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Less blood loss, shorter hospital stays seen with minimally invasive lumbar fusion

Issue: Issue 4 2008

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The long-term results of two studies comparing minimally invasive to open transforaminal lumbar interbody fusion show at least comparable clinical outcomes and significantly less blood loss and shorter hospital stay with the minimally invasive approach.

However, one study warns of a potentially higher rate of neural injury-related complications with the mini technique.

In a retrospective review, Sigita Burneikiene, MD, and colleagues studied 139 patients with symptomatic degenerative disc disease that was treated at one or two levels with either a minimally invasive or open transforaminal lumbar interbody fusion (TLIF) approach with a minimum follow-up of 24 months.

While the investigators found no significant differences between the groups regarding the total operative time, patient satisfaction, MacNab’s criteria score and postop Visual Analog Scale (VAS) scores, they discovered that the minimally invasive group had significantly lower estimated blood loss and a significantly shorter hospital stay than patients in the open approach group.

They also discovered that the minimally invasive group had a 10.5% rate of neurological deficiency compared to 1.6% for the open group.

“The minimally invasive TLIF approach may provide equivalent long-term clinical outcomes compared to the open TLIF approach,” Burneikiene said during her presentation at Spine Week 2008. “The potential benefit of minimized tissue disruption, reduced blood loss and length of the hospitalization must be weighed against the increased rate of neural injury-related complications.”

Blood loss

The study included 63 patients in the open group and 76 patients in the minimally invasive group. The groups showed similar characteristics for age, gender, number of previous surgeries and number of two-level procedures performed. The patients had an average follow-up of 37.5 months.

“The estimated blood loss was significantly lower and hospitalization was shorter in the minimally invasive TLIF group,” Burneikiene said.

The minimally invasive group showed the mean estimated blood loss of 163 ml vs. 366.8 ml in the open group. The minimally invasive group had a mean hospital stay of 3 days compared to 4.2 days in the open group, she said.

While the investigators found no significant differences between the groups for the overall complication rate, they found a significant difference between the groups regarding major complications and found more minor complications in the open group.

Four year results

Larry T. Khoo, MD, and colleagues also found benefits using the minimally invasive approach. The investigators prospectively studied 148 patients with one-and two-level degenerative disease who underwent either minimally invasive or open TLIF procedures.

They discovered that the minimally invasive group had 25% of the blood loss seen in the open group and also showed operative times that were about 33% shorter than those of the open group. Similarly, the minimally invasive group had significantly fewer perioperative complications than the open cohort.

In addition, the minimally invasive group showed significantly lower back pain and Owestry Disability Index (ODI) scores than the open group at 3- and 4-years postop. An economic analysis of the last 34 open and minimally invasive procedures revealed a $5,000 savings with the mini approach.

“At 4 years, minimally invasive TLIF has now proven itself to be the gold standard of care for our own practice for one- and two-level degenerative disease with clear benefits in this Class II/III prospective nonrandomized study,” Khoo said during his presentation at Spine Week 2008. “[We] can show statistically significant differences in operative time, blood loss, perioperative complications, pain scores at 6 weeks, 3 months and 6 months; ODI scores at 3 and 4 years and decreased global health care costs upon discharge.”

The study included 96 patients in the mini group and 54 patients in the open group. The groups had an even distribution of one- and two-level cases and two surgeons performed all of the operations.

Using CT radiologic flexion/extension criteria, the investigators found no significant differences between the groups regarding fusion rates. While they found shorter operative times with the minimally invasive approach, Khoo noted that the learning curve with the approach decreased between 60 and 80 cases. “Initially, some of the single levels took us approximately 4 to 5 hours to treat, but with time, the average operative one-level time is approximately 90 minutes now,” he said.

Complications

They found no significant differences between the groups for back or leg pain scores at 1 and 2 years. “However, for reasons that are still unclear to us, possibly due to muscle trauma or adjacent level disease, the back pain [VAS] scores of the open group are rising rapidly at the 3- and 4-year mark and achieving a statistical difference,” he said. The investigators also discovered that the open group had significantly higher ODI scores than the mini group at the same time points.

In addition, the open group had a significantly higher rate of perioperative complications. “This is more likely due to pain and stasis in the open group, with the pain scores being higher in the open group and longer hospital stays,” Khoo said.

Yet, the groups showed similar rates for cerebro spinal fluid (CSF) leaks and incomplete decompression.

“Overall, with regards to CSF leak, there was a high learning curve initially with the minimally invasive TLIF technique – 10% CSF leak rate in the first 50 cases – but now in the last subsequent cases, they are achieving approximately 1% to 2% rate as well,” Khoo said.

Moreover, the minimally invasive group had a three times lower reoperation rate than the open group, he added.

For more information:

• Sigita Burneikiene, MD, can be reached at Boulder Neurosurgical Associates, 1155 Alpine Ave., Suite 320, Boulder, CO 80304, U.S.A.; +1-303-998-0004; e-mail: sigitab@bnasurg.com. She has no financial conflicts to disclose.
• Larry T. Khoo, MD, can be reached at UCLA Comprehensive Spine Center, 1245 16th St., Suite. 220, UCLA Medical Center, Los Angeles, CA 90404, U.S.A.; +1-310-319-2257; e-mail: lkhoo@mednet.ucla.edu. He receives consulting fees and has speaking arrangements with Trans-1.

Reference:

• Burneikiene S, Nelson EL, Roeca CM, et al. Minimally invasive versus open transforaminal lumbar interbody fusion. Paper AB46. Khoo LT, Chen NF, Sheikh, et al. Long-term outcomes of minimally invasive versus open transforaminal lumbar interbody fusion: Surgical results and outcomes in a series of 128 patients. Paper AB45. Both presented at Spine Week 2008. May 26-31, 2008. Geneva.