Minimally invasive transforaminal lumbar interbody fusion using the biportal endoscopic techniques versus microscopic tubular technique

Abstract

BACKGROUND CONTEXT

Minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) with microscopic tubular technique is an established surgical procedure with several potential advantages, including decreased surgical-related morbidity, reduced length of hospital stay, and accelerated early rehabilitation. A recently introduced biportal endoscopic technique for spine surgery presents familiar surgical anatomy and can be conducted using a conventional approach with a minimal footprint; it is also applicable to TLIF.

PURPOSE

To compare the clinical and radiological outcomes of biportal endoscopic technique transforaminal lumbar interbody fusion (BE-TLIF) and