Transdural retrieval of retropulsed transforaminal lumbar interbody fusion cages.

Transforaminal lumbar interbody fusions (TLIFs) are performed for various lumbar spine pathologies. Posterior migration of an interbody cage is a complication that may result in neurologic injury and require reoperation. Sparse information exists regarding the safety and efficacy of a transdural approach for cage retrieval. We describe a surgical technique, in which centrally retropulsed cages were safely retrieved transdurally. A patient with prior L3-S1 posterior lumbar fusion and L4-S1 TLIFs presented with radiculopathy and weakness in dorsiflexion. Imaging revealed posterior central migration of TLIF cages causing compression of the traversing L5 nerve root. Cages were removed transdurally; the correction was performed with an all-posterior T10-pelvis fusion. Aside from temporary weakness in right-sided dorsiflexion, the patient experienced complete resolution in their radiculopathy and strength returned to its presurgical state by 3 months. The transdural approach for interbody removal can be safely performed and should be a tool in the spine surgeon's armamentarium.

Full-Endoscopic Posterior Lumbar Interbody Fusion: A Review and Technical Note.

Remarkable innovations in spinal endoscopic surgery have broadened its applications over the past 20 years. Full-endoscopic fusions have been widely reported, and several full-endoscopic approaches for interbody fusion have been published. In general, full-endoscopic lumbar interbody fusion (LIF) is called Endo-LIF, and facet-preserving endo-LIF through the transforaminal route is called trans-Kambin's triangle LIF, which has a relatively longer history than facet-sacrificing endo-LIF via the posterolateral route. Both approaches can reduce intraoperative and postoperative bleeding. However, there is a higher risk of subsidence and exit nerve root injury. There is no direct decompression in either of the interbody fusions, and additional decompression is required if there is severe lumbar bony canal stenosis. However, the posterior interlaminar approach, which is a well-known standard in full-endoscopic spine surgery, has rarely been applied in the field of endoscopic lumbar fusion surgery. Full-endoscopic posterior LIF (FE-PLIF) via an interlaminar approach can accomplish direct decompression of bony canal stenosis and safe interbody fusion. FE-PLIF via an interlaminar approach demonstrated a longer operation time, less blood loss, and shorter hospitalization duration than minimally invasive transforaminal LIF. FE-PLIF, which can accomplish direct decompression for bony spinal canal stenosis, is superior to other Endo-LIFs. However, FE-PLIF requires technical dexterity to improve efficiency and reduce technical complexity.

Transforaminal lumbar interbody fusion subsidence: computed tomography analysis of incidence, associated risk factors, and impact on outcomes.

OBJECTIVE: The aims of this study were to 1) define the incidence of transforaminal lumbar interbody fusion (TLIF) interbody subsidence; 2) determine the relative importance of preoperative and intraoperative patient- and instrumentation-specific risk factors predictive of postoperative subsidence using CT-based assessment; and 3) determine the impact of TLIF subsidence on postoperative complications and fusion rates. METHODS: All adult patients who underwent one- or two-level TLIF for lumbar degenerative conditions at a multi-institutional academic center between 2017 and 2019 were retrospectively identified. Patients with traumatic injury, infection, malignancy, previous fusion at the index level, combined anterior-posterior procedures, surgery with greater than two TLIF levels, or incomplete follow-up were excluded. Interbody subsidence at the superior and inferior endplates of each TLIF level was directly measured on the endplate-facing surface of both coronal and sagittal CT scans obtained greater than 6 months postoperatively. Patients were grouped based on the maximum subsidence at each operative level classified as mild, moderate, or severe based on previously documented < 2-mm, 2- to 4-mm, and ≥ 4-mm thresholds, respectively. Univariate and regression analyses compared patient demographics, medical comorbidities, preoperative bone quality, surgical factors including interbody cage parameters, and fusion and complication rates across subsidence groups. RESULTS: A total of 67 patients with 85 unique fusion levels met the inclusion and exclusion criteria. Overall, 28% of levels exhibited moderate subsidence and 35% showed severe subsidence after TLIF with no significant difference in the superior and inferior endplate subsidence. Moderate (≥ 2-mm) and severe (≥ 4-mm) subsidence were significantly associated with decreases in cage surface area and Taillard index as well as interbody cages with polyetheretherketone (PEEK) material and sawtooth surface geometry. Severe subsidence was also significantly associated with taller preoperative disc spaces, decreased vertebral Hounsfield units (HU), the absence of bone morphogenetic protein (BMP) use, and smooth cage surfaces. Regression analysis revealed decreases in Taillard index, cage surface area, and HU, and the absence of BMP use predicted subsidence. Severe subsidence was found to be a predictor of pseudarthrosis but was not significantly associated with revision surgery. CONCLUSIONS: Patient-level risk factors for TLIF subsidence included decreased HU and increased preoperative disc height. Intraoperative risk factors for TLIF subsidence were decreased cage surface area, PEEK cage material, bullet cages, posterior cage positioning, smooth cage surfaces, and sawtooth surface designs. Severe subsidence predicted TLIF pseudarthrosis; however, the causality of this relationship remains unclear.

