Abordaje paraespinal de Wiltse: nota técnica y revisión de sus ventajas y limitaciones / Wiltse paraspinal approach: technical note and review of its advantages and limitations

Objetivo: Describir paso a paso el abordaje paraespinal de Wiltse y resaltar las principales ventajas y limitaciones relatadas en la literatura. Material y métodos: Se realizó una descripción del abordaje de Wiltse paso a paso y detalladamente paso a paso, haciendo hincapié en algunos trucos y limitaciones adquiridos con la práctica. Se revisó la literatura disponible con una búsqueda en PubMed y Lilacs bajo los términos Mesh: "Wiltse approach", "paraspinal approach", "muscle sparing approach", "lumbar spine", para destacar ventajas y desventajas de la técnica. Se analizaron 10 trabajos que tenían relación con el objetivo de esta publicación. Ninguno de los trabajos hallados en la búsqueda describía en detalle los pasos del abordaje paraespinal. Se describió: preparación, posicionamiento, incisión, apertura fascial, disección, identificación ósea, desperiostización, descompresión, discectomía, instrumentación, artrodesis y cierre. Resultados: La mayoría de los trabajos resaltaron la utilidad del abordaje como técnica de mínima invasión, con sangrado intraoperatorio mínimo, cortas estadías hospitalarias y bajo índice de infecciones. Conclusión: El abordaje clásico descripto por Wiltse sigue los principios de cirugía de mínima invasión, respetando los planos musculares y tejidos blandos paraespinales, permitiendo amplias descompresiones, discectomías y fusiones con bajos índices de complicaciones.

Objective: To provide a step-by-step description of the Wiltse paraspinal approach, and analyze the main advantages and limitations described in the literature. Methods: We provide a detailed step-by-step description of the Wiltse approach, focusing on some of the strategies we have learned and limitations we have seen in daily clinical practice. A literature review was conducted, consisting of Pub Med and Lilacs searches using the Mesh terms: "Wiltse approach", "paraspinal approach", "muscle sparing approach", and "lumbar spine". Ten papers related to our objectives were assessed, step by step considering patient preparation and positioning, skin incisions, fascial opening, dissection, bone identification, retraction, deperiostization, decompression, discectomy, instrumentation, arthrodesis, and closure. Results: Most papers underline the usefulness of the Wiltse paraspinal approach as a minimally-invasive procedure, emphasizing the minimal intra-operative bleeding, short hospital stays, and low infection rates. However, none of the identified papers thoroughly described specific steps taken using this approach. Conclusion: The classical approach described by Wiltse observes the principles of minimally-invasive surgical procedures, sparing both the muscle planes and soft tissues, thereby allowing for ample decompression, discectomies, and spinal fusions with low complication rates.

Paraspinal Muscle Sparing Versus Percutaneous Screw Fixation: A Comparative Enzyme Study of Tissue Injury during the Treatment of L4-L5 Spondylolisthesis

OBJECTIVE: Screw fixation via the paraspinal muscle sparing approach and by percutaneous screw fixation are known to diminish the risk of complications, such as, iatrogenic muscle injury as compared with the conventional midline approach. The purpose of this study was to evaluate tissue injury markers after these less traumatic screw fixation techniques for the treatment of L4-L5 spondylolisthesis. METHODS: Twenty-two patients scheduled for posterior lumbar interbody fusion (PLIF) at the L4-L5 segment for spondylolisthesis were prospectively studied. Patients were divided into two groups by screw fixation technique (Group I: paraspinal muscle sparing approach and Group II: percutaneous screw fixation). Levels of serum enzymes representing muscle injury (CK-MM and Troponin C type 2 fast), pro-inflammatory cytokine (IL-8), and anti-inflammatory cytokine (IL-1ra) were analyzed using ELISA techniques on the day of the surgery and 1, 3, and 7 days after the surgery. RESULTS: Serum CK-MM, Troponic C type 2 fast (TNNC2), and IL-1ra levels were significantly elevated in Group I on postoperative day 1 and 3, and returned to preoperative levels on postoperative day 7. No significant intergroup difference was found between IL-8 levels despite higher concentrations in Group I on postoperative day 1 and 3. CONCLUSION: This study shows that percutaneous screw fixation procedure is the preferable minimally invasive technique in terms of minimizing muscle injury associated with L4-L5 spondylolisthesis.

Paraspinal Muscle Sparing versus Percutaneous Screw Fixation : A Prospective and Comparative Study for the Treatment of L5-S1 Spondylolisthesis

OBJECTIVE: Both the paraspinal muscle sparing approach and percutaneous screw fixation are less traumatic procedures in comparison with the conventional midline approach. These techniques have been used with the goal of reducing muscle injury. The purpose of this study was to evaluate and to compare the safety and efficacy of the paraspinal muscle sparing technique and percutaneous screw fixation for the treatment of L5-S1 spondylolisthesis. METHODS: Twenty patients who had undergone posterior lumbar interbody fusion (PLIF) at the L5-S1 segment for spondylolisthesis were prospectively studied. They were divided into two groups by screw fixation technique (Group I : paraspinal muscle sparing approach and Group II: percutaneous screw fixation). Clinical outcomes were assessed by Low Back Outcome Score (LBOS) and Visual Analogue Scale (VAS) for back and leg pain at different times after surgery. In addition, modified MacNab's grading criteria were used to assess subjective patients' outcomes 6 months after surgery. Postoperative midline surgical scarring, intraoperative blood loss, mean operation time, and procedure-related complications were analyzed. RESULTS: Excellent or good results were observed in all patients in both groups 6 months after surgery. Patients in both groups showed marked improvement in terms of LBOSs all over time intervals. Postoperative midline surgical scarring and intraoperative blood loss were lower in Group II compared to Group I although these differences were not statistically significant. Low back pain (LBP) and leg pain in both groups also showed significant improvement when compared to preoperative scores. However, at 7 days and 1 month after surgery, patients in Group II had significantly better LBP scores compared to Group I. CONCLUSION: In terms of LBP during the early postoperative period, patients who underwent percutaneous screw fixation showed better results compared to ones who underwent screw fixation via the paraspinal muscle sparing approach. Our results indicate that the percutaneous screw fixation procedure is the preferable minimally invasive technique for reducing LBP associated with L5-S1 spondylolisthesis.