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Kim, Suk, Lee, Lee, Park, Son, Kwack, and Hong: Comparative Study of the Clinical Outcomes of Unilateral Transforaminal Lumbar Interbody Fusion(TLIF) with Bilateral TLIF using Wiltse Approach and Conventional Approach
Original Article

Journal of Korean Spine Surg 2011;18(4):208-216.

Published online: 21 December 2011

DOI: https://doi.org/10.4184/jkss.2011.18.4.208

Comparative Study of the Clinical Outcomes of Unilateral Transforaminal Lumbar Interbody Fusion(TLIF) with Bilateral TLIF using Wiltse Approach and Conventional Approach

Ki-Tack Kim, M.D., Kyung-Soo Suk, M.D., Sang-Hun Lee, M.D., Jung-Hee Lee, M.D., Kyoung-Jun Park, M.D., Eun-Seok Son, M.D.∗, , Yoon-Ho Kwack, M.D., Se-Hyuk Hong, M.D.

Department of Orthopedic Surgery, College of Medicine, Graduate School, Kyung Hee University

∗Kyung Hee University Department of medicine, Graduate School, Kyung Hee University

Corresponding author: Eun-Seok Son, M.D. Department of Medicine, Graduate School, Kyung Hee University TEL: TEL : 82-53-250-7729, FAX: 82-53-250-7205 E-mail: esson75@hanmail.net

Received 4 March 2011       Revised 30 May 2011       Accepted 31 May 2011

Copyright © 2011 Korean Society of Spine Surgery

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Study Design

Comparative study.

Objectives

To compare the outcomes of unilateral TLIF, bilateral TLIF using Wiltse approach and bilateral TLIF using conventional midline approach.

Summary of Literature Review

There are many studies about outcomes of Unilateral TLIF, but few have compared the 3 different fusion procedures.

Materials and Methods

60 patients were divided into 3 groups. Each group has enrolled 20 patients (Study group: unilateral TLIF, Control group 1: bilateral TLIF using Wiltse approach, Control group 2: bilateral TLIF using conventional midline approach). For clinical outcomes, we compared operative time, blood loss, time for ambulation and discharge, VAS for back pain and leg pain and ODI among three groups. For radiologic evaluation, disc height and segmental lordosis were examined.

Results

The mean operative time was 147 minutes in study group(SG), 172 minutes in control group 1(CG1), 167 minutes in control group 2(CG2). The mean total blood loss was 466ml in SG, 569ml in CG1, 1140ml in CG2 respectively. VAS for back pain at the third postoperative day significantly decreased in SG and CG1 compared with CG2. There was no significant difference in ODI, disc height and segmental lordosis among the groups.

Conclusion

Using Wiltse approach, there were several advantages in decreasing blood loss, immediate postoperative back pain, hospital stay and early ambulation. Clinical and radiological results of unilateral TLIF were comparable with bilateral TLIF.

Keywords: Minimally invasive surgery, Wiltse, Transforaminal lumbar interbody fusion

REFERENCES

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2. Foley KT, Holly LT, Schwender JD. Minimally invasive lumbar fusion. Spine (Phila Pa 1976). 2003; 28(15 Suppl):S26–35.
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3. Holly LT, Schwender JD, Rouben DP, Foley KT. Minimally invasive transforaminal lumar inerbody fusion: indications, technique, and complications. Neurosurg Focus. 2006; 20:E6.
4. Shunwu F, Xing Z, Fengdong Z, Xiangqian F. Minimally invasive transforaminal lumbar interbody fusion for the treatment of degenerative lumbar diseases. Spine (Phila Pa 1976). 2010; 35:1615–20.
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6. Kim KT, Suk KS, Lee YH, Kim YW, Lee SH. The Posterior Decompression and Posterior Lumbar Interbody Fusion Using a Mini-open Technique – New Suggestion of Minimally Invasive Technique – A Prelimainary Report. J Korean Orthop Assoc. 2003; 38:492–7.
7. Kim KT, Lee SH, Lee YH, Bae SC, Suk KS. Clinical outcomes of 3 fusion methods through the posterior approach in the lumbar spine. Spine (Phila Pa 1976). 2006; 31:1351–7.
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8. Humphreys SC, Hodges SD, Patwardhan AG, Eck JC, Murphy RB, Covington LA. Comparison of posterior and transforaminal approaches to lumbar interbody fusion. Spine (Phila Pa 1976). 2001; 26:567–71.
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10. Isaacs RE, Podichetty VK, Santiago P, et al. Minimally invasive microendoscopy-assisted transforaminal lumbar interbody fusion wit instrumentation. J Neurosurg Spine. 2005; 3:98–105.
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Figures and Tables%

