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

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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.


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.


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).


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.

Abbreviations used in this paper: CCI = Charlson Comorbidity Index; MI = minimally invasive; PLIF = posterior lumbar interbody fusion; SSI = surgical site infection; TLIF = transforaminal LIF.

Article Information

Address correspondence to: Matthew J. McGirt, M.D., 4347 Village at Vanderbilt, Nashville, Tennessee 37232-8618. email:

Please include this information when citing this paper: published online March 18, 2011; DOI: 10.3171/2011.1.SPINE10571.

© AANS, except where prohibited by US copyright law.




Arnold PMRobbins SPaullus WFaust SHolt RMcGuire R: Clinical outcomes of lumbar degenerative disc disease treated with posterior lumbar interbody fusion allograft spacer: a prospective, multicenter trial with 2-year follow-up. Am J Orthop 38:E115E1222009


Barker FG II: Efficacy of prophylactic antibiotic therapy in spinal surgery: a meta-analysis. Neurosurgery 51:3914012002


Beiner JMGrauer JKwon BKVaccaro AR: Postoperative wound infections of the spine. Neurosurg Focus 15:3E142003


Burke TAWisniewski TErnst FR: Resource utilization and costs associated with chemotherapy-induced nausea and vomiting (CINV) following highly or moderately emetogenic chemotherapy administered in the US outpatient hospital setting. Support Care Cancer 19:1311402010


Calderone RRGarland DECapen DAOster H: Cost of medical care for postoperative spinal infections. Orthop Clin North Am 27:1711821996


Calderone RRThomas JC JrHaye WAbeles D: Outcome assessment in spinal infections. Orthop Clin North Am 27:2012051996


Charlson MEPompei PAles KLMacKenzie CR: A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis 40:3733831987


Dhall SSWang MYMummaneni PV: Clinical and radiographic comparison of mini-open transforaminal lumbar interbody fusion with open transforaminal lumbar interbody fusion in 42 patients with long-term follow-up. J Neurosurg Spine 9:5605652008


Dorr LDMaheshwari AVLong WTWan ZSirianni LE: Early pain relief and function after posterior minimally invasive and conventional total hip arthroplasty. A prospective, randomized, blinded study. J Bone Joint Surg Am 89:115311602007


Fritzell PHagg OJonsson DNordwall A: Cost-effectiveness of lumbar fusion and nonsurgical treatment for chronic low back pain in the Swedish Lumbar Spine Study: a multicenter, randomized, controlled trial from the Swedish Lumbar Spine Study Group. Spine 29:421434Z32004


Gaynes RPCulver DHHoran TCEdwards JRRichards CTolson JS: Surgical site infection (SSI) rates in the United States, 1992–1998: the National Nosocomial Infections Surveillance System basic SSI risk index. Clin Infect Dis 33:Suppl 2S69S772001


Gejo RMatsui HKawaguchi YIshihara HTsuji H: Serial changes in trunk muscle performance after posterior lumbar surgery. Spine 24:102310281999


Glassman SDPolly DWDimar JRCarreon LY: The cost effectiveness of single-level instrumented posterolateral lumbar fusion at five years after surgery. Spine [epub ahead of print]2010


Goyal NWimberley DWHyatt AZeiller SVaccaro ARHilibrand AS: Radiographic and clinical outcomes after instrumented reduction and transforaminal lumbar interbody fusion of mid and high-grade isthmic spondylolisthesis. J Spinal Disord Tech 22:3213272009


Hackenberg LHalm HBullmann VVieth VSchneider MLiljenqvist U: Transforaminal lumbar interbody fusion: a safe technique with satisfactory three to five year results. Eur Spine J 14:5515582005


Ikuta KTono OTanaka TArima JNakano SSasaki K: Surgical complications of microendoscopic procedures for lumbar spinal stenosis. Minim Invasive Neurosurg 50:1451492007


Lee CKVessa PLee JK: Chronic disabling low back pain syndrome caused by internal disc derangements. The results of disc excision and posterior lumbar interbody fusion. Spine 20:3563611995


Mentzer SJDeCamp MMHarpole DH JrSugarbaker DJ: Thoracoscopy and video-assisted thoracic surgery in the treatment of lung cancer. Chest 107:6 Suppl298S301S1995


Moskowitz A: Transforaminal lumbar interbody fusion. Orthop Clin North Am 33:3593662002


Ntoukas VMüller A: Minimally invasive approach versus traditional open approach for one level posterior lumbar interbody fusion. Minim Invasive Neurosurg 53:21242010


O'Toole JEEichholz KMFessler RG: Surgical site infection rates after minimally invasive spinal surgery. Clinical article. J Neurosurg Spine 11:4714762009


Olsen MAMayfield JLauryssen CPolish LBJones MVest J: Risk factors for surgical site infection in spinal surgery. J Neurosurg 98:2 Suppl1491552003


Park YHa JW: Comparison of one-level posterior lumbar interbody fusion performed with a minimally invasive approach or a traditional open approach. Spine 32:5375432007


Peng CWYue WMPoh SYYeo WTan SB: Clinical and radiological outcomes of minimally invasive versus open transforaminal lumbar interbody fusion. Spine 34:138513892009


Picada RWinter RBLonstein JEDenis FPinto MRSmith MD: Postoperative deep wound infection in adults after posterior lumbosacral spine fusion with instrumentation: incidence and management. J Spinal Disord 13:42452000


Pull ter Gunne AFCohen DB: Incidence, prevalence, and analysis of risk factors for surgical site infection following adult spinal surgery. Spine 34:142214282009


Rantanen JHurme MFalck BAlaranta HNykvist FLehto M: The lumbar multifidus muscle five years after surgery for a lumbar intervertebral disc herniation. Spine 18:5685741993


Schizas CTzinieris NTsiridis EKosmopoulos V: Minimally invasive versus open transforaminal lumbar interbody fusion: evaluating initial experience. Int Orthop 33:168316882009


Sihvonen THerno APaljarvi LAiraksinen OPartanen JTapaninaho A: Local denervation atrophy of paraspinal muscles in postoperative failed back syndrome. Spine 18:5755811993


Song KYPark CHKang HCKim JJPark SMJun KH: Is totally laparoscopic gastrectomy less invasive than laparoscopy-assisted gastrectomy?: prospective, multicenter study. J Gastrointest Surg 12:101510212008


Styf JRWillen J: The effects of external compression by three different retractors on pressure in the erector spine muscles during and after posterior lumbar spine surgery in humans. Spine 23:3543581998


Tsutsumimoto TShimogata MOhta HMisawa H: Miniopen versus conventional open posterior lumbar interbody fusion for the treatment of lumbar degenerative spondylolisthesis: comparison of paraspinal muscle damage and slip reduction. Spine 34:192319282009


Villavicencio ATBurneikiene SBulsara KRThramann JJ: Perioperative complications in transforaminal lumbar interbody fusion versus anterior-posterior reconstruction for lumbar disc degeneration and instability. J Spinal Disord Tech 19:92972006


Wang MYCummock MDYu YTrivedi RA: An analysis of the differences in the acute hospitalization charges following minimally invasive versus open posterior lumbar interbody fusion. Clinical article. J Neurosurg Spine 12:6946992010


Whitehouse JDFriedman NDKirkland KBRichardson WJSexton DJ: The impact of surgical-site infections following orthopedic surgery at a community hospital and a university hospital: adverse quality of life, excess length of stay, and extra cost. Infect Control Hosp Epidemiol 23:1831892002




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