Minimally invasive microendoscopy-assisted transforaminal lumbar interbody fusion with instrumentation

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Object

The authors have developed a novel technique for percutaneous fusion in which standard microendoscopic discectomy is modified. Based on data obtained in their cadaveric studies they considered that this minimally invasive interbody fusion could be safely implemented clinically. The authors describe their initial experience with a microendoscopic transforaminal lumbar interbody fusion (METLIF) technique, with regard to safety in the placement of percutaneous instrumentation, perioperative morbidity, and early postoperative results.

Methods

The METLIF procedure was performed unilaterally in 20 patients with single-level lumbar spondylolisthesis or pure mechanical back pain with endoscopic assistance, hemilaminectomy, unilateral facetectomy, and microdiscectomy. Two interbody grafts were placed via the lateral exposure of the disc space. Bilateral percutaneous pedicle screws were then inserted.

Compared with patients who had undergone single-level posterior LIF at the same institutions, intraoperative blood loss, hospital length of stay (LOS), and postoperative narcotic agent use were significantly lower in the METLIF group. The mean LOS for the percutaneous fusion group was 3.4 days (5.1 days in those who underwent PLIF; p < 0.02). There have been no procedure-related complications in this series to date.

Conclusions

The METLIF technique provided an option for percutaneous interbody fusion similar to that in open surgery while minimizing destruction to adjacent tissues. This technique was safe and exhibited a trend toward decreased intraoperative blood loss, postoperative pain, total narcotic use, and the risk of transfusion.

Article Information

Address reprint requests to: Robert E. Isaacs, M.D., Duke University Medical Center, Durham, North Carolina 27710. email: podichv@ccf.org.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Preoperative and postoperative lateral radiographs obtained in a patient who underwent an METLIF for an isthmic spondylolisthesis at L5—S1. Note the improvement in disc height achieved despite the lack of posterior element or pedicle screw distraction.

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    Early postoperative axial CT scans acquired in a patient who underwent an L4–5 METLIF clearly revealing the location of entry into the fascia (circled in black) as well as the approach angle of the procedure (black arrows). Note how the grafts follow this approach trajectory and the location of the chiseled paths used to prepare the endplates (black lines). Other slices of this CT scan (not shown) confirmed the proper placement of the pedicle screws while graft material can be seen in this image between the allografts and posterolaterally, emphasizing that the procedure being performed in essentially identical to the open procedure.

  • View in gallery

    Representative postoperative results achieved in a 39-year-old man 1 year following an L5—S1 ME-TLIF. Anteroposterior (left), flexion (center), and extension (right) radiographs clearly demonstrating fusion of the L5—S1 interspace.

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    Graphs depicting age (upper) and sex (lower) distributions of patients in the study. Actual age in years and number of men and women is given above each bar. O = open.

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    Distribution of cases by vertebral level in the study is shown. Actual number of cases per level is given above each bar in the graph.

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    Bar graphs. Upper: Operative time (a), blood loss (b), and transfusion rate (c) are compared between METLIF and control PLIF groups. Center and Lower: Blood loss (center) and transfusion rate (lower) are compared between METLIF and control PLIF groups. A statistically significant difference was observed between groups for blood loss (p < 0.002) and transfusion rate (p < 0.001).

  • View in gallery

    Duration of hospital stay (upper) and narcotic use (lower) for each group. A statistically significant difference (**p < 0.02) was noted in both analyses.

References

  • 1.

    Arai YTakahashi MKurosawa HShitoto K: Comparative study of iliac bone graft and carbon cage with local bone graft in posterior lumbar interbody fusion. J Orthop Surg (Hong Kong) 10:172002Arai Y Takahashi M Kurosawa H Shitoto K: Comparative study of iliac bone graft and carbon cage with local bone graft in posterior lumbar interbody fusion. J Orthop Surg (Hong Kong) 10:1–7 2002

    • Search Google Scholar
    • Export Citation
  • 2.

    Branch CLBranch CL Jr: Posterior lumbar interbody fusion: the keystone technique in Lin PMGill K (eds): Lumbar Interbody Fusion. Rockville, MD: Aspen1989 pp 211219Branch CL Branch CL Jr: Posterior lumbar interbody fusion: the keystone technique in Lin PM Gill K (eds): Lumbar Interbody Fusion. Rockville MD: Aspen 1989 pp 211–219

    • Search Google Scholar
    • Export Citation
  • 3.