Fig. 1.
Schematic illustrations show the three different fusion procedures. (A) Unilateral TLIF (B) Bilateral TLIF using Wiltse's approach (C) Bilateral TLIF using conventional midline approach
jkss-18-208f1.tif
Fig. 2.
These photographs show the unilateral TLIF procedures.(A) Conventional approach at symptomatic side (B) Unilateral disc preparation and cage insertion (C) Decompression of contralateral side (D) Wiltse approach at contralateral side (E) Pedicle screw insertion through Wiltse approach
jkss-18-208f2.tif
Fig. 3.
Radiographic measurement of anterior (A2/A1, original magnification x 100) and posterior disc heights. (P2/P1, original magnification x 100)
jkss-18-208f3.tif
Fig. 4.
These radiographs are taken from the patient who underwent unilateral TLIF at 2 years follow up. Suspicious nonunion is observed in these radiographs. (A, B) X-ray shows radiolucent area around the cage. (C, D) CT scan shows discontinuity of bridging bone in interbody space.
jkss-18-208f4.tif
Table 1.
Operative and Perioperative Data
Unilateral TLIF Bilateral TLIF(Wiltse) Conventional TLIF
Operating time 147.4 +/- 24.2 172.3 +/- 31.6 167.4 +/- 28.4
Blood Loss* 212 + 253 254 + 315 486 + 653
(intra+post) = 465.7 +/-59.9 = 569.3 +/- 45.8 1139.5 +/- 52.7
Admission day* 5.1 +/- 1.2 6.5 +/- 1.6 7.9 +/- 2.1
Walking time* 3.1 +/- 0.9 3.4 +/- 1.1 4.7 +/- 1.4
Back pain at PO 3D* 3.1 +/- 0.6 3.3 +/- 0.8 6.1 +/- 1.3

According to ANOVA, there were significant differences in blood loss, admission day, walking time, back pain at PO 3D (*) TLIF: transforaminal lumbar interbody fusion, intra: intraoperative, post: postoperative PO 3D: postoperative 3 days

Table 2.
Pain and Disability Scores at Followup Back Pain
Unilateral TLIF Bilateral TLIF(Wiltse) Conventional TLIF P*
Preoperative 7.98 +/- 1.21 7.32 +/- 1.87 7.55 +/- 1.19 0.987
F/U at 6 months 1.21 +/- 1.09 1.83 +/- 0.97 2.73 +/- 1.03 0.132
F/U at 2 years 2.69 +/- 0.98 2.97 +/- 0.89 3.51 +/-0.84 0.821
Leg Pain
Preoperative 8.01 +/- 1.56 7.78 +/- 1.57 7.88 +/- 1.81 0.891
F/U at 6 months 1.34 +/- 1.29 1.89 +/- 1.21 2.02 +/- 1.20 0.071
F/U at 2 years 1.02 +/- 0.83 1.23 +/- 0.74 1.78 +/- 0.79 0.311
Oswestry Low Back Questionnaire
Preoperative 57.8 +/- 8.3 58.9 +/- 7.9 56.3 +/- 10.3 0.921
F/U at 6 months 21.5 +/- 9.8 21.9 +/- 10.9 23.1 +/- 10.1 0.085
F/U at 2 years 23.8 +/- 9.3 22.5 +/- 9.1 23.9 +/- 9.9 0.219

Pain was measured on a 10-point VAS, and functional disability was assessed with the Oswestry Low Back Pain Questionnaire. The VAS score ranged from 0 to 10 (maximum pain), and Oswestry, from 0 to 100 (maximum severity). The paired-sample t test was used to calculate the differences within each group during the followup. No significant differences between preoperative and postoperative scores were found within each group (P <0.001).*ANOVA was used to calculate the differences among the groups. No significant differences were found among the groups. F/U: follow up

Table 3.
Change of Disc Height
Unilateral TLIF postoperative F/U at 6 months F/U at 2 years p*
ADH 178.7 +/- 57.2 148.7 +/- 45.3 142.1 +/- 67.3 <0.001
PDH 150.4 +/-45.2 139.5 +/- 63.4 130.5 +/- 48.4 <0.001
Bilat TLIF(Wiltse) postoperative F/U at 6 months F/U at 2 years p*
ADH 183.5 +/- 55.7 161.1 +/- 43.9 153.6 +/- 57.9 <0.001
PDH 168.7 +/- 45.5 145.6 +/- 55.8 141.3 +/- 45.2 <0.001
Conventional TLIF postoperative F/U at 6 months F/U at 2 years p*
ADH 186.7 +/- 60.9 168.3 +/- 56.2 157.3 +/- 54.8 <0.001
PDH 163.3 +/- 58.0 148.2 +/- 45.8 139.1 +/- 41.2 <0.001

Values are expressed as percentages.*The paired-sample t test was used to calculate significance in each group. There were no significant differences in the disc height among the groups. ANOVA was used. ADH: anterior disc height, PDH: posterior disc height

Table 4.
Change of Mean Segmental Lordosis
Preoperative F/U at 6 months F/U at 2 years p*
Unilateral TLIF 11.7 +/- 5.8 16.4 +/- 6.1 13.8 +/- 5.2 <0.05
Bilateral TLIF(Wiltse) 12.1 +/- 10.1 16.8 +/- 8.5 14.2 +/- 8.9 <0.05
Conventional TLIF 13.8 +/- 7.8 17.1 +/- 7.1 14.6 +/- 6.7 <0.05

Values are expressed in degrees.*The paired-sample t test was used to calculate significance in each group. There were no significant differences of the lumbar angle among the groups. ANOVA was used. F/U: follow up

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