Can minimally invasive transforaminal lumbar interbody fusion achieve a better clinical and radiological outcome than traditional open technique in isthmic spondylolisthesis?

Abstract

Background: Spondylolisthesis is a prevalent condition in the lumbar spine that can cause low back pain, leg pain, neurogenic claudication, and impact health-related quality of life in symptomatic individuals.

Aim: to assess the results of minimally invasive TLIF (MIS-TLIF) versus open-TLIF and the impact of correcting spino-pelvic parameters on the Health-Related Quality of Life (HRQoL) in patients with low-grade isthmic spondylolisthesis. The primary objective was to compare the effectiveness of both methods in correcting spinopelvic parameters. The secondary objectives involved comparing clinical improvement, operating time, blood loss, complications, and postoperative hospital stays between the two procedures.

Patients and methods: Seventy-two patients with low-grade isthmic spondylolisthesis were enrolled in this retrospective cohort-control study, with a minimum follow-up period of 18 months. Disability was assessed using the Oswestry Disability Index (ODI), while back and leg discomfort were rated using the Visual Analogue Scale (VAS) for each patient. The measurements comprised the sacral slope (SS), pelvic tilt (PT), pelvic incidence (PI), and Meyerding slip grades. We measured lumbar lordosis (LL), and segmental lordosis.

Results: The seventy-two patients were 60 female and 12 males. There was no statistically significant difference in the duration of operation between the two groups. In the MIS group, there was a notable reduction in blood loss, higher radiation exposure, and a shorter hospital stay (P < 0.001). The back VAS showed more favorable outcomes in the MIS-TLIF, while the leg VAS showed better results in the Open-TLIF in the early outcome. Both procedures significantly reduced leg and back pain VAS scores and ODI, with no notable difference between the two groups at the final follow-up. Post-surgery, the pelvic incidence (PI) and lumbar lordosis (LL) matched properly in all patients, showing a rise in LL and sacral slope along with a decrease in pelvic tilt.

Conclusion: Both open-TLIF and MIS-TLIF are effective methods for correcting spino-pelvic parameters and improving HRQoL in patients with low-grade isthmic spondylolisthesis. The rapid improvement in back pain experienced by these patients favored the use of MIS-TLIF. However, the cost-effectiveness of this approach must be carefully evaluated.

Keywords: Isthmic spondylolitheisis; MIS-TLIF; Minimal invasive; Spino-pelvic parameter.

Fig. 1

The open TLIF case, A and B anterior–posterior and lateral radiology of the slipped level, C and D MRI sagittal and axial cut, E intraoperative photo during insertion of the cage, F and G the final Anterior–posterior and lateral view of the operated level, and finally H: intra-operative photo of the operative field

Fig. 2

The MIS-TLIF case, A and B anterior–posterior and lateral radiology of the slipped level, C CT scan of the fractured pars, D and E showing MRI sagittal and axial cut of the slipped level

Fig. 3

operative photos of the MIS-TLIF case: A showing the guide wires placed in the pedicles of the L4-5 with the tube system fixed over the facet joint before the osteotomy, B lateral radiology view during insertion of the cage, C intraoperative photo with the tube system in place with the percutaneous guide wires in place, D intraoperative microscopic picture of the dura (blue arrow) and the window for the insertion of the cage marked by the white arrow, E and F the final anterior–posterior and lateral view of the slipped level after insertion of the rods and G intraoperative photo of the operative microscope used

Fig. 4

Modified Oswestry disability index

Fig. 5

VAS for back pain

Fig. 6

VAS for leg pain

Fig. 7

Long standing radiographyof the whole spine pre and postoperative of the open-TLIF case in (A and B) and the MIS-TLIF case (C and D) with measurement of the spinopelvic parameters