    Brantigan JWSteffee ADLewis MLQuinn LMPersenaire JM: Lumbar interbody fusion using the Brantigan I/F cage for posterior lumbar interbody fusion and variable pedicle screw placement system: two-year results from a Food and Drug Administration investigational device exemption clinical trial. Spine 25:143714462000Brantigan JW Steffee AD Lewis ML Quinn LM Persenaire JM: Lumbar interbody fusion using the Brantigan I/F cage for posterior lumbar interbody fusion and variable pedicle screw placement system: two-year results from a Food and Drug Administration investigational device exemption clinical trial. Spine 25:1437–1446 2000

    • Search Google Scholar
    • Export Citation
  • 4.

    Cloward RB: Spondylolisthesis: treatment by laminectomy and posterior interbody fusion. Clin Orthop Relat Res 154:74821981Cloward RB: Spondylolisthesis: treatment by laminectomy and posterior interbody fusion. Clin Orthop Relat Res 154:74–82 1981

    • Search Google Scholar
    • Export Citation
  • 5.

    Cloward RB: The treatment of ruptured lumbar intervertebral discs by vertebral body fusion. I. Indications, operative technique, after care. J Neurosurg 10:1541681953Cloward RB: The treatment of ruptured lumbar intervertebral discs by vertebral body fusion. I. Indications operative technique after care. J Neurosurg 10:154–168 1953

    • Search Google Scholar
    • Export Citation
  • 6.

    Elias WJSimmons NEKaptain GJChadduck JBWhitehill R: Complications of posterior lumbar interbody fusion when using a titanium-threaded cage device. J Neurosurg (Spine 1) 93:45522000Elias WJ Simmons NE Kaptain GJ Chadduck JB Whitehill R: Complications of posterior lumbar interbody fusion when using a titanium-threaded cage device. J Neurosurg (Spine 1) 93:45–52 2000

    • Search Google Scholar
    • Export Citation
  • 7.

    Escobar ETransfeldt EGarvey TOgilvie JGraber JSchultz L: Video-assisted versus open anterior lumbar spine fusion surgery: a comparison of four techniques and complications in 135 patients. Spine 28:7297322003Escobar E Transfeldt E Garvey T Ogilvie J Graber J Schultz L: Video-assisted versus open anterior lumbar spine fusion surgery: a comparison of four techniques and complications in 135 patients. Spine 28:729–732 2003

    • Search Google Scholar
    • Export Citation
  • 8.

    Fessler RGKhoo LT: Minimally invasive cervical microendoscopic foraminotomy: an initial clinical experience. Neurosurgery 51:S37S452002Fessler RG Khoo LT: Minimally invasive cervical microendoscopic foraminotomy: an initial clinical experience. Neurosurgery 51:S37–S45 2002

    • Search Google Scholar
    • Export Citation
  • 9.

    Foley KTGupta SK: Percutaneous pedicle screw fixation of the lumbar spine: preliminary clinical results. J Neurosurg (Suppl 1) 97:7122002Foley KT Gupta SK: Percutaneous pedicle screw fixation of the lumbar spine: preliminary clinical results. J Neurosurg (Suppl 1) 97:7–12 2002

    • Search Google Scholar
    • Export Citation
  • 10.

    Fraser RD: Interbody, posterior, and combined lumbar fusions. Spine 20:S1671771995Fraser RD: Interbody posterior and combined lumbar fusions. Spine 20:S167–177 1995

    • Search Google Scholar
    • Export Citation
  • 11.

    Guiot BHKhoo LTFessler RG: A minimally invasive technique for decompression of the lumbar spine. Spine 27:4324382002Guiot BH Khoo LT Fessler RG: A minimally invasive technique for decompression of the lumbar spine. Spine 27:432–438 2002

    • Search Google Scholar
    • Export Citation
  • 12.

    Hacker RJ: Comparison of interbody fusion approaches for disabling low back pain. Spine 22:6606661997Hacker RJ: Comparison of interbody fusion approaches for disabling low back pain. Spine 22:660–666 1997

    • Search Google Scholar
    • Export Citation
  • 13.

    Hee HTCastro FP JrMajd MEHolt RTMyers L: Anterior/posterior lumbar fusion versus transforaminal lumbar interbody fusion: analysis of complications and predictive factors. J Spinal Disord 14:5335402001Hee HT Castro FP Jr Majd ME Holt RT Myers L: Anterior/posterior lumbar fusion versus transforaminal lumbar interbody fusion: analysis of complications and predictive factors. J Spinal Disord 14:533–540 2001

    • Search Google Scholar
    • Export Citation
  • 14.

