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Transcript of Fessler_TLIF
CLINICAL OUTCOME FOLLOWING TLIF
• Professor,
Department of Neurosurgery,
Northwestern University,
Feinberg School of Medicine
•Interest: • MIS, Deformity, Intradural Tumors
Richard G. Fessler, MD, PhD
CLINICAL OUTCOME FOLLOWING TLIF
ONE AND TWO YEAR FOLLOW-UP OF
PROSPECTIVE DATA
Richard G. Fessler, MD, PhD
Professor
Northwestern University Feinberg School of Medicine
Chicago, IL
CONFLICT OF INTEREST
Medtronic
Consultant
Research funding
Royalty (Not related to MIS)
DePuy
Royalty (Not related to MIS)
Stryker
Consultant
ALIF
Intra-abdominal complications*
Vascular 11. 5 %
Neurological 17.9 %
Incisional 6.4 %
Urological 2.6 %
GI 6.4 %
Respiratory 7.7 %
Peritoneal 3.8 %
Spinal “event” 14.1 %
*Sasso et al, Spine, 2004
Posterior Lumbar Interbody Fusion (PLIF)
360 degree fusion
dorsal approach
anterior column support
minimizes the risk to intra-abdominal and retroperitoneal structures.
ADVANTAGES
Posterior Lumbar Interbody Fusion (PLIF)
Devitalization of the paraspinous musculature
Bilateral partial facetectomies -further destabilizing the spine
Pain
Nerve root / retraction injury
5 % average Cx rate in literature
DISADVANTAGES
Iatrogenic Muscle Injury
Kawaguchi Y. et. al. Spine, 1998; 23(21): 2282 -2288
Styf J.R. et. al. Spine, 1998; 23(3): 354-358
Weber B.R. et. al. Spine 1997; 22(15): 1765 - 1772
Kawaguchi Y. et. al. Spine, 1996; 21(22): 2683 - 2688
Kawaguchi Y. et. al. Spine, 1996; 21(8): 941 - 944
Kawaguchi Y. et. al. Spine, 1994; 19(22): 2590 - 2602
Rantanen J. et. al. Spine, 1993; 18(5): 568 - 574
Sihvonen T. et. al. Spine, 1993; 18(5): 575 - 581
Mayer T.G. et. al. Spine, 1989; 12(1): 33 - 36
Macnab I. et. al. Spine, 1977; 2(4): 294 - 298
Naylor A. JBJS, 1974; 56-B(1): 17 - 29
Jackson R.K. JBJS, 1971; 53-B(4): 609 - 616
Rationale: Microendoscopic TLIF
with Instrumentation
Adapt lumbar MED / MEDS
Avoid intra-abdominal surgery
Smaller skin incision
Decreased tissue trauma
Decreased muscle injury
Improved visualization
Improved post-operative course
? Improved long-term results
Surgical Technique
MAST-TLIF
Incision is determined fluoroscopically
Serial dilation of METRx
Facetectomy
Discectomy and Distraction
End Plate Preparation
Graft Insertion
Percutaneous Instrumentation
“Bulls-eye”
technique
Tapping
Screw Placement
Rod Placement
Percutaneous PLIF and Instrumentation
The Procedure
HAS IT IMPROVED OUTCOME?
PARASPINAL MUSCLE CHANGES ON MRI FOLLOWING POSTERIOR LUMBAR SURGERY
Muscle cross-sectional area (CSA) was measured and compared for the longissimus, illiocostalis and multifidus in the pre- and post-operative scan.
T 2 MRI, axial, 2mm cuts, no gap
Medical imaging processing and Visualization software from NIH
Lacey E. Bresnahan, PhD, R. David Fessler, BA, Richard
G. Fessler, MD., PhD ISSLS, May 1-4, 2009
OPEN
MEAN DECREASE 18 %
MED
MEAN INCREASE 2 %
Altered structure and function of spinal muscle fibers following posterior lumbar surgery
Muscle atrophy
Reduction in cross-sectional area
Increase fatty tissue
Reduction in muscle strength
Can lead to further post-op low back pain (LBP)
Clinical SignificanceMuscle Injury
Open
MIS
Long-Term Strength Assessment of Postoperative Spinal Surgery Patients
“…every strength parameter tested except male isokinetic flexion strength showed at least a 30% decrease when compared with normal values.”
