Using minimally invasive techniques adds to the value equation for select patients

Mok, Jung; Gang, Catherine Himo; Qureshi, Sheeraz A.; McAnany, Steven J.

doi:10.21037/jss.2019.05.03

Cited by 14 publications

(9 citation statements)

References 38 publications

(34 reference statements)

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“…8 MIS techniques being utilized to treat degenerative lumbar conditions focus on minimal bony and ligamentous resection for insertion of the interbody cage. While the maintenance of these structures may be associated with reduced postoperative pain, 9,10 it likely restricts the amount of lordosis that can be generated at the operative level. 7,11 The combined impact of the surgical approach, cage position, and built-in cage lordotic angle on the amount of postoperative SL achieved remains unclear.…”

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confidence: 99%

Does interbody cage lordosis impact actual segmental lordosis achieved in minimally invasive lumbar spine fusion?

Lovecchio

Vaishnav

Steinhaus

et al. 2020

Neurosurgical Focus

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OBJECTIVEIn an effort to prevent loss of segmental lordosis (SL) with minimally invasive interbody fusions, manufacturers have increased the amount of lordosis that is built into interbody cages. However, the relationship between cage lordotic angle and actual SL achieved intraoperatively remains unclear. The purpose of this study was to determine if the lordotic angle manufactured into an interbody cage impacts the change in SL during minimally invasive surgery (MIS) for lumbar interbody fusion (LIF) done for degenerative pathology.METHODSThe authors performed a retrospective review of a single-surgeon database of adult patients who underwent primary LIF between April 2017 and December 2018. Procedures were performed for 1–2-level lumbar degenerative disease using contemporary MIS techniques, including transforaminal LIF (TLIF), lateral LIF (LLIF), and anterior LIF (ALIF). Surgical levels were classified on lateral radiographs based on the cage lordotic angle (6°–8°, 10°–12°, and 15°–20°) and the position of the cage in the disc space (anterior vs posterior). Change in SL was the primary outcome of interest. Subgroup analyses of the cage lordotic angle within each surgical approach were also conducted.RESULTSA total of 116 surgical levels in 98 patients were included. Surgical approaches included TLIF (56.1%), LLIF (32.7%), and ALIF (11.2%). There were no differences in SL gained by cage lordotic angle (2.7° SL gain with 6°–8° cages, 1.6° with 10°–12° cages, and 3.4° with 15°–20° cages, p = 0.581). Subgroup analysis of LLIF showed increased SL with 15° cages only (p = 0.002). The change in SL was highest after ALIF (average increase 9.8° in SL vs 1.8° in TLIF vs 1.8° in LLIF, p < 0.001). Anterior position of the cage in the disc space was also associated with a significantly greater gain in SL (4.2° vs −0.3°, p = 0.001), and was the only factor independently correlated with SL gain (p = 0.016).CONCLUSIONSCompared with cage lordotic angle, cage position and approach play larger roles in the generation of SL in 1–2-level MIS for lumbar degenerative disease.

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confidence: 99%

Does interbody cage lordosis impact actual segmental lordosis achieved in minimally invasive lumbar spine fusion?

Lovecchio

Vaishnav

Steinhaus

et al. 2020

Neurosurgical Focus

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“…Another study found a similar result for anterior cervical discectomy and fusion—overall charges for ambulatory anterior cervical discectomy and fusion were <50% of the charges in the inpatient setting 29. While some spine procedures are steadily shifting out of the hospital setting, one of the most prevalent and costly procedures—the lumbar fusion—remains largely an inpatient event 30–34. Some studies have reported a gradual increase in the prevalence of outpatient or ambulatory lumbar fusions in recent years; however, this trend has been halting at best 16.…”

Section: Discussionmentioning

confidence: 86%

“…29 While some spine procedures are steadily shifting out of the hospital setting, one of the most prevalent and costly proceduresthe lumbar fusion-remains largely an inpatient event. [30][31][32][33][34] Some studies have reported a gradual increase in the prevalence of outpatient or ambulatory lumbar fusions in recent years; however, this trend has been halting at best. 16 One possible explanation for this is that surgeons and medical centers question the safety of outpatient lumbar fusion, fearing that the lack of inpatient observation after surgery could increase the risk of complications.…”

