Comparison of a novel hand-held retractor-assisted transforaminal lumbar interbody fusion by the wiltse approach and posterior TLIF: a one-year prospective controlled study.

BACKGROUND: This study aims to compare the clinical outcomes and safety of a novel hand-held retractor system-assisted Wiltse TLIF with that P-TLIF and assess whether this hand-held retractor system assisted Wiltse TLIF can yield less paraspinal muscle injury. METHODS: 56 patients (P-TLIF: 26, Wiltse TLIF: 30) were included in this one year prospective controlled study. The operation time, intraoperative blood loss, postoperative drainage, mobilization time, and discharge time were recorded. The clinical outcomes were evaluated by ODI, VAS, JOA, and SF-36 scores (7 days, 3, 6, and 12 months after surgery). Paraspinal muscle injury was assessed by postoperative MRI (6 months after surgery). CK and C-reaction protein were measured pre and postoperatively, and CT or X-ray (one year postoperatively) was used to assess bony union/non-union. RESULTS: The Wiltse (study) group was associated with significantly less estimated blood loss (79.67 ± 28.59 ml vs 192.31 ± 59.48 ml, P = 0.000*), postoperative drainage (43.33 ± 27.89 ml vs 285.57 ± 123.05 ml, P = 0.000*), and shorter mobilization (4.1 ± 1.2 d vs. 3.0 ± 0.9 d, P < 0.05) and discharge times (7.7 ± 1.9 d vs. 6.1 ± 1.2 d, P = 0.002*) than the P-TLIF (control) group. Serum CK activity at 24 h postoperatively in the study group was significantly lower than in the control group (384.10 ± 141.99 U/L vs 532.76 ± 225.76 U/L, P = 0.018*). At 7 days after surgery, VAS (2.3 ± 0.6 vs 3.2 ± 0.7, P = 0.000*)and ODI scores (43.9 ± 11.9 vs 55.2 ± 12.9, P = 0.001*) were lower, while the JOA scores (18.4 ± 3.4 vs 16.3 ± 4.2, P = 0.041*) was higher in the control group than in the study group. Results observed at 3 months of follow-up were consistent with those at 7 days. After six months postoperatively, paraspinal muscle degeneration in the control group was more significant than in the study group (P = 0.008*). CONCLUSION: Our study showed that this novel hand-held retractor system assisted Wiltse approach TLIF can significantly reduce paraspinal muscle injury, postoperative drainage, and intraoperative blood loss, mobilization and discharge time, as well as yield better short-term outcomes compared to P-TLIF. TRIAL REGISTRATION: 25/09/2023 NCT06052579.

Clinical application of a modified wiltse approach in middle and lower thoracic vertebrae: a case-control study of thoracic fracture patients.

BACKGROUND: The Wiltse approach has been extensively employed in thoracolumbar surgeries due to its minimal muscle damage. However, in the middle and lower thoracic spine, the conventional Wiltse approach necessitates the severance of the latissimus dorsi and trapezius muscles, potentially leading to muscular injury. Consequently, we propose a modified Wiltse approach for the middle and lower thoracic vertebrae, which may further mitigate muscular damage. METHODS: From May 2018 to April 2022, 60 patients with spinal fractures in the middle and lower thoracic vertebrae (T5-12) were enrolled in this study. Thirty patients underwent surgery using the modified Wiltse approach (Group A), while the remaining 30 patients received traditional posterior surgery (Group B). The observation indices included operation time, intraoperative blood loss, incision length, number of C-arm exposures, postoperative drainage, postoperative ambulation time, discharge time, as well as preoperative and postoperative Cobb's angle, percentage of anterior vertebral body height (PAVBH), visual analog scale (VAS) Score, and Oswestry disability index (ODI). RESULTS: Compared to the traditional posterior approach, the modified Wiltse approach demonstrated significant advantages in operation time, intraoperative blood loss, length of incision, postoperative ambulation time, postoperative drainage, and discharge time, as well as postoperative VAS and ODI scores. No significant differences were observed between the two groups in terms of number of C-arm exposures, postoperative Cobb's angle, or postoperative PAVBH. CONCLUSION: We propose a modification of the Wiltse approach for the middle and lower thoracic vertebral regions, which may further minimize muscular damage and facilitate the recovery of patients who have undergone surgery in the middle and lower thoracic vertebrae.

[Clinical and radiographic evaluation of oblique lumbar interbody fusion combined with posterior surgery via Wiltse approach for adult degenerative scoliosis].