Kahanovitz, Spine 1989 Apr; 14(4)
ResultsProspective
MAST TLIF vs OPEN PLIF
Demographics
0
10
20
30
40
50
Age
Open
Minimally-
Invasive
0
10
20
30
40
50
60
70
80
90
100
Male Female
Level of Surgery
100
0102030405060708090
L23 L34 L45 L5S1
Open
MAST
Operative Data
4.6
3.50
0
1
2
3
4
5
6
7
Operative Time (in hrs)
Open
Minimallyp=0.19 NS
Operative Data
0
200
400
600
800
1000
1200
Blood Loss
Open
Minimally-
Invasive
p<0.002
36
00
5
10
15
20
25
30
35
40
45
50
%Transfusion
p < 0.001
Hospital Data
0
20
40
60
80
100
120
140
160
180
200
Open
Minimally-
Invasive
0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
5
Pain Rx (in MSO4 Eqvs.) Length of Stay (in days)
P<0.05P<0.10 NS
0
0.2
0.4
0.6
0.8
1
1.2
1 0.63 0.51 0.47 0.34
Preop 1wk 2-4wks 6wks 3-6mo
“Worst” Pain (% of Preop Value-VAS)
Narcotic Intake
0
20
40
60
80
100
120
140
Preop 1wk 2-4wks 6wks
On Long-term Narcotics Preop
0
2
4
6
8
10
12
14
16
Preop 1wk 2-4wks 6wks 3-6mo
(% of Preop Value)
Without Narcotics Preop
(MS04 Eqvs./day)
No CSF leaks
No infections
No medial breaches of the pedicle
No neurological injuries related to the procedure
No positioning-related complications
No hardware failures
Complications
1 CSF leak
No infections
No medial breaches of the pedicle
No neurological injuries related to the procedure
1 positioning-related complication
No hardware failures
Minimally-Invasive Open PLIF
1 YEAR RESULTSMAST TLIF PRE vs POST-OP
INDICATIONS
Degenerative disc disease-1 or 2 level
Grade I or II spondylolisthesis
Mechanical back pain
Radiculopathy
Instability (> 6 mm movement on F/E)
DESIGN
Prospective 62 patients
University of Chicago
All patients completed pre-operative and post-operative (1.5, 6, 12, 24) data forms VAS
Oswestry
SF-36
All data collected by research staff not otherwise involved with the study
Independent statistician (Paired t-test)
Follow-up: Data for 1 year
DESIGN AND DEMOGRAPHICS
0
10
20
30
40
50
60
AGE0
5
10
15
20
25
30
35
40
MEN WOMEN
Fusion rate: 100%
A/P, lat, F/E xrays
Bone growth
No motion
RESULTS
0
1
2
3
4
5
6
7
8
9
10
Pre-op Post--op
0
1
2
3
4
5
6
7
8
9
10
Pre-op Post-op
* p<.0001
VAS-BACK
*p<.002
VAS-Left leg
0
1
2
3
4
5
6
7
8
9
10
Pre-op Post-op
NS
VAS-Right leg
(paired t-statistic)
Visual Analog Score
0
1
2
3
4
5
6
7
8
9
10
Pre-op 6 wk 6 mo 1 yr 2 yr
BIAS analysis
RESULTS
0
10
20
30
40
50
60
Pre-Op Post-Op
Oswestry
*p < .0001
(Paired t-statistic)
RESULTS
0
10
20
30
40
50
60
70
80
90
100
Pre-op Post-op
NS
SF 36-GH
0
10
20
30
40
50
60
70
80
90
100
Pre-op Post-op
*p<.0001
SF 36-PF(Paired t-statistic)
SF-36Physical Functioning
0
10
20
30
40
50
60
Pre-op 6 wk 6 mo 1 yr 2 yr
OTHER VARIABLES
Sex
NS
VAS, Oswestry, SF-36
Age
NS
VAS, Oswestry, SF-36
LONG TERM RESULTSBACK PAIN
0
10
20
30
40
50
60
70
80
90
100
No Pain Better No Better
OPEN *
MAST
VAS * Dickman, Fessler, MacMillan, Haid,
J NSG 1992
LONG TERM RESULTSBACK PAIN
0
10
20
30
40
50
60
70
80
BETTER NO BETTER
Oswestry
-20
-10
0
10
20
30
40
50
60
BETTER NO BETTER
SF-36
%
Change
From
Pre-op
%
Change
From
Pre-op
COMPLICATIONS
2 CSF leaks
1 local wound infection
1 DVT (acute on chronic)*
2 graft retropulsions
One year follow upTwo prospectively followed cohorts
Non-randomized
Two institutions
PLIF Saint John, NB, Canada
mTLIF Chicago, IL, USA
Patients requiring lumbar interbody fusions
All patients followed using VAS pain scores and Oswestry Disability Index
Radiographic determination of fusion
ResultsTLIF
29 patients
19 female
Mean age = 54 ± 14*
Previous surgery (5)
Disc same level – 2
Laminectomy same level - 3
PLIF
31 patients
14 female (n.s.)