Section: Discussionmentioning

confidence: 99%

Ambulatory Lumbar Fusion

Subramanian

Araghi

Sivaganesan

et al. 2022

Spine

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Study Design/Setting. Systematic review. Objective. The primary purpose was to propose patient selection criteria and perioperative best practices that can serve as a starting point for an ambulatory lumbar fusion program. The secondary purpose was to review patient-reported outcomes (PROs) after ambulatory lumbar fusion. Summary of Background. As healthcare costs rise, there is an increasing emphasis on cost saving strategies (i.e. outpatient/ambulatory surgeries). Lumbar fusion procedures remain a largely inpatient surgery. Early studies have shown that fusion procedures can be safely preformed in an outpatient setting but no review has summarized these findings and best practices. Materials and Methods. This study was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. PubMed/MEDLINE, The Cochrane Library, and Embase were searched. The following data were collected: (1) study design; (2) number of participants; (3) patient population; (4) procedure types; (5) procedure setting; (6) inclusion criteria; (7) protocols; (8) adverse events; (9) PROs; and (10) associations between patient/surgical factors, setting, and outcomes. Results. The search yielded 20 publications. The following selection criteria for ambulatory lumbar fusion were identified: age below 70, minimal comorbidities, low/normal body mass index, no tobacco use, and no opioid use. The perioperative protocol can include a multimodal analgesic regimen. The patient should be observed for at least three hours after surgery. The patient should not be discharged without an alertness check and a neurological examination. Patients experienced significant improvements in PROs after ambulatory lumbar fusion; similarly, when compared to an inpatient group, ambulatory lumbar fusion patients experienced a comparable or superior improvement in PROs. Conclusion. There are two critical issues surrounding ambulatory lumbar fusion: (1) Who is the ideal patient, and (2) What needs to be done to enable expedited discharge? We believe this review will provide a foundation to assist surgeons in making decisions regarding the performance of lumbar fusion on an ambulatory basis. Level of Evidence. Level III.

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“…Minimally invasive techniques have been reported to decrease intraoperative blood loss and injury to the surrounding tissues, and this may be particularly beneficial in the elderly. [3][4][5][6][7][8][9] Lumbar fusion is a more invasive procedure compared to decompression alone because it frequently involves…”

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Improvement following minimally invasive transforaminal lumbar interbody fusion in patients aged 70 years or older compared with younger age groups

Shahi

Dalal

Shinn

et al. 2023

Neurosurgical Focus

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OBJECTIVE The goal of this study was to assess the outcomes of minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) in patients ≥ 70 years old and compare them to younger age groups. METHODS This was a retrospective study of data that were collected prospectively. Patients who underwent primary single-level MI-TLIF were included and divided into 3 groups: age < 60, 60–69, and ≥ 70 years. The outcome measures were as follows: 1) patient-reported outcome measures (PROMs) (i.e., visual analog scale [VAS] for back and leg pain, Oswestry Disability Index [ODI], 12-Item Short-Form Health Survey Physical Component Summary [SF-12 PCS]); 2) minimum clinically important difference (MCID) achievement; 3) return to activities; 4) opioid discontinuation; 5) fusion rates; and 6) complications/reoperations. RESULTS A total of 147 patients (age < 60 years, 62; 60–69 years, 47; ≥ 70 years, 38) were included. All the groups showed significant improvements in all PROMs at the early (< 6 months) and late (≥ 6 months) time points and there was no significant difference between the groups. Although MCID achievement rates for VAS leg and ODI were similar, they were lower in the ≥ 70-year-old patient group for VAS back and SF-12 PCS. Although the time to MCID achievement for ODI and SF-12 PCS was similar, it was greater in the ≥ 70-year-old patient group for VAS back and leg. There was no significant difference between the groups in terms of return to activities, opioid discontinuation, fusion rates, and complication/reoperation rates. CONCLUSIONS Although patients > 70 years of age may be less likely and/or take longer to achieve MCID compared to their younger counterparts, they show an overall significant improvement in PROMs, a similar likelihood of returning to activities and discontinuing opioids, and comparable fusion and complication/reoperation rates following MI-TLIF.

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Using minimally invasive techniques adds to the value equation for select patients

Cited by 14 publications

References 38 publications

Does interbody cage lordosis impact actual segmental lordosis achieved in minimally invasive lumbar spine fusion?

Does interbody cage lordosis impact actual segmental lordosis achieved in minimally invasive lumbar spine fusion?

Ambulatory Lumbar Fusion

Improvement following minimally invasive transforaminal lumbar interbody fusion in patients aged 70 years or older compared with younger age groups

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