CLINICAL OUTCOME
FOLLOWING TLIF
• Professor,
Department of Neurosurgery,
Northwestern University,
Feinberg School of Medicine
•Interest:
• MIS, Deformity, Intradural Tumors
Richard G. Fessler, MD, PhD
CLINICAL OUTCOME FOLLOWING TLIF
ONE AND TWO YEAR FOLLOW-UP OF
PROSPECTIVE DATA
Richard G. Fessler, MD, PhD
Professor
Northwestern University Feinberg School of Medicine
Chicago, IL
CONFLICT OF
INTEREST
Medtronic
Consultant
Research funding
Royalty (Not related to MIS)
DePuy
Royalty (Not related to MIS)
Stryker
Consultant
ALIF
Intra-abdominal complications*
Vascular 11. 5 %
Neurological 17.9 %
Incisional 6.4 %
Urological 2.6 %
GI 6.4 %
Respiratory 7.7 %
Peritoneal 3.8 %
Spinal “event” 14.1 %
*Sasso et al, Spine, 2004
Posterior Lumbar
Interbody Fusion (PLIF)
ADVANTAGES
360 degree fusion
dorsal approach
anterior column support
minimizes the risk to intra-abdominal
and retroperitoneal structures.
Posterior Lumbar
Interbody Fusion (PLIF)
DISADVANTAGES
Devitalization of the
paraspinous musculature
Bilateral partial facetectomies -
further destabilizing the spine
Pain
Nerve root / retraction injury
5 % average Cx rate in literature
Iatrogenic Muscle Injury
Kawaguchi Y. et. al. Spine, 1998; 23(21): 2282 -2288
Styf J.R. et. al. Spine, 1998; 23(3): 354-358
Weber B.R. et. al. Spine 1997; 22(15): 1765 - 1772
Kawaguchi Y. et. al. Spine, 1996; 21(22): 2683 - 2688
Kawaguchi Y. et. al. Spine, 1996; 21(8): 941 - 944
Kawaguchi Y. et. al. Spine, 1994; 19(22): 2590 - 2602
Rantanen J. et. al. Spine, 1993; 18(5): 568 - 574
Sihvonen T. et. al. Spine, 1993; 18(5): 575 - 581
Mayer T.G. et. al. Spine, 1989; 12(1): 33 - 36
Macnab I. et. al. Spine, 1977; 2(4): 294 - 298
Naylor A. JBJS, 1974; 56-B(1): 17 - 29
Jackson R.K. JBJS, 1971; 53-B(4): 609 - 616
Rationale: Microendoscopic
TLIF
with Instrumentation
Adapt lumbar MED / MEDS
Avoid intra-abdominal surgery
Smaller skin incision
Decreased tissue trauma
Decreased muscle injury
Improved visualization
Improved post-operative course
? Improved long-term results
Surgical Technique
MAST-TLIF
Incision is determined fluoroscopically
Serial dilation of METRx
Facetectomy
Discectomy and Distraction
End Plate Preparation
Graft Insertion
Percutaneous Instrumentation
“Bulls-eye”
technique
Tapping
Screw Placement
Rod Placement
Percutaneous PLIF and
Instrumentation
The Procedure
HAS IT IMPROVED OUTCOME?
PARASPINAL MUSCLE CHANGES ON MRI
FOLLOWING POSTERIOR LUMBAR SURGERY
Lacey E. Bresnahan, PhD, R. David Fessler, BA, Richard
G. Fessler, MD., PhD ISSLS, May 1-4, 2009
Muscle cross-sectional area (CSA) was measured and compared for
the longissimus, illiocostalis and multifidus in the pre- and post-
operative scan.
T 2 MRI, axial, 2mm cuts, no gap
Medical imaging processing and Visualization software from NIH
OPEN MED
MEAN DECREASE 18 % MEAN INCREASE 2%
Clinical Significance
Muscle Injury
Open Altered structure and
function of spinal muscle
fibers following posterior
lumbar surgery
Muscle atrophy
Reduction in cross-sectional
MIS area
Increase fatty tissue
Reduction in muscle strength
Can lead to further post-op
low back pain (LBP)
Long-Term Strength Assessment of
Postoperative Spinal Surgery Patients
“…every strength parameter tested except male
isokinetic flexion strength showed at least a 30%
decrease when compared with normal values.”