Objective: To assess the clinical effect of oblique lumbar interbody fusion (OLIF) combined with posterior surgery via Wiltse approach for adult degenerative scoliosis. Methods: The clinical data of 27 patients with adult degenerative scoliosis who received OLIF operation from April 2015 to June 2018 in Tongji Hospital were analyzed retrospectively. There were 17 males and 10 females with an average age of (54±11) years. All patients were treated with OLIF combined with pedicle screw fixation via Wiltse approach. Operation time, blood loss and surgery complications were all recorded. Clinical and radiographic evaluation were investigated at 1 week, 3 months of post operation and final follow-up. Visual analog scale (VAS) for low back pain and leg pain, Oswestry disability index (ODI) for low back pain were used to evaluate the clinical efficacy of surgery. Lumbar coronal cobb angle, lumbar lordosis (LL), pelvic tilt (PT), mismatch of PI and PT, sagittal vertical axis (SVA) were investigated with full spine standing X-ray. The data were compared with factor analysis of variance. Results: All patients were followed-up for 6-52 months ((30±5) months). The operation time was (235±33) min, the blood loss was (433±62) ml. VAS for low back pain and eg pain and the ODI were significantly improved from 6.8±1.4, 7.3±1.4 and 71%±11% preoperatively to 1.1±1.2, 1.0±0.9 and 17%±6% at the latest follow-up (F=115.302,139.855,291.198, all P<0.05).Lumbar coronal Cobb angle of patients was reduced from 28°±8° preoperatively to 9°±4° at the latest follow-up (F=66.352, P<0.05). The LL was significantly increased from 20°±11° preoperatively to 33°±7° (F=17.678, P<0.05), and PT, PI-LL and SVA were significantly increased from 31°±6°,35°±12° and (90±29) mm preoperatively to 26°±5°, 21°±6° and (32±17) mm at the latest follow-up (F=6.211,23.809,53.372, all P<0.05). There was no severe vascular andnerve injuries during and after operation. Conclusion: OLIF combined with posterior surgery via Wiltse approach is a safe and effective operation in the treatment of adult degenerative scoliosis with mild to moderate sagittal imbalance, it can correct the coronal and sagittal deformity, and achieve less surgery injury, less complications and good clinical results.

Comparison of pedicle fixation by the Wiltse approach and the conventional posterior open approach for thoracolumbar fractures, using MRI, histological and electrophysiological analyses of the multifidus muscle.

PURPOSE: To use imaging, histology and electrophysiological assessment to compare the Wiltse approach to pedicle fixation with the conventional posterior open approach for thoracolumbar fractures. METHODS: We analyzed clinical and histopathological information of consecutive patients with thoracolumbar fractures who underwent short-segment pedicle fixation using either the Wiltse approach or the posterior open approach. Seventy-five patients were enrolled between June 2010 and August 2014 (Wiltse group 35 cases; posterior open group 40 cases). The two groups were compared for MRI appearance, histological and electrophysiological changes in multifidus muscle. RESULTS: On MRI, multifidus cross-sectional area (CSA) in the Wiltse group decreased by only 7.6% between pre-op and the last follow-up, compared to 35.4% in the posterior open group, and less fatty infiltration was found in the Wiltse group. Histologically, post-op (removal of internal fixation) tissue from the posterior open group showed disordered myofibrils, with diameter and CSA decreased by 11.6 and 24.3%, respectively; also, the myofibril gap became larger with fat deposition and scar formation. The Wiltse group had no such significant changes. Electrophysiologically, in the posterior open group, median frequency slope (MFs) significantly increased by 67.6% with average amplitude (AA) significantly decreased by 17.5% between pre-op and 12 months post-op. No significant changes were found in the Wiltse group. At 12 months post-op, AA was significantly lower and MFs was higher in the posterior open group than the Wiltse group. CONCLUSION: The Wiltse approach showed a lower incidence of multifidus atrophy and denervation, and less fatty infiltration. It is an effective and minimally invasive approach for thoracolumbar fractures.

Clinical outcomes of two minimally invasive transforaminal lumbar interbody fusion (TLIF) for lumbar degenerative diseases.

BACKGROUND: There are two modified TLIF, including MIS-TLIF and TLIF through Wiltse approach (W-TLIF). Although both of the two minimally invasive surgical procedures can be effective in the treatment for lumbar degenerative diseases, no comparative analysis has been made so far regarding their clinical outcomes. OBJECTIVE: To compare the clinical outcomes of MIS-TLIF and W-TLIF for the treatment for single-segment degenerative lumbar diseases. METHODS: Ninety-seven patients with single-segment degenerative lumbar disorders were included in this study. Forty-seven underwent MIS-TLIF surgery (group A). For group B, fifty patients underwent W-TLIF. The Japanese Orthopedic Association (JOA) score, the visual analog scale (VAS) of low back pain (LBP) and leg pain, MRI score and atrophy rate of CSA, interbody fusion rate were assessed during the postoperative follow-up. RESULTS: Incision length, blood loss, operative time, CPK, and postoperative incision pain VAS were better in group A (P < 0.05). The seconds of intraoperative fluoroscopy in groups A and B were 76 ± 9 and 7 ± 2, respectively (P < 0.05). In group B, The blood loss and CPK at L5-S1 were significantly higher than those at L4-5. Postoperative JOA scores, VAS of leg pain, and fusion rate were statistically the same between the two groups. VAS of LBP, MRI score, and atrophy rate of CSA was better in group A than in group B (P < 0.05). CONCLUSION: Both methods are effective in the treatment for lumbar degenerative disease. MIS-TLIF has less blood loss, shorter surgical incision, and less lower postoperative back pain, while W-TLIF is less expensive for hospital stay with lower exposure to X-rays.

