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Abstract
Objectives
The aim of this study was to demonstrate surgical strategies for successful minimally invasive transforaminal lumbar interbody fusion (TLIF).
Summary of Literature Review
Although many studies have reported the benefits and disadvantages of minimally invasive TLIF, few have described surgical strategies to improve the success rate or to reduce complications.
Materials and Methods
We searched for studies reporting the clinical and radiological outcomes of minimally invasive TLIF, and analyzed the optimal indications, technical pitfalls, and tips for successful surgical outcomes.
Results
The ideal candidate for minimally invasive TLIF is a patient with single or 2-level low-grade adult degenerative or isthmic spondylolisthesis. Incomplete decompression, dura tearing, nerve root injury, and implant-related complications were found to be the most commonly reported adverse events, especially in the early periods of a surgeon's experience. Precise positioning for skin incision and tube insertion, complete neural decompression, proper interbody preparation for bone graft and cage insertion, and the correct placement of percutaneous pedicle screws are critical strategies for successful surgical outcomes. Fully understanding the surgical pitfalls and tips described in this review is also important to avoid potential complications.
Conclusions
It is imperative not only to carry out a comprehensive preoperative evaluation and proper patient selection, but also to perform meticulous surgical procedures with thoughtful considerations of potential pitfalls, in order to improve the success rate and to reduce the complications of minimally invasive TLIF.
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Fig. 2.
Under microscopic visualization, a high-speed drill was used to make a cut through the lamina, just medial to the facet joint. The cut was extended cranially to the level of the pars, at which point a transverse cut was made through the pars (A). Once these cuts were made, the inferior articular process was free floating, and it was then removed and saved as an autograft. The remaining superior articular process was also resected, as was the underlying ligamentum flavum, exposing the dural sac and the lateral edge of the traversing nerve root (B).
Fig. 3.
If a more central and/or contralateral decompression was desired (as for concomitant spinal stenosis), the tubular retractor was wanded medially (A). Bilateral neural decompression with a unilateral approach (B).
Fig. 4.
Contralateral placement of percutaneous pedicle screws and interbody traction to restore optimal disc height.
Fig. 6.
Bone grafts (including autobone, allobone, and demineralized bone matrix, mixed with bone marrow aspirates) and a cage insertion noted in an axial computed tomographic image (A) and a coronal image (B).
Fig. 7.
Surgical tips for percutaneous pedicle screw placement. It is important to create a true anterior-to-posterior (AP) fluoroscopic view for the target vertebrae. This not only allows the surgeon to find the correct entry point, but also to have a correct lateral trajectory of the intended screw placement without a fluoroscopic lateral view (A). It is necessary to have a sufficient lateral-to-medial trajectory of the guide needle until its tip appears to be at the lateral cortical margin of the pedicle at the AP fluoroscopic projection (B).
Fig. 8.
Incorrect placement of percutaneous pedicle screws. Placing the screw without a sufficient lateral-to-medial trajectory, resulting in a so-called vertical trajectory (A), and driving the screw deeper than necessary (B) can result in cranial facet joint and/or pedicle wall violation.
Table 1.
| Khan et al., 2015 | p-values | Favors | Phan et al., 2015 | p-values | Favors | |
|---|---|---|---|---|---|---|
| Number of included studies | 30 including 1 RCT‡ | 21 including 2 RCTs | ||||
| Mean differences and 95% CI§ | ||||||
| VAS|| (≤6 months) | 0.22 (−1.02, 1.45) | 0.73 | - | - | ||
| VAS (>12 months) | −1.89 (−2.80,-0.98) | <0.001¶ | MI-TLIF∗∗ | - | - | |
| VAS (Overall) | - | - | −0.41 (−0.76, -0.06) | <0.001 | MI-TLIF | |
| ODI†† (≤6 months) | 2.33 (−0.57, 5.22) | 0.12 | - | - | ||
| ODI (>12 months) | 0.18 (−1.84, 2.20) | 0.86 | - | - | ||
| ODI (Overall) | - | - | −2.21 (−4.26, -0.15) | 0.04 | MI-TLIF | |
| EBL‡‡ (mL) | −256 (196, 318) | <0.001 | MI-TLIF | −256 (−351, -161) | <0.001 | MI-TLIF |
| Length of stay (days) | −1.30 (−1.36, -1.23) | <0.001 | MI-TLIF | −1.86 (−2.69, -1.04) | <0.001 | MI-TLIF |
| Operative time (minutes) | −6.61 (−44.48, 31.26) | 0.73 | 4.74 (−58.55, 68.03) | 0.88 | ||
| Radiation exposure (seconds) | 38.2 (36.26, 40.20) | <0.001 | O-TLIF | 37.27 (13.78, 60.77) | 0.002 | O-TLIF |
| Risk ratio and 95% CI | ||||||
| Fusion rates | 1.00 (0.95, 1.05) | 0.61 | - | - | ||
| Overall complications | 0.65 (0.50, 0.83) | <0.001 | MI-TLIF | 0.77 (0.52, 1.15) | 0.20 | |
| Reoperation rates | - | - | 0.71 (0.44, 1.13) | 0.15 | ||
| Infection rates | - | - | 0.27 (0.14, 0.53) | <0.001 | MI-TLIF |
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