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OBJECTIVE The wide exposure required for a standard posterior lumbar interbody fusion (PLIF) can cause unnecessary trauma to the lumbar musculoligamentous complex. By combining existing microendoscopic, percutaneous instrumentation and interbody technologies, a novel, minimally invasive, percutaneous PLIF technique was developed to minimize such iatrogenic tissue injury (MIP-PLIF). METHODS The MIP-PLIF technique was validated in three cadaveric torsos with six motion segments decompressed and fused. Preoperative variables measured from imaging included interpedicular distance, pedicular height and width, interspinous distance, lordosis, intervertebral height, Cobb angle, and foraminal height and volume. Using the METRx and MD spinal access systems (Medtronic Sofamor Danek, Memphis, TN), bilateral laminotomies were performed using a hybrid of microsurgical and microendoscopic techniques. The intervertebral disc spaces were then distracted and prepared with the Tangent (Medtronic Sofamor Danek) interbody instruments. Either a 10 or 12 by 22 mm interbody graft was then placed. Using the Sextant (Medtronic Sofamor Danek) system, percutaneous pedicle screw-rod fixation of the motion segment was completed. We then applied MIP-PLIF in three patients. RESULTS For segments with preoperative intervertebral/foraminal height loss, MIP-PLIF was effective in restoring both heights in all cases. The amount of improvement (9.7 to 38% disc height increase; 7.7 to 29.9% foraminal height increase) varied directly with the size of the graft used and the original degree of disc and foraminal height loss. Segmental lordosis improved by 29% on average. Graft and screw placement was accurate in the cadavers, except for a single Grade 1 screw violation of one pedicle. The average operative time was 3.5 hours per level. In our three clinical cases, the MIP-PLIF procedure required a mean of 5.4 hours, estimated blood loss was 185 ml, and inpatient stay was 2.8 days, with no intravenous narcotic use after 2 days in any of the patients. All screw and graft placements were confirmed. CONCLUSION A complete PLIF procedure can be safely and effectively performed using minimally invasive techniques, thereby potentially reducing the pain and morbidity associated with standard open surgery. Prospective, randomized outcome studies will be required to validate the efficacy of this exciting new surgical technique.

Object. The authors studied a consecutive series of patients with spinal stenosis in whom surgery was performed by a single surgeon who used a microscopic tubular retractor system (METRx-MD); patients underwent prospective evaluation involving radiography and magnetic resonance (MR) imaging. The objective was to assess the feasibility and surgery-related efficacy of performing unilateral-approach bilateral decompression and utilization of METRx-MD instrumentation in patients with spinal stenosis. Methods. Seventeen consecutive patients with spinal stenosis underwent bilateral decompression; surgery was performed via a unilateral approach using METRx-MD instrumentation. The procedures were performed on an outpatient basis after induction of general anesthesia. Preoperative and 3-month follow-up plain radiographs with flexion—extension views were obtained. Preoperative and postoperative MR imaging was also performed. All studies were assessed by a single radiologist blinded to the clinical results. Twenty-two levels were surgically decompressed. The mean operative time was 90 minutes and the mean blood loss was 28 ml per level. Preoperatively stenosis was severe at 13 levels, moderate/severe at eight, and moderate at one. Postoperatively stenosis was absent at 13 levels, mild at seven, mild/moderate at one, and moderate at one. Preoperatively degenerative spondylolisthesis was documented in eight patients, with flexion—extension radiography revealing motion in three cases. On early (3-month) postoperative x-ray films there was no evidence of progression in any case. Grade I spondylolisthesis developed postoperatively in one patient, who remained asymptomatic. Conclusions. Minimally invasive bilateral decompression and instrumentation-assisted fusion can be successfully performed via a unilateral approach in patients with acquired spinal stenosis; the procedure can be undertaken on an outpatient basis, with reasonable operative times, minimal blood loss, and acceptable morbidity rates.

Objective: Literature on family function in stroke rehabilitation is reviewed in 3 areas: the impact of family function on recovery from stroke, the impact of stroke on family function, and psychosocial intervention in stroke. Study Design: Literature review. Results: Family function influences stroke rehabilitation. Family-based interventions are emerging but have not been proven effective. Health system changes have expanded the family's role in stroke care, increasing the need for psychosocial intervention research. Conclusions: Family function appears to influence stroke outcomes; a familysystems perspective promotes understanding of psychosocial outcomes in stroke; research has focused mainly on individual rather than family-systems models; tools to evaluate family process after stroke are inadequate; and more research is needed to develop and test optimal family intervention strategies.

Level III, retrospective comparative study.

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The short-term results of this third-generation technique show that it is a safe procedure with good clinical outcomes and compares favourably with earlier techniques.

GC improved the quality of chronic illness care received by multimorbid care recipients but did not improve caregivers' depressive symptoms, affect, or productivity.