Comparison of intraoperative and postoperative outcomes between open, wiltse, and percutaneous approach to traumatic thoracolumbar spine fractures without neurological injury: A systematic review and meta-analysis.

Background: Traumatic thoracolumbar fracture fixation without neurological injury can be performed using the traditional open, mini-open Wiltse, and percutaneous approaches. This systematic review and meta-analysis aims to compare perioperative outcomes between these approaches. Methods: PubMed, Web of Science, Scopus, Embase, and the Cochrane Library were searched for all relevant observational comparative studies. Results: 5 randomized trials and 22 comparative cohort studies were included. Compared to the traditional open approach (n=959), the Wiltse approach (n=410) was associated with significantly lower operative time, intraoperative estimated blood loss (EBL), and length of stay (LOS). There was no significant difference between the two in terms of postoperative visual analog scale (VAS) and Cobb angle. Compared to the percutaneous approach (n=980), the Wiltse approach was associated with shorter operative and fluoroscopy time, as well as significantly improved Cobb and vertebral body angles. The percutaneous approach was associated with improved vertebral body height. There was no significant difference between the two for blood loss, postoperative VAS, or LOS. Compared to the traditional open approach, the percutaneous approach was associated with shorter operative time, lower EBL, shorter LOS and better postoperative VAS and Oswestry Disability Index. There was no difference between the two in postoperative Cobb angle, vertebral angle, or vertebral body height. Overall study heterogeneity was high. Conclusions: Utilization of minimally invasive surgical approaches holds great promise for lowering patient morbidity and optimizing care. A prospective trial is needed to assess outcomes and guide surgical decision making.

The use of intraoperative CT-neuronavigation in Wiltse approach. A technical note.

Introduction: The paraspinal approach was first introduced in 1968 and later refined by Leon Wiltse to gain access to the lateral interevertebral foraminal region. However, challenges can arise due to unfamiliarity with this approach, unique patient anatomy, or in case of revision surgery, potentially elevating the risk of complications and/or poor outcome. Methods: Here we report on two cases in which the intraoperative Oarm CT neuronavigation was used during a Wiltse approach. Under general anesthesia, the spinous process near the surgical level is exposed through a midline incision. The patient's reference anchor is then attached to the exposed spinous process. Intraoperative CT is acquired and transferred to the Stealth Station S8 Surgical Navigation System (Medtronic). The Wiltse approach is now performed through a paramedian incision under neuronavigation guidance and perfectly tailored to the patient's unique anatomy. Results: The first case was a patient harboring a left lumbar intraextraforaminal schwannoma and the second one was a patient with an extraforaminal lumbar disc herniation at the adjacent level of a previous lumbar instrumentation. We were able to easily identify and remove both the lesions minimizing the surgical approach with no complication and optimal clinical outcome. Discussion and Conclusion: Our cases demonstrate the feasibility of application of intraoperative O-arm CT-neuronavigation to the Wiltse approach. In our opinion, this technique helps in minimizing the surgical approach and rapidly identifying the lesion of interest. Further studies are needed to address the effective utility and advantages of intraoperative CT-neuronavigation in this specific surgical scenario.

The feasibility and efficacy of pedicle fixation by the Wiltse approach in the thoracic spine.

Study design: Retrospective Cohort Study. Objectives: To explore the feasibility and assess the efficacy of pedicle fixation with the Wiltse approach in the thoracic spine. Summary of background data: The current application of Wiltse approach is mainly practiced in the lumbar and thoracolumbar spines. Its application in the thoracic spine, however, has received little attention, especially in cases that requires only pedicel screw fixation without spinal decompression. Methods: The study analyzed the clinical records of consecutive patients with thoracic diseases who underwent pedicle fixation with either Wiltse or the conventional transmuscular approach (Wiltse group: 60 cases; Transmuscular group: 48 cases). Perioperative parameters, Visual Analogue Scale (VAS) scores, accuracy of pedicle screw placement, dead space between the muscles, Magnetic Resonance Imaging (MRI) appearance, electrophysiological changes in the multifidus muscle were compared between the two groups. Results: Compared with the transmuscular group, the Wiltse group was significantly better in blood loss and postoperative VAS scores. No difference was observed in incision length, operation time, and hospital stay. The dead space between the muscle cross-sectional region in the transmuscular group was 315 ± 53 mm2, and no dead space was found in the Wiltse group. On MRI images, the multifidus cross-sectional area (CSA) in the Wiltse group between the preoperative period and the last follow-up reduced by only 10.1%, while transmuscular group showed 46.1% CSA reduction. Electrophysiologically, the median frequency slope of the transmuscular group grew by 47.8% with average amplitude reduced by 16.4% between the preoperative period and 12-month postoperative. Conclusion: The Wiltse approach for pedicle fixation in the thoracic spine is a feasible and effective treatment, with fewer traumas and reliable clinical results. In particular, the Wiltse approach reduces postoperative dead space between the muscles and causes less atrophy in the multifidus muscle.

