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MIS-TLIF: Technical Note, Learning Goals behind Case Selection during Early Part of Learning Curve and Clinical Outcomes in First 150 Cases

Journal of Clinical Orthopaedics | Vol 7 | Issue 1 |  Jan-Jun 2022 | page: 85-93 | Umesh Srikantha, Parichay Perikal, Akshay Hari, Yadhu Lokanath, Deepak Somasundaram, Nirmala Subramaniam, Ravi Gopal Varma


Author: Umesh Srikantha [1], Parichay Perikal [1], Akshay Hari [1], Yadhu Lokanath [1], Deepak Somasundaram [1], Nirmala Subramaniam [1], Ravi Gopal Varma [1]

[1] Department of Neurosurgery, Aster CMI Hospital, Bengaluru, Karnataka, India

[2] Department of Neurosurgery, Ramaiah Medical College and Hospitals, Bengaluru, Karnataka, India

 

Address of Correspondence
Dr. Umesh Srikantha,
Department of Neurosurgery, Aster CMI Hospital, Bengaluru, Karnataka, India.
E-mail: umeshsrikantha@gmail.com


Abstract

Introduction: Minimally Invasive Transforaminal Lumbar Interbody Fusion (MIS-TLIF) has been shown to offer several advantages over conventional (open) TLIF and is being increasingly employed by young surgeons early in their careers. It is important to know the appropriate technique and the correct cases to be selected in the early phase to achieve good outcomes during the learning curve. A detailed and illustrative technical note along with a guide for case selection at different phases of experience has been presented in this article.

Methods: The first consecutive single surgeon series of 150 MIS-TLIF cases done over 4 years between 2012 and 2015 were considered for analysis. Demographic and peri-operative data and previously documented follow-up were collected from case records. Telephonic questionnaire and consultation were done to collect latest status, any procedures/surgeries done elsewhere for issues related to index procedure. Results were stratified as Group 1 – first 25 cases; Group 2 – 26–75 cases; Group 3 – 76–150 cases.

Results: The major indication for surgery in group 1 was either Grade 1 spondylolisthesis or lumbar canal stenosis with concomitant axial symptoms. The incidence of relatively complex cases (Grade 2 or 3 listhesis; Revision cases; Multilevel cases) increased with each successive group. As expected, the operative time (calculated for only single-level cases) improved with time. The overall rate of peri-operative complications was higher in group 2 as compared to groups 1 and 3, predominantly due to an increased incidence of intra-operative dural tears in group 2. Symptomatic screw malposition was detected in five screws, all were managed conservatively. The median duration of follow-up for the entire group was 39 months (Range – 1–119 months). Eighty-two (55%) patients had follow-up of more than 1 year while 31 (20.6%) patients had follow-up of more than 7 years. Around 80–85% of patients at each point of follow-up assessment had a successful outcome (McNab 4 and 5). The re-operation rate for index level problems or adjacent segment was 2.6%, only one of which was done at the author’s center.

Conclusions: Minimally invasive TLIF is a safe and effective procedure with favorable long-term results and acceptable complication rates. Though technically challenging in initial phases, a good understanding of the technique and principles of minimally invasive spine surgery along with fulfilling helpful pre-requisites and appropriate case selection as mentioned in this article, will help to smoothen the learning curve and avoid unfavorable outcomes in early stages.

Keywords: Minimally Invasive, transforaminal lumbar interbody fusion, learning curve, long-term outcome, case selection, minimally invasive transforaminal lumbar interbody fusion


