Browsing by Subject "Minimally Invasive Surgical Procedures"
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Item Open Access A Comparison of Minimally Invasive and Open Transforaminal Lumbar Interbody Fusion for Grade 1 Degenerative Lumbar Spondylolisthesis: An Analysis of the Prospective Quality Outcomes Database.(Neurosurgery, 2020-09) Chan, Andrew K; Bisson, Erica F; Bydon, Mohamad; Foley, Kevin T; Glassman, Steven D; Shaffrey, Christopher I; Wang, Michael Y; Park, Paul; Potts, Eric A; Shaffrey, Mark E; Coric, Domagoj; Knightly, John J; Fu, Kai-Ming; Slotkin, Jonathan R; Asher, Anthony L; Virk, Michael S; Kerezoudis, Panagiotis; Alvi, Mohammed A; Guan, Jian; Haid, Regis W; Mummaneni, Praveen VBackground
It remains unclear if minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) is comparable to traditional, open TLIF because of the limitations of the prior small-sample-size, single-center studies reporting comparative effectiveness.Objective
To compare MI-TLIF to traditional, open TLIF for grade 1 degenerative lumbar spondylolisthesis in the largest study to date by sample size.Methods
We utilized the prospective Quality Outcomes Database registry and queried patients with grade 1 degenerative lumbar spondylolisthesis who underwent single-segment surgery with MI- or open TLIF methods. Outcomes were compared 24 mo postoperatively.Results
A total of 297 patients were included: 72 (24.2%) MI-TLIF and 225 (75.8%) open TLIF. MI-TLIF surgeries had lower mean body mass indexes (29.5 ± 5.1 vs 31.3 ± 7.0, P = .0497) and more worker's compensation cases (11.1% vs 1.3%, P < .001) but were otherwise similar. MI-TLIF had less blood loss (108.8 ± 85.6 vs 299.6 ± 242.2 mL, P < .001), longer operations (228.2 ± 111.5 vs 189.6 ± 66.5 min, P < .001), and a higher return-to-work (RTW) rate (100% vs 80%, P = .02). Both cohorts improved significantly from baseline for 24-mo Oswestry Disability Index (ODI), Numeric Rating Scale back pain (NRS-BP), NRS leg pain (NRS-LP), and Euro-Qol-5 dimension (EQ-5D) (P > .001). In multivariable adjusted analyses, MI-TLIF was associated with lower ODI (β = -4.7; 95% CI = -9.3 to -0.04; P = .048), higher EQ-5D (β = 0.06; 95% CI = 0.01-0.11; P = .02), and higher satisfaction (odds ratio for North American Spine Society [NASS] 1/2 = 3.9; 95% CI = 1.4-14.3; P = .02). Though trends favoring MI-TLIF were evident for NRS-BP (P = .06), NRS-LP (P = .07), and reoperation rate (P = .13), these results did not reach statistical significance.Conclusion
For single-level grade 1 degenerative lumbar spondylolisthesis, MI-TLIF was associated with less disability, higher quality of life, and higher patient satisfaction compared with traditional, open TLIF. MI-TLIF was associated with higher rates of RTW, less blood loss, but longer operative times. Though we utilized multivariable adjusted analyses, these findings may be susceptible to selection bias.Item Open Access A comparison of minimally invasive transforaminal lumbar interbody fusion and decompression alone for degenerative lumbar spondylolisthesis.(Neurosurgical focus, 2019-05) Chan, Andrew K; Bisson, Erica F; Bydon, Mohamad; Glassman, Steven D; Foley, Kevin T; Potts, Eric A; Shaffrey, Christopher I; Shaffrey, Mark E; Coric, Domagoj; Knightly, John J; Park, Paul; Wang, Michael Y; Fu, Kai-Ming; Slotkin, Jonathan R; Asher, Anthony L; Virk, Michael S; Kerezoudis, Panagiotis; Alvi, Mohammed Ali; Guan, Jian; Haid, Regis W; Mummaneni, Praveen VOBJECTIVEThe optimal minimally invasive surgery (MIS) approach for grade 1 lumbar spondylolisthesis is not clearly elucidated. In this study, the authors compared the 24-month patient-reported outcomes (PROs) after MIS transforaminal lumbar interbody fusion (TLIF) and MIS decompression for degenerative lumbar spondylolisthesis.METHODSA total of 608 patients from 12 high-enrolling sites participating in the Quality Outcomes Database (QOD) lumbar spondylolisthesis module underwent single-level surgery for degenerative grade 1 lumbar spondylolisthesis, of whom 143 underwent MIS (72 MIS TLIF [50.3%] and 71 MIS decompression [49.7%]). Surgeries were classified as MIS if there was utilization of percutaneous screw fixation and placement of a Wiltse plane MIS intervertebral body graft (MIS TLIF) or if there was a tubular decompression (MIS decompression). Parameters obtained at baseline through at least 24 months of follow-up were collected. PROs included the Oswestry Disability Index (ODI), numeric rating scale (NRS) for back pain, NRS for leg pain, EuroQol-5D (EQ-5D) questionnaire, and North American Spine Society (NASS) satisfaction questionnaire. Multivariate models were constructed to adjust for patient characteristics, surgical variables, and baseline PRO values.RESULTSThe mean age of the MIS cohort was 67.1 ± 11.3 years (MIS TLIF 62.1 years vs MIS decompression 72.3 years) and consisted of 79 (55.2%) women (MIS TLIF 55.6% vs MIS decompression 54.9%). The proportion in each cohort reaching the 24-month follow-up did not differ significantly between the cohorts (MIS TLIF 83.3% and MIS decompression 84.5%, p = 0.85). MIS TLIF was associated with greater blood loss (mean 108.8 vs 33.0 ml, p < 0.001), longer operative time (mean 228.2 vs 101.8 minutes, p < 0.001), and longer length of hospitalization (mean 2.9 vs 0.7 days, p < 0.001). MIS TLIF was associated with a significantly lower reoperation rate (14.1% vs 1.4%, p = 0.004). Both cohorts demonstrated significant improvements in ODI, NRS back pain, NRS leg pain, and EQ-5D at 24 months (p < 0.001, all comparisons relative to baseline). In multivariate analyses, MIS TLIF-as opposed to MIS decompression alone-was associated with superior ODI change (β = -7.59, 95% CI -14.96 to -0.23; p = 0.04), NRS back pain change (β = -1.54, 95% CI -2.78 to -0.30; p = 0.02), and NASS satisfaction (OR 0.32, 95% CI 0.12-0.82; p = 0.02).CONCLUSIONSFor symptomatic, single-level degenerative spondylolisthesis, MIS TLIF was associated with a lower reoperation rate and superior outcomes for disability, back pain, and patient satisfaction compared with posterior MIS decompression alone. This finding may aid surgical decision-making when considering MIS for degenerative lumbar spondylolisthesis.Item Open Access Are Minimally Invasive Spine Surgeons or Classical Open Spine Surgeons More Consistent with Their Treatment of Adult Spinal Deformity?(World neurosurgery, 2022-09) Uribe, Juan S; Koffie, Robert M; Wang, Michael Y; Mundis, Gregory M; Kanter, Adam S; Eastlack, Robert K; Anand, Neel; Park, Paul; Smith, Justin S; Burton, Douglas C; Chou, Dean; Kelly, Michael P; Kim, Han Jo; Bess, Shay; Shaffrey, Christopher I; Schwab, Frank J; Lenke, Lawrence G; Mummaneni, Praveen VObjective