Acceptable Fusion Rate of Single-Level OLIF Using Pure Allograft Combined with Posterior Instrumentation through the Wiltse Approach: A 2-Year Follow-Up Study.

OBJECTIVE: Autogenic bone grafts have shown successful fusion rates in the treatment of degenerative lumbar disorders, but taking too many autogenic bones may result in donor site ischemia or infection. This study aimed to evaluate the outcomes of single-level oblique lumbar interbody fusion (OLIF) using pure allograft combined with posterior pedicle screw instrumentation through the Wiltse approach. METHODS: A retrospective case analysis was performed on a series of consecutive patients who received a single-level OLIF procedure combined with posterior pedicle screw instrumentation through the Wiltse approach between July 1, 2017, and December 31, 2019, in which pure allogenic bone graft was used and filled in the large window of the cage. The patients were followed up as scheduled at 1 day and 3, 6, 12, 24 months after operation. Clinical outcome was assessed by multiple questionnaires, including Oswestry disability index (ODI), Japanese Orthopaedic Association (JOA) score rating system, short form-36 health survey (SF-36), and visual analog scale (VAS) for low back pain. Radiographic outcome was evaluated by measuring the parameters such as disc height, lumbar lordosis, and segmental angle on the standard standing lateral radiographs, and the space angle of the fusion level on the dynamic views of the lateral radiographs. Subsidence of the cage and intervertebral fusion status were evaluated on both the radiographic and CT scan images. RESULTS: A total of 34 patients were finally included in this study. At 2-year follow-up, the VAS for low back pain, ODI, JOA, and SF-36 scores all had significant improvement (p < 0.001). Substantial increase of anterior and posterior disc heights was observed (p < 0.001). Both lumbar lordosis and segmental angle became larger (p < 0.05). No visible change of the space angle of the fusion level was found on the dynamic views. The 1-year fusion rate of 73.5% on CT scans proceeded to 82.4% at 2-year follow-up. The fusion rate was as high as 91.2% according to Bridwell interbody fusion grading system on radiographic images. The clinical outcomes in patients with incomplete fusion were just as good as those with complete fusion. The six patients with cage subsidence had higher ODI (p < 0.001) and lower JOA (p < 0.001) and SF-36 PCS (p = 0.011) scores than those without cage subsidence. CONCLUSION: The use of pure allograft in single-level OLIF resulted in an acceptable fusion rate and satisfactory clinical effect at 2-year follow-up. Supplementation of posterior pedicle screw through the minimally invasive Wiltse approach ensured the favorable outcomes both clinically and radiographically.

Use of Wiltse approach in lumbar plexus schwannoma: A technical note.

Background: Lumbar plexus schwannomas are a rare occurrence in neurosurgery, with few reported cases and no standard surgical approach. This study describes a successful surgical resection with no complications using the Wiltse approach. Methods: Patient presented with an intra-psoas tumor suggesting schwannoma. We described the surgical technique involved step by step. Results: The patient recovered from the surgery with no complications. The anatomopathological examination confirmed the schwannoma diagnosis. The post operatory magnetic resonance imaging showed complete resection. Conclusion: This study shows that the use of Wiltse approach, mainly used for classical herniated disc extraforaminal, can be used successfully on Lumbar plexus schwannomas.

Wiltse transforaminal thoracic interbody fusion approach for the treatment of single­segment thoracic spinal tuberculosis in elderly patients with osteoporosis: A retrospective study of 20 cases.

The aim of the present study was to investigate the clinical feasibility and efficacy of the Wiltse approach and TTIF in elderly patients with single-segment thoracic tuberculosis (SSTTB) complicated with osteoporosis and neurological dysfunction. Between January 2017 and January 2019, 20 elderly patients underwent the Wiltse TTIF approach at a single hospital. The follow-up time of these patients was 37.15±7.37 months (range, 24-48 months). The preoperative kyphosis angle was 35.41±6.71˚. The degree of neurological deficit in each patient was assessed using the Frankel spinal cord injury classification. In addition, TB activity was monitored using erythrocyte sedimentation rate and C-reactive protein levels, and the degree of osteoporosis was evaluated using femoral neck bone mineral density T-scores. The 20 patients with SSTTB were completely cured without recurrence. The postoperative kyphotic angle was 8.80±0.79˚, without significant loss of correction at the final follow-up. Bone graft fusion was observed within 6-9 months, with all patients reporting relief of their back pain. The neurological condition of all the patients improved postoperatively. The present study indicates that Wiltse TTIF surgery combined with anti-TB chemotherapy has satisfactory efficacy in elderly patients with SSTTB complicated by osteoporosis and neurological impairment.

Study of single-level lumbar degenerative diseases treated by unilateral wiltse access with unilateral nail rod fixation assisted by a new automatic retraction device.