Mean age = 42 ± 11
Previous surgery (4)
Disc same level – 2
Adjacent anterior fusion – 1
Distant posterior fusion - 1
* p < 0.05
Open
CSF leak – 2
Ileus – 3
Footdrop – 2
Infection – 1
MAST
CSF leak – 3
Migration of interbody graft – 2
Both cases Boomerang
DVT – 1
Results
Complications
Results
0
10
20
30
40
50
60
70
80
90
100
Open MAST
Pseudarthroses
Fusions
96.6%83.9%
p = 0.068
Results
Mean Estimated Blood Loss
0
200
400
600
800
1000
1200
c.c
.'s Open
MAST
p < 0.0001
Results
Mean Hospital Stay
0
20
40
60
80
100
120
140
160
180
Ho
urs Open
MAST
p < 0.027
Clinical Outcomes
0
10
20
30
40
50
60
70
80
90
100
VAS Back VAS Leg Oswestry
PreOp TLIF 1 yr TLIF PreOp PLIF 1 yr PLIF
p=0.001p=0.009
p=0.002
p<0.001p<0.001
p<0.001
p = 0.9p = 0.9 p = 0.4
p = 0.0001p < 0.0001
p < 0.0001
THANK YOU
OBESITY:OUTCOME FOLLOWING MINIMALLY INVASIVE FUSION SURGERY
Rosen, D., Ferguson, S., Ogden, A.T., Huo, D., Fessler, R.G.: Obesity and
Self Reported Outcome after Minimally Invasive Lumbar Spinal Fusion
Surgery. Neurosurgery 63:956-960, 2008.
DEMOGRAPHICS
Age 56.4 (19-85)
Height 169 cm
Weight 82.2 kg
BMI 28.7 kg/m2
TOTAL 110 patients
WEIGHT DISTRIBUTION
< 25 NORMAL
25-30 OVERWEIGHT
> 30 OBESE
> 30
25-30
< 25
RESULTS
VAS = NS DIFFERENCE between groups
ODI = NS DIFFERENCE between groups
SF-36 = NS DIFFERENCE between groups
Linear Regression Analysis = No correlation between BMI and any outcome measure
OPERATIVE TIME
0
1
2
3
4
5
6
7
8
9
10
< 25 25-30 > 30
HOURS
BMINo significant difference
ESTIMATED BLOOD LOSS
0
2
4
6
8
10
12
14
16
18
< 25 25-30 > 30
< 100 cc
100-250 cc
> 250 cc
No significant difference
MAJOR COMPLICATIONS
1 Positioning injury (?)
= 0.8 %
(This occurred in the “normal” group)
MINOR COMPLICATIONS
OVERALL 22 %
< 25
25-30
> 30
BMI < 25 BMI 25-30 BMI > 30
Post-op radiculopathy
3 2
Lower extremity weakness
1
Urinary retention 2
Durotomy 1 1
Superficial wound infection
1
Delirium 3 2
Nausea 1
CHF exacerbation
1
Hypertension 1 1
Hypotension 1 1
Ileus 1
PERCENT OF TOTAL 23 26 14
COMPARISON
OPEN MISS
Increased complication rate YES NO
Increased wound infection rate
YES NO
Increased operative time YES NO
Increased blood loss YES NO
Length of stay NO NO
Outcome after fusion NO NO
Patient satisfaction YES NO
John E. O‟Toole, MD, Griffin Meyers, BA, and Richard G. Fessler, MD, PhD Reduction in Spinal
Surgical Site Infection Rates After Minimally Invasive Surgery
Journal of Neursurgery: Spine, 11: 471-476, 2009.
Reported infection rate in open surgery 0.9 to 15 %.
1338 MIS procedures
12 mo follow up
0.2 % overall infection rate
0.7 % for MEDS and TLIF
0.1 % for all others
CONCLUSIONS
MIS is equivalent to or superior to open surgery for:
Neurologic result
Pain relief
Fusion rate
For virtually every operation developed and tested to date.
CONCLUSIONS MIS achieves these results with
Less EBL
Less stress response
Less pain meds
Less ICU stay
Less hospital stay
Faster D/C
Faster recovery
Faster return to work
Lower complication rate
Lower infection rate
And can more safely be used in high risk patients
ACKNOWLEDGEMENTS
FELLOWS Larry Khoo University of California, Los Angeles (2000-2001)
Mick Perez Detroit (2001-2002)
Rob Isaacs Duke University (2001-2002)
Faheem Sandhu Dallas, TX (2002-2003)
Paul Santiago Washington University, St. Louis, MO (2002-2003)
Bong Soo Kim Neurosurgery resident-Temple (2003-2004)
Trent Tredway University of Washington (2003-2004)
John Song Northwestern University (2004-2005)
Sean Christie QE II Health Science Center (2004-2005)
John O’Toole Rush University Medical School (2005-2006)
Kurt Eichholz Vanderbilt University (2005-2006)
Vishal Gala Georgia Spine Institute (2006-2007)
Jean-Marc Voyadzis George Washington University (2006-2007)
Justin Smith Univeristy of Virginia (2007-2008)
Fred Ogden Columbia University (2007-2008)
Jim Thoman Indianapolis Neurosurgical (2008-2009)
Sathish Subbaiah Mount Sinai (2008-2009)
STUDENTS Melody Hrubes University of Illinois-Chicago
Lacey Bresnahan, ME University of Illinois-Chicago
THANK YOU
THERE IS NO LONGER ANY QUESTION
MINIMALLY INVASIVE TLIF PROVIDES
SIGNIFICANT ADVANTAGES
Conclusions
The MAST-TLIF technique provides an
option for percutaneous interbody fusion.
