Postoperative changes in paraspinal muscle volume: comparison between paramedian interfascial and midline approaches for lumbar fusion

Abstract

In this study, we compared the paramedian interfascial approach (PIA) and the traditional midline approach (MA) for lumbar fusion to determine which approach resulted in the least amount of postoperative back muscle atrophy. We performed unilateral transforaminal posterior lumbar interbody fusion via MA on the symptomatic side and pedicle screw fixation via PIA on the other side in the same patient. We evaluated the damage to the paraspinal muscle after MA and PIA by measuring the preoperative and postoperative paraspinal muscle volume in 26 patients. The preoperative and postoperative cross-sectional area, thickness, and width of the multifidus muscle were measured by computed tomography. The degree of postoperative paraspinal muscle atrophy was significantly greater on the MA side than on the contralateral PIA side (-20.7% and -4.8%, respectively, p<0.01). In conclusion, the PIA for lumbar fusion yielded successful outcomes for the preservation of paraspinal muscle in these 26 patients. We suggest that the success of PIA is due to less manipulation and retraction of the paraspinal muscle and further studies on this technique may help confirm whether less muscle injury has positive effects on the long-term clinical outcome.

Fig. 1

The drawing shows the pedicle screw fixation via paramedian interfascial approach to the lumbar spine. IS, interspinalis muscle; LS, longissimus muscle; MF, multifidus muscle; PS, psoas muscle.

Fig. 2

The cross-sectional area, thickness, and width of multifidus muscle were measured on the computed tomography. IS, interspinalis muscle; LS, longissimus muscle; MF, multifidus muscle; PS, psoas muscle.

Fig. 3

Changes of the multifidus muscles on computed tomography in a 57-yr-old woman (A: preoperative; B: follow-up). Note the significant multifidus muscle atrophy on the side of midline approach (B).

Fig. 4

Box plot showing the postoperative changes of the crosssectional area of multifidus muscle on the side of paramedian interfascial and midline approach. Box plots show the median value (horizontal line in box), and the interquartile range (25-75%) is represented by the box. ^*p<0.05.

Fig. 5

Postoperative changes in paraspinal muscle thickness. (A) On the side of midline approach, (B) On the side of paramedian interfascial approach.

Fig. 6

Box plot showing the postoperative changes of the thickness of multifidus muscle on the side of paramedian interfascial and midline approach. (A) male patients, (B) female patients. Box plots show the median value (horizontal line in box), and the interquartile range (25-75%) is represented by the box. ^*p<0.05.