OBJECTIVE: To evaluate the clinical efficacy of unilateral wiltse transforaminal lumbar interbody fusion (TLIF) combined with unilateral nail bar system fixation for single-level lumbar degenerative diseases with the assistance of a new automatic retraction device in a retrospective comparative study. METHODS: A total of 46 patients with single-level lumbar degenerative diseases from September 2019 to December 2021 were retrospectively analyzed. Bilateral nail bar fixation with bullet-type fusion cage (ctrl group, 24 patients) and unilateral nail bar fixation on the affected side with kidney-like fusion cage (study group, 22 patients) were performed in TLIF via wiltse intermuscular approach assisted by a new automatic retraction device. The differences in intraoperative blood loss, operative time, intraoperative fluoroscopy time, postoperative drainage, bed rest, VAS score, ODI score, JOA score, serological creatine kinase (CK), the proportion of multifidus atrophy, modified Pfirrmann classification and intervertebral space height of the upper intervertebral disc were compared between the two groups based on clinical and imaging data. RESULTS: Intraoperative bleeding, operative time, and postoperative drainage were significantly lower in study group than ctrl group, and there were no significant differences in bed rest time and intraoperative fluoroscopy time between them. In addition, there was no statistical difference in CK between the study group and the ctrl group at 24 and 48 h postoperatively. Moreover, no statistically significant difference was found in VAS score of low back pain, VAS score of lower limb pain, ODI index, modified Pfirrmann classification of the upper intervertebral disc and intervertebral space height of the upper intervertebral disc between two groups. The atrophy ratio of multifidus muscle was significantly lower in the study group. CONCLUSION: The new automatic retraction device assisted unilateral TLIF surgery with wiltse approach combined with unilateral nail bar fixation is a simple, effective and easy to master surgical method for single-level lumbar degenerative diseases.

Recent Efficacy of Oblique Lateral Interbody Fusion Combined With Wiltse Approach Pedicle Screw Fixation for Degenerative Single-Level Lumbar Spondylolisthesis.

BACKGROUND: The study aimed to explore the recent efficacy of oblique lateral interbody fusion (OLIF) combined with Wiltse approach pedicle screw fixation in the treatment of single-level degenerative lumbar spondylolisthesis (DLS). METHODS: This is a retrospective study. The study enrolled 54 patients with single-level DLS who were treated at the Affiliated Jiangnan Hospital of Zhejiang Chinese Medical University from May 2018 to June 2020. (OLIF group) 24 cases operated using OLIF combined with Wiltse approach pedicle screw fixation, and (PLIF group) 30 cases operated by PLIF. The primary outcome measures were visual analog scale (VAS) pain scores, Oswestry dysfunction index (ODI), and the lower lumbar spine anterior convexity angle. RESULTS: There were significant differences in VAS (2.63 ± 0.58 vs. 3.57 ± 0.63, P < 0.001) and ODI (9.67 ± 0.92 vs. 10.63 ± 1.40, P < 0.05) between the OLIF group and PLIF group on postoperative 3 days. And there was a significant decrease in VAS (2.63 ± 0.58 vs. 1.08 ± 0.28, P < 0.05) and ODI (3.57 ± 0.63 vs. 1.10 ± 0.31, P < 0.05) in both groups on postoperative 3 days and at 6 months postoperative comparisons. OLIF group showed better intervertebral space height and the lower lumbar spine anterior convexity angle scores on postoperative 3 days and 6 months, the difference was statistically significant(all P < 0.05). CONCLUSIONS: OLIF combined with the Wiltse approach pedicle screw fixation can achieve good short-term clinical results in the treatment of single-level DLS. This surgical approach is less invasive, promotes early functional recovery, shortens hospitalization time, and improves the quality of life.

Multitrack and multianchor point screw technique combined with the Wiltse approach for lesion debridement for lumbar tuberculosis.

BACKGROUND: The incidence of lumbar tuberculosis is high worldwide, and effective treatment is a continuing problem. AIM: To study the safety and efficacy of the multitrack and multianchor point screw technique combined with the contralateral Wiltse approach for lesion debridement to treat lumbar tuberculosis. METHODS: The C-reactive protein (CRP) level, erythrocyte sedimentation rate (ESR), visual analogue scale (VAS) score, oswestry disability index (ODI) and American Spinal Injury Association (ASIA) grade were recorded and analysed pre- and postoperatively. RESULTS: The CRP level and ESR returned to normal, and the VAS score and ODI were decreased at 3 mo postoperatively, with significant differences compared with the preoperative values (P < 0.01). Neurological dysfunction was relieved, and the ASIA grade increased, with no adverse events. CONCLUSION: The multitrack, multianchor point screw fixation technique combined with the contralateral Wiltse approach for debridement is an effective and safe method for the treatment of lumbar tuberculosis.

