John Paul G. Kolcun, G. Damian Brusko, Gregory W. Basil, Richard Epstein and Michael Y. Wang
Open spinal fusion surgery is often associated with significant blood loss, postoperative pain, and prolonged recovery times. Seeking to minimize surgical and perioperative morbidity, the authors adopted an endoscopic minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) technique performed without general anesthesia. In this report, they present data on the first 100 patients treated with this procedure.
The authors conducted a retrospective review of the first 100 patients who underwent awake endoscopic MIS-TLIF at a single institution between 2014 and 2017. Surgery was performed while the patient was sedated but without intubation or the use of general anesthetic or narcotic agents. Long-lasting (liposomal) bupivacaine was used for local analgesia. The discectomy and placement of an expandable interbody graft were performed endoscopically, followed by percutaneous pedicle screw implantation. Inclusion criteria for the procedure consisted of diagnosis of degenerative disc disease with grade I or II spondylolisthesis and evidence of spinal stenosis or nerve impingement with intractable symptomatology.
Of the first 100 patients, 56 were female and 44 were male. Single-level fusion was performed in 84 patients and two-level fusion in 16 patients. The most commonly fused level was L4–5, representing 77% of all fused levels. The mean (± standard deviation) operative time was 84.5 ± 21.7 minutes for one-level fusions and 128.1 ± 48.6 minutes for two-level procedures. The mean intraoperative blood loss was 65.4 ± 76.6 ml for one-level fusions and 74.7 ± 33.6 ml for two-level fusions. The mean length of hospital stay was 1.4 ± 1.0 days. Four deaths occurred in the 100 patients; all four of those patients died from complications unrelated to surgery. In 82% of the surviving patients, 1-year follow-up Oswestry Disability Index (ODI) data were available. The mean preoperative ODI score was 29.6 ± 15.3 and the mean postoperative ODI score was 17.2 ± 16.9, which represents a significant mean reduction in the ODI score of −12.3 using a two-tailed paired t-test (p = 0.000001). In four cases, the surgical plan was revised to include general endotracheal anesthesia intraoperatively and was successfully completed. Other complications included two cases of cage migration, one case of osteomyelitis, and one case of endplate fracture; three of these complications occurred in the first 50 cases.
This series of the first 100 patients to undergo awake endoscopic MIS-TLIF demonstrates outcomes comparable to those reported in our earlier papers. This procedure can provide a safe and efficacious option for lumbar fusion with less morbidity than open surgery. Further refinements in surgical technique and technologies will allow for improved success.
G. Damian Brusko, John Paul G. Kolcun, Julie A. Heger, Allan D. Levi, Glen R. Manzano, Karthik Madhavan, Timur Urakov, Richard H. Epstein and Michael Y. Wang
Lumbar fusion is typically associated with high degrees of pain and immobility. The implementation of an enhanced recovery after surgery (ERAS) approach has been successful in speeding the recovery after other surgical procedures. In this paper, the authors examined the results of early implementation of ERAS for lumbar fusion.
Beginning in March 2018 at the authors’ institution, all patients undergoing posterior, 1- to 3-level lumbar fusion surgery by any of 3 spine surgeons received an intraoperative injection of liposomal bupivacaine, immediate single postoperative infusion of 1-g intravenous acetaminophen, and daily postoperative visits from the authors’ multidisciplinary ERAS care team. Non–English- or non–Spanish-speaking patients and those undergoing nonelective or staged procedures were excluded. Reviews of medical records were conducted for the ERAS cohort of 57 patients and a comparison group of 40 patients who underwent the same procedures during the 6 months before implementation.
Groups did not differ significantly with regard to sex, age, or BMI (all p > 0.05). Length of stay was significantly shorter in the ERAS cohort than in the control cohort (2.9 days vs 3.8 days; p = 0.01). Patients in the ERAS group consumed significantly less oxycodone-acetaminophen than the controls on postoperative day (POD) 0 (408.0 mg vs 1094.7 mg; p = 0.0004), POD 1 (1320.0 mg vs 1708.4 mg; p = 0.04), and POD 3 (1500.1 mg vs 2105.4 mg; p = 0.03). Postoperative pain scores recorded by the physical therapy and occupational therapy teams and nursing staff each day were lower in the ERAS cohort than in controls, with POD 1 achieving significance (4.2 vs 6.0; p = 0.006). The total amount of meperidine (8.8 mg vs 44.7 mg; p = 0.003) consumed was also significantly decreased in the ERAS group, as was ondansetron (2.8 mg vs 6.0 mg; p = 0.02). Distance ambulated on each POD was farther in the ERAS cohort, with ambulation on POD 1 (109.4 ft vs 41.4 ft; p = 0.002) achieving significance.
In this very initial implementation of the first phase of an ERAS program for short-segment lumbar fusion, the authors were able to demonstrate substantial positive effects on the early recovery process. Importantly, these effects were not surgeon-specific and could be generalized across surgeons with disparate technical predilections. The authors plan additional iterations to their ERAS protocols for continued quality improvements.
Michael Y. Wang, Stacie Tran, G. Damian Brusko, Robert Eastlack, Paul Park, Pierce D. Nunley, Adam S. Kanter, Juan S. Uribe, Neel Anand, David O. Okonkwo, Khoi D. Than, Christopher I. Shaffrey, Virginie Lafage, Gregory M. Mundis Jr., Praveen V. Mummaneni and the MIS-ISSG Group
The past decade has seen major advances in techniques for treating more complex spinal disorders using minimally invasive surgery (MIS). While appealing from the standpoint of patient perioperative outcomes, a major impediment to adoption has been the significant learning curve in utilizing MIS techniques.
Data were retrospectively analyzed from a multicenter series of adult spinal deformity surgeries treated at eight tertiary spine care centers in the period from 2008 to 2015. All patients had undergone a less invasive or hybrid approach for a deformity correction satisfying the following inclusion criteria at baseline: coronal Cobb angle ≥ 20°, sagittal vertical axis (SVA) > 5 cm, or pelvic tilt > 20°. Analyzed data included baseline demographic details, severity of deformity, surgical metrics, clinical outcomes (numeric rating scale [NRS] score and Oswestry Disability Index [ODI]), radiographic outcomes, and complications. A minimum follow-up of 2 years was required for study inclusion.
Across the 8-year study period, among 222 patients, there was a trend toward treating increasingly morbid patients, with the mean age increasing from 50.7 to 62.4 years (p = 0.013) and the BMI increasing from 25.5 to 31.4 kg/m2 (p = 0.12). There was no statistical difference in the severity of coronal and sagittal deformity treated over the study period. With regard to radiographic changes following surgery, there was an increasing emphasis on sagittal correction and, conversely, less coronal correction. There was no statistically significant difference in clinical outcomes over the 8-year period, and meaningful improvements were seen in all years (ODI range of improvement: 15.0–26.9). Neither were there statistically significant differences in major complications; however, minor complications were seen less often as the surgeons gained experience (p = 0.064). Operative time was decreased on average by 47% over the 8-year period.
Trends in surgical practice were seen as well. Total fusion construct length was unchanged until the last year when there was a marked decrease in conjunction with a decrease in interbody levels treated (p = 0.004) while obtaining a higher degree of sagittal correction, suggesting more selective but powerful interbody reduction methods as reflected by an increase in the lateral and anterior column resection techniques being utilized.
The use of minimally invasive methods for adult spinal deformity surgery has evolved over the past decade. Experienced surgeons are treating older and more morbid patients with similar outcomes. A reliance on selective, more powerful interbody approaches is increasing as well.