Functional Outcomes of Fluoroscopy-Guided Intra-articular Steroids in Lumbar Facet Arthropathy: A Retrospective Comparative Study of Dexamethasone Versus Triamcinolone Acetonide.

Introduction  Mechanical low back pain frequently originates from the lumbar facet joint (LFJ). Axial low back discomfort can result from osteoarthritis in the LFJ. Depending on the severity of LFJ degeneration, the effect of intra-articular (IA) LFJ corticosteroid injection may vary. For LFJ discomfort, IA block with steroids and local anaesthetics has also been utilised, with varying degrees of success. The main objective of this study was to assess the efficacy of IA steroid injections dexamethasone vs. triamcinolone acetonide for the treatment of LFJ syndrome and to compare functional outcome in terms of Visual Analog Scale (VAS) score, Modified Oswestry Disability Index (MODI) score, and short-form McGill Pain Questionnaire between the two groups. Methodology Dexamethasone 8 mg or triamcinolone acetonide 40 mg was given intra-articularly to 27 patients comprising group A and 33 patients comprising group B, respectively (total 60 patients). Before intervention and at one, three, and six months, observation was conducted using the VAS score, short-form McGill pain questionnaire, and MODI score. Results There was a significant difference between both the groups after the procedure with pain alleviation and functional improvement, more in the group that received triamcinolone acetonide. A significant difference was observed in all three parameters that assessed pain with differences more pronounced at six months. Conclusion Pain reduction and clinical outcomes were better among the group that received triamcinolone acetonide. Injection of a steroid alone is associated with its own side effects. When a lumbar transforaminal epidural injection is used to treat radiculopathy in the lumbar area, particulate medication (triamcinolone) is more effective than non-particulate medication (dexamethasone) with no known drug-related complications.

What is the early fate of adjacent segmental lordosis compensation at L3-4 and L5-S1 following a lateral versus transforaminal lumbar Interbody Fusion at L4-5?

INTRODUCTION: Degenerative spondylolisthesis causes translational and angular malalignment, resulting in a loss of segmental lordosis. This leads to compensatory adjustments in adjacent levels to maintain balance. Lateral lumbar interbody fusion (LLIF) and transforaminal lumbar interbody fusion (TLIF) are common techniques at L4-5. This study compares compensatory changes at adjacent L3-4 and L5-S1 levels six months post LLIF versus TLIF for grade 1 degenerative spondylolisthesis at L4-5. METHODS: A retrospective study included patients undergoing L4-5 LLIF or TLIF with posterior pedicle screw instrumentation (no posterior osteotomy) for grade 1 spondylolisthesis. Pre-op and 6-month post-op radiographs measured segmental lordosis (L3-L4, L4-L5, L5-S1), lumbar lordosis (LL), and pelvic incidence (PI), along with PI-LL mismatch. Multiple regressions were used for hypothesis testing. RESULTS: 113 patients (61 LLIF, 52 TLIF) were studied. TLIF showed less change in L4-5 lordosis (mean = 1.04°, SD = 4.34) compared to LLIF (mean = 4.99°, SD = 5.53) (p = 0.003). L4-5 angle changes didn't correlate with L3-4 changes, and no disparity between LLIF and TLIF was found (all p > 0.16). In LLIF, greater L4-5 lordosis change predicted reduced compensatory L5-S1 lordosis (p = 0.04), while no significant relationship was observed in TLIF patients (p = 0.12). CONCLUSION: LLIF at L4-5 increases lordosis at the operated level, with compensatory decrease at L5-S1 but not L3-4. This reciprocal loss at adjacent L5-S1 may explain inconsistent improvement in lumbar lordosis (PI-LL) post L4-5 fusion.