Comparison of Wiltse Approach of Pedicle Screw Fixation With or Without Vertebroplasty in the Treatment of Genant III Degree Osteoporotic Thoracolumbar Fractures: Analysis of Clinical Findings, Radiographic Parameters, and Follow-Up Complications.

STUDY DESIGN: A retrospective case-control study. OBJECTIVE: This study aimed to compare the effects of the Wiltse approach of pedicle screw fixation (PSF) either in combination with or without vertebroplasty (VP) in the treatment of Genant III degree osteoporotic thoracolumbar fractures (Genant III-OTLFs). METHODS: A retrospective study of Genant III-OTLFs was performed from January 2018 to December 2019, including 54 cases of PSF + VP and 56 cases of PSF. Clinical indicators [visual analog scale (VAS) score, Oswestry disability index (ODI)], radiographic parameters [local kyphosis angle (LKA), percentage of anterior, central, and posterior vertebral heights (AVH%, CVH%, and PVH%, respectively)] and follow-up complications [adjacent vertebral fracture (AVF), residual pain (RP), vertebral height loss (VHL), and internal fixation failure (IFF)] were compared between the 2 groups. RESULTS: No differences in surgical outcomes, clinical indicators, and radiographic parameters were observed between the 2 groups during the preoperation period and 7 days post-operatively (P > .05). However, the VAS score [2.0 (.6), 1.9 (.5)], ODI [23.7 (4.0), 22.6 (3.0)], LKA [9.5 (1.8), 10.6 (3.0)], AVH% [90.1 (2.7), 87.7 (6.0)], CVH% [92.5 (2.6), 91.3 (3.7)], and PVH% [93.4 (2.0), 92.7 (2.4)] at 1 year post-operatively and last follow-up of the PSF + VP group were better than those of the PSF group [2.5 (.8), 3.1 (1.1), 26.6 (3.8), 29.6 (4.6), 12.2 (1.6), 16.6 (3.2), 84.9 (4.0), 69.9 (6.6), 88.1 (3.1), 78.2 (5.1), 89.7 (2.3), 84.8 (4.6)], respectively (P < .001). During follow-up, the incidence of AVF had no difference (P > .05), while that of RP (32.1 vs 14.8%), VHL (33.9 vs 9.3%) and IFF (17.9 vs 5.6%) had statistical differences between them (P < .05). CONCLUSION: The Wiltse approach of PSF combined with VP for Genant III-OTLFs can not only effectively relieve pain, restore vertebral height, and correcte kyphosis, but also better maintain vertebral height, delay kyphosis progression, and reduce complications during follow-up.

Influence of the facet joint angle on facet joint degeneration following pedicle screw fixation without fusion in thoracolumbar fractures.

BACKGROUND: Posterior approach pedicle screw fixation without fusion is widely used in the treatment of neurologically intact type A3 thoracolumbar fractures. OBJECTIVE: To analyze the influence of the facet joint (FJ) angle on FJ degeneration following posterior approach pedicle screw fixation without fusion in neurologically intact type A3 thoracolumbar fractures. METHODS: Fifty-eight patients who underwent pedicle screw fixation via the traditional posterior approach (n= 28) or the Wiltse approach (n= 30) were enrolled. A CT scan was performed before fixation and before fixation removal (Within 1.5 to 2 years after fixation) to evaluate the FJs parameters, including FJ inclination (FJI), FJ tropism (FJT), FJ violation, and FJ degeneration grade (FJDG), of three fixed segments and the adjacent segment below the fixed segments. RESULTS: There was no significant difference in FJ violation rate, FJDG deterioration, or FJ angle between the two groups (P> 0.05). FJDG deterioration showed a weak positive correlation with FJI and FJT before fixation, and the angular change in FJI (P< 0.05); and FJT before fixation and the angular change in FJI were risk factors for FJDG deterioration (P< 0.01). CONCLUSION: The Wiltse approach did not increase the rate of FJDG deterioration and FJs angle changes. However, the FJT before fixation and the angular change in FJI were risk factors for FJDG deterioration.

Hidden blood loss between percutaneous pedicle screw fixation and the mini-open Wiltse approach with pedicle screw fixation for neurologically intact thoracolumbar fractures: a retrospective study.

BACKGROUND: The aim of this study was to determine the proportion of hidden blood loss (HBL) in patients treated with minimally invasive surgery, and to compare the HBL between patients treated with percutaneous pedicle screw fixation (PPSF) and the mini-open Wiltse approach with pedicle screw fixation (MWPSF). METHODS: From January 2017 to January 2019, a total of 119 patients with thoracolumbar fractures were included in the analysis, of which 58 cases received PPSF and 61 cases received MWPSF. The clinical information and demographic results were collected and compared. And the HBL of the patients is calculated by the combination formulas of Nadler, Gross and Sehat. RESULTS: Compared with the PPSF group, operation time of MWPSF is shorter. The fluoroscopy times are 13.6 ± 3.0 in PPSF group and 5.6 ± 1.6 in MWPSF group (p < 0.001). As shown in Table 3, the intraoperative blood loss in PPSF group is 31.9 ± 9.6 ml, which is significantly less than that in the MWPSF group (44.0 ± 14.9 ml). The HBL (445.7 ± 228.9 ml), and HBL% (91.2 ± 7.7%) of the PPSF group are significantly higher than that in the MWPSF group (P < 0.05). And the total blood loss (TBL) of the PPSF group (477.6 ± 228.8 ml) is also more than that in the MWPSF group (401.0 ± 171.3 ml). CONCLUSIONS: Our results suggest that in the minimally invasive surgical treatment of thoracolumbar fractures, the perioperative HBL is much higher than visible blood loss (VBL). Although PPSF has less intraoperative blood loss, it has higher TBL and HBL than those of MWPSF. Compared with MWPSF, we should pay more attention to the postoperative anemia status of patients with thoracolumbar fractures undergoing PPSF surgery.

