Outcomes following minimally invasive lateral transpsoas interbody fusion for degenerative low grade lumbar spondylolisthesis: A systematic review

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Highlights

  • Systematic review summarizing outcomes following MIS-LLIF for low-grade lumbar spondylolisthesis.

  • High radiographic fusion rates and favorable patient reported outcomes were found.

  • No cases of pseudarthrosis were reported.

  • Postoperative neurologic deficits were found to be transient.

  • High patient satisfaction rates were reported.

Abstract

A variety of surgical approaches have been described to treat low grade lumbar degenerative spondylolisthesis (DS). Minimally invasive spinal fusion techniques were first introduced to minimize morbidities associated with invasive surgical treatments. Minimally invasive lateral transpsoas interbody fusion, also known as lateral lumbar interbody fusion (LLIF), is a relatively new method of lumbar arthrodesis that avoids various approach related complications compared to its posterior and anterior counterparts.

A systematic and critical review of recent literature was conducted in accordance with PRISMA guidelines. The sources of the data were PubMed, MEDLINE, Embase, Cochrane and Scopus. Key search terms were "transpsoas", "interbody fusion", "LLIF", "XLIF" and "spondylolisthesis". Papers included in the review were original research articles in peer-reviewed journals. The articles were thoroughly examined and compared on the basis of study design, outcomes, and results. Only studies which met the eligibility criteria were included.

Eight studies were included in the qualitative and quantitative analysis (three retrospective, four prospective, one randomized controlled trial). A total of 308 patients (227 females) (pooled age 64.5 years) and a total of 353 operated levels were analyzed. Mean follow up time ranged from 6.2 to 24 months. There were no reported cases of durotomies or pseudarthrosis in any study. All neurologic complications were reported to be transient with no permanent deficits. Mean improvement in ODI scores ranged between 19.5 (38.6%) to 36 (54.5%). Mean improvement in slip ranged from 47 to 67.5%. Three studies also reported that patient satisfaction and willingness to undergo the procedure again approached 90%.

Minimally invasive transpsoas interbody fusion possibly leads to favorable clinical and radiological outcomes while avoiding the possible complications of its more traditional open and minimally invasive counterparts. Further studies are needed to better establish its role in the management of low grade degenerative lumbar spondylolisthesis.

Introduction

Spondylolisthesis, defined as the displacement of a vertebral body relative to the segment below, is an important pathology in the aging adult lumbar spine that can present as axial low back pain, radiculopathy or neurogenic claudication [1]. Surgical intervention is warranted in cases of refractory symptoms or when conservative management has failed [[2], [3], [4], [5]]. Traditional surgical treatment options have ranged from decompression alone or decompression with fusion (anterior or posterior) with or without listhesis correction to multilevel fusion for deformity correction [6,7]. Within the last decade, the advent of modern minimally invasive surgery (MIS) techniques has shortened operative times while minimizing blood loss, soft tissue dissection, muscle damage as well as postoperative incisional pain [33]. Compared to patients with degenerative disc disease, adjacent segment disease and post-laminectomy syndrome, patients with degenerative spondylolisthesis have been reported to have greater improvements in disability after lumbar fusion [23,34].

A variety of MIS arthrodesis techniques have been described, including anterior, posterior or transforaminal lumbar interbody fusion. Minimally invasive lateral lumbar interbody fusion (LLIF), also known as extreme lateral interbody fusion (XLIF, NuVasive) or direct lateral interbody fusion (DLIF, Medtronic, Memphis, TN, USA), was first described by McAfee in 1998 [8]. The procedure employs a minimally invasive retroperitoneal transpsoas approach to the lumbar spine using a tubular retractor system under real time electrophysiologic monitoring to avoid injury to the nerves of the lumbar plexus.(REF) Compared to conventional techniques, it avoids various approach-related morbidities such as vascular complications, bowel injury associated with an anterior approach and injury to the dura and nerve roots with posterior approaches [18]. Furthermore, it allows preservation of posterior bony elements and back muscles thus sparing spinal stability. It also allows the placement of a larger interbody cage thereby raising disc height and achieving indirect decompression of the neural foramen [35].

To the best of our knowledge, no review has analyzed the clinical, perioperative and radiological outcomes of LLIF for the treatment of spondylolisthesis. The aim of our study is to conduct a systematic review of available literature to evaluate the aforementioned outcomes in patients with low grade spondylolisthesis.

Section snippets

Literature search

This study adhered to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines [9]. A comprehensive search of several databases from each database’s inception to February 1st, 2017, any language was conducted. The databases included Ovid MEDLINE Epub Ahead of Print, Ovid Medline In-Process & Other Non-Indexed Citations, Ovid MEDLINE, Ovid EMBASE, Ovid Cochrane Central Register of Controlled Trials, Ovid Cochrane Database of Systematic Reviews, and Scopus. The

Search results

Our literature search yielded 143 studies of which 100 unique abstracts were assessed. After review of 21 full-text articles, a total of 8 studies were included in the qualitative and quantitative analysis [[24], [25], [26], [27], [28], [29], [30],37,38] (Fig. 1). Table 1 summarizes study characteristics. Seven studies were single-institution (three retrospective, four prospective cohorts) and one study was a multi-institution randomized controlled trial comparing lateral with transforaminal

Discussion

Minimally invasive transpsoas approach to the spine is being increasingly used to treat degenerative spine disease and spinal deformities. While an increasing amount of data on the clinical and radiological outcomes of this technique are now available, this is the first review to analyze these outcomes with respect to low grade lumbar spondylolisthesis.

In the present review, we found that all studies included uniformly reported no permanent neurologic deficits resulting from the procedure.

Conclusion

In this review, we analyzed current literature on lateral transpsoas interbody fusion for low grade lumbar spondylolisthesis. Overall, we found favorable patient reported and radiologic outcomes at final follow-up. Neurologic complication rates secondary to lumbar plexus injury, including thigh numbness, pain and hip flexion weakness, were very low and transient in nature. Future research should focus on prospective studies in order to provide further insight into the findings of this study.

Disclosures

The authors have no conflicts of interest of funding sources to disclose.

Acknowledgments

N/A

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