Postoperative Care Pathways Following Lumbar Total Disc Replacement: Results of a Modified Delphi Approach.

STUDY DESIGN: A modified Delphi method was used to establish consensus. Subject matter experts were invited to participate as the expert panel. Best practice statements were distributed to the panel. Panel members were asked to mark "agree" or "disagree" after a series of statements during several rounds until either consensus could be obtained or the practice method was deemed unable to achieve consensus. OBJECTIVE: Lumbar total disc replacement (TDR) is acknowledged as an alternative to spinal fusion in appropriately selected patients. There is a lack of unanimity on the appropriate postoperative patient protocols and rehabilitation expectations for the procedure. The long-term viability of Lumbar TDR, further adoption in the community setting and specific patient outcomes are contingent on the existence of appropriate postoperative recovery programs. SUMMARY OF BACKGROUND DATA: Currently there are no established methods for postoperative care following lumbar TDR. Establishing a postoperative clinical pathway algorithm may improve patient outcomes with respect to lumbar TDR. METHOD: A lumbar TDR expert panel of 22 spine surgeons employed a modified Delphi method to drive consensus on postoperative care following single-level Lumbar TDR. The panel first reviewed literature and guidelines relevant to postoperative care following lumbar TDR. Panel members considered 21 survey questions intended to determine "standard-practice" postoperative care recommendations for patients who have undergone lumbar TDR for the initial recovery phase (0-4 wk) and rehabilitation (4-20 wk). Each panel member participated in a round of anonymous voting followed by a group discussion. Consensus was defined as 80% agreement or higher among the respondents. RESULTS: Consensus was achieved in 11 of the 21 survey questions. There was a high degree of consensus around the key goals for both the initial recovery and rehabilitation phases, ceased use of narcotics for pain management by 4 weeks postoperative, unrestricted walking immediately following surgery, timelines for physical therapy (within 2-4 wk) and return to work based on level of activity (as early as 1 wk postoperative). Lack of agreement included the use of back bracing and timing of postoperative visits. Generally, panel members felt that patient expectations regarding return to function were different following lumbar TDR versus fusion and warrant further study. CONCLUSION: Surgeon and patient alignment around postoperative expectations may significantly affect the long-term results of lumbar TDR. This surgeon consensus study found agreement for immediate postoperative ambulation, rapid reduction in opioids within the first month, and early return to work. When expectations are appropriately set with patients preoperatively, both provider and patient have shared goals in the return-to-function process. LEVEL OF EVIDENCE: 5.

Minimally invasive percutaneous posterior lumbar interbody fusion.

OBJECTIVE: The wide exposure required for a standard posterior lumbar interbody fusion (PLIF) can cause unnecessary trauma to the lumbar musculoligamentous complex. By combining existing microendoscopic, percutaneous instrumentation and interbody technologies, a novel, minimally invasive, percutaneous PLIF technique was developed to minimize such iatrogenic tissue injury (MIP-PLIF). METHODS: The MIP-PLIF technique was validated in three cadaveric torsos with six motion segments decompressed and fused. Preoperative variables measured from imaging included interpedicular distance, pedicular height and width, interspinous distance, lordosis, intervertebral height, Cobb angle, and foraminal height and volume. Using the METRx and MD spinal access systems (Medtronic Sofamor Danek, Memphis, TN), bilateral laminotomies were performed using a hybrid of microsurgical and microendoscopic techniques. The intervertebral disc spaces were then distracted and prepared with the Tangent (Medtronic Sofamor Danek) interbody instruments. Either a 10 or 12 by 22 mm interbody graft was then placed. Using the Sextant (Medtronic Sofamor Danek) system, percutaneous pedicle screw-rod fixation of the motion segment was completed. We then applied MIP-PLIF in three patients. RESULTS: For segments with preoperative intervertebral/foraminal height loss, MIP-PLIF was effective in restoring both heights in all cases. The amount of improvement (9.7 to 38% disc height increase; 7.7 to 29.9% foraminal height increase) varied directly with the size of the graft used and the original degree of disc and foraminal height loss. Segmental lordosis improved by 29% on average. Graft and screw placement was accurate in the cadavers, except for a single Grade 1 screw violation of one pedicle. The average operative time was 3.5 hours per level. In our three clinical cases, the MIP-PLIF procedure required a mean of 5.4 hours, estimated blood loss was 185 ml, and inpatient stay was 2.8 days, with no intravenous narcotic use after 2 days in any of the patients. All screw and graft placements were confirmed. CONCLUSION: A complete PLIF procedure can be safely and effectively performed using minimally invasive techniques, thereby potentially reducing the pain and morbidity associated with standard open surgery. Prospective, randomized outcome studies will be required to validate the efficacy of this exciting new surgical technique.