Comparing clinical and radiological outcomes between single-level OLIF and XLIF: A systematic review and meta-analysis.

Background Context: Oblique lumbar interbody fusion (OLIF) and extreme lateral interbody fusion (XLIF) are 2 popular minimally invasive spinal fusion techniques with unique approach-related complication profiles. Accordingly, patient-specific anatomical factors, such as vascular anatomy or iliac crest height, greatly influence which technique to use. Previous studies comparing these approaches do not account for the inability of XLIF to access the L5-S1 disc space and therefore do not exclude this level in their analysis. The purpose of this study was to compare radiological and clinical outcomes of these techniques in the L1-L5 region. Methods: A query of 3 electronic databases (PubMed, CINAHL plus, and SCOPUS) was performed, without time restriction, to identify studies that evaluated outcomes of single-level OLIF and/or XLIF between L1 and L5. Based on heterogeneity, a random effects meta-analysis was performed to evaluate the pooled estimation of each variable between the groups. An overlap of 95% confidence intervals suggests no statistically significant difference at the p<.05 level. Results: A total of 1,010 patients (408 OLIF, 602 XLIF) were included from 24 published studies. Improvements in disc height (OLIF: 4.2 mm; XLIF: 5.3 mm), lumbar segmental (OLIF: 2.3°; XLIF: 3.1°), and lumbar lordotic angles (OLIF: 5.3°; XLIF: 3.3°) showed no significant difference. The rate of neuropraxia was significantly greater in the XLIF group at 21.2% versus 10.9% in the OLIF group (p<.05). However, the rate of vascular injury was higher in the OLIF cohort at 3.2% (95% CI:1.7-6.0) as compared to 0.0 (95% CI: 0.0-1.4) in the XLIF cohort. Improvements in VAS-b (OLIF: 5.6; XLIF: 4.5) and ODI (OLIF: 37.9; XLIF: 25.6) scores were not significantly different between the 2 groups. Conclusions: This meta-analysis demonstrates similar clinical and radiological outcomes between single-level OLIF and XLIF from L1 to L5. XLIF had significantly higher rates of neuropraxia, whereas OLIF had greater rates of vascular injury.

Minimally Invasive Transforaminal Lumbar Interbody Fusion (MI-TLIF): A Video Technique Guide.