Comparison of different concentrations of ropivacaine in epidural anesthesia for percutaneous transforaminal endoscopic discectomy: a randomized controlled trial.

BACKGROUND: This study investigated the optimal concentration of ropivacaine epidural anesthesia for clinical use in percutaneous transforaminal endoscopic discectomy (PTED) by comparing the effects of different concentrations. METHODS: Seventy patients scheduled for their first PTED procedure were enrolled in this randomized controlled trial. Patients were randomized to receive ropivacaine at varying concentrations (0.3% or 0.4%). Primary outcome measures included the numeric rating scale (NRS) and hip extension level (HEL). Secondary outcome measures included intraoperative fentanyl dosage and postoperative complications. RESULTS: One patient withdrew due to severe postoperative complications. The remaining 69 patients were allocated to the 0.3% (n = 34) and 0.4% (n = 35) groups, respectively. Baseline characteristics showed no significant differences between the two groups (P > 0.05). The NRS score was significantly lower in the 0.4% group than in the 0.3% group (P < 0.01), whereas the HEL score was significantly higher (P < 0.001). The average fentanyl dose in the 0.4% group was significantly lower than that in the 0.3% group (P < 0.01). Postoperative complications occurred in five and two patients in the 0.3% and 0.4% groups, respectively. CONCLUSION: Although 0.4% ropivacaine (20 mL) impacts muscle strength, it does not impede PTED surgery. Given its effective analgesic properties and few postoperative complications, 0.4% ropivacaine can be considered a preferred dose for PTED. TRIAL REGISTRATION: This study was registered with the Chinese Clinical Trials Registry (Registration number: ChiCTR2200060364; Registration Date: 29/5/2022) and on chictr.org.cn ( https://www.chictr.org.cn/showproj.html?proj=171002 ).

Clinical Outcomes of the Transforaminal Lumbar Interbody Fusion Technique Among Patients With Low Back Pain Showing Type 1 Modic Changes on MRI.

Introduction The unilateral transforaminal lumbar interbody fusion (TLIF) signifies a different surgical method, circumventing both the anterior method and the method via the spinal canal. Due to the shortage of literature available for clinical outcomes and consequences post-TLIF, we undertook the current study to assess the TLIF technique's clinical outcomes among patients with low back pain showing type 1 Modic changes on MRI. Material and methods A cross-sectional study was conducted between January 2019 and March 2021. All patients included in the study had Modic type 1 change and disabling low back pain as the main complaint and/or leg pain. Data were collected on age, body mass index (BMI), gender, and other risk factors like diabetes mellitus, steroid use, and smoking. Pain intensity was evaluated using a visual analog scale (VAS) before and after surgery. A radiographic evaluation was also performed. Pre and post-operative pain scores and differences in disc height were assessed using the Wilcoxon rank sum test. A p-value of less than 0.05 was considered significant. Results The mean length of stay in the hospital was 4.3±1.61. The mean pre-operative lower back pain score was 8.78±0.79. The mean post-operative score was substantially lowered to 0.83±0.7. There was a significant difference between pre- and post-operative lumbar pain (p-value < 0.001). There was a significant increase in mean disc height from pre-operative (7.14 mm) to post-operative (11.02 mm) and also at one year (10.21 mm) with a p-value of <0.001. Of the patients, 82.14% did not have any complications, and 3.57% each had either delayed wound healing without any infection or transient post-operative radiculopathy that improved in six weeks. Conclusion TLIF procedure can be considered safe to provide anterior and posterior column support by adopting a unilateral posterior approach. The outcomes were favorable in terms of no prolonged length of stay, less blood loss, no mortality, reduction in the severity of pain, and improvement in disc height. However, the appropriate selection of patients for this technique is pivotal for the success of the procedure.

Are the facet joint parameters risk factors for cage subsidence after TLIF in patients with lumbar degenerative spondylolisthesis?