References

  1. Foley KT, Lefkowitz MA. Advances in minimally invasive spine surgery. Clin Neurosurg 2002;49:499-517.
  2. Parker SL, Lerner J, McGirt MJ. Effect of minimally invasive technique on return to work and narcotic use following transforaminal lumbar inter-body fusion. Prof Case Manag 2012;17:229-35.
  3. Chan AK, Bisson EF, Bydon M, Foley KT, Glassman SD, Shaffrey CI, et al. Acomparison 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;87:555-62.
  4. Tian NF, Wu YS, Zhang XL, Xu HZ, Chi YL, Mao FM. Minimally invasive versus open transforaminal lumbar interbody fusion: A meta-analysis based on the current evidence. Eur Spine J 2013;22:1741-9.
  5. Schizas C, Tzinieris N, Tsiridis E, Kosmopoulos V. Minimally invasive versus open transforaminal lumbar interbody fusion: Evaluating initial experience. Int Orthop 2009;33:1683-8.
  6. Starkweather AR, Witek-Janusek L, Nockels RP, Peterson J, Mathews HL. The multiple benefits of minimally invasive spinal surgery: Results comparing transforaminal lumbar interbody fusion and posterior lumbar fusion. J Neurosci Nurs 2008;40:32-9.
  7. Fan S, Hu Z, Zhao F, Zhao X, Huang Y, Fang X. Multifidus muscle changes and clinical effects of one-level posterior lumbar interbody fusion: Minimally invasive procedure versus conventional open approach. Eur Spine J 2009;19:316-24.
  8. Lee KH, Yeo W, Soeharno H, Yue WM. Learning curve of a complex surgical technique: Minimally invasive transforaminal lumbar interbody fusion (MIS TLIF). J Spinal Disord Tech 2014;27:E234-40.
  9. Lee JC, Jang HD, Shin BJ. Learning curve and clinical outcomes of minimally invasive transforaminal lumbar interbody fusion: Our experience in 86 consecutive cases. Spine (Phila Pa 1976) 2012;37:1548-57.
  10. Romano-Feinholz S, Soriano-Solis S, Zúñiga-Rivera JC, Gutiérrez-Partida CF, Rodríguez-García M, Soriano-Solís HA, et al. Learning curve in single-level minimally invasive TLIF: Experience of a neurosurgeon. Coluna/Columna 2017;16:279-82.
  11.  Epstein NE. Learning curves for minimally invasive spine surgeries: Are they worth it? Surg Neurol Int 2017;8:61.
  12. Silva PS, Pereira P, Monteiro P, Silva PA, Vaz R. Learning curve and complications of minimally invasive transforaminal lumbar interbody fusion. Neurosurg Focus 2013;35:E7.
  13. Lee JC, Jang HD, Shin BJ. Learning curve and clinical outcomes of minimally invasive transforaminal lumbar interbody fusion: Our experience in 86 consecutive cases. Spine (Phila Pa 1976) 2012;37:1548.
  14. Klingler J-H, Volz F, Krüger MT, Kogias E, Rölz R, Scholz C, et al. Accidental durotomy in minimally invasive transforaminal lumbar interbody fusion: Frequency, risk factors, and management. Sci World J 2015;2015:532628.
  15. Aspalter S, Senker W, Radl C, Aichholzer M, Aufschnaiter-Hießböck K, Leitner C, et al. Accidental dural tears in minimally invasive spinal surgery for degenerative lumbar spine disease. Front Surg 2021;8:708243.
  16. Patel J, Kundnani V, Raut S, Meena M, Ruparel S. Perioperative complications of minimally invasive transforaminal lumbar interbody fusion (MI-TLIF): 10 Years of experience with MI-TLIF. Global Spine J 2021;11:733-9.
  17. Heemskerk JL, Oluwadara Akinduro O, Clifton W, Quiñones-Hinojosa A, Abode-Iyamah KO. Long-term clinical outcome of minimally invasive versus open single-level transforaminal lumbar interbody fusion for degenerative lumbar diseases: A meta-analysis. Spine J 2021;21:2049-65.
  18. Cheng JS, Park P, Le H, Reisner L, Chou D, Mummaneni PV. Short-term and long-term outcomes of minimally invasive and open transforaminal lumbar interbody fusions: Is there a difference? Neurosurg Focus 2013;35:E6.
  19. Wong AP, Smith ZA, Stadler JA, Hu XY, Yan JZ, Li XF, et al. Minimally invasive transforaminal lumbar interbody fusion (MI-TLIF): Surgical technique, long-term 4-year prospective outcomes, and complications compared with an open TLIF cohort. Neurosurg Clin N Am 2014;25:279-304.
  20. Xie L, Wu WJ, Liang Y. Comparison between minimally invasive transforaminal lumbar inter-body fusion and conventional open transforaminal lumbar interbody fusion: An updated meta-analysis. Chin Med J (Engl) 2016;129:1969-86.
  21. Kim CH, Easley K, Lee JS, Hong JY, Virk M, Hsieh PC, et al. Comparison of minimally invasive versus open transforaminal interbody lumbar fusion. Global Spine J 2020;10 Suppl 2:143S-50S.
  22. Parker SL, Mendenhall SK, Shau DN, Zuckerman SL, Godil SS, Cheng JS, et al. Minimally invasive versus open transforaminal lumbar interbody fusion for degenerative spondylolisthesis: Comparative effectiveness and cost-utility analysis. World Neurosurg 2014;82:230-8.

 

How to Cite this article: Srikantha U, Perikal P, Hari A, Lokanath Y, Somasundaram D, Subramaniam N, Varma RG. MIS-TLIF: Technical Note, Learning Goals behind Case Selection during Early Part of Learning Curve and Clinical Outcomes in First 150 Cases. Journal of Clinical Orthopaedics Jan-Jun 2022;7(1):85-93.

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