Short-term and mid-term evaluation of three types of minimally invasive lumbar fusion surgery for treatment of L4/L5 degenerative spondylolisthesis

Abstract

This was a single-centre retrospective study. Minimally invasive techniques for transforaminal lumbar interbody fusion (MIS-TLIF), oblique lumbar interbody fusion (OLIF), and percutaneous endoscopic transforaminal lumbar interbody fusion (Endo-TLIF) have been extensively used for lumbar degenerative diseases. The present study analyses the short-term and mid-term clinical effects of the above three minimally invasive techniques on L4/L5 degenerative spondylolisthesis. In this retrospective study, 98 patients with L4/L5 degenerative spondylolisthesis received MIS-TLIF, 107 received OLIF, and 114 received Endo-TLIF. All patients were followed up for at least one year. We compared patient data, including age, sex, body mass index (BMI), Oswestry disability index (ODI), visual analogue scale of low back pain (VAS-B), visual analogue scale of leg pain (VAS-L), surgical time, blood loss, drainage volume, hospital stay, complications, and neurological status. Moreover, we performed imaging evaluations, including lumbar lordosis angle (LLA), disc height (DH) and intervertebral fusion status. No significant differences were noted in age, sex, BMI, preoperative ODI, preoperative VAS-B, preoperative VAS-L, preoperative LLA, or preoperative DH. Patients who underwent OLIF had significantly decreased blood loss, a lower drainage volume, and a shorter hospital stay than those who underwent MIS-TLIF or Endo-TLIF (P < 0.05). The VAS-B in the OLIF group significantly decreased compared with in the MIS-TLIF and Endo-TLIF groups at 6 and 12 months postoperatively (P < 0.05). The VAS-L in the Endo-TLIF group significantly decreased compared with that in the MIS-TLIF and OLIF groups at 6 months postoperatively (P < 0.05). The ODI in the OLIF group was significantly better than that in the MIS-TLIF and Endo-TLIF groups at 6 months postoperatively (P < 0.05). No statistically significant differences in the incidence of complications and healthcare cost were found among the three groups. Follow-up LLA and DH changes were significantly lower in the OLIF group than in the other groups (P < 0.05). The intervertebral fusion rate was significantly higher in the OLIF group than in the other groups at 6 and 12 months postoperatively (P < 0.05). In conclusion, while MIS-TLIF, OLIF, and Endo-TLIF techniques can effectively treat patients with L4/5 degenerative spondylolisthesis, OLIF has more benefits, including less operative blood loss, a shorter hospital stay, a smaller drainage volume, efficacy for back pain, effective maintenance of lumbar lordosis angle and disc height, and a higher fusion rate. OLIF should be the preferred surgical treatment for patients with L4/5 degenerative spondylolisthesis.

Keywords: Endo-TLIF; Lumbar degenerative spondylolisthesis; MIS-TLIF; OLIF.

Figure 1

Method for measuring the LLA and DH.

Figure 2

A typical MIS-TLIF case. (A–C) Posterior unilateral percutaneous pedicle screw fixation and vertebral reduction via fluoroscopy. (D) Insertion of the expansion tube and installation of the quadrant working channel. (E) Decompression and fusion under the working channel. (F–G) Position of the cage and percutaneous pedicle screws in anteroposterior and lateral X-ray views. (H) Incision and drainage tube.

Figure 3

A typical OLIF case. (A, B) Marks of the L4/L5 segment and incision. (C) Exposure of the operative field and installation of the working passage. (D) Discectomy and endplate preparation. (E, F) Assessing the interbody cage. (G–I) Implantation of the cage. (J–L) Position of the cage and percutaneous pedicle screws in anteroposterior and lateral X-ray views.

Figure 4

A typical Endo-TLIF case. (A) Marks of the L4/L5 vertebral pedicle and incision. (B) Posterior unilateral percutaneous pedicle screw fixation. (C) Discectomy, endplate preparation and nerve root decompression under endoscopy. (D–F) Implantation of the cage. (H) Position of cage and pedicle screws in anteroposterior and lateral X-ray views.

Figure 5

A 74-year-old woman had cage subsidence after OLIF. Preoperative lumbar spine anteroposterior and lateral radiographs (A, B), lumbar flexion–extension stress lateral radiographs (C, D). X-ray radiographs (E, F) and CT (G) at 1 month postoperatively show that the cage was in a good position. X-ray radiographs (H, I) and CT (J, K) at 3 months postoperatively showed cage subsidence.

Figure 6

A 65-year-old man had intervertebral infection after Endo-TLIF. A-P and lateral plain film of the lumbar vertebra showed narrowing of the intervertebral space (A, B); sagittal and coronal CT showed that the vertebrae were rough, blurry, broken and sclerotic (C, D); sagittal T1- and T2-weighted MRI showed intervertebral infection (E, F) at 6 months after surgery.

Figure 7

(A, B) CT at 12 months postoperatively showing intervertebral fusion after MIS-TLIF. (C, D) CT at 12 months postoperatively showing intervertebral fusion after OLIF. (E, F) CT at 12 months postoperatively showing intervertebral fusion after Endo-TLIF.