PURPOSE: To assess whether preoperative facet joint parameters in patients with degenerative lumbar spondylolisthesis (DS) are risk factors for cage subsidence (CS) following transforaminal lumbar interbody fusion (TLIF). METHODS: We enrolled 112 patients with L4-5 DS who underwent TLIF and were followed up for > 1 year. Preoperative demographic characteristics, functional areas of paraspinal muscles and psoas major muscles (PS), total functional area relative to vertebral body area, functional cross-sectional area (FCSA) of PS and lumbar spine extensor muscles, normalized FCSA of PS to the vertebral body area (FCSA/VBA), lumbar indentation value, facet joint orientation, facet joint tropism (FT), cross-sectional area of the superior articular process (SAPA), intervertebral height index, vertebral Hounsfield unit (HU) value, lordosis distribution index, t-scores, sagittal plane parameters, visual analog scale (VAS) for low back pain, VAS for leg pain, Oswestry disability index, global alignment and proportion score and European quality of life-5 dimensions (EQ-5D) were assessed. RESULTS: Postoperative CS showed significant correlations with preoperative FO(L3-4), FT (L3 and L5), SAPA(L3-5), L5-HU, FCSA/VBA(L3-4), Pre- T-score, post-6-month VAS for back pain and EQ-5D scores among other factors. According to ROC curve analysis, the optimal decision points for FO(L3-4), L3-SAPA, FCSA/VBA(L3-4), L5-HU, and Pre- T-score were 35.88°, 43.76°,114.93, 1.73, 1.55, 136, and - 2.49. CONCLUSIONS: This study identified preoperative FO, SAPA, preoperative CT, Pre- T-score and the FCSA/VBA as independent risk factors for CS after TLIF for DS. These risk factors should enable spinal surgeons to closely monitor and prevent the occurrence of CS.

Intradiscal Osteotomy and Bilateral Expandable Transforaminal Interbody Fusion Cages for Iatrogenic Kyphotic Deformity: A Technical Report.

Objectives Expandable transforaminal interbody fusion (TLIF) devices have been developed to introduce more segmental lordosis through a narrow operative corridor, but there are concerns about the degree of achievable correction with a small graft footprint. In this report, we describe the technical nuances associated with placing bilateral expandable cages for correction of iatrogenic deformity. Materials and Methods A 60-year-old female with symptomatic global sagittal malalignment and a severe lumbar kyphotic deformity after five prior lumbar surgeries presented to our institution. We performed multilevel posterior column osteotomies, a L3-4 intradiscal osteotomy, and placed bilateral lordotic expandable TLIF cages at the level of maximum segmental kyphosis. Results We achieve a 21-degree correction of the patient's focal kyphotic deformity and restoration of the patient global sagittal alignment. Conclusion This case demonstrates both the feasibility and utility of placing bilateral expandable TLIF cages at a single disc space in the setting of severe focal sagittal malalignment. This technique expands the implant footprint and, when coupled with an intradiscal osteotomy, allows for a significant restoration of segmental lordosis.

Adhesive surface electrodes versus needle-based neuromonitoring in lumbar spinal surgery.

Background: The relative safety and more widespread utility of an adhesive surface electrode-based neuromonitoring (ABM) system may reduce the time and cost of traditional needle-based neuromonitoring (NBM). Methods: This retrospective cohort review included one- and two-level transforaminal lumbar interbody fusion procedures (2019-2023). The primary variables studied included were time (in minutes) from patient entry into the operating room (OR) to incision, time from patient entry into the OR to closure, and time from incision to closure. Univariate and bivariate analyses were performed to compare the outcomes between the ABM (31 patients) and NBM (51 patients) modalities. Results: We found no significant differences in the time from patient entry into the OR to incision (ABM: 71.8, NBM: 70.3, P = 0.70), time from patient entry into the OR to closure (ABM: 284.2, NBM: 301.7, P = 0.27), or time from incision to closure (ABM: 212.4, NBM: 231.4, P = 0.17) between the two groups. Further, no patients from either group required reoperation for mal-positioned instrumentation, and none sustained a new postoperative neurological deficit. The ABM approach did, however, allow for a reduction in neurophysiologist-workforce and neuromonitoring costs. Conclusion: The introduction of the ABM system did not lower surgical time but did demonstrate similar efficacy and clinical outcomes, with reduced clinical invasiveness, neurophysiologist-associated workforce, and overall neuromonitoring cost compared to NBM.

Enhancing contrast distribution with the far lateral approach in lumbar transforaminal epidural steroid injections: A retrospective analysis.