Kahanovitz, Spine 1989 Apr; 14(4)
Results
Prospective
MAST TLIF vs OPEN PLIF
Demographics
100
Open
50 90
Minimally-
Invasive 80
40 70
60
30
50
40
20
30
20
10
10
0 0
Age Male Female
Level of Surgery
MAST
100
90
80
70
60
50
40
30
20
10
0
L23 L34 L45 L5S1
Open
Operative Data
7
p=0.19 NS Open
Minimally
6
3
4.6
2
1
3.50
0
Operative Time (in hrs)
Operative Data
p<0.002 p < 0.001
Open
50
1200
Minimally- 45
Invasive 40
1000 36
35
800 30
25
600
20
400 15
10
200
5
0
0 0
Blood Loss %Transfusion
Hospital Data
Open
P<0.05 5 P<0.10 NS
200
Minimally- 4.5
180 Invasive
160 4
140 3.5
120 3
100 2.5
80 2
60 1.5
40 1
20 0.5
0 0
Pain Rx (in MSO4 Eqvs.) Length of Stay (in days)
“Worst” Pain (% of Preop Value-VAS)
1.2
0.8
0.6
0.4
0.2
0
Preop 1wk 2-4wks 6wks 3-6mo
1 0.63 0.51 0.47 0.34
Narcotic Intake
On Long-term Narcotics Preop Without Narcotics Preop
140
16
120 14
100
12
10
80
8
60
6
40 4
20
2
0
0
Preop 1wk 2-4wks 6wks
Preop 1wk 2-4wks 6wks 3-6mo
(% of Preop Value) (MS04 Eqvs./day)
Complications
Minimally-Invasive Open PLIF
No CSF leaks 1 CSF leak
No infections No infections
No medial breaches of the No medial breaches of the
pedicle pedicle
No neurological injuries related No neurological injuries
to the procedure related to the procedure
No positioning-related 1 positioning-related
complications complication
No hardware failures No hardware failures
1 YEAR RESULTS
MAST TLIF PRE vs POST-OP
INDICATIONS
Degenerative disc disease-1 or 2 level
Grade I or II spondylolisthesis
Mechanical back pain
Radiculopathy
Instability (> 6 mm movement on F/E)
DESIGN
Prospective 62 patients
University of Chicago
All patients completed pre-operative and post-
operative (1.5, 6, 12, 24) data forms
VAS
Oswestry
SF-36
All data collected by research staff not otherwise
involved with the study
Independent statistician (Paired t-test)
Follow-up: Data for 1 year
DESIGN AND
DEMOGRAPHICS
40
60
35
30 50
25 40
20
30
15
20
10
10
5
0
0
MEN WOMEN AGE
Fusion rate: 100%
A/P, lat, F/E xrays
Bone growth
No motion
RESULTS
10 10 10
9 9 9
8 8 8
7 7 7
6 6 6
5 5 5
* p<.0001 *p<.002
4 4
4
NS
3 3 3
2 2 2
1 1 1
0 0 0
Pre-op Post--op Pre-op Post-op Pre-op Post-op
VAS-BACK VAS-Left leg VAS-Right leg
(paired t-statistic)
Visual Analog Score
10
9
8
7
6
5
4
3
2
1
0
Pre-op 6 wk 6 mo 1 yr 2 yr
BIAS analysis
RESULTS
60
50
40 *p < .0001
30
20
10
0
Pre-Op Post-Op
Oswestry
(Paired t-statistic)
RESULTS
100 100
90 90
80 NS 80
70 70 *p<.0001
60 60
50 50
40 40
30 30
20 20
10 10
0 0
Pre-op Post-op Pre-op Post-op
SF 36-GH SF 36-PF
(Paired t-statistic)
SF-36
Physical Functioning
60
50
40
30
20
10
0
Pre-op 6 wk 6 mo 1 yr 2 yr
OTHER VARIABLES
Sex
NS
VAS, Oswestry, SF-36
Age
NS
VAS, Oswestry, SF-36
LONG TERM RESULTS
BACK PAIN
100
90
80
70
60
50 OPEN *
40 MAST
30
20
10
0
No Pain Better No Better
VAS * Dickman, Fessler, MacMillan, Haid,
J NSG 1992
LONG TERM RESULTS
BACK PAIN
80
60
70 50
60 40
%
50 % 30
Change
From Change
40 From 20
Pre-op
Pre-op
30 10
20 0
10 -10
0 -20
BETTER NO BETTER BETTER NO BETTER
Oswestry SF-36
COMPLICATIONS
2 CSF leaks
1 local wound infection
1 DVT (acute on chronic)*
2 graft retropulsions
One year follow up
Two prospectively followed cohorts
Non-randomized
Two institutions
PLIF Saint John, NB, Canada
mTLIF Chicago, IL, USA
Patients requiring lumbar interbody fusions
All patients followed using VAS pain scores and
Oswestry Disability Index
Radiographic determination of fusion
Results
PLIF TLIF
31 patients 29 patients
14 female (n.s.) 19 female
Mean age = 42 ± 11 Mean age = 54 ± 14*
Previous surgery (4) Previous surgery (5)
Disc same level – 2 Disc same level – 2
Adjacent anterior fusion – 1 Laminectomy same level - 3
Distant posterior fusion - 1
* p < 0.05
Results
Complications
Open MAST
CSF leak – 2 CSF leak – 3
Ileus – 3 Migration of interbody
graft – 2
Footdrop – 2 Both cases Boomerang
Infection – 1 DVT – 1
Results
p = 0.068
100
90
96.6%
80 83.9%