Spine surgeons have a heuristic sense of how to surgically restore alignment and address adult spinal deformity (ASD) symptoms, but consensus on the extent of treatment remains unclear. We sought to determine the variability of surgical approaches in treating ASD.Methods
Sixteen spine surgeons were surveyed on treatment approaches in 10 select ASD cases. We repeated the survey with the same surgeons 4 weeks later, with cases ordered differently. We examined the variability in length of construct, use of interbody spacers, osteotomies, and pelvic fixation frequency.Results
Treatment approaches for each case varied by surgeon, with some surgeons opting for long fusion constructs in cases for which others offered no surgery. There was no consensus among surgeons on the number of levels fused, interbody spacer use, or anterior/posterior osteotomies. Intersurgeon and intrasurgeon variability was 48% (kappa = 0.31) and 59% (kappa = 0.44) for surgeons performing minimally invasive surgery (MIS) versus 37% (kappa = 0.21) and 47% (kappa = 0.30) for those performing open surgery. In the second-round survey, 8 of 15 (53%) surgeons substantially changed the construct length, number of interbody spacers, and osteotomies in at least half the cases they previously reviewed. Surgeons performing MIS versus open surgery were less likely to extend constructs to the pelvis (42.5% vs. 67.5%; P = 0.02), but construct length was not correlated with whether a surgeon performed MIS or open surgery.Conclusions
Spinal deformity surgeons lack consensus on the optimal surgical approach for treating ASD. Classifying surgeons as performing MIS or open surgery does not mitigate this variability.Item Open Access Can a Minimal Clinically Important Difference Be Achieved in Elderly Patients with Adult Spinal Deformity Who Undergo Minimally Invasive Spinal Surgery?(World neurosurgery, 2016-02) Park, Paul; Okonkwo, David O; Nguyen, Stacie; Mundis, Gregory M; Than, Khoi D; Deviren, Vedat; La Marca, Frank; Fu, Kai-Ming; Wang, Michael Y; Uribe, Juan S; Anand, Neel; Fessler, Richard; Nunley, Pierce D; Chou, Dean; Kanter, Adam S; Shaffrey, Christopher I; Akbarnia, Behrooz A; Passias, Peter G; Eastlack, Robert K; Mummaneni, Praveen V; International Spine Study GroupBackground
Older age has been considered a relative contraindication to complex spinal procedures. Minimally invasive surgery (MIS) techniques to treat patients with adult spinal deformity (ASD) have emerged with the potential benefit of decreased approach-related morbidity.Objective
To determine whether a minimal clinically important difference (MCID) could be achieved in patients ages ≥ 65 years with ASD who underwent MIS.Methods
Multicenter database of patients who underwent MIS for ASD was queried. Outcome metrics assessed were Oswestry Disability Index (ODI) and visual analog scale (VAS) scores for back and leg pain. On the basis of published reports, MCID was defined as a positive change of 12.8 ODI, 1.2 VAS back pain, and 1.6 VAS leg pain.Results
Forty-two patients were identified. Mean age was 70.3 years; 31 (73.8%) were women. Preoperatively, mean coronal curve, pelvic tilt, pelvic incidence to lumbar lordosis mismatch, and sagittal vertical axis were 35°, 24.6°, 14.2°, and 4.7 cm, respectively. Postoperatively, mean coronal curve, pelvic tilt, pelvic incidence to lumbar lordosis, and sagittal vertical axis were 18°, 25.4°, 11.9°, and 4.9 cm, respectively. A mean of 5.0 levels was treated posteriorly, and a mean of 4.0 interbody fusions was performed. Mean ODI improved from 47.1 to 25.1. Mean VAS back and leg pain scores improved from 6.8 and 5.9 to 2.7 and 2.7, respectively. Mean follow-up was 32.1 months. For ODI, 64.3% of patients achieved MCID. For VAS back and leg pain, 82.9% and 72.2%, respectively, reached MCID.Conclusions
MCID represents the threshold at which patients feel a meaningful clinical improvement has occurred. Our study results suggest that the majority of elderly patients with modest ASD can achieve MCID with MIS.Item Open Access Clinical and radiographic parameters associated with best versus worst clinical outcomes in minimally invasive spinal deformity surgery.(Journal of neurosurgery. Spine, 2016-07) Than, Khoi D; Park, Paul; Fu, Kai-Ming; Nguyen, Stacie; Wang, Michael Y; Chou, Dean; Nunley, Pierce D; Anand, Neel; Fessler, Richard G; Shaffrey, Christopher I; Bess, Shay; Akbarnia, Behrooz A; Deviren, Vedat; Uribe, Juan S; La Marca, Frank; Kanter, Adam S; Okonkwo, David O; Mundis, Gregory M; Mummaneni, Praveen V; International Spine Study GroupOBJECTIVE Minimally invasive surgery (MIS) techniques are increasingly used to treat adult spinal deformity. However, standard minimally invasive spinal deformity techniques have a more limited ability to restore sagittal balance and match the pelvic incidence-lumbar lordosis (PI-LL) than traditional open surgery. This study sought to compare "best" versus "worst" outcomes of MIS to identify variables that may predispose patients to postoperative success. METHODS A retrospective review of minimally invasive spinal deformity surgery cases was performed to identify parameters in the 20% of patients who had the greatest improvement in Oswestry Disability Index (ODI) scores versus those in the 20% of patients who had the least improvement in ODI scores at 2 years' follow-up. RESULTS One hundred four patients met the inclusion criteria, and the top 20% of patients in terms of ODI improvement at 2 years (best group, 22 patients) were compared with the bottom 20% (worst group, 21 patients). There were no statistically significant differences in age, body mass index, pre- and postoperative Cobb angles, pelvic tilt, pelvic incidence, levels fused, operating room time, and blood loss between the best and worst