DEBATE 67 year old with degenerative spondylolisthesis and moderate - - PowerPoint PPT Presentation

DEBATE

67 year old with degenerative spondylolisthesis and moderate lumbar stenosis

Traditional Open Lumbar Decompression and Fusion – Still the One!

Frank X Pedlow Jr MD

Spine Service Massachusetts General Hospital

Boston MA

No disclosures

67 yo with degenerative spondylolisthesis and stenosis L45

X-rays MRI

Has been given three opinions:

• 1. minimally invasive decompression
• 2. OLIF with percutaneous posterior

screws

• 3. minimally invasive decompression

and TLIF

Lumbar Degenerative spondylolisthesis with stenosis

• Common cause of low back pain,

radiculopathy, and/or neurogenic claudication

• Well studied condition
• One study reports a treatment

satisfaction rate of 86.6 percent

• Weinsten et al JBJS Am 2009

Goals of surgical treatment

• Decompress neural elements
• Stabilize spine
• Obtain fusion
• Optimize sagittal alignment

• Classic 1991 study: prospective, randomized , 50 pts,

3yr f/u

• Laminectomy and fusion was shown to be superior to

laminectomy alone

• Noninstrumented PLF with ICBG
• 36% non-union rate did not seem to effect clinical
• utcome in this study time frame

• 76 patients , 2 yr f/u patients with instrumented

fusion had higher fusion rate ( 82%-45%)

• No statistically significant difference in outcomes

• A follow-up study of 47 of these patients those with a solid

fusion had significantly better clinical outcome

• Conclusion: successful fusion has a clinical benefit and

instrumentation may assist in achieving fusion

• Largest study to date
• Prospective, multicenter trial with randomized cohort and

concurrent observational cohort compared surgical and non- surgical treatment

• At 2 years surgical treatment group had greater improvement in

pain and function

• 4 yrs – surgical group had better Oswestry Disability Index, Medical

Outcomes Study 36-Item short form physical function score, and symptomatic improvement

Cost-effectiveness?

• 2008 subanalysis of SPORT data to determine economic value /

short-term cost-effectiveness of surgical treatment

• Concluded surgical management was not highly cost-effective

at 2 years, but was cost-effective at 4 yrs Tosteson st al, Spine 2011; 36(24) Once again, No difference in cost effectiveness between fusion types.

Treatment of Degenerative Spondylolisthesis and Lumbar Stenosis

• Good evidence in the literature of treatment consisting of open

lumbar decompression, posterolateral fusion and posterior spinal instrumentation

Proposed advantages of minimally invasive decompression and TLIF

• less blood loss
• Better fusion rate
• lower infection rate
• Less soft tissue disruption / damage to spinal muscles
• Less post-op pain
• Improve alignment / better fusion with interbody
• Shorter hospital stay
• Faster recovery
• Better outcomes
• More cost effective

Does fusion method matter?

• 380 surgical patients from SPORT trial
• Posterolateral fusion in situ ( 80 / 21%)
• PLF with instrumentation ( 213 / 56%)
• 360 degree fusion ( 63 / 17%)
• At 3 and 4 year f/u no statistically significant difference in

clinical outcome between 3 fusion techniques

Posterolateral vs Interbody fusion in Degenerative Spondylolisthesis

3 systematic reviews and meta-analysis

– Campbell et al, Global Spine Journal 2017 – McAnany et al, SPINE 2-16 – Liu et al, Eur Spine J 2014

Conclusions: – No significant difference in clinical outcomes or fusion rates in 2 papers – One paper ( Liu) revealed moderate-quality evidence that PLIF improved patient satisfaction and fusion rate compared to PLF, but with no difference in compication rate, blood loss or operating time

Does MIS TLIF lead to less muscle damage?

• Conclusion – an unexpected increase in intra-operative muscle trauma as

evidenced by higher postoperative CPK levels was seen in the minimally invasive rather than open TLIF, but did not correlate with any differences in 2 yr pain improvement and functional disability

• MIS greater muscle trauma – yet comparable 2 year outcomes

Does MIS TLIF lead to less blood loss and a lower infection rate?

• Three papers are used to support this claim:
• 1.

– Prospective study ( n-82 ) comparing open to minimally invasive fusion for degenerative spine pathologies – MIS less pain, shorter hospital stay, lower opioid use, lower total complication rate – But diverse pathologies - Only 9 patients in the open group and 18 in MIS had Degenerative Spondylolisthesis

Does MIS TLIF lead to less blood loss and a lower infection rate?

• 2

.J Spinal Disord Tech 2006:19:92-97

• retrospective study 167 patients – 74 MIS TLIF vs 51 open TLIF vs 43

anterior / posterior surgery. Some multiple levels

• pathologies: DDD, facet arthropathy, spondylolisthesis, stenosis
• conclusion : complication rate for AP surgery more than 2x that of MIS-TLIF
• thus not a paper we can use to compare standard open lumbar

decompression and fusion for deg spondy with MIS TLIF

Does MIS TLIF lead to less blood loss and a lower infection rate?

