Comparative analysis of perioperative surgical site infection after minimally invasive versus open posterior/transforaminal lumbar interbody fusion: analysis of hospital billing and discharge data from 5170 patients

Abstract

<jats:sec> <jats:title>Object</jats:title> <jats:p>Surgical site infection (SSI) after lumbar fusion results in significant patient morbidity and associated medical resource utilization. Minimally invasive (MI) techniques for posterior/transforaminal lumbar interbody fusion (P/TLIF) were introduced with the goals of smaller wounds, less tissue trauma, reduced blood loss, and quicker postoperative recovery, while maintaining comparable surgical results. Studies with sufficient power to directly compare the incidence of SSI following MI versus open P/TLIF procedures have been lacking. Furthermore, the direct medical cost associated with the treatment of SSI following the P/TLIF procedure is poorly understood and has not been adequately assessed. Thus, the aim in the present study was to determine the incidence of perioperative SSI in patients undergoing MI versus open P/TLIF and the direct hospital cost associated with the diagnosis and management of SSI after P/TLIF as reported in a large administrative database.</jats:p></jats:sec> <jats:sec> <jats:title>Methods</jats:title> <jats:p>The authors retrospectively reviewed hospital discharge and billing records from the Premier Perspective Database for 2003 to 2009 to identify patients undergoing 1- or 2-level MI or open P/TLIF for lumbar spondylotic disease, disc degeneration, or spondylolisthesis. The ICD-9-CM procedure codes were used to identify patients undergoing P/TLIF and those experiencing SSI. Infection-related costs were obtained from the total costs incurred by the hospital for SSI-related care provided during inpatient or hospital outpatient encounters.</jats:p></jats:sec> <jats:sec> <jats:title>Results</jats:title> <jats:p>Five thousand one hundred seventy patients undergoing P/TLIF were identified. Demographic profiles, including the Charlson Comorbidity Index, were similar between MI and open cohorts. Overall, 292 patients (5.6%) experienced an SSI with a mean direct cost of $15,817 per SSI. For 1-level MI versus open P/TLIF, the incidence of SSI (38 [4.5%] vs 77 [4.8%], p = 0.77) and the mean SSI-associated cost per P/TLIF ($684 vs $724, p = 0.680) were similar. For 2-level MI versus open P/TLIF, the incidence of SSI (27 [4.6%] vs 150 [7.0%], p = 0.037) and mean SSI-associated cost per P/TLIF ($756 vs $1140, p = 0.030) were both significantly lower among MI-treated patients. In a multivariate model that accounted for differences in demographics and patient severity, open fusion was associated with a strong trend of increased incidence of SSI as compared with MI fusion (OR 1.469, 95% CI 0.959–2.250).</jats:p></jats:sec> <jats:sec> <jats:title>Conclusions</jats:title> <jats:p>In this multihospital study, the MI technique was associated with a decreased incidence of perioperative SSI and a direct cost savings of $38,400 per 100 P/TLIF procedure when used in 2-level fusion. There was no significant difference in the incidence of SSIs between the open and MI cohorts for 1-level fusion procedures. The results of this study provide further evidence of the reduced patient morbidity and health care costs associated with MI P/TLIF.</jats:p></jats:sec>

Does the microendoscopic technique reduce mortality and major complications in patients undergoing lumbar discectomy? A propensity score–matched analysis using a nationwide administrative database

“…Data in the present study are consistent with those in previous reports evaluating minimally invasive techniques. 20,26,28,38 In a retrospective study using an administrative database, McGirt and colleagues 20 reported that their minimally invasive technique was associated with a decrease in the incidence of SSI following 2-level posterior/transforaminal lumbar interbody fusion. O'Toole and colleagues postulated several possible reasons for the lower risk of SSI associated with minimally invasive surgery: reduced exposure of deep tissue, preventive effect of a tubular retractor for local contamination, smaller incisions, and reduced dead space in the surgical site after closure.…”

The anatomic rationale for transforaminal endoscopic interbody fusion: a cadaveric analysis

“…The potential advantages of converting a minimally invasive TLIF to a surgery performed under fully endoscopic visualization include a smaller incision, decreased blood loss, shorter patient recovery time, and the possibility of performing the surgery without general anesthesia. 5,8,[11][12][13] The significant anatomical feature of the lumbar neural foramen that makes endoscopic TLIF a challenge is the small working area between the traversing and exiting roots through which 1) a large amount of facet bone and disc material must be removed to achieve satisfactory nerve decompression, 2) sufficient endplate preparation…”

“…6,7 The minimally invasive TLIF procedure has been recently shown to reduce morbidity and health care costs in comparison with open TLIF. 5,8,10,11,14 We set out to evaluate the relevant anatomy at the neural foramen in consideration for the development of an interbody fusion device, appropriate instruments for neural decompression, and OBjEcTIVE The authors describe a cadaveric analysis to determine the ideal dimensions and trajectory for considering endoscopic transforaminal interbody implantation. mEThOdS The soft tissues of 8 human cadavers were removed from L-1 to the sacrum, exposing the posterior bony elements.…”

Minimally invasive lumbopelvic instrumentation for traumatic sacrolisthesis in an elderly patient

“…The advent of minimally invasive spine surgery (MIS) has been well applied to instrumentation constructs through most of the spinal axis with good results, allowing patients to have smaller incisions, less blood loss, shorter hospital stays, decreased rates of infections, and subsequent cost benefits [4][5][6]. Advocates of these techniques suggest that these factors lead to earlier mobilization and rehabilitation and decreased morbidity from being immobilized.…”