This technique is safe, diminishes
intraoperative blood loss, postoperative
pain, total narcotic use, and the risk of
transfusion.
One year results demonstrate statistically
significant decreases in VAS, increases in
Oswestry, and improvement in SF-36
physical functioning.
A minimally-invasive TLIF can be
performed without a significant increase
in surgically-related complications.
OPEN vs Minimal Access Spine Surgery
0
20
40
60
80
100
1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001
MISS
OPEN
Curtis Dickman Barrow Neurological Institute (1990-1991)
Bruce McCormick University of California, San Francisco (1991-1992)
Daniel May University of Zurich (1992-1993)
Emily Friedman Oklahoma Neurosurgical (1992)
John Marshak Hudson Orthopedics, Georgia (1992-1993)
Michael Sturgill Private Practice-Racine, Wisconsin (1993-1994)
Srinath Samadrala University Southern California (1995-1996)
Ehud Mendel MD Anderson Cancer Center (1996-1997)
Ben Guiot University of South Florida (1997-1998)
Daniel Kim Stanford University (1997-1998)
Sim Brara Kaiser Permanente Los Angeles, California (1998-1999)
Paul Boone Vanderbilt University (1998-1999)
Anthony Frempong-Boadu New York University (1999-2000)
Larry Khoo University of California, Los Angeles (2000-2001)
Dan Laich Denver Neurosurgical (2000-2001)
Mick Perez Rush Medical School (2001-2002)
Rob Isaacs Cleveland Clinic, Fort Lauderdale (2001-2002)
Faheem Sandhu Private Practice-Dallas, TX (2002-2003)
Paul Santiago Washington University, St. Louis, MO (2002-2003)
Bong Soo Kim Neurosurgery resident-Temple (2003-2004)
Trent Tredway University of Washington (2003-2004)
John Song Current fellow (2004-2005)
Sean Christie Current fellow (2004-2005)
FELLOWS
2-level TLIFs
Two level TLIF/Sextant
SPONDYLOLISTHESIS
0
5
10
15
20
25
Nl Align Spondy
Minimally-Invasive Interbody Fusion – Cadaveric Study
3 cadaveric torsos
6 motion segments fused – interbody grafting followed by percutaneous pedicle screws
Intervertebral height, foraminal height and volume increased
No significant pedicle violations
Could be safely and efficaciously implemented for clinical use
Neurosurgery November supplement, 2002
Study # 1Methods
Prospective
125 consecutive patients
May ‟01 to September „03
First study: 1 yr f/u of 75 pts with matched open controls
Grade 1 – 2 spondylolisthesis or pure mechanical back pain
Symptoms radiculopathy and back pain w/ collapsed disc
Failed extensive conservative management
Methods
Operations all performed with one senior surgeon (R.F.)
Control group: 20 open, single-level PLIF at the same institutions over the same time period
Rush Medical Center, Chicago, IL
Columbus Hospital, Chicago, IL
Ravenswood Hospital, Chicago, IL
Sextant™ Instrumentation with TLIF
1 month Post OP
3 MONTHS
IF YOU DON‟T DO MINIMAL ACCESS SPINE SURGERY…
ITS TIME TO LEARN!
BOTTOM LINE
IF YOU DON‟T WANT TO LEARN…
BE A “BRAIN” SURGEON!!!
Case – Spondylolisthesis
Case - Spondylolisthesis
Case – Mechanical LBP s/p failed discectomy
Graft Placement / PLF
Conclusions
The METLIF technique provides an
option for percutaneous interbody fusion.
This technique is safe, diminishes
intraoperative blood loss, postoperative
pain, total narcotic use, and the risk of
transfusion.
Initial data suggests early postoperative
pain reduction.
A minimally-invasive TLIF can be
performed without a significant increase
in surgically-related complications.
CONCLUSIONS
The results appear to be long lasting
FEA/biomechanical data suggests biomechanically that the results will be superior to open surgery in the long term