    Humphreys SCHodges SDPatwardhan AGEck JCMurphy RBCovington LA: Comparison of posterior and transforaminal approaches to lumbar interbody fusion. Spine 26:5675712001Humphreys SC Hodges SD Patwardhan AG Eck JC Murphy RB Covington LA: Comparison of posterior and transforaminal approaches to lumbar interbody fusion. Spine 26:567–571 2001

    • Search Google Scholar
    • Export Citation
  • 15.

    Kawaguchi YMatsui HTsuji H: Back muscle injury after posterior lumbar spine surgery. A histologic and enzymatic analysis. Spine 21:9419441996Kawaguchi Y Matsui H Tsuji H: Back muscle injury after posterior lumbar spine surgery. A histologic and enzymatic analysis. Spine 21:941–944 1996

    • Search Google Scholar
    • Export Citation
  • 16.

    Kawaguchi YYabuki SStyf JOlmarker KRydevik BMatsui Het al: Back muscle injury after posterior lumbar spine surgery. Topographic evaluation of intramuscular pressure and blood flow in the porcine back muscle during surgery. Spine 21:268326881996Kawaguchi Y Yabuki S Styf J Olmarker K Rydevik B Matsui H et al: Back muscle injury after posterior lumbar spine surgery. Topographic evaluation of intramuscular pressure and blood flow in the porcine back muscle during surgery. Spine 21:2683–2688 1996

    • Search Google Scholar
    • Export Citation
  • 17.

    Khan SNSandhu HSLane JMCammisa FP JrGirardi FP: Bone morphogenetic proteins: relevance in spine surgery. Orthop Clin North Am 33:4474632002Khan SN Sandhu HS Lane JM Cammisa FP Jr Girardi FP: Bone morphogenetic proteins: relevance in spine surgery. Orthop Clin North Am 33:447–463 2002

    • Search Google Scholar
    • Export Citation
  • 18.

    Khoo LTPalmer SLaich DTFessler RG: Minimally invasive percutaneous posterior lumbar interbody fusion. Neurosurgery 51:S166S1812002Khoo LT Palmer S Laich DT Fessler RG: Minimally invasive percutaneous posterior lumbar interbody fusion. Neurosurgery 51:S166–S181 2002

    • Search Google Scholar
    • Export Citation
  • 19.

    Kuslich SDUlstrom CLGriffith SLAhern JWDowdle JD. The Bagby and Kuslich method of lumbar interbody fusion. History, techniques, and 2-year follow-up results of a United States prospective, multicenter trial. Spine 23:26712791998Kuslich SD Ulstrom CL Griffith SL Ahern JW Dowdle JD. The Bagby and Kuslich method of lumbar interbody fusion. History techniques and 2-year follow-up results of a United States prospective multicenter trial. Spine 23:267–1279 1998

    • Search Google Scholar
    • Export Citation
  • 20.

    Lin PM: Posterior lumbar interbody fusion technique: complications and pitfalls. Clin Orthop Relat Res 193:901021985Lin PM: Posterior lumbar interbody fusion technique: complications and pitfalls. Clin Orthop Relat Res 193:90–102 1985

    • Search Google Scholar
    • Export Citation
  • 21.

    Loguidice VAJohnson RGGuyer RDStith WJOhnmeiss DDHochschuler SHet al: Anterior lumbar interbody fusion. Spine 13:3663691988Loguidice VA Johnson RG Guyer RD Stith WJ Ohnmeiss DD Hochschuler SH et al: Anterior lumbar interbody fusion. Spine 13:366–369 1988

    • Search Google Scholar
    • Export Citation
  • 22.

    Ma GW: Posterior interbody fusion with specialized instruments. Clin Orthop Relat Res 193:57631985Ma GW: Posterior interbody fusion with specialized instruments. Clin Orthop Relat Res 193:57–63 1985

    • Search Google Scholar
    • Export Citation
  • 23.

    McAfee PCRegan JRZdeblick TZuckerman JPicetti GD IIIHeim Set al: The incidence of complications in endoscopic anterior thoracolumbar spinal reconstructive surgery. A prospective multicenter study comprising the first 100 consecutive cases. Spine 20:162416321995McAfee PC Regan JR Zdeblick T Zuckerman J Picetti GD III Heim S et al: The incidence of complications in endoscopic anterior thoracolumbar spinal reconstructive surgery. A prospective multicenter study comprising the first 100 consecutive cases. Spine 20:1624–1632 1995

    • Search Google Scholar
    • Export Citation
  • 24.

