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Research ArticleBiologics

Biologics and Minimally Invasive Approach to TLIFs: What Is the Risk of Radiculitis?

Erik Wang, Carolyn Stickley, Jordan Manning, Christopher G. Varlotta, Dainn Woo, Ethan Ayres, Edem Abotsi, Dennis Vasquez-Montes, Charla R. Fischer, Jonathan Stieber, Martin Quirno, Themistocles S. Protopsaltis, Peter G. Passias and Aaron J. Buckland
International Journal of Spine Surgery October 2020, 7114; DOI: https://doi.org/10.14444/7114
Erik Wang
Department of Orthopaedics, NYU Langone Orthopedic Hospital, New York, New York
BA
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Carolyn Stickley
Department of Orthopaedics, NYU Langone Orthopedic Hospital, New York, New York
BS
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Jordan Manning
Department of Orthopaedics, NYU Langone Orthopedic Hospital, New York, New York
BA
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Christopher G. Varlotta
Department of Orthopaedics, NYU Langone Orthopedic Hospital, New York, New York
BS
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Dainn Woo
Department of Orthopaedics, NYU Langone Orthopedic Hospital, New York, New York
BS
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Ethan Ayres
Department of Orthopaedics, NYU Langone Orthopedic Hospital, New York, New York
MPH
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Edem Abotsi
Department of Orthopaedics, NYU Langone Orthopedic Hospital, New York, New York
BA
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Dennis Vasquez-Montes
Department of Orthopaedics, NYU Langone Orthopedic Hospital, New York, New York
MS
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Charla R. Fischer
Department of Orthopaedics, NYU Langone Orthopedic Hospital, New York, New York
MD
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Jonathan Stieber
Department of Orthopaedics, NYU Langone Orthopedic Hospital, New York, New York
MD
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Martin Quirno
Department of Orthopaedics, NYU Langone Orthopedic Hospital, New York, New York
MD
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Themistocles S. Protopsaltis
Department of Orthopaedics, NYU Langone Orthopedic Hospital, New York, New York
MD
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Peter G. Passias
Department of Orthopaedics, NYU Langone Orthopedic Hospital, New York, New York
MD
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Aaron J. Buckland
Department of Orthopaedics, NYU Langone Orthopedic Hospital, New York, New York
MBBS, FRACS
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ABSTRACT

Background: 

Bone morphogenetic protein (BMP) and allograft containing mesenchymal stem cells (live cell) are popular biologic substitutes for iliac crest autograft used in transforaminal lumbar interbody fusion (TLIF). Use of these agents in the pathogenesis of postoperative radiculitis remains controversial. Recent studies have independently linked minimally invasive (MIS) TLIF with increased radiculitis risk compared to open TLIF. The purpose of this study was to assess the rate of postoperative radiculitis in open and MIS TLIF patients along with its relationship to concurrent biologic adjuvant use.

Methods: 

Patients ≥18 years undergoing single-level TLIF from June 2012 to December 2018 with minimum 1-year follow-up were included. Outcome measures were rate of radiculitis, intra- and postoperative complications, revision surgery; length of stay (LOS), and estimated blood loss (EBL).

Results: 

There were 397 patients: 223 with open TLIFs, 174 with MIS TLIFs. One hundred and fifty-nine surgeries used bone morphogenetic protein (BMP), 26 live cell, 212 neither. Open TLIF: higher mean EBL, LOS, and Charlson Comorbidity Index (CCI) than MIS. Postoperative radiculitis in 37 patients (9.32% overall): 16 cases MIS BMP (15.69% of their cohort), 6 MIS without BMP (8.33%), 5 open BMP (8.77%), 10 open without BMP (6.02%). MIS TLIF versus open TLIF: no differences in 1-year reoperation rates, infection/wound complication, pseudarthrosis, or postoperative complication rate. BMP versus non-BMP: no differences in reoperation rates, infection/wound complication, pseudarthrosis, or postoperative complication rate. Multivariate logistic regression found that neither BMP (P = .109) nor MIS (P = .314) was an independent predictor for postoperative radiculitis when controlled for age, gender, body mass index, and CCI. Using paired open and MIS groups (N = 168 each) with propensity score matching, these variables were still not independently associated with radiculitis (P = .174 BMP, P = .398 MIS). However, the combination of MIS with BMP was associated with increased radiculitis risk in both the entire patient cohort (odds ratio [OR]: 2.259 [1.117–4.569], P = .023, N = 397) and PSM cohorts (OR: 2.196 [1.045–4.616], P = .038, N = 336) compared to other combinations of surgical approach and biologic use.

Conclusions: 

Neither the MIS approach nor BMP use is an independent risk factor for post-TLIF radiculitis. However, risk of radiculitis significantly increases when they are used in tandem. This should be considered when selecting biological adjuvants for MIS TLIF.

Level of Evidence: 

3

  • radiculitis
  • biologics
  • bone morphogenetic protein
  • minimally invasive surgery

Footnotes

  • Disclosures and COI: The authors report no conflicts of interest. Each institution obtained approval from their local institutional review board to enroll patients in this retrospective study.

  • This manuscript is generously published free of charge by ISASS, the International Society for the Advancement of Spine Surgery. Copyright © 2020 ISASS.
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International Journal of Spine Surgery: 19 (S2)
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Biologics and Minimally Invasive Approach to TLIFs: What Is the Risk of Radiculitis?
Erik Wang, Carolyn Stickley, Jordan Manning, Christopher G. Varlotta, Dainn Woo, Ethan Ayres, Edem Abotsi, Dennis Vasquez-Montes, Charla R. Fischer, Jonathan Stieber, Martin Quirno, Themistocles S. Protopsaltis, Peter G. Passias, Aaron J. Buckland
International Journal of Spine Surgery Oct 2020, 7114; DOI: 10.14444/7114

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Biologics and Minimally Invasive Approach to TLIFs: What Is the Risk of Radiculitis?
Erik Wang, Carolyn Stickley, Jordan Manning, Christopher G. Varlotta, Dainn Woo, Ethan Ayres, Edem Abotsi, Dennis Vasquez-Montes, Charla R. Fischer, Jonathan Stieber, Martin Quirno, Themistocles S. Protopsaltis, Peter G. Passias, Aaron J. Buckland
International Journal of Spine Surgery Oct 2020, 7114; DOI: 10.14444/7114
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Keywords

  • radiculitis
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