Lumbar interbody fusion agreed



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Lumbar interbody fusion agreed

Representative case of a patient before and after the agreed TLIF. Preoperative (left) and postoperative (right) radiographs demonstrating adequate fusion and reduction of spondylolisthesis. Credit: 2019 AANS

As can be inferred from the article's title, "Endoscopic transforaminal lumbar interbody fusion without general anesthesia: surgical and clinical outcomes in 100 consecutive patients with a minimum follow-up of 1 year" by John Paul G. Kolcun et al. (published today in Neurosurgical Focus, provides the reader with a glimpse of how effective lumbar surgery in selected patients can be when performed without general anesthesia, open surgery or a long convalescence in the hospital.

Bottom. Transforaminal lumbar interbody fusion (also known as TLIF) is a surgical procedure used to stabilize the spine and reduce lumbar pain in patients with one or more damaged spinal discs or other degenerative spinal changes affecting adjacent nerves. Accessing the spine through an incision in the patient's back, the surgeon removes the damaged disc, located between two vertebrae, and replaces it with a spacer to provide adequate height between adjacent vertebrae. This spacer, often a cage, contains bone graft and possibly a bone-inducing protein preparation. Often, surgeons insert pedicle screws and rods or attach additional bone grafts to form a bridge between neighboring vertebrae. Over time, new bones grow, fusing the two vertebrae.

TLIF can be performed at a spinal level or at various levels. The procedure is more often performed as open surgery, but in recent years it has also been performed with minimally invasive percutaneous techniques, now with the integration of endoscopic methods for a part of the procedure.

People with severe low back pain need relief. Those facing the possibility of surgery have generally exhausted medical and physical therapies. However, the prospect of surgery can be daunting: prolonged hospital stay, significant blood loss during surgery, postoperative pain, and fear of becoming dependent on opioid medications.

Surgery that is minimally invasive and does not require general anesthesia would be an attractive option for most people in this situation.

Present study. In this paper, the authors reviewed the first 100 cases of minimally invasive, minimally invasive transforaminal lumbar inter-body fusion (MIS-TLIF) at the University of Miami Hospital – all performed by senior author Michael Y. Wang. Between July 2014 and August 2017. The authors also provide details on how this procedure differs from the conventional open and MIS-TLIF surgeries.

The agreed endoscopic MIS-TLIF achieves spinal fusion in selected patients without the need for general endotracheal anesthesia and with much less dissection of muscles and other soft tissues than occurs in open surgery. Patients ideally receive mild to moderate sedation and local analgesia; remaining aware, they are able to provide feedback to both the surgeon and the anesthesiologist. The endoscopic approach limits damage to adjacent tissues, making postoperative recovery quicker, less painful, and possibly less prone to complications.

Patients in this report included 56 women and 44 men with a mean age of 66 years. Single-level TLIF was performed in 84 patients and two-level TLIF in 16. The most common site of TLIF was L4-5. To evaluate the clinical and operative results, the authors analyzed the hospital length of hospital stay, duration of surgery, intraoperative blood loss, and patient scores on the Oswestry disability index both prior to surgery and the follow-up examination recent (1 year or more).

The authors state that, compared to conventional MIS-TLIF reports in the literature, duration of hospital stay (mean 1.4 days) and surgery (mean 84.5 minutes for one-level surgical procedures and 128.1 hours for two-level procedures) and intraoperative blood loss (mean of 65.4 ml for one-level procedures and 74.7 ml for two-level procedures) was lower in the cases of agreed endoscopic TLIF-MIS. They also state that after a minimum of 1 year of follow-up, there was no suggestion of mechanical instability determined by clinical examination and X-ray imaging.

The difference between the preoperative (mean 29.6) and postoperative Oswestry Disability Index scores (mean of 17.2) in the patients in this study shows clinical improvement with strong statistical significance (p <0.05).

There were few complications in this series. In four patients, the surgical plan was reviewed to include general endotracheal anesthesia; surgery was successful in all cases. Four other patients presented early postoperative complications, requiring revision: cage migration (two cases), bone infection and end plate fracture. Three of the four postoperative complications occurred during the first half of the study period.

The agreed endoscopic MIS-TLIF procedure was developed prior to the University of Miami initiating protocols based on the principles of Enhanced Recovery After Surgery (ERAS). The authors note, however, that this procedure coincides with the objectives of ERAS ("minimal tissue destruction, reduced blood loss and less reliance on intraoperative narcotic analgesia") and expect additional benefits in future patients undergoing endoscopic MIS. TLIF combined with non-surgical ERAS components.

When asked about the study, Dr. Wang said, "As more and more people suffer from spinal diseases both in the US and around the world, spine surgeons have worked tirelessly to develop the safest, most effective and least intimidating therapies." We believe this study demonstrates that the agreed TLIF procedure is one of these new techniques to provide relief to patients against disabling pain without debilitating surgery. "

The newspaper is accompanied by an editorial of drs. Marcus D. Mazur and Andrew T. Dailey, focusing on the role and its integration of minimally invasive surgery agreed upon and the principles of ERAS. Improved recovery after spine surgery is the topic of this month Neurosurgical Focus. "Endoscopic transforaminal lumbar interbody fusion without general anesthesia: surgical and clinical outcomes in 100 consecutive patients with a minimum of 1 year follow-up" is one of 15 articles in this issue.


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More information:
Kolcun JPG, Brusko GD, Basil GW, Epstein R, Wang MY: Endoscopic transforaminal lumbar interbody fusion without general anesthesia: surgical and clinical outcomes in 100 consecutive patients with a minimum follow-up of 1 year. Neurosurgical Focus 46 (4): E14, 2019. DOI: 10.3171 / 2018.12.FOCUS18701

Mazur MD, Dailey AT: Editorial: Reduce column fusion charge. Neurosurgical Focus 46 (4): E15, 2019. DOI: 10.3171 / 2019.1.FOCUS1945

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