    McDonnell MFGlassman SDDimar JR IIPuno RMJohnson JR: Perioperative complications of anterior procedures of the spine. J Bone Joint Surg Am 78:8398471996McDonnell MF Glassman SD Dimar JR II Puno RM Johnson JR: Perioperative complications of anterior procedures of the spine. J Bone Joint Surg Am 78:839–847 1996

    • Search Google Scholar
    • Export Citation
  • 25.

    Moskowitz A: Transforaminal lumbar interbody fusion. Orthop Clin North Am 33:3593662002Moskowitz A: Transforaminal lumbar interbody fusion. Orthop Clin North Am 33:359–366 2002

    • Search Google Scholar
    • Export Citation
  • 26.

    Perez-Cruet MJFoley KTIsaacs RERice-Wyllie LWellington RSmith MMet al: Microendoscopic lumbar discectomy: technical note. Neurosurgery 51:S129S1362002Perez-Cruet MJ Foley KT Isaacs RE Rice-Wyllie L Wellington R Smith MM et al: Microendoscopic lumbar discectomy: technical note. Neurosurgery 51:S129–S136 2002

    • Search Google Scholar
    • Export Citation
  • 27.

    Pradhan BBNassar JADelamarter RBWang JC: Single-level lumbar spine fusion: a comparison of anterior and posterior approaches. J Spinal Disord Tech 15:3553612002Pradhan BB Nassar JA Delamarter RB Wang JC: Single-level lumbar spine fusion: a comparison of anterior and posterior approaches. J Spinal Disord Tech 15:355–361 2002

    • Search Google Scholar
    • Export Citation
  • 28.

    Rajaraman VVingan RRoth PHeary RFConklin LJacobs GB: Visceral and vascular complications resulting from anterior lumbar interbody fusion. J Neurosurg (Spine 1) 91:60641999Rajaraman V Vingan R Roth P Heary RF Conklin L Jacobs GB: Visceral and vascular complications resulting from anterior lumbar interbody fusion. J Neurosurg (Spine 1) 91:60–64 1999

    • Search Google Scholar
    • Export Citation
  • 29.

    Rosenberg WSMummaneni PV: Transforaminal lumbar interbody fusion: technique, complications, and early results. Neurosurgery 48:5695752001Rosenberg WS Mummaneni PV: Transforaminal lumbar interbody fusion: technique complications and early results. Neurosurgery 48:569–575 2001

    • Search Google Scholar
    • Export Citation
  • 30.

    Stonecipher TWright S: Posterior lumbar interbody fusion with facet-screw fixation. Spine 14:4684711989Stonecipher T Wright S: Posterior lumbar interbody fusion with facet-screw fixation. Spine 14:468–471 1989

    • Search Google Scholar
    • Export Citation
  • 31.

    Tiusanen HSeitsalo SOsterman KSoini J: Retrograde ejaculation afer anterior interbody lumbar fusion. Eur Spine J 4:3393421995Tiusanen H Seitsalo S Osterman K Soini J: Retrograde ejaculation afer anterior interbody lumbar fusion. Eur Spine J 4:339–342 1995

    • Search Google Scholar
    • Export Citation
  • 32.

    Wetzel FTLaRocca H: The failed posterior lumbar interbody fusion. Spine 16:8398451991Wetzel FT LaRocca H: The failed posterior lumbar interbody fusion. Spine 16:839–845 1991

    • Search Google Scholar
    • Export Citation
  • 33.

    Whitecloud TS IIIRoesch WWRicciardi JE: Transforaminal interbody fusion versus anterior-posterior interbody fusion of the lumbar spine: a financial analysis. J Spinal Disord 14:1001032001Whitecloud TS III Roesch WW Ricciardi JE: Transforaminal interbody fusion versus anterior-posterior interbody fusion of the lumbar spine: a financial analysis. J Spinal Disord 14:100–103 2001

    • Search Google Scholar
    • Export Citation
  • 34.

    Zdeblick TA: A prospective randomized study of the surgical treatment of L5—S1 degenerative disc disease. Proceedings of the Tenth Annual Meeting of the North American Spine Society. Washington DC1995Zdeblick TA: A prospective randomized study of the surgical treatment of L5—S1 degenerative disc disease. Proceedings of the Tenth Annual Meeting of the North American Spine Society. Washington DC 1995

    • Search Google Scholar
    • Export Citation

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