[Clinical study of Wiltse approach with fulcrum reduction technique in the treatment of AO-A type thoracolumbar fractures].

Objective: To investigate the effectiveness of Wiltse approach with fulcrum reduction technique and pedicle internal fixation in the treatment of AO-A type thoracolumbar fractures. Methods: The clinical data of 16 patients with AO-A type thoracolumbar fractures treated with Wiltse approach with fulcrum reduction technique and pedicle internal fixation between September 2013 and January 2019 were retrospectively analyzed. There were 9 males and 7 females, the age ranged from 38 to 60 years, with an average age of 50.7 years. Causes of injury included 9 cases of falling from height, 3 cases of traffic accidents, 3 cases of falling, and 1 case crushed by heavy objects. Fractured segment involved T 11 in 2 cases, T 12 in 5 cases, L 1 in 7 cases, and L 2 in 2 cases. There were 6 cases of type A1, 3 cases of type A2, 5 cases of type A3, and 2 cases of type A4 according to AO fracture classification. The operation time, intraoperative blood loss, and removal time of internal fixator were recorded. Before operation, immediately after operation, before and after removal of internal fixator, the local kyphotic angle (LKA), anterior vertebral height (AVH), and posterior vertebral height (PVH) of fractured vertebral body were measured; visual analogue scale (VAS) score of back pain were evaluated before operation, at 3 days after operation, before and after removal of internal fixator. Results: The operation time of the patients was 50-95 minutes, with an average of 70.7 minutes; the intraoperative blood loss was 50-230 mL, with an average of 132.9 mL; the internal fixator was removed after 18-30 months, with an average of 23.6 months. All patients were followed up 20-32 months, with an average of 25.6 months. No incision infection, hematoma, and other surgery-related complications, and internal fixator rupture residual complications occurred. All 16 patients achieved satisfactory reduction results. Immediate postoperative LKA, AVH, and PVH were significantly improved when compared with preoperative ones ( P<0.05). There was a certain degree of reduction loss before internal fixator removal, and the difference in LKA was significant ( P<0.05), but the difference in AVH and PVH were not significant ( P>0.05). There was a certain degree of reduction loss after internal fixator removal, but only the difference in AVH was significant ( P<0.05), and there was no significant difference in LKA and PVH ( P>0.05). The VAS score of the back pain significantly improved at 3 days after operation and before internal fixator removal when compared with preoperative score ( P<0.05). The pain after internal fixator removal was significantly worse than that before internal fixator removal ( P<0.05). Conclusion: The Wiltse approach with fulcrum reduction technique and pedicle internal fixation in the treatment of AO-A thoracolumbar fractures has a short operation time, less intraoperative blood loss, and the posterior soft tissue and other structures are well protected during the operation. It can provide satisfactory clinical reduction results.

A Comparative Study of a New Retractor-Assisted WILTSE TLIF, MIS-TLIF, and Traditional PLIF for Treatment of Single-Level Lumbar Degenerative Diseases.