groups. However, the mean preoperative ODI score was significantly higher (worse disability) at baseline in the group that had the greatest improvement in ODI score (58.2 vs 39.7, p < 0.001). There was no difference in preoperative PI-LL mismatch (12.8° best vs 19.5° worst, p = 0.298). The best group had significantly less postoperative sagittal vertical axis (SVA; 3.4 vs 6.9 cm, p = 0.043) and postoperative PI-LL mismatch (10.4° vs 19.4°, p = 0.027) than the worst group. The best group also had better postoperative visual analog scale back and leg pain scores (p = 0.001 and p = 0.046, respectively). CONCLUSIONS The authors recommend that spinal deformity surgeons using MIS techniques focus on correcting a patient's PI-LL mismatch to within 10° and restoring SVA to < 5 cm. Restoration of these parameters seems to impact which patients will attain the greatest degree of improvement in ODI outcomes, while the spines of patients who do the worst are not appropriately corrected and may be fused into a fixed sagittal plane deformity.Item Open Access Comparison of Complications and Clinical and Radiographic Outcomes Between Nonobese and Obese Patients with Adult Spinal Deformity Undergoing Minimally Invasive Surgery.(World neurosurgery, 2016-03) Park, Paul; Wang, Michael Y; Nguyen, Stacie; Mundis, Gregory M; La Marca, Frank; Uribe, Juan S; Anand, Neel; Okonkwo, David O; Kanter, Adam S; Fessler, Richard; Eastlack, Robert K; Chou, Dean; Deviren, Vedat; Nunley, Pierce D; Shaffrey, Christopher I; Mummaneni, Praveen V; International Spine Study GroupObjective
Obesity can be associated with increased complications and potentially worse outcomes. We aimed to evaluate the impact of obesity on complications and outcomes in patients with adult spinal deformity (ASD) who underwent minimally invasive surgery (MIS).Methods
A multicenter database of patients with ASD treated via MIS was queried. Of 190 patients in the database, 77 fit the inclusion criteria of 3 or more spinal levels treated minimally invasively. Patients were divided by body mass index (BMI) <30 (nonobese; n = 59) and BMI ≥ 30 (obese; n = 18).Results
Mean BMI was 24.6 nonobese and 35.0 obese (P < 0.001). There were mean 3.8 interbody fusions nonobese and 4.7 obese (P = 0.065). Levels treated posteriorly averaged 5.8 nonobese and 5.9 obese (P = 0.502). Mean follow-up was 34.4 months nonobese and 35.3 months obese (P = 0.976). Baseline radiographic parameters were similar between groups. Postoperatively, SVA averaged 83.9 mm obese and 20.4 mm nonobese (P = 0.002). Postoperative lumbar lordosis-pelvic incidence mismatch averaged 17.9° obese and 9.9° nonobese (P = 0.028). Both groups had improvement in Oswestry Disability Index (ODI) scores with no difference in postoperative ODI scores between groups (P = 0.090). Similarly, both groups had decreased VAS scores for back and leg pain with no difference between groups postoperatively. Twenty (33.9%) nonobese patients versus 7 (38.9%) obese patients had complications (P = 0.452).Conclusions
Our results suggest that obesity does not negatively impact complication rate or clinical outcomes in patients with ASD treated via MIS approaches.Item Open Access Comparison of radiographic results after minimally invasive, hybrid, and open surgery for adult spinal deformity: a multicenter study of 184 patients.(Neurosurgical focus, 2014-05) Haque, Raqeeb M; Mundis, Gregory M; Ahmed, Yousef; El Ahmadieh, Tarek Y; Wang, Michael Y; Mummaneni, Praveen V; Uribe, Juan S; Okonkwo, David O; Eastlack, Robert K; Anand, Neel; Kanter, Adam S; La Marca, Frank; Akbarnia, Behrooz A; Park, Paul; Park, Paul; Lafage, Virginie; Terran, Jamie S; Shaffrey, Christopher I; Klineberg, Eric; Deviren, Vedat; Fessler, Richard G; International Spine Study GroupObject
Various surgical approaches, including open, minimally invasive, and hybrid techniques, have gained momentum in the management of adult spinal deformity. However, few data exist on the radiographic outcomes of different surgical techniques. The objective of this study was to compare the radiographic and clinical outcomes of the surgical techniques used in the treatment of adult spinal deformity.Methods
The authors conducted a retrospective review of two adult spinal deformity patient databases, a prospective open surgery database and a retrospective minimally invasive surgery (MIS) and hybrid surgery database. The time frame of enrollment in this study was from 2007 to 2012. Spinal deformity patients were stratified into 3 surgery groups: MIS, hybrid surgery, and open surgery. The following pre- and postoperative radiographic parameters were assessed: lumbar major Cobb angle, lumbar lordosis, pelvic incidence minus lumbar lordosis (PI-LL), sagittal vertical axis, and pelvic tilt. Scores on the Oswestry Disability Index (ODI) and a visual analog scale (VAS) for both back and leg pain were also obtained from each patient.Results
Of the 234 patients with adult spinal deformity, 184 patients had pre- and postoperative radiographs and were thus included in the study (MIS, n = 42; hybrid, n = 33; open, n = 109). Patients were a mean of 61.7 years old and had a mean body mass index of 26.9 kg/m(2). Regarding radiographic outcomes, the MIS group maintained a significantly smaller mean lumbar Cobb angle (13.1°) after surgery compared with the open group (20.4°, p = 0.002), while the hybrid group had a significantly larger lumbar curve correction (26.6°) compared with the MIS group (18.8°, p = 0.045). The mean change in the PI-LL was larger for the hybrid group (20.6°) compared with the open (10.2°, p = 0.023) and MIS groups (5.5°, p = 0.003). The mean sagittal vertical axis correction was greater for the open group (25 mm) compared with the MIS group (≤ 1 mm, p = 0.008). Patients in the open group had a significantly larger postoperative thoracic kyphosis (41.45°) compared with the MIS patients (33.5°, p = 0.005). There were no significant differences between groups in terms of pre- and postoperative mean ODI and VAS scores at the 1-year follow-up. However, patients in the MIS group had much lower estimated blood loss and transfusion rates compared with patients in the hybrid or open groups (p < 0.001). Operating room time was significantly longer with the hybrid group compared with the MIS and open groups (p < 0.001). Major complications occurred in 14% of patients in the MIS group, 14% in the hybrid group, and 45% in the open group (p = 0.032).Conclusions