70
60
50 Pseudarthroses
40 Fusions
30
20
10
0
Open MAST
Results
Mean Estimated Blood Loss
1200
1000
800
c.c.'s
Open
600
MAST
400
200
p < 0.0001
Results
Mean Hospital Stay
180
160
140
120
Hours
100 Open
80 MAST
60
40
20
0
p < 0.027
Clinical Outcomes
p < 0.0001 p<0.001
100 p = 0.0001 p<0.001
90 p < 0.0001 p<0.001
80
70 p=0.001
60 p=0.009
50 p=0.002
p = 0.9
40
p = 0.9 p = 0.4
30
20
10
VAS Back VAS Leg Oswestry
PreOp TLIF 1 yr TLIF PreOp PLIF 1 yr PLIF
THANK YOU
OBESITY:
OUTCOME FOLLOWING MINIMALLY
INVASIVE FUSION SURGERY
Rosen, D., Ferguson, S., Ogden, A.T., Huo, D., Fessler, R.G.: Obesity and
Self Reported Outcome after Minimally Invasive Lumbar Spinal Fusion
Surgery. Neurosurgery 63:956-960, 2008.
DEMOGRAPHICS
Age 56.4 (19-85)
Height 169 cm
Weight 82.2 kg
BMI 28.7 kg/m2
TOTAL 110 patients
WEIGHT
DISTRIBUTION
> 30 < 25 < 25 NORMAL
25-30 OVERWEIGHT
> 30 OBESE
25-30
RESULTS
VAS = NS DIFFERENCE between groups
ODI = NS DIFFERENCE between groups
SF-36 = NS DIFFERENCE between groups
Linear Regression Analysis = No correlation
between BMI and any outcome measure
OPERATIVE TIME
10
9
8
7
6
HOURS 5
4
3
2
1
0
< 25 25-30 > 30
BMI
No significant difference
ESTIMATED BLOOD LOSS
18
16
14
12
10 < 100 cc
8 100-250 cc
6 > 250 cc
4
2
0
< 25 25-30 > 30
No significant difference
MAJOR
COMPLICATIONS
1 Positioning injury (?)
= 0.8 %
(This occurred in the “normal” group)
MINOR
COMPLICATIONS
OVERALL 22 %
> 30 < 25
25-30
BMI < 25 BMI 25-30 BMI > 30
Post-op 3 2
radiculopathy
Lower extremity 1
weakness
Urinary retention 2
Durotomy 1 1
Superficial wound 1
infection
Delirium 3 2
Nausea 1
CHF 1
exacerbation
Hypertension 1 1
Hypotension 1 1
Ileus 1
PERCENT OF TOTAL
23 26 14
COMPARISON
OPEN MISS
Increased complication rate YES NO
Increased wound infection YES NO
rate
Increased operative time YES NO
Increased blood loss YES NO
Length of stay NO NO
Outcome after fusion NO NO
Patient satisfaction YES NO
John E. O‟Toole, MD, Griffin Meyers, BA, and
Richard G. Fessler, MD, PhD Reduction in Spinal
Surgical Site Infection Rates After Minimally Invasive
Surgery
Journal of Neursurgery: Spine, 11: 471-476, 2009.
Reported infection rate in open surgery
0.9 to 15 %.
1338 MIS procedures
12 mo follow up
0.2 % overall infection rate
0.7 % for MEDS and TLIF
0.1 % for all others
CONCLUSIONS
MIS is equivalent to or superior to open
surgery for:
Neurologic result
Pain relief
Fusion rate
For virtually every operation developed
and tested to date.
CONCLUSIONS
MIS achieves these results with
Less EBL
Less stress response
Less pain meds
Less ICU stay
Less hospital stay
Faster D/C
Faster recovery
Faster return to work
Lower complication rate
Lower infection rate
And can more safely be used in high risk patients
ACKNOWLEDGEMENTS
FELLOWS
Larry Khoo University of California, Los Angeles (2000-2001)
Mick Perez Detroit (2001-2002)
Rob Isaacs Duke University (2001-2002)
Faheem Sandhu Dallas, TX (2002-2003)
Paul Santiago Washington University, St. Louis, MO (2002-2003)
Bong Soo Kim Neurosurgery resident-Temple (2003-2004)
Trent Tredway University of Washington (2003-2004)
John Song Northwestern University (2004-2005)
Sean Christie QE II Health Science Center (2004-2005)
John O’Toole Rush University Medical School (2005-2006)
Kurt Eichholz Vanderbilt University (2005-2006)
Vishal Gala Georgia Spine Institute (2006-2007)
Jean-Marc Voyadzis George Washington University (2006-2007)
Justin Smith Univeristy of Virginia (2007-2008)
Fred Ogden Columbia University (2007-2008)
Jim Thoman Indianapolis Neurosurgical (2008-2009)
Sathish Subbaiah Mount Sinai (2008-2009)
STUDENTS
Melody Hrubes University of Illinois-Chicago
Lacey Bresnahan, ME University of Illinois-Chicago
THANK YOU
THERE IS NO LONGER ANY QUESTION
MINIMALLY INVASIVE TLIF PROVIDES
SIGNIFICANT ADVANTAGES
Conclusions
The MAST-TLIF technique provides an
option for percutaneous interbody fusion.