BACKGROUND: Herniated intervertebral disc (HIVD) with radiculopathy is a common degenerative spine disorder. Transforaminal epidural steroid injection (TFESI) is one of the pain relief treatments for lumbar radiculopathy recommended by evidence-based guidelines. Adequate contrast distribution is correlated with better pain control, but the best approach has not been confirmed yet. AIM: To confirm the distribution of contrast medium injected with a new approach of TFESI, that is, far lateral lateral recess approach (FLLR-TFESI). METHODS: Patients receiving TFESI due to HIVD with radiculopathy between 2010 January and 2020 August were retrospectively enrolled. While the FLLR-TFESI was taken as the experimental group, the conventional approach was viewed as the control group. The baseline characteristics, the pattern of contrast enhancement under fluoroscopic guidance, and the complications of these patients were collected and analyzed. RESULTS: A total of 380 patients were analyzed (143 in control group and 237 in experimental group). The two groups were balanced in most baseline characteristics, except disc extrusion (p = 0.01) and scoliosis (p = 0.04). The FLLR-TFESI have a better contrast distribution (p < 0.01), even after adjustment (p < 0.001). No intrathecal injection was noted, but higher rate of intra-disc injection was noted in FLLR-TFESI group (10% vs. 3%, p = 0.008). CONCLUSION: The FLLR-TFESI has a superior contrast enhancement and distribution in comparison to conventional approach. Prospective study to confirm the study result as well as the clinical benefits is suggested in the future.

Percutaneous Transforaminal Endoscopic Discectomy for Adjacent Segment Disease versus Lumbar Disc Herniation in Elderly Patients.

Purpose: Percutaneous transforaminal endoscopic discectomy (PTED) was used as a minimally invasive treatment option for lumbar disc herniation (LDH). However, studies focusing on the clinical outcomes of PTED for elderly patients with adjacent segment disease (ASD) were limited. This study aims to compare the clinical outcomes of PTED between ASD and LDH in elderly patients. Patients and Methods: This retrospective study enrolled 39 patients with ASD and 39 patients with LDH. Both groups had undergone PTED in Beijing Chaoyang Hospital from July 4, 2016 to July 30, 2021. Visual analog scale for back pain (VAS-BP) and leg pain (VAS-LP) and Oswestry disability index (ODI) were used to value the clinical outcomes of patients preoperatively, immediately postoperatively, 12, and 24 months postoperatively, and at final follow-up. Patients' satisfaction was evaluated based on the MacNab criteria. Results: All operations were completed. The excellent or good clinical outcomes at final follow-up was demonstrated by 87.15% (34/39) and 89.74% (35/39) in ASD and non-ASD patients, respectively. Clinical improvement was observed immediately postoperatively in both groups and sustained stability during the postoperative follow-up. The ASD group demonstrated significantly longer hospital stays (p = 0.02) and operative time (p < 0.01) than the non-ASD group. Conclusion: PTED is an effective and minimally invasive treatment option for revision surgery of ASD, especially for elderly patients. However, the long-term prognosis of PTED treating ASD still needs further exploration.

Comparison of robot-assisted versus fluoroscopy-guided transforaminal lumbar interbody fusion (TLIF) for lumbar degenerative diseases: a systematic review and meta-analysis of randomized controlled trails and cohort studies.