Background: Minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) has been established as an excellent alternative to the traditional open approach for the treatment of degenerative conditions of the lumbar spine1-3. Description: The procedure is performed with the patient under general anesthesia and on a radiolucent table in order to allow for intraoperative fluoroscopy. The procedure is performed through small incisions made over the vertebral levels of interest, typically utilizing either a fixed or expandable type of tubular dilator, which is eventually seated against the facet joint complex4. A laminectomy and/or facetectomy is performed in order to expose the disc space, and the ipsilateral neural elements are visualized5. The end plates are prepared, and an interbody device is placed after the disc is removed. Pedicle screws and rods are then placed for posterior fixation. Alternatives: Nonoperative alternatives include physical therapy and corticosteroid injections. Other operative techniques include open TLIF or other types of lumbar fusion approaches, such as posterior lumbar interbody fusion (PLIF), anterior lumbar interbody fusion, lateral or extreme lateral interbody fusion, or oblique lumbar interbody fusion. Rationale: Open TLIF was developed in order to obtain a more lateral approach to the lumbar disc space than was previously possible with PLIF. The goal of this was to minimize the amount of thecal-sac and nerve-root retraction required during PLIF4. Additionally, as the number of patients who required revision after PLIF increased, the need arose for an approach to the lumbar spine that circumvented the posterior midline scarring from previous PLIF surgical sites6. MI-TLIF was introduced to reduce the approach-related paraspinal muscle damage of open TLIF5. Indications for MI-TLIF include most degenerative pathology of the lumbar spine, including disc herniation, low-grade spondylolisthesis, and spinal and foraminal stenosis7. However, MI-TLIF allows for less robust correction of deformity than other minimally invasive approaches; therefore, MI-TLIF may not be as effective in cases of substantial spinal deformity or high-grade spondylolisthesis8. Expected Outcomes: MI-TLIF results in significantly less blood loss, postoperative pain, and hospital length of stay compared with open TLIF1-3. Although some studies have suggested increased operative time for MI-TLIF9,10, meta-analyses have shown comparable operative times between the 2 techniques1-3. It is thought that the discrepancy in reported operative times is the result of a learning curve and that, once that is overcome, the difference in operative time between the 2 techniques becomes minimal11,12. One disadvantage of MI-TLIF that has remained constant in the literature is its increased intraoperative fluoroscopy time compared with open TLIF3,13. The complication rate has largely been found to be equivalent between open and MI-TLIF1-3 or slightly lower with MI-TLIF14, especially in the hands of an experienced surgeon15. Finally, the fusion rate and improvement in patient outcome scores have also been found to be largely equivalent1-3. Important Tips: We suggest placing the ipsilateral pedicle screw after the interbody cage has been inserted.Fully visualize the Kambin triangle16 prior to performing the facetectomy. Protect the exiting and traversing nerve roots by placing small cottonoids around them and retracting delicately.Bone removed during facetectomy can be utilized as autograft for the interbody cage.Avoid removing pedicle bone during decompression.If central stenosis is present, the neural decompression should be extended medial to the epidural fat so that the dura mater can be visualized all of the way to the contralateral pedicle.Perform an adequate end plate preparation prior to interbody insertion while being mindful to avoid injuring the end plate, to minimize the risk of future cage subsidence.Confirm correct placement of the interbody device on intraoperative fluoroscopy.If bone morphogenic protein is utilized, be careful not to pack too much posteriorly as this may cause nerve irritation. Acronyms and Abbreviations: TLIF = transforaminal lumbar interbody fusionMI-TLIF = minimally invasive TLIFPLIF = posterior lumbar interbody fusionALIF = anterior lumbar interbody fusionLLIF = lateral lumbar interbody fusionXLIF = extreme lateral interbody fusionOLIF = oblique lumbar interbody fusionDLIF = direct lateral interbody fusionMRI = magnetic resonance imagingA/P = anteroposteriorEMG = electromyographicBMP = bone morphogenic proteinXR = x-ray (radiograph)OTC = over the counterDVT = deep vein thrombosisPE = pulmonary embolismMI = myocardial infarctionMIS = minimally invasive surgeryOR = operating roomLOS = length of stayVAS = visual analog scaleODI = Oswestry Disability IndexM-H = Mantel-HaenszelRR = risk ratioCI = confidence intervalNSAIDs = nonsteroidal anti-inflammatory drugs.

Cerebrospinal fluid (CSF) leak after elective lumbar spinal fusion: Who is at risk?

PURPOSE: CSF leaks are a known complication of lumbar fusion surgery. There is a scarcity of literature describing the incidence and risk factors associated with this complication. The aim of this study was to identify patients who are at risk of developing postoperative CSF leak. METHODS: The Nationwide Inpatient Sample database was used to identify patients who had lumbar fusion in the US from 2002 to 2014. Inpatient outcomes included the incidence and risk of developing CSF leak based on selected patient-specific characteristics. Secondary outcomes included average length of stay, mean costs, and mortality rates. All statistical analyses were conducted based on multivariate regression models using the SPSS software. RESULTS: A total of 439,220 patients who underwent elective lumbar fusion procedures were identified. Of these patients, 2.6% (11,636 /439,220) were found to have CSF leak. Independent important risk factors for CSF leak development included: older age (OR: 1.025; 95% CI: 1.02-1.03; p < 0.0001), posterior approach (OR: 1.71; 95% CI: 1.59-1.85; p < 0.0001) compared to anterior approach, chronic deficiency anemia (OR: 1.21; 95% CI:1.14-1.30; p < 0.0001), obesity (OR: 1.22; 95% CI: 1.15-1.30; p < 0.0001), and pulmonary circulatory disease (OR: 1.44; 95% CI: 1.18-1.75; p < 0.0001). CSF leak was associated with increased length of stay (5.39 ± 3.86 vs. 3.74 ± 2.55; p < 0.0001), hospitalization costs (120,129.0 ± 88,123.5 vs. 89,226.8 ± 65,350.3; p < 0.0001) and mortality (0.3% vs. 0.1%; p < 0.05). CONCLUSION: Spine surgeons should be aware of certain patient and procedure-specific characteristics that increase the risk of developing postoperative CSF leak after lumbar fusion in order to improve patient outcomes.