OBJECTIVES: To compare the clinical efficacy of a new retractor-assisted Wiltse transforaminal lumbar interbody fusion (TLIF), minimally invasive TLIF (MIS-TLIF), and traditional posterior lumbar interbody fusion (PLIF) in treating single-level lumbar degenerative diseases. METHODS: A retrospective study was conducted by analyzing the clinical and imaging data of consecutive patients with single-level lumbar degenerative diseases who underwent the new retractor-assisted Wiltse TLIF, MIS-TLIF, or traditional PLIF. This study enrolled 87 concurrent patients between June 2016 and December 2019 (Wiltse TLIF 29 cases; MIS-TLIF 28 cases; PLIF 30 cases). The three groups were compared for perioperative indicators (including intraoperative blood loss, postoperative drainage volume, operation time, intraoperative fluoroscopy time, bedridden time), creatine kinase (CK), visual analog score (VAS), Oswestry disability index (ODI), Japanese Orthopaedic Association (JOA) score, intervertebral fusion rate, muscle atrophy, and fatty infiltration (including ratio of multifidus atrophy and ratio of lean-to-total cross-sectional area [CSA]). RESULTS: Intraoperative blood loss (F = 62.628, p < 0.001), postoperative drainage volume (F = 72.048, p < 0.001), and bedridden time (χ2  = 62.289, p < 0.001) were significantly lower in the MIS-TLIF and Wiltse groups than in the PLIF group. The operative and intraoperative radiation times of the MIS-TLIF group were significantly longer than those of the Wiltse and PLIF groups. The CK concentration in the Wiltse and MIS-TLIF groups were significantly lower than those in the PLIF group 1 day (F = 9.331, p < 0.001) and 3 days after surgery (F = 15.967, p < 0.001). The PLIF group's back pain VAS score was higher than those of the Wiltse and MIS-TLIF groups. The PLIF group had a higher ODI 6 months (F = 3.282, p = 0.042) and 12 months (F = 5.316, p = 0.007) after surgery and a lower JOA score than the Wiltse and MIS-TLIF groups 6 months (F = 3.234, p = 0.044) and 12 months (F = 3.874, p = 0.025) after surgery. The ratio of multifidus atrophy in the PLIF group (41.70 ± 8.84%) was significantly higher than those of the Wiltse group (24.13 ± 6.82%) and the MIS-TLIF group (22.35 ± 5.03%). The ratio of lean-to-total CSA in the PLIF group was lower than those of the Wiltse and MIS-TLIF groups after surgery (F = 8.852, p < 0.001). MIS-TLIF group showed longer operation time (169.11 ± 29.38 min) and intraoperative fluoroscopy time (87.61 ± 3.13 s) than the Wiltse group. CONCLUSION: Wiltse TLIF assisted by the new retractor is a more convenient and minimally invasive surgical method than the traditional PLIF and MIS-TLIF methods, which are linked to a long learning curve and long operation and fluoroscopy time.

[Clinical efficacy of oblique lumbar interbody fusion combined with unilateral pedicle screw fixation via Wiltse approach in the treatment of lumbar spinal stenosis].

OBJECTIVE: To evaluate the efficacy of oblique lumbar interbody fusion combined with unilateral pedicle screw fixation via Wiltse approach in the treatment of lumbar spinal stenosis. METHODS: From July 2017 to January 2019, 90 patients with lumbar spinal stenosis, including 38 males and 52 females, aged from 43 to 75 years old with an average of(59.9±8.8) years old, and were treated with oblique lumbar interbody fusion(OLIF) combined with Wiltse unilateral pedicle screw fixation. Surgical decompression and fixation was performed in 50 cases of single segment, 32 cases of double segments and 8 cases of three segments. The distribution of responsible segments included 8 cases of L2-L3, 12 cases of L3-L4 and 30 cases of L4-L5 on single segment, 10 cases of L2-L4 and 22 cases of L3-L5 on double segments, and 8 cases of L2-L5 on three segments. The operation time, blood loss and occurrence of complications were recorded, Visual analogue scale(VAS), Oswestry Disability Index(ODI) and SF-36 scale were used to evaluate clinical efficacy. Lumbar X-ray and MRI were taken at three days after operation, interverterbral space height, intervertebral foraminal height, interverterbral foraminal area, and spinal canal area were measured, and interbody fusion was evaluated according to CT at half a year after operation. RESULTS: All patients were followed up from 12 to 33 months, with an average of (20.2±6.6) months. Mean operation time was (103.3±35.9) min, and mean intraoperative blood loss was (70.4±17.8) ml. VAS of low back pain leg pain, and ODI decreased from 6.2±1.1, 6.1±0.9 and (59.9±4.2)% to 2.7±0.5, 2.5±0.5 and (31.3±8.8)%. SF-36 scale significantly increased from (37.2±3.1) to (54.9±6.1) at the six months postoperation(P<0.05). The intervertebral space height, intervertebral foraminal height, intervertebral foraminal area, and spinal canal area were significantly improved at 3 days after operation(P<0.05). Six months after operation, CT scan showed well fusion in 87 cases, but 3 cases with poor fusion, including 1 case of single segment, 2 cases of multi-segments. The total fusion rate was 96.7% (87/90), the single segment fusion rate was 98.0% (49/50), and the multi-segments fusion rate was 95.0%(38/40). The overall incidence of complications was 17.8%(16/90), including transient iliopsoas muscle weakness in 5 cases (5.6%), endplate fracture in 2 cases (2.2%), peritoneal injury in 1 case (1.1%), postoperative hematoma in 1 case (1.1%), adjacent segment disease in 1 case(1.1%), and fusion cage subsidence in 6 cases (6.7%). Three patients was followed up for recurrent nerve root pain and the symptoms were relieved after revision operation. All complications were relieved or disappeared in varying degrees during the follow-up period, and there were no complications such as cage displacement and screw fracture. CONCLUSION: OLIF combined with unilateral pedicle screw fixation via Wiltse approach is effective in treating lumbar spinal stenosis with minimally invasive advantages such as less trauma and less complications. Under the premise of strictly grasping the indications, this method could also achieve satisfactory clinical results in multi-segments oprations.