EBMComparative outcomes of Minimally invasive surgery for posterior lumbar fusion

Fellow 陳磊晏

骨科微創手術 Knee scope

Shoulder scope

MIS THR

MIS TKR

Trauma

MIS Spine surgery

Size Dose Matter !?

Minimal invasive physically and psychologically

Potential advantage of MIS spine surgery

Smaller incisions and scars

Minimal soft-tissue destruction and scarring

Less surgical blood loss

Shorter hospital stay

Less postoperative pain

Less need for postoperative pain medicine

Faster return to work and daily activities

Disadvantage

Inadequate decompression

Longer surigical time

More radiation exposure

Learning curve

Sanjay.S J Neurosurg Spine 2008

Nature Reviews Neurology 8, 363-365 (July 2012)

Surgical procedure under fluoroscopy

CORR 2014

Compared MIS and open transforaminal or posterior lumbar interbody fusion (TLIF/PLIF)

(1) surgical end points (including EBL, surgical

time, and fluoroscopy time)

(2) clinical outcomes (Oswestry Disability Index [ODI] and

VAS pain scores)

(3) adverse events

Material and methods

MEDLINE,Embase, Web of Science, and Cochrane Library from

database computer data to May 2012

(MeSH) search terms included derivatives of

‘‘minimally invasive’’/’’minimal access’’

‘‘lumbar spine’’/’’lumbar vertebrae’’

‘‘fusion’’/’’surgical procedures’’

Pubmed search “ minimal invasive spine surgery”

Inclusion criteria

(1)10 or more patients per study arm and reporting at least one of the following

(2)a. surgical end points b. clinical outcome (ODI or VAS pain scores) c. adverse events

Study identification and exclsuion

J Spinal Disord Tech ,2011

Retrospective MIS TLIF vs Open TLIF

N=15 each arm

Grade I spondylolisthesis

Hospital day : MIS vs open 3 vs 5.5 day, P=0.001

Return to work: MIS vs open 8.5 vs 17.1 wk, P=0.02.

No difference in 2-year VAS of back pain, leg pain, Oswestry disability index, and EuroQol-5D scores.

J Neurosurg Spine, 2008 Retrospective cohort

Each arm n=21

Grad I spondylolisthesis , single level

Neurosurgery ,2010 Prospective

Spondylolisthesis with radiculopathy

MIS PLIF n=23 , Open PLIF n=24

MIS shorter hospital stay and ambulate earlier (median 7 vs 4 days ; 4 vs 2 days)

Reduce leg and back pain and restore function(SF-36 ) to a similar in 12 months

Kong Hwee Lee. Eur Spine J (2012)

Prospective observational cohort study

Single level MIS TLIF vs Open TLIF

N=72 each group

Longer fluoroscopic time (open: 17.6 s, MIS: 49.0 s, p<0.05),

Less blood loss (open: 447.4 ml,MIS: 50.6 ml, p<0.05)

No post-operative drainage (open: 528.9 ml, MIS: 0 ml, p<0.05)

MIS needed less morphine (open: 33.5 mg, MIS: 3.4 mg, p<0.05)

Ambulate earlier (open: 3.4 days, MIS: 1.2 days, P<0.05)

MBD earlier (open: 6.8 days, MIS: 3.2 days, p<0.05).

6 months: clinical outcome improving significantly and similarly in VAS, ODI, SF-36

Radiological analysis: similar grade 1 fusion rates (open: 52.2 %, MIS: 59.4 %, p>0.05)

Asymptomatic cage migration (open: 8.7 %, MIS: 5.8 %, p>0.05)

2 years: Grade 1 fusion (open: 98.5 %, MIS: 97.0 %, P>0.05)

with minimal cage migration (open: 1.4 %, MIS: 0 %, p>0.05).

Prosepctive cohort

N=41 , MIS PLIF vs open PLIF

MIS approach shorter hospital stay, time to ambulate , lower opioid use and total complication rates.

R.J. Mobbs. J Clinical Neuroscience 2012

Chang. W. Spine 2009 Prospective study

Gr I II listhesis + LBP + radiculopathy

N=29 each , MIS TLIF vs Open TLIF

Back pain and leg pain VAS P>0.05

ODI score P>0.05

Fusion grading P>0.05

Comparison of Paraspinal Muscle Damage and Slip Reduction

Takahiro .T. Spine 2009

L4-5 , MIS PLIF vs Open PLIF

N=10 each

Multifidus atrophy by MRI pre op and post 1 yr at L3-4, L5-S1 level

The serum creatinine phosphokinase (CPK) level at post op day 1 and 7

11.28+/-6.70 5.41 +/-1.85

Atrophy ratio : L3 L3-4 differ

T2 change:L5-S1 S1 differ

Jian. W. Eur Spine J 2010

Prospective

Single level , lytic or deg. spondylolisthesis

MIS TLIF (n=42) vs Open TLIF (n=43)

MIS group significantly lesser blood loss, need for BT, lesser postop back pain, and shorter hospital stay. The X ray time longer

Results

Surgical end points

Surgical time tended to be equivalent between the MIS and open cohorts (n = 23 studies 104 to 390 minutes and 132 to 365 minutes in the MIS and open

EBL ranging from 51 to 496 mL in MIS

125 to 1147 mL in open

Fluoroscopy time was consistently higher in the MIS groups (n = 7 studies, with 49 to 297 sec compared to 24 to 123 sec in open

Patient-reported Outcomes

Postoperative pain was found to be equivalent in the 15 studies

ODI values were reported in 13 studies between 12 and 36 months postoperatively were generally equivalent between the MIS and open cohorts (range: 10.7–33 for MIS versus 6.4–33.7 for open).

Patient-reported Outcomes

Hospital stay was shorter for the MIS cohorts (n = 21 ) with MIS patients experiencing a 1.8- to 11-day hospitalization compared to 3 to 15 days for the open patient.

Lack of randomization may have led to selection bias regarding case complexity and a trend toward lower EBL and shorter hospital LOS in MIS patients.

Adverse Events

Conclusion

In this systematic review, including more than 1600 patients from 26 studies, showed

lower EBL

shorter hospital LOS

equivalent patient-reported outcomes (VAS pain scores and ODI values, intermediate-term)

a trend toward lower surgical and medical complications in patients

Limitation

Sample size n=10~76 each arm

Decision making , non-randomized , selection bias (severity, patient expectation, social economic status…..)

Patient selection impacts on the rates of complications

Summary Equivalent clinical patient-reported outcomes

Possible improved surgical outcomes and lower complication rates in MIS

Need well-designed prospective observational studies or randomized trials

Thank you for your attention

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