BACKGROUND: As an emerging technology in robot-assisted (RA) surgery, the potential benefits of its application in transforaminal lumbar interbody fusion (TLIF) lack substantial support from current evidence. OBJECTIVE: We aimed to investigate whether the RA TLIF is superior to FG TLIF in the treatment of lumbar degenerative disease. METHODS: We systematically reviewed studies comparing RA versus FG TLIF for lumbar degenerative diseases through July 2022 by searching PubMed, Embase, Web of Science, CINAHL (EBSCO), Chinese National Knowledge Infrastructure (CNKI), WanFang, VIP, and the Cochrane Library, as well as the references of published review articles. Both cohort studies (CSs) and randomized controlled trials (RCTs) were included. Evaluation criteria included the accuracy of percutaneous pedicle screw placement, proximal facet joint violation (FJV), radiation exposure, duration of surgery, estimated blood loss (EBL), and surgical revision. Methodological quality was assessed using the Cochrane risk of bias and ROBINS-I Tool. Random-effects models were used, and the standardized mean difference (SMD) was employed as the effect measure. We conducted subgroup analyses based on surgical type, the specific robot system used, and the study design. Two investigators independently screened abstracts and full-text articles, and the certainty of evidence was graded using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach. RESULTS: Our search identified 539 articles, of which 21 met the inclusion criteria for quantitative analysis. Meta-analysis revealed that RA had 1.03-folds higher "clinically acceptable" accuracy than FG (RR: 1.0382, 95% CI: 1.0273-1.0493). And RA had 1.12-folds higher "perfect" accuracy than FG group (RR: 1.1167, 95% CI: 1.0726-1.1626). In the case of proximal FJV, our results indicate a 74% reduction in occurrences for patients undergoing RA pedicle screw placement compared to those in the FG group (RR: 0.2606, 95%CI: 0.2063- 0.3293). Seventeen CSs and two RCTs reported the duration of time. The results of CSs suggest that there is no significant difference between RA and FG group (SMD: 0.1111, 95%CI: -0.391-0.6131), but the results of RCTs suggest that the patients who underwent RA-TLIF need more surgery time than FG (SMD: 3.7213, 95%CI: 3.0756-4.3669). Sixteen CSs and two RCTs reported the EBL. The results suggest that the patients who underwent RA pedicle screw placement had fewer EBL than FG group (CSs: SMD: -1.9151, 95%CI: -3.1265-0.7036, RCTs: SMD: -5.9010, 95%CI: -8.7238-3.0782). For radiation exposure, the results of CSs suggest that there is no significant difference in radiation time between RA and FG group (SMD: -0.5256, 95%CI: -1.4357-0.3845), but the patients who underwent RA pedicle screw placement had fewer radiation dose than FG group (SMD: -2.2682, 95%CI: -3.1953-1.3411). And four CSs and one RCT reported the number of revision case. The results of CSs suggest that there is no significant difference in the number of revision case between RA and FG group (RR: 0.4087,95% CI 0.1592-1.0495). Our findings are limited by the residual heterogeneity of the included studies, which may limit the interpretation of the results. CONCLUSION: In TLIF, RA technology exhibits enhanced precision in pedicle screw placement when compared to FG methods. This accuracy contributes to advantages such as the protection of adjacent facet joints and reductions in intraoperative radiation dosage and blood loss. However, the longer preoperative preparation time associated with RA procedures results in comparable surgical duration and radiation time to FG techniques. Presently, FG screw placement remains the predominant approach, with clinical surgeons possessing greater proficiency in its application. Consequently, the integration of RA into TLIF surgery may not be considered the optimal choice. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42023441600.

Association between delayed ambulation and increased risk of adverse events after lumbar fusion surgery in elderly patients.

PURPOSE: The relationship between delayed ambulation (DA) and postoperative adverse events (AEs) following transforaminal lumbar interbody fusion (TLIF) in elderly patients remains elusive. The aim of our study was to evaluate the effects of DA on the postoperative AEs including complications, readmission and prolonged length of hospital stay (LOS). METHODS: This was a retrospective analysis of a prospectively established database of elderly patients (aged 65 years and older) who underwent TLIF surgery. The early ambulation (EA) group was defined as patients ambulated within 48 h after surgery, whereas the delayed ambulation (DA) group was patients ambulated at a minimum of 48 h postoperatively. The DA patients were 1:1 propensity-score matched to the EA patients based on age, gender and the number of fused segments. Univariate analysis was used to compare postoperative outcomes between the two groups, and multivariate logistic regression analysis was used to identify risk factors for adverse events and DA. RESULTS: After excluding 125 patients for various reasons, 1025 patients (≤ 48 h: N = 659 and > 48 h: N = 366) were included in the final analysis. After propensity score matching, there were 326 matched patients in each group. There were no significant differences in the baseline data and the surgery-related variables between the two groups (p > 0.05). The patients in the DA group had a significant higher incidence of postoperative AEs (46.0% vs. 34.0%, p = 0.002) and longer LOS (p = 0.001). Multivariate logistic regression identified that age, operative time, diabetes, and DA were independently associated with postoperative AEs, whereas greater age, higher international normalized ratio, and intraoperative estimated blood loss were identified as independent risk factors for DA. CONCLUSIONS: Delayed ambulation was an independent risk factor for postoperative AEs after TLIF in elderly patients. Older age, increased intraoperative blood loss and worse coagulation function were associated with delayed ambulation.

[Comparative analysis of the results of microdiscectomy and minimally invasive transforaminal lumbar interbody fusion in the treatment of adjacent-level intervertebral disc herniations with lumbosacral transitional vertebra in elderly patients.]