This technique is safe, diminishes
intraoperative blood loss, postoperative
pain, total narcotic use, and the risk of
transfusion.
One year results demonstrate statistically
significant decreases in VAS, increases in
Oswestry, and improvement in SF-36
physical functioning.
A minimally-invasive TLIF can be
performed without a significant increase
in surgically-related complications.
OPEN vs
Minimal Access Spine Surgery
MISS
100
80
60
40
20
OPEN
0
1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001
FELLOWS
Curtis Dickman Barrow Neurological Institute (1990-1991)
Bruce McCormick University of California, San Francisco (1991-1992)
Daniel May University of Zurich (1992-1993)
Emily Friedman Oklahoma Neurosurgical (1992)
John Marshak Hudson Orthopedics, Georgia (1992-1993)
Michael Sturgill Private Practice-Racine, Wisconsin (1993-1994)
Srinath Samadrala University Southern California (1995-1996)
Ehud Mendel MD Anderson Cancer Center (1996-1997)
Ben Guiot University of South Florida (1997-1998)
Daniel Kim Stanford University (1997-1998)
Sim Brara Kaiser Permanente Los Angeles, California (1998-1999)
Paul Boone Vanderbilt University (1998-1999)
Anthony Frempong-Boadu New York University (1999-2000)
Larry Khoo University of California, Los Angeles (2000-2001)
Dan Laich Denver Neurosurgical (2000-2001)
Mick Perez Rush Medical School (2001-2002)
Rob Isaacs Cleveland Clinic, Fort Lauderdale (2001-2002)
Faheem Sandhu Private Practice-Dallas, TX (2002-2003)
Paul Santiago Washington University, St. Louis, MO (2002-2003)
Bong Soo Kim Neurosurgery resident-Temple (2003-2004)
Trent Tredway University of Washington (2003-2004)
John Song Current fellow (2004-2005)
Sean Christie Current fellow (2004-2005)
2-level TLIFs
Two level TLIF/Sextant
SPONDYLOLISTHESIS
25
20
15
10
0
Nl Align Spondy
Minimally-Invasive Interbody
Fusion – Cadaveric Study
3 cadaveric torsos
6 motion segments fused – interbody
grafting followed by percutaneous pedicle
screws
Intervertebral height, foraminal height
and volume increased
No significant pedicle violations
Could be safely and efficaciously
implemented for clinical use
Neurosurgery November supplement,
2002
Study # 1
Methods
Prospective
125 consecutive patients
May ‟01 to September „03
First study: 1 yr f/u of 75 pts
with matched open controls
Grade 1 – 2 spondylolisthesis
or pure mechanical back pain
Symptoms radiculopathy and
back pain w/ collapsed disc
Failed extensive conservative
management
Methods
Operations all performed with
one senior surgeon (R.F.)
Control group: 20 open, single-
level PLIF at the same institutions
over the same time period
Rush Medical Center, Chicago, IL
Columbus Hospital, Chicago, IL
Ravenswood Hospital, Chicago, IL
Sextant™ Instrumentation with TLIF
1 month Post OP
3 MONTHS
BOTTOM LINE
IF YOU DON‟T DO MINIMAL
ACCESS SPINE SURGERY…
ITS TIME TO LEARN!
IF YOU DON‟T WANT TO
LEARN…
BE A “BRAIN” SURGEON!!!
Case – Spondylolisthesis
Case - Spondylolisthesis
Case – Mechanical LBP s/p
failed discectomy
Graft Placement / PLF
Conclusions
The METLIF technique provides an
option for percutaneous interbody fusion.
This technique is safe, diminishes
intraoperative blood loss, postoperative
pain, total narcotic use, and the risk of
transfusion.
Initial data suggests early postoperative
pain reduction.
A minimally-invasive TLIF can be
performed without a significant increase
in surgically-related complications.
CONCLUSIONS
The results appear to be long lasting
FEA/biomechanical data suggests
biomechanically that the results will be
superior to open surgery in the long term