylosis, including 54% (n=108) with degenerative lumbar spondylosis and lumbar canal stenosis and 6% (n=12) with degenerative spondylolisthesis. Of the 120 patients who presented with lumbar spine problems, 90% (n=108) reported improvement in their symptoms; the ODI score improved from 42.5%±4.1% preoperative score to 15.6%±2.3% postoperative score (p-value<0.001). Of the 12 patients with no improvement, 10 patients underwent percutaneous procedures for their lumbar spine pathology with good results, one patient underwent surgery, and one declined any intervention. Conclusions: A significant number of patients (60%) undergoing bilateral TKR also present with symptomatic lumbar spine problems. Patients with mild to moderate lumbar spine degenerative symptoms and no associated severe radiating pain on activity are more likely to experience relief of their symptoms post-TKR.

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This study's primary objective was to compare the clinico-radiological outcomes and incidence of perioperative complications of transforaminal lumbar interbody fusion (TLIF) at lower lumbar levels for elderly and younger patients. The secondary objective was to evaluate the effect of age on clinical outcomes and patient satisfaction in the two groups. Overview of Literature: The lumbar interbody fusion surgery in elder age has been reported to produce a higher complication rate and suboptimal results. Literature evaluating efficacy and safety of TLIF in elderly population is scanty. The effect of age on clinical outcome and the overall patient satisfaction after TLIF has been understudied. Methods: This retrospective study was conducted from 2011 to 2017 with 121 patients, who underwent TLIF and were divided into two cohorts based on age (group A, >65 years and group B, <65 years). Perioperative clinical/radiological parameters, postoperative complications, and satisfactory outcomes were evaluated in both groups. A statistical analysis between two matched groups was performed with logistic regression analysis and Student t-test. Results: The mean age was 73.8±4.5 years in group A and 47.3±12.7 years in group B. There was no statistical difference in surgical time (p=0.15), mobilization, or hospital stay (p=0.15) between the two groups. There were no statistically significant differences noted in the Oswestry Disability Index, Visual Analog Scale, or Wang's outcome score between the two groups at final follow-up. Postoperative complications not affecting outcome were common in the elderly group, but there was no statistically significant difference noted among neurological or cardiopulmonary events between the two groups. Conclusions: In judiciously selected patients with proper preoperative risk assessment and optimized medical co-morbidities, TLIF surgery can have successful results, in terms of clinical outcome and satisfaction, in the elderly. Older age should not be a contraindication for TLIF in patients with degenerative lumbar disease.

Study Design. Cohort. Objective. To evaluate perioperative morbidity in patients undergoing minimally invasive spine surgery of the lumbar spine while continuing the antiplatelet drug (APD) perioperatively as compared with those not continuing these drugs and those not on these drugs. Summary of Background Data. While discontinuation of antiplatelet drugs carries with it the risk of thrombosis of the cardiac stents, myocardial infarction, peripheral vascular occlusion, cerebro-vascular events and other thrombotic complications, continuation of these drugs has the risk of intra spinal bleeding and the serious consequences of subsequent epidural hematoma with associated spinal cord compression. Methods. This institutional review board approved study included 1587 patients from 2011 to 2018. Perioperative parameters were analyzed for 216 patients who underwent spinal surgery after the discontinuation of anticoagulation therapy, 240 patients who continued to take APD daily through the perioperative period and 1131 patients who were never exposed to APD therapy. The operative time, intraoperative estimated blood loss, length of hospital stay, incidence of clinically evident hematoma, and transfusion of blood products were also recorded and compared in three cohorts. Results. The patients who continued taking APD in the perioperative period had a longer length of hospital stay on average (2.5 ± 0.67 vs. 1.59 ± 0.76 and 1.67 ± 0.83, P < 0.05), whereas there was no significant difference in the operative time, estimated blood loss, the amount of blood products transfused, and overall intra and postoperative complication rate. There were no instances of postoperative wound soakage or neurological deficit suggestive of possible spinal epidural hematomas in either of the study groups. Conclusion. The current study has observed no appreciable increase in perioperative morbidities including bleeding related complication rates in patients undergoing lumbar minimally invasive spine surgery while continuing to take APD compared with patients who either discontinued APD prior to surgery or those not taking APD. Level of Evidence: 4