The purpose of the study was a comparative analysis the effectiveness of microsurgical discectomy and minimally invasive transforaminal lumbar interbody fusion in the treatment of disk herniation adjacent to the anomaly of the lumbosacral junction segment in elderly patients. The study included 80 elderly patients (over 60 years old), divided into two groups: the 1st-(n=39) who underwent microsurgical discectomy; the 2nd- patients (n=41) operated on using minimally invasive transforaminal interbody fusion and percutaneous transpedicular stabilization (MI-TLIF). For the comparative analysis, we used gender characteristics (gender, age), constitutional characteristics (BMI), degree of physical status according to ASA, intraoperative parameters of interventions and the specificity of postoperative patient management, clinical data, and the presence of complications. Long-term outcomes were assessed at a minimum follow-up of 3 years. As a result, it was found that the use of MI-TLIF allows achieving better long-term clinical outcomes, fewer major complications in comparison with the microsurgical discectomy technique in the treatment of disc herniation adjacent to the anomaly of the lumbosacral junction segment in elderly patients.

Comparative clinical efficacy of percutaneous coaxial large-channel endoscopic lumbar interbody fusion and transforaminal lumbar interbody fusion for degenerative lumbar spinal stenosis: a retrospective study.

This study aimed to evaluate the clinical efficacy of percutaneous coaxial large-channel endoscopic lumbar interbody fusion (PCLE-LIF) and transforaminal lumbar interbody fusion (TLIF) in the treatment of degenerative lumbar spinal stenosis. The clinical data of patients with degenerative lumbar spinal stenosis who underwent PCLE-LIF (experimental group) and TLIF (control group) surgery from September 2019 to September 2021 were retrospectively analyzed. We collected clinical data and compared the two groups in terms of perioperative parameters, treatment response rate, inflammatory response markers, postoperative complications, postoperative pain, and functional recovery. The results showed that the treatment outcomes in the experimental group were significantly better than those in the control group. Specifically, perioperative parameters and inflammatory response markers in the experimental group were significantly better than those in the control group, with statistically significant differences (P < 0.05). The overall treatment response rate in the experimental group was significantly higher than that in the control group (P < 0.05). Meanwhile, the incidence of postoperative complications in the experimental group was lower than that in the control group, postoperative VAS pain scores and ODI functional scores were lower, and postoperative JOA functional scores were higher than those in the control group, with statistically significant differences (P < 0.05). In conclusion, PCLE-LIF appears to be a promising technique with better clinical outcomes in the treatment of degenerative lumbar spinal stenosis.

Restoring L4-S1 Lordosis Shape in Severe Sagittal Deformity: Impact of Correction Techniques on Alignment and Complication Profile.

BACKGROUND: Severe sagittal plane deformity with loss of L4-S1 lordosis is disabling and can be improved through various surgical techniques. However, data are limited on the differing ability of anterior lumbar interbody fusion (ALIF), pedicle subtraction osteotomy (PSO), and transforaminal lumbar interbody fusion (TLIF) to achieve alignment goals in severely malaligned patients. METHODS: Severe adult spinal deformity patients with preoperative PI-LL >20°, L4-S1 lordosis <30°, and full body radiographs and PROMs at baseline and 6-week postoperative visit were included. Patients were grouped into ALIF (1-2 level ALIF at L4-S1), PSO (L4/L5 PSO), and TLIF (1-2 level TLIF at L4-S1). Comparative analyses were performed on demographics, radiographic spinopelvic parameters, complications, and PROMs. RESULTS: Among the 96 included patients, 40 underwent ALIF, 27 underwent PSO, and 29 underwent TLIF. At baseline, cohorts had comparable age, sex, race, Edmonton frailty scores, and radiographic spinopelvic parameters (P > 0.05). However, PSO was performed more often in revision cases (P < 0.001). Following surgery, L4-S1 lordosis correction (P = 0.001) was comparable among ALIF and PSO patients and caudal lordotic apex migration (P = 0.044) was highest among ALIF patients. PSO patients had higher intraoperative estimated blood loss (P < 0.001) and motor deficits (P = 0.049), and in-hospital ICU admission (P = 0.022) and blood products given (P = 0.004), but were otherwise comparable in terms of length of stay, blood transfusion given, and postoperative admission to rehab. Likewise, 90-day postoperative complication profiles and 6-week PROMs were comparable as well. CONCLUSIONS: ALIF can restore L4-S1 sagittal alignment as powerfully as PSO, with fewer intraoperative and in-hospital complications. When feasible, ALIF is a suitable alternative to PSO and likely superior to TLIF for correcting L4-S1 lordosis among patients with severe sagittal malalignment.