This study provides valuable baseline characteristics of radiographic parameters among 3 different surgical techniques used in the treatment of adult spinal deformity. Each technique has advantages, but much like any surgical technique, the positive and negative elements must be considered when tailoring a treatment to a patient. Minimally invasive surgical techniques can result in clinical outcomes at 1 year comparable to those obtained from hybrid and open surgical techniques.Item Open Access Comparison of two minimally invasive surgery strategies to treat adult spinal deformity.(Journal of neurosurgery. Spine, 2015-04) Park, Paul; Wang, Michael Y; Lafage, Virginie; Nguyen, Stacie; Ziewacz, John; Okonkwo, David O; Uribe, Juan S; Eastlack, Robert K; Anand, Neel; Haque, Raqeeb; Fessler, Richard G; Kanter, Adam S; Deviren, Vedat; La Marca, Frank; Smith, Justin S; Shaffrey, Christopher I; Mundis, Gregory M; Mummaneni, Praveen V; International Spine Study GroupObject
Minimally invasive surgery (MIS) techniques are becoming a more common means of treating adult spinal deformity (ASD). The aim of this study was to compare the hybrid (HYB) surgical approach, involving minimally invasive lateral interbody fusion with open posterior instrumented fusion, to the circumferential MIS (cMIS) approach to treat ASD.Methods
The authors performed a retrospective, multicenter study utilizing data collected in 105 patients with ASD who were treated via MIS techniques. Criteria for inclusion were age older than 45 years, coronal Cobb angle greater than 20°, and a minimum of 1 year of follow-up. Patients were stratified into 2 groups: HYB (n = 62) and cMIS (n = 43).Results
The mean age was 60.7 years in the HYB group and 61.0 years in the cMIS group (p = 0.910). A mean of 3.6 interbody fusions were performed in the HYB group compared with a mean of 4.0 interbody fusions in the cMIS group (p = 0.086). Posterior fusion involved a mean of 6.9 levels in the HYB group and a mean of 5.1 levels in the cMIS group (p = 0.003). The mean follow-up was 31.3 months for the HYB group and 38.3 months for the cMIS group. The mean Oswestry Disability Index (ODI) score improved by 30.6 and 25.7, and the mean visual analog scale (VAS) scores for back/leg pain improved by 2.4/2.5 and 3.8/4.2 for the HYB and cMIS groups, respectively. There was no significant difference between groups with regard to ODI or VAS scores. For the HYB group, the lumbar coronal Cobb angle decreased by 13.5°, lumbar lordosis (LL) increased by 8.2°, sagittal vertical axis (SVA) decreased by 2.2 mm, and LL-pelvic incidence (LL-PI) mismatch decreased by 8.6°. For the cMIS group, the lumbar coronal Cobb angle decreased by 10.3°, LL improved by 3.0°, SVA increased by 2.1 mm, and LL-PI decreased by 2.2°. There were no significant differences in these radiographic parameters between groups. The complication rate, however, was higher in the HYB group (55%) than in the cMIS group (33%) (p = 0.024).Conclusions
Both HYB and cMIS approaches resulted in clinical improvement, as evidenced by decreased ODI and VAS pain scores. While there was no significant difference in degree of radiographic correction between groups, the HYB group had greater absolute improvement in degree of lumbar coronal Cobb angle correction, increased LL, decreased SVA, and decreased LL-PI. The complication rate, however, was higher with the HYB approach than with the cMIS approach.Item Open Access Complications in adult spinal deformity surgery: an analysis of minimally invasive, hybrid, and open surgical techniques.(Neurosurgical focus, 2014-05) Uribe, Juan S; Deukmedjian, Armen R; Mummaneni, Praveen V; Fu, Kai-Ming G; Mundis, Gregory M; Okonkwo, David O; Kanter, Adam S; Eastlack, Robert; Wang, Michael Y; Anand, Neel; Fessler, Richard G; La Marca, Frank; Park, Paul; Lafage, Virginie; Deviren, Vedat; Bess, Shay; Shaffrey, Christopher I; International Spine Study GroupObject
It is hypothesized that minimally invasive surgical techniques lead to fewer complications than open surgery for adult spinal deformity (ASD). The goal of this study was to analyze matched patient cohorts in an attempt to isolate the impact of approach on adverse events.Methods
Two multicenter databases queried for patients with ASD treated via surgery and at least 1 year of follow-up revealed 280 patients who had undergone minimally invasive surgery (MIS) or a hybrid procedure (HYB; n = 85) or open surgery (OPEN; n = 195). These patients were divided into 3 separate groups based on the approach performed and were propensity matched for age, preoperative sagittal vertebral axis (SVA), number of levels fused posteriorly, and lumbar coronal Cobb angle (CCA) in an attempt to neutralize these patient variables and to make conclusions based on approach only. Inclusion criteria for both databases were similar, and inclusion criteria specific to this study consisted of an age > 45 years, CCA > 20°, 3 or more levels of fusion, and minimum of 1 year of follow-up. Patients in the OPEN group with a thoracic CCA > 75° were excluded to further ensure a more homogeneous patient population.Results
In all, 60 matched patients were available for analysis (MIS = 20, HYB = 20, OPEN = 20). Blood loss was less in the MIS group than in the HYB and OPEN groups, but a significant difference was only found between the MIS and the OPEN group (669 vs 2322 ml, p = 0.001). The MIS and HYB groups had more fused interbody levels (4.5 and 4.1, respectively) than the OPEN group (1.6, p < 0.001). The OPEN group had less operative time than either the MIS or HYB group, but it was only statistically different from the HYB group (367 vs 665 minutes, p < 0.001). There was no significant difference in the duration of hospital stay among the groups. In patients with complete data, the overall complication rate was 45.5% (25 of 55). There was no significant difference in the total complication rate among the MIS, HYB, and OPEN groups (30%, 47%, and 63%, respectively; p = 0.147). No intraoperative complications were reported for the MIS group, 5.3% for the HYB group, and 25% for the OPEN group (p < 0.03). At least one postoperative complication occurred in 30%, 47%, and 50% (p = 0.40) of the MIS, HYB, and OPEN groups, respectively. One major complication occurred in 30%, 47%, and 63% (p = 0.147) of the MIS, HYB, and OPEN groups, respectively. All patients had significant improvement in both the Oswestry Disability Index (ODI) and visual analog scale scores after surgery (p < 0.001), although the MIS group did not have significant improvement in leg pain. The occurrence of complications had no impact on the ODI.Conclusions