Two-Attending Surgeon Teams Improve Outcomes of Single-Level Anterior Cervical Discectomy and Fusion.

Given the shift toward value-based healthcare, strategies that decrease risk in commonly performed procedures such as anterior cervical discectomy and fusion (ACDF) are of interest. The objective of this study was to analyze the effect of a two-attending surgeon team on the outcomes of patients undergoing single-level ACDF. A retrospective matched-cohort study of patients undergoing single-level ACDF for degenerative cervical spondylosis, with minimum 2-year follow-up was performed. Patients were subdivided into two cohorts: cases with procedures performed by one attending surgeon assisted by a resident physician and cases with procedures performed by an attending surgeon with another attending surgeon as first-assist. Patients were matched by age, sex, body mass index, smoking status, American Society of Anesthesia grade and Charlson Comorbidity Index. Perioperative data and complications were compared. Standard binomial and categorical comparative analysis were performed. Forty-two patients were included (21 in each group). There were 22 males and 20 females, with a mean age of 47.7 years and mean follow-up of 43.4 months. There were no differences in any demographic variable between groups, indicating successful matching. Cohort B had decreased anesthesia time (114.9 vs. 157.1 minutes, P < 0.001), operative time (58.1 vs. 98.9 minutes, P < 0.001) and blood loss (14.8 vs. 24.3 mL, P = 0.012). There were no significant differences in terms of post-operative complications including dysphagia, wound infection, neurologic or cardiovascular related complications. A two-attending surgeon team significantly reduces anesthesia time, surgical time, and blood loss in single-level ACDF procedures without an increase in complications or a decrease in fusion rates.

Traumatic subcutaneous emphysema of the hand/forearm: A case report.

Subcutaneous emphysema is commonly associated with infection caused by gas-producing organisms. In this case report, we describe a rare instance of traumatic subcutaneous emphysema of the hand and forearm caused by a puncture injury to the first web space of the hand. Our objective is to increase awareness of the potential for seemingly minor trauma to cause entrapment of significant air in subcutaneous tissues, thereby decreasing the likelihood that a clinically benign-appearing patient will be started down an unnecessarily aggressive treatment pathway. A 16-year-old, otherwise healthy white female, presented to the pediatric emergency room with an impressive amount of subcutaneous emphysema that developed over a 12-h period after sustaining an accidental laceration to the first web space of her right hand. She appeared nontoxic and had a clinically benign presentation. A comprehensive work-up was performed. She was splinted by the orthopedic surgery resident on call, and was admitted to the Pediatric Intensive Care Unit for overnight monitoring. She received tetanus vaccination and broad-spectrum antibiotics. The patient was discharged 2 days after admittance, with a splint applied to her right hand and forearm. She undertook home-based physical and occupational therapy. She had a pain-free range-of-motion in the right wrist, elbow and shoulder. The swelling in the right hand subsided completely. Although initially alarming, traumatic subcutaneous emphysema in an otherwise healthy patient from minor wounds (as featured in this case) does not necessarily mean one ought to proceed down an aggressive treatment algorithm. Careful evaluation of the patient's history, clinical examination findings, and determination of the Laboratory Risk Indicator for Necrotizing Fasciitis score can help guide physicians in the management of traumatic subcutaneous emphysema and potentially avoid unnecessary and costly interventions.

Obesity Does Not Adversely Affect Long-term Outcomes of Minimally Invasive Transforaminal Lumbar Interbody Fusion: A Matched Cohort Analysis.

Minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) is an established technique for the treatment of degenerative spine disease. The larger body habitus of obese patients increases the intraoperative complexity of MI-TLIF. Therefore, it is unclear whether this procedure is appropriate for this population. The goal of this study was to compare postoperative outcomes for obese patients vs nonobese patients undergoing MI-TLIF through a matched cohort analysis. A retrospective review was performed to identify patients who underwent MI-TLIF at a single institution with a minimum follow-up of 5 years. Patients were divided into 2 cohorts: nonobese (body mass index <30 kg/m2) and obese (body mass index ≥30 kg/m2). Each cohort was matched for age, sex, and levels operated. Perioperative data and patient-reported outcomes were compared. Radiographic outcomes were measured at final follow-up. Standard binomial and categorical comparative analyses were performed. A total of 148 patients were included. Of obese patients, 17.6% required revision surgery compared with 16.2% of nonobese patients (P=.826). Both cohorts had a similar proportion of pelvic incidence-lumbar lordosis mismatch correction (P=.780). Mean change in functional outcome scores for each cohort did not differ significantly. Obese patients had clinically minor but statistically significantly greater blood loss and longer operative times than nonobese patients (P<.001). Obese and non-obese patients undergoing MI-TLIF showed no long-term differences in revision rate, radiologic outcome, or functional outcome after long-term follow-up. Obese patients had slightly greater blood loss and longer operative times. Our findings suggest that MI-TLIF is an appropriate alternative to traditional open lumbar fusion for obese patients. [Orthopedics. 2022;45(4):203-208.].

Should we bridge the cervicothoracic junction in long cervical fusions? A meta-analysis and systematic review of the literature.

OBJECTIVE: Long posterior cervical decompression and fusion (PCF) is commonly performed to surgically treat patients with multilevel cervical pathology. In cases in which constructs may necessitate crossing the cervicothoracic junction (CTJ), recommendations for appropriate caudal fusion level vary in the literature. The aim of this study was to report the clinical and radiological outcomes of multilevel PCFs ending at C7 versus those crossing the CTJ. METHODS: A systematic search of PubMed, CINAHL Plus, and Scopus was conducted to identify articles that evaluated clinical and radiological outcomes of long PCFs that ended at C7 (cervical group) or crossed the CTJ (thoracic group). Based on heterogeneity, random-effects models of a meta-analysis were used to estimate the pooled estimates and the 95% confidence intervals. RESULTS: PCF outcome data of 1120 patients from 10 published studies were included. Compared with the cervical group, the thoracic group experienced greater mean blood loss (453.0 ml [95% CI 333.6-572.5 ml] vs 303.5 ml [95% CI 203.4-403.6 ml]), longer operative times (235.5 minutes [95% CI 187.7-283.3 minutes] vs 198.5 minutes [95% CI 157.9-239.0 minutes]), and a longer length of stay (6.7 days [95% CI 3.3-10.2 days] vs 6.2 days [95% CI 3.8-8.7 days]); however, these differences were not statistically significant. None of the included studies specifically investigated factors that led to the decision of whether to cross the CTJ. The cervical group had a mean fusion rate of 86% (95% CI 71%-94%) compared with the thoracic group with a rate of 90% (95% CI 81%-95%). Of patients in the cervical group, 17% (95% CI 10%-28%) required revision surgery compared with 7% (95% CI 4%-13%) of those in the thoracic group, but this difference was not statistically significant. The proportion of patients who experienced complications in the cervical group was found to be 28% (95% CI 12%-52%) versus 14% (95% CI 7%-26%) in the thoracic group; however, this difference was not statistically significant. There was no significant difference (no overlap of 95% CIs) in the incidence of adjacent-segment disease, pseudarthrosis, or wound-related complications between groups. CONCLUSIONS: This meta-analysis suggests similar clinical and radiographic outcomes in multilevel PCF, regardless of inclusion of the CTJ. The lowest instrumented level did not significantly affect revision rates or complications. The ideal stopping point must be tailored to each patient on an individualized basis.