Predictors of outcome following an epidural steroid injection for disc-related sciatica: a Delphi consensus study.

PURPOSE: Trial data shows modest reductions in leg pain, disability and surgery avoidance following epidural steroid injections (ESI) for severe sciatica. Despite their common use, there is no clear evidence about which patients are more likely to benefit from ESI. The aim of this study was to generate consensus on potential predictors of outcome following ESI for disc-related sciatica. METHODS: A list of potential predictors of outcome was generated during a consensus meeting of seven experts. The items were subsequently presented in a two round on-line Delphi study to generate consensus among experts on which items are potential predictors of outcome. Consensus was defined as 70% agreement among participants. RESULTS: Sixty-one items were generated during the consensus meeting. Of ninety experts invited to participate in the on-line Delphi study, 44 (48%) and 33 (73%) took part in rounds one and two respectively. Twenty-eight additional items suggested by participants in round one were included in round two. Overall, 14 items reached consensus reflecting domains of health, medication use, pain intensity, psychosocial factors, imaging findings and type of injection. CONCLUSION: Based on expert consensus, items that can be routinely collected in clinical practice were identified as potential predictors of outcomes following ESI.

Cortical Trajectory Versus Traditional Pedicle Screw Trajectory in Open Transforaminal Lumbar Interbody Fusion: Meta-analysis of Complications and Clinical Outcomes.

BACKGROUND: Lumbar degenerative disease imposes a substantial burden on global healthcare expenditures. Transforaminal lumbar interbody fusion (TLIF) utilizing either traditional trajectory (TT) pedicle screws or cortical bone trajectory (CT) pedicle screws have become increasingly common. This meta-analysis evaluates the outcomes and safety of open TLIF with TT compared to CT. METHODS: PubMed, Cochrane, and Google Scholar (pages 1-20) were explored until April 2024. The studied outcomes included complications, revision surgeries, operative room (OR) time, estimated blood loss (EBL), length of hospital stay (LOS), incision length, Visual Analog Scale (VAS), Oswestry Disability Index (ODI), and the Japanese Orthopedic Association (JOA) score. RESULTS: Five studies were included in this meta-analysis. A total of 770 patients undergoing TLIF were included, with 415 in the CT group and 355 in the TT group. No statistically significant differences were found in the rate of overall complications, including specific complications, the rate of revision surgeries, PROMS scores, OR time, and EBL. However, the CT group demonstrated shorter LOS (p=0.05), and shorter incision lengths (p<.001) compared to the TT group. CONCLUSION: Both TT and CT techniques in TLIF procedures demonstrated comparable rates of complications, reoperations, and PROMs. Despite similar OR times and EBL, the CT group exhibited shorter incision lengths, and shorter LOS compared to the TT group. Both cortical and traditional trajectory pedicle screws are safe and effective options for TLIF. There are potential benefits to CT such as shorter incision and LOS, although TT remains an essential tool for spinal instrumentation techniques.

Percutaneous transforaminal endoscopic discectomy for Upper Lumbar Disc Herniation versus lower lumbar disc herniation: clinical outcomes and technical consideration.

BACKGROUND: Upper lumbar disc herniation (ULDH) accounts for 1-10% of all lumbar disc herniations (LDH). This study aimed to evaluate the clinical characteristics and outcomes of patients with ULDH who underwent percutaneous transforaminal endoscopic discectomy (PTED) compared with those with lower LDH. METHODS: 60 patients with ULDH or L4-L5 LDH treated with PTED between May 2016 and October 2021. MacNab criteria, visual analog scale (VAS) of back pain and leg pain, and Japanese Orthopedic Association (JOA) were evaluated before and after surgery. RESULTS: In the L1-L3 group, 59.1% of the patients had a positive femoral nerve tension test, and 81.8% of the patients had a sensory deficit. Both groups showed significant improvements in VAS scores for low back and leg pain, and JOA scores postoperatively. No significant differences in the degree of improvement were observed between the two groups. The excellent/good rate was 81.8% in the L1-L3 group and 84.2% in the L4-L5 group, showing no significant difference. CONCLUSION: PTED has comparable efficacy in treating ULDH as it does in treating lower LDH, it is a safe and effective treatment method for ULDH.