• 3. Lawton et al. The surgical technique of minimally

invasive transforaminal lumbar interbody fusion. Journal of Neurosurgical Sciences 2011 September;55(3):259-6

• Retrospective review of 84 patients and description of MIS TLIF technique
• Multiple pathologies treated
• State safe and effective technique with less blood loss, tissue damage and

shorter hospitalization - but no comparison group

Does the interbody used in MIS-TLIF improve alignment and slip reduction?

• Clinical Neurology and Neurosurgery 138 ( 2015)
• Retrospective review of 103 patients comparing PLF vs PLF+PLIF/TLIF
• Some multiple level cases
• Conclusions

– PLF+PLIF/TLIF greater correction of spondylolisthesis and less likely to undergo re-operation

• Higher rate on non-union, adjacent segment disease, instrumentation failure

– However PLF cohort had better clinical outcomes

• Statistically significant decrease in back pain, radiculopathy, sensory deficits and

bowel/bladder dysfunction in PLF cohort

Outcomes

• Neurosurg Focus 43(2): E11, 2017
• Queried the national, multicenter Quality Outcomes Database

(QOD) register for patients undergoing surgery of Grd 1 Deg Spondy

• 345 patients ( open – 245, MIS – 91); 11 sites
• No difference in terms of patient reported outcomes, LOS, and 90

day RTW between 2 groups

• Possible benefit of MIS in patients undergoing 2 level procedure

• Biomed Research international 2017
• Reviewed current prospective literature finally using 5

nonrandom prospective comparative studies

• Conclusion: MI less blood loss, shorter hospital stay, longer
• perative time
• MI and open surgery have similar results in pain, functional
• utcomes, complications, fusion rates and secondary surgery
• Once again, not exact match in terms of pathologies treated

and surgical treatment methods used to this debate

Outcomes

• Compared Open vs MIS-TLIF or PLIF
• 26 papers , all degenerative lumbar disorders
• Conclusion:

– equipoise in surgical and clinical outcomes, intraoperative complications – Low quality of literature precludes firm conclusions

Outcomes

• First systematic review of the literature regarding MIS and open spinal

fusion for degenerative spondylolisthesis

• 5 retrospective and 5 prospective studies - 602 patients
• Once again studies incorporated varying techniques( ex: open TLIF) levels

and pathologies ( ex: L5-S1 lytic spondy as well as L45 degen spondy)

• No significant difference btw MIS and open surgery in terms of

functional or pain outcomes

• MIS had greater operative time and lower functional scores

Technical difficulty – learning curve

• J Spinal Disord Tech 2014: 27: E234-240
• 90 cases over 5 years, single surgeon
• Technical proficiency in MIS TLIF was achieved after 44 cases
• AFTER THAT- Shorter op times, less radiation, less pain, more relief of back

and neuro. symptoms

Technical difficulty – learning curve

• 100 consecutive MIS-TLIFs by a single surgeon
• Experience led to decreased operative time, EBL, intraoperative fluids, and

duration of anesthesia

• No significant difference in intraoperative or postoperative complications
• Conclusion: MIS TLIF technically difficult procedure proficiency in which improves

with experience and understanding of technique

Radiation exposure

• 24 patients underwent MIS-TLIF, single surgeon
• Mean flouroscopy time 1.69 minutes
• Mean exposure per case

– 76 mRem dominant hand – 27 mRem at Waist under apron – 32 mRem unprotected thyroid – Patients skin: 59.5 mGy PA plane, 78.8 mGy lateral plane

• Surgeon exposure is limited but requires careful monitoring
• Annual dose limits could be exceeded if a large number of cases done

Conclusions

• Open lumbar decompression and posterolateral instrumented fusion

has many advantages over MIS-TLIF

– Better, safer decompression

• Better visualization, access to contralateral lateral recess and foramen

– More familiar fusion technique

• MI -Interbody fusion technique demanding, high learning curve

– Easier to treat potential complications

• Dural tear, mal-positioned screw, possible less chance for discitis

– Less risk to neural elements

• Cage placement can put nerves at risk

– Use of local bone graft /allograft eliminates need to harvest graft – Less radiation exposure

Rothman Institutes march

Northwell Health signs strategic affiliation agreement with Rothman Institute April 20, 2017

Marc j. Levine MD

• My co-fellow at Emory
• A good friend
• An excellent surgeon
• A better father and husband
• We’ll see what he has to say
• But one thing we know……

……people from NJ are always right

Thank you

• Iowa Orthop J. 2015; 35: 130–134.
• Retrospective review, not randomized
• 154 patients, 6 different surgeons
• Open PLF, open PLIF/PLF, MIS TLIF
• Concluded MIS TLIF provided interbody fusion with less

blood loss and lower transfusion rate, lower complication rate compared to open surgery

• Open PLIF was a subgroup in addition to open PLF, and

had highest blood loss and transfusion requirements

Shermans March

Shermans march