Results in this study suggest that the surgical approach may impact complications. The MIS group had significantly fewer intraoperative complications than did either the HYB or OPEN groups. If the goals of ASD surgery can be achieved, consideration should be given to less invasive techniques.Item Open Access Does Minimally Invasive Percutaneous Posterior Instrumentation Reduce Risk of Proximal Junctional Kyphosis in Adult Spinal Deformity Surgery? A Propensity-Matched Cohort Analysis.(Neurosurgery, 2016-01) Mummaneni, Praveen V; Park, Paul; Fu, Kai-Ming; Wang, Michael Y; Nguyen, Stacie; Lafage, Virginie; Uribe, Juan S; Ziewacz, John; Terran, Jamie; Okonkwo, David O; Anand, Neel; Fessler, Richard; Kanter, Adam S; LaMarca, Frank; Deviren, Vedat; Bess, R Shay; Schwab, Frank J; Smith, Justin S; Akbarnia, Behrooz A; Mundis, Gregory M; Shaffrey, Christopher I; International Spine Study GroupBackground
Proximal junctional kyphosis (PJK) is a known complication after spinal deformity surgery. One potential cause is disruption of posterior muscular tension band during pedicle screw placement.Objective
To investigate the effect of minimally invasive surgery (MIS) on PJK.Methods
A multicenter database of patients who underwent deformity surgery was propensity matched for pelvic incidence (PI) to lumbar lordosis (LL) mismatch and change in LL. Radiographic PJK was defined as proximal junctional angle >10°. Sixty-eight patients made up the circumferential MIS (cMIS) group, and 68 were in the hybrid (HYB) surgery group (open screw placement).Results
Preoperatively, there was no difference in age, body mass index, PI-LL mismatch, or sagittal vertical axis. The mean number of levels treated posteriorly was 4.7 for cMIS and 8.2 for HYB (P < .001). Both had improved LL and PI-LL mismatch postoperatively. Sagittal vertical axis remained physiological for the cMIS and HYB groups. Oswestry Disability Index scores were significantly improved in both groups. Radiographic PJK developed in 31.3% of the cMIS and 52.9% of the HYB group (P = .01). Reoperation for PJK was 4.5% for the cMIS and 10.3% for the HYB group (P = .20). Subgroup analysis for patients undergoing similar levels of posterior instrumentation in the cMIS and HYB groups found a PJK rate of 48.1% and 53.8% (P = .68) and a reoperation rate of 11.1% and 19.2%, respectively (P = .41). Mean follow-up was 32.8 months.Conclusion
Overall rates of radiographic PJK and reoperation for PJK were not significantly decreased with MIS pedicle screw placement. However, a larger comparative study is needed to confirm that MIS pedicle screw placement does not affect PJK.Item Open Access Does MIS Surgery Allow for Shorter Constructs in the Surgical Treatment of Adult Spinal Deformity?(Neurosurgery, 2017-03) Uribe, Juan S; Beckman, Joshua; Mummaneni, Praveen V; Okonkwo, David; Nunley, Pierce; Wang, Michael Y; Mundis, Gregory M; Park, Paul; Eastlack, Robert; Anand, Neel; Kanter, Adam; Lamarca, Frank; Fessler, Richard; Shaffrey, Chris I; Lafage, Virginie; Chou, Dean; Deviren, Vedat; MIS-ISSG GroupBackground
The length of construct can potentially influence perioperative risks in adult spinal deformity (ASD) surgery. A head-to-head comparison between open and minimally invasive surgery (MIS) techniques for treatment of ASD has yet to be performed.Objective
To examine the impact of MIS approaches on construct length and clinical outcomes in comparison to traditional open approaches when treating similar ASD profiles.Methods
Two multicenter databases for ASD, 1 involving MIS procedures and the other open procedures, were propensity matched for clinical and radiographic parameters in this observational study. Inclusion criteria were ASD and minimum 2-year follow-up. Independent t -test and chi-square test were used to evaluate and compare outcomes.Results
A total of 1215 patients were identified, with 84 patients matched in each group. Statistical significance was found for mean levels fused (4.8 for circumferential MIS [cMIS] and 10.1 for open), mean interbody fusion levels (3.6 cMIS and 2.4 open), blood loss (estimated blood loss 488 mL cMIS and 1762 mL open), and hospital length of stay (6.7 days cMIS and 9.7 days open). There was no significant difference in preoperative radiographic parameters or postoperative clinical outcomes (Owestry Disability Index and visual analog scale) between groups. There was a significant difference in postoperative lumbar lordosis (43.3° cMIS and 49.8° open) and pelvic incidence-lumbar lordosis correction (10.6° cMIS and 5.2° open) in the open group. There was no significant difference in reoperation rate between the 2 groups.Conclusion
MIS techniques for ASD may reduce construct length, reoperation rates, blood loss, and length of stay without affecting clinical and radiographic outcomes when compared to a similar group of patients treated with open techniques.Item Open Access Instrument Tracking for Prone Lateral Surgery.(World neurosurgery, 2023-01) Srinivasan, Ethan S; Hamouda, Farrah; Gnaedinger, Anika G; Wang, Timothy Y; Chan, Andrew K; Shaffrey, Christopher I; Erickson, Melissa M; Than, Khoi D; Abd-El-Barr, Muhammad MThe prone lateral transpsoas approach for lumbar interbody fusion and posterior instrumentation enables a large surface area implant without disruption of the posterior spine musculature from a single position.1,2 The addition of virtual live fluoroscopy instrument tracking navigation to surgery provides multiple benefits, including a reduction in patient and surgeon radiation exposure, highly accurate and dynamic spatial tool localization, and flexible equipment and patient positioning.3,4 Here, we highlight the use of virtual live fluoroscopy in prone lateral spine surgery. A 75-year-old man presented with prior L3-L5 fusion and progressive lower extremity pain and weakness. Using the described techniques, the patient underwent a lateral retroperitoneal interbody fusion and posterior instrumentation at L2-L3. The operation proceeded without complication, and the patient reported improved ambulation at 6-week follow-up. The prone lateral transpsoas approach and minimally invasive posterior instrumentation for lumbar interbody fusion permits effective fusion without significant posterior muscle disruption from a single position. The integration of virtual live fluoroscopy enables real-time instrument tracking throughout the minimally invasive case, with reductions in patient and surgeon radiation exposure. Video 1 depicts the use and benefits of this technology in lateral spine surgery. Compared with computed tomography-guided navigation, virtual live fluoroscopy technology enables rapid remapping to iatrogenic anatomic changes for more fluid progression through the operation.5 Virtual live fluoroscopy instrument tracking is a valuable tool that increases the safety and efficiency of single-position lateral spine surgery.Item Open Access Less invasive surgery for treating adult spinal deformities: ceiling effects for deformity correction with 3 different techniques.(Neurosurgical focus, 2014-05) Wang, Michael Y; Mummaneni, Praveen V; Fu, Kai-Ming G; Anand, Neel; Okonkwo, David O; Kanter, Adam S; La Marca, Frank; Fessler, Richard; Uribe, Juan; Shaffrey, Christopher I; Lafage, Virginie; Haque, Raqeeb M; Deviren, Vedat; Mundis, Gregory M; Minimally Invasive Surgery Section of the International Spine Study GroupObject
Minimally invasive surgery (MIS) options for the treatment of adult spinal deformity (ASD) have advanced significantly over the past decade. However, a wide array of options have been described as being MIS or less invasive. In this study the authors investigated a multiinstitutional cohort of patients with ASD who were treated with less invasive methods to determine the extent of deformity correction achieved.Methods
This study was a retrospective review of multicenter prospectively collected data in 85 consecutive patients with ASD undergoing MIS surgery. Inclusion criteria were as follows: age older than 45 years; minimum 20° coronal lumbar Cobb angle; and 1 year of follow-up. Procedures were classified as follows: 1) stand-alone (n = 7); 2) circumferential MIS (n = 43); or 3) hybrid (n = 35).Results
An average of 4.2 discs (range 3-7) were fused, with a mean follow-up duration of 26.1 months in this study. For the stand-alone group the preoperative Cobb range was 22°-51°, with 57% greater than 30° and 28.6% greater than 50°. The mean Cobb angle improved from 35.7° to 30°. A ceiling effect of 23° for curve correction was observed, regardless of preoperative curve severity. For the circumferential MIS group the preoperative Cobb range was 19°-62°, with 44% greater than 30° and 5% greater than 50°. The mean Cobb angle improved from 32° to 12°. A ceiling effect of 34° for curve correction was observed. For the hybrid group the preoperative Cobb range was 23°-82°, with 74% greater than 30° and 23% greater than 50°. The mean Cobb angle improved from 43° to 15°. A ceiling effect of 55° for curve correction was observed.Conclusions
Specific procedures for treating ASD have particular limitations for scoliotic curve correction. Less invasive techniques were associated with a reduced ability to straighten the spine, particularly with advanced curves. These data can guide preoperative technique selection when treating patients with ASD.Item Open Access Mini-Open Lateral Corpectomy for Thoracolumbar Junction Lesions.(Operative neurosurgery (Hagerstown, Md.), 2020-06) Huangxs, Shengbin; Christiansen, Peter A; Tan, Haitao; Smith, Justin S; Shaffrey, Mark E; Uribe, Juan S; Shaffrey, Christopher I; Yen, Chun-PoBackground
Neoplastic, traumatic, infectious, and degenerative pathologies affecting the thoracolumbar junction pose a unique challenge to spine surgeons. Posterior or anterior approaches have traditionally been utilized to treat these lesions. Although minimally invasive surgeries through a lateral approach to the thoracic or lumbar spine have gained popularity, lateral access to the thoracolumbar junction remains technically challenging due to the overlying diaphragm positioned at the interface of the peritoneum and pleura.Objective
To describe a mini-open lateral retropleural retroperitoneal approach for pathologies with spinal cord/cauda equina compression at the thoracolumbar junction.Methods
A mini-open lateral corpectomy is described in detail in a patient with an L1 metastatic tumor.Results
Satisfactory decompression and spinal column reconstruction were achieved. The patient obtained neural function recovery following the procedure with no intra- or postoperative complications.Conclusion
The morbidities associated with traditional posterior or anterior approaches to thoracolumbar junction pathologies have led to a growing interest in minimally invasive alternatives. The mini-open lateral approach allows for a safe and efficacious corpectomy and reconstruction for thoracolumbar junction pathologies. Thorough understanding of the anatomy, particularly of the diaphragm, is critical. This approach will have expanded roles in the management of patients with thoracolumbar neoplasms, fractures, infections, deformities, or degenerative diseases.Item Open Access Minimally Invasive Pulmonary Fibroelastoma Resection.(Innovations (Philadelphia, Pa.), 2019-11-19) Nellis, Joseph R; Wojnarski, Charles M; Fitch, Zachary W; Andersen, Nicholas A; Turek, Joseph WPulmonary fibroelastomas are a rare primary cardiac tumor with less than 50 cases reported in the literature to date. We performed a minimally invasive valve-sparing tumor resection through a left anterior mini-incision (LAMI). The procedure was performed without cardiac arrest or aortic cross clamp, expediting postoperative recovery and allowing for an uncomplicated discharge on postoperative day 5. LAMI is a safe and reliable alternative to median sternotomy for patients requiring interventions on the right ventricular outflow tract and main pulmonary artery, including pulmonary fibroelastoma resection and pulmonary valve replacement when needed.Item Open Access Minimally Invasive Surgery for Mild-to-Moderate Adult Spinal Deformities: Impact on Intensive Care Unit and Hospital Stay.(World neurosurgery, 2019-07) Chou, Dean; Mundis, Gregory; Wang, Michael; Fu, Kai-Ming; Shaffrey, Christopher; Okonkwo, David; Kanter, Adam; Eastlack, Robert; Nguyen, Stacie; Deviren, Vedat; Uribe, Juan; Fessler, Richard; Nunley, Pierce; Anand, Neel; Park, Paul; Mummaneni, Praveen; International Spine Study GroupObjective
To compare circumferential minimally invasive (cMIS) versus open surgeries for mild-to-moderate adult spinal deformity (ASD) with regard to intensive care unit (ICU) and hospital lengths of stay (LOS).Methods
A retrospective review of 2 multicenter ASD databases with 426 ASD (sagittal vertical axis <6 cm) surgery patients with 4 or more fusion levels and 2-year follow-up was conducted. ICU stay, LOS, and estimated blood loss (EBL) were compared between open and cMIS surgeries.Results
Propensity matching resulted in 88 patients (44 cMIS, 44 open). cMIS were older (61 vs. 53 years, P = 0.005). Mean levels fused were 6.5 in cMIS and 7.1 in open (P = 0.368). Preoperative lordosis was higher in open than in cMIS (42.7° vs. 40.9°, P = 0.016), and preoperative visual analog score back pain was greater in open than in cMIS (7 vs. 6.2, P = 0.033). Preoperative and postoperative spinopelvic parameters and coronal Cobb angles were not different. EBL was 534 cc in cMIS and 1211 cc in open (P < 0.001). Transfusions were less in cMIS (27.3% vs. 70.5%, P < 0.001). ICU stay was 0.6 days for cMIS and 1.2 days for open (P = 0.009). Hospital LOS was 7.9 days for cMIS versus 9.6 for open (P = 0.804).Conclusions
For patients with mild-to-moderate ASD, cMIS surgery had a significantly lower EBL and shorter ICU stay. Major and minor complication rates were lower in cMIS patients than open patients. Overall LOS was shorter in cMIS patients, but did not reach statistical significance.Item Open Access Minimally invasive versus open fusion for Grade I degenerative lumbar spondylolisthesis: analysis of the Quality Outcomes Database.(Neurosurgical focus, 2017-08) Mummaneni, Praveen V; Bisson, Erica F; Kerezoudis, Panagiotis; Glassman, Steven; Foley, Kevin; Slotkin, Jonathan R; Potts, Eric; Shaffrey, Mark; Shaffrey, Christopher I; Coric, Domagoj; Knightly, John; Park, Paul; Fu, Kai-Ming; Devin, Clinton J; Chotai, Silky; Chan, Andrew K; Virk, Michael; Asher, Anthony L; Bydon, MohamadOBJECTIVE Lumbar spondylolisthesis is a degenerative condition that can be surgically treated with either open or minimally invasive decompression and instrumented fusion. Minimally invasive surgery (MIS) approaches may shorten recovery, reduce blood loss, and minimize soft-tissue damage with resultant reduced postoperative pain and disability. METHODS The authors queried the national, multicenter Quality Outcomes Database (QOD) registry for patients undergoing posterior lumbar fusion between July 2014 and December 2015 for Grade I degenerative spondylolisthesis. The authors recorded baseline and 12-month patient-reported outcomes (PROs), including Oswestry Disability Index (ODI), EQ-5D, numeric rating scale (NRS)-back pain (NRS-BP), NRS-leg pain (NRS-LP), and satisfaction (North American Spine Society satisfaction questionnaire). Multivariable regression models were fitted for hospital length of stay (LOS), 12-month PROs, and 90-day return to work, after adjusting for an array of preoperative and surgical variables. RESULTS A total of 345 patients (open surgery, n = 254; MIS, n = 91) from 11 participating sites were identified in the QOD. The follow-up rate at 12 months was 84% (83.5% [open surgery]; 85% [MIS]). Overall, baseline patient demographics, comorbidities, and clinical characteristics were similarly distributed between the cohorts. Two hundred fifty seven patients underwent 1-level fusion (open surgery, n = 181; MIS, n = 76), and 88 patients underwent 2-level fusion (open surgery, n = 73; MIS, n = 15). Patients in both groups reported significant improvement in all primary outcomes (all p < 0.001). MIS was associated with a significantly lower mean intraoperative estimated blood loss and slightly longer operative times in both 1- and 2-level fusion subgroups. Although the LOS was shorter for MIS 1-level cases, this was not significantly different. No difference was detected with regard to the 12-month PROs between the 1-level MIS versus the 1-level open surgical groups. However, change in functional outcome scores for patients undergoing 2-level fusion was notably larger in the MIS cohort for ODI (-27 vs -16, p = 0.1), EQ-5D (0.27 vs 0.15, p = 0.08), and NRS-BP (-3.5 vs -2.7, p = 0.41); statistical significance was shown only for changes in NRS-LP scores (-4.9 vs -2.8, p = 0.02). On risk-adjusted analysis for 1-level fusion, open versus minimally invasive approach was not significant for 12-month PROs, LOS, and 90-day return to work. CONCLUSIONS Significant improvement was found in terms of all functional outcomes in patients undergoing open or MIS fusion for lumbar spondylolisthesis. No difference was detected between the 2 techniques for 1-level fusion in terms of patient-reported outcomes, LOS, and 90-day return to work. However, patients undergoing 2-level MIS fusion reported significantly better improvement in NRS-LP at 12 months than patients undergoing 2-level open surgery. Longer follow-up is needed to provide further insight into the comparative effectiveness of the 2 procedures.Item Open Access Minimally invasive versus open transforaminal lumbar interbody fusion for grade I lumbar spondylolisthesis: 5-year follow-up from the prospective multicenter Quality Outcomes Database registry.(Neurosurgical focus, 2023-01) Chan, Andrew K; Bydon, Mohamad; Bisson, Erica F; Glassman, Steven D; Foley, Kevin T; Shaffrey, Christopher I; Potts, Eric A; Shaffrey, Mark E; Coric, Domagoj; Knightly, John J; Park, Paul; Wang, Michael Y; Fu, Kai-Ming; Slotkin, Jonathan R; Asher, Anthony L; Virk, Michael S; Michalopoulos, Giorgos D; Guan, Jian; Haid, Regis W; Agarwal, Nitin; Park, Christine; Chou, Dean; Mummaneni, Praveen VObjective
Minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) has been used to treat degenerative lumbar spondylolisthesis and is associated with expedited recovery, reduced operative blood loss, and shorter hospitalizations compared to those with traditional open TLIF. However, the impact of MI-TLIF on long-term patient-reported outcomes (PROs) is less clear. Here, the authors compare the outcomes of MI-TLIF to those of traditional open TLIF for grade I degenerative lumbar spondylolisthesis at 60 months postoperatively.Methods
The authors utilized the prospective Quality Outcomes Database registry and queried for patients with grade I degenerative lumbar spondylolisthesis who had undergone single-segment surgery via an MI or open TLIF method. PROs were compared 60 months postoperatively. The primary outcome was the Oswestry Disability Index (ODI). The secondary outcomes included the numeric rating scale (NRS) for back pain (NRS-BP), NRS for leg pain (NRS-LP), EQ-5D, North American Spine Society (NASS) satisfaction, and cumulative reoperation rate. Multivariable models were constructed to assess the impact of MI-TLIF on PROs, adjusting for variables reaching p < 0.20 on univariable analyses and respective baseline PRO values.Results
The study included 297 patients, 72 (24.2%) of whom had undergone MI-TLIF and 225 (75.8%) of whom had undergone open TLIF. The 60-month follow-up rates were similar for the two cohorts (86.1% vs 75.6%, respectively; p = 0.06). Patients did not differ significantly at baseline for ODI, NRS-BP, NRS-LP, or EQ-5D (p > 0.05 for all). Perioperatively, MI-TLIF was associated with less blood loss (108.8 ± 85.6 vs 299.6 ± 242.2 ml, p < 0.001) and longer operations (228.2 ± 111.5 vs 189.6 ± 66.5 minutes, p < 0.001) but had similar lengths of hospitalizations (MI-TLIF 2.9 ± 1.8 vs open TLIF 3.3 ± 1.6 days, p = 0.08). Discharge disposition to home or home health was similar (MI-TLIF 93.1% vs open TLIF 91.1%, p = 0.60). Both cohorts improved significantly from baseline for the 60-month ODI, NRS-BP, NRS-LP, and EQ-5D (p < 0.001 for all comparisons). In adjusted analyses, MI-TLIF, compared to open TLIF, was associated with similar 60-month ODI, ODI change, odds of reaching ODI minimum clinically important difference, NRS-BP, NRS-BP change, NRS-LP, NRS-LP change, EQ-5D, EQ-5D change, and NASS satisfaction (adjusted p > 0.05 for all). The 60-month reoperation rates did not differ significantly (MI-TLIF 5.6% vs open TLIF 11.6%, p = 0.14).Conclusions
For symptomatic, single-level grade I degenerative lumbar spondylolisthesis, MI-TLIF was associated with decreased blood loss perioperatively, but there was no difference in 60-month outcomes for disability, back pain, leg pain, quality of life, or satisfaction between MI and open TLIF. There was no difference in cumulative reoperation rates between the two procedures. These results suggest that in appropriately selected patients, either procedure may be employed depending on patient and surgeon preferences.Item Open Access Morbidity and mortality in the surgical treatment of 10,329 adults with degenerative lumbar stenosis.(Journal of neurosurgery. Spine, 2010-05) Fu, Kai-Ming G; Smith, Justin S; Polly, David W; Perra, Joseph H; Sansur, Charles A; Berven, Sigurd H; Broadstone, Paul A; Choma, Theodore J; Goytan, Michael J; Noordeen, Hilali H; Knapp, D Raymond; Hart, Robert A; Zeller, Reinhard D; Donaldson, William F; Boachie-Adjei, Oheneba; Shaffrey, Christopher IObject
The purpose of this study was to evaluate the prospectively collected Scoliosis Research Society (SRS) database to assess the incidences of morbidity and mortality (M&M) in the operative treatment of degenerative lumbar stenosis, one of the most common procedures performed by spine surgeons.Methods
All patients who underwent surgical treatment for degenerative lumbar stenosis between 2004 and 2007 were identified from the SRS M&M database. Inclusion criteria for analysis included an age >or= 21 years and no history of lumbar surgery. Patients were treated with either decompression alone or decompression with concomitant fusion. Statistical comparisons were performed using a 2-sided Fisher exact test.Results
Of the 10,329 patients who met the inclusion criteria, 6609 (64%) were treated with decompression alone, and 3720 (36%) were treated with decompression and fusion. Among those who underwent fusion, instrumentation was placed in 3377 (91%). The overall mean patient age was 63 +/- 13 years (range 21-96 years). Seven hundred nineteen complications (7.0%), including 13 deaths (0.1%), were identified. New neurological deficits were reported in 0.6% of patients. Deaths were related to cardiac (4 cases), respiratory (5 cases), pulmonary embolus (2 cases), and sepsis (1 case) etiologies, and a perforated gastric ulcer (1 case). Complication rates did not differ based on patient age or whether fusion was performed. Minimally invasive procedures were associated with fewer complications and fewer new neurological deficits (p = 0.01 and 0.03, respectively).Conclusions
The results from this analysis of the SRS M&M database provide surgeons with useful information for preoperative counseling of patients contemplating surgical intervention for symptomatic degenerative lumbar stenosis.Item Open Access Pathophysiology of major surgery and the role of enhanced recovery pathways and the anesthesiologist to improve outcomes.(Anesthesiol Clin, 2015-03) Scott, Michael J; Miller, Timothy EEnhanced recovery pathways have been increasingly adopted into surgical specialties with the aim of reducing the stress response and improving the metabolic response to surgical insult. Enhanced recovery pathways encompass a large range of perioperative elements that together aim to restore a patient's gut function, mobility, function and well-being to preoperative levels as soon as feasible after major surgery. There is increasing evidence that rapid recovery and return to normal function reduces complications. This may not just have a benefit by reducing morbidity and mortality but also have an effect on long-term survival. There also may be additional benefits for patients with cancer.