Open versus minimally invasive TLIF: literature review and meta-analysis

Abstract

Study design: This study is a comparative, literature review.

Objective: The aim of this study is to provide a comparative analysis of open vs. minimally invasive TLIF using a literature review and a meta-analysis. Lumbar interbody fusion is a well-established surgical procedure for treating several spinal disorders. Transforaminal lumbar interbody fusion (TLIF) was initially introduced in the early 1980s. To reduce approach-related morbidity associated with traditional open TLIF (OTLIF), minimally invasive TLIF (MITLIF) was developed. We aimed to provide a comparative analysis of open vs. minimally invasive TLIF using a literature review.

Methods: We searched the online database PubMed (2005-2017), which yielded an initial 194 studies. We first searched the articles' abstracts. Based on our inclusion criteria, we excluded 162 studies and included 32 studies: 18 prospective, 13 retrospective, and a single randomized controlled trial. Operative time, blood loss, length of hospital stay, radiation exposure time, complication rate, and pain scores (visual analogue scale, Oswestry Disability Index) for both techniques were recorded and presented as means. We then performed a meta-analysis.

Results: The meta-analysis for all outcomes showed reduced blood loss (P < 0.00001) and length of hospital stay (P < 0.00001) for MITLIF compared with OTLIF, but with increased radiation exposure time with MITLIF (P < 0.00001). There was no significant difference in operative time between techniques (P = 0.78). The complication rate was lower with MITLIF (11.3%) vs. OTLIF (14.2%), but not statistically significantly different (P = 0.05). No significant differences were found in visual analogue scores (back and leg) and Oswestry Disability Index scores between techniques, at the final follow-up.

Conclusion: MITLIF and OTLIF provide equivalent long-term clinical outcomes. MITLIF had less tissue injury, blood loss, and length of hospital stay. MITLIF is also a safe alternative in obese patients and, in experienced hands, can also be used safely in select cases of spondylodiscitis even with epidural abscess. MITLIF is also a cost-saving procedure associated with reduced hospital and social costs. Long-term studies are required to better evaluate controversial items such as operative time.

Keywords: Interbody fusion; Lumbar; Minimally invasive; Open; Transforaminal.

Fig. 1

Flow diagram of the search strategy and study selection process

Fig. 2

Forest plot of the study comparisons: comparison between MITLIF and OTLIF outcomes for operative time

Fig. 3

Forest plot of the study comparisons: comparison between MITLIF and OTLIF outcomes for blood loss

Fig. 4

Forest plot of the study comparisons: comparison between MITLIF and OTLIF outcomes for length of hospital stay

Fig. 5

Forest plot of the study comparisons: comparison between MITLIF and OTLIF outcomes for: complications

Fig. 6

Forest plot of the study comparisons: comparison between MITLIF and OTLIF outcomes for radiation exposure time

Fig. 7

Forest plot of the study comparisons: comparison between MITLIF and OTLIF outcomes for preoperative visual analog scale scores for back pain

Fig. 8

Forest plot of the study comparisons: comparison between MITLIF and OTLIF outcomes for preoperative visual analog scale scores for leg pain

Fig. 9

Forest plot of the study comparisons: comparison between MITLIF and OTLIF outcomes for visual analog scale scores for back pain at final follow-up

Fig. 10

Forest plot of study comparisons: comparison between MITLIF and OTLIF outcomes for visual analog scale scores for leg pain at last follow-up

Fig. 11

Forest plot of study comparisons: comparison between preoperative and last follow-up visual analog scale scores for back pain within the MITLIF group

Fig. 12

Forest plot of study comparisons: comparison between preoperative and last follow-up visual analog scale scores for leg pain within the MITLIF group

Fig. 13

Forest plot of the study comparisons: comparison between preoperative and last follow-up visual analog scale scores for back pain within the OTLIF group

Fig. 14

Forest plot of the study comparisons: comparison between preoperative and last follow-up visual analog scale scores for leg pain within the OTLIF group

Fig. 15

Forest plot of the study comparisons: comparison between MITLIF and OTLIF outcomes for preoperative Oswestry disability index (%)

Fig. 16

Forest plot of the study comparisons: comparison between MITLIF and OTLIF outcomes for Oswestry disability index (%) at last follow-up

Fig. 17

Forest plot of the study comparisons: comparison between preoperative and last follow-up Oswestry disability index (%) within the MITLIF group

Fig. 18

Forest plot of the study comparisons: comparison between preoperative and last follow-up Oswestry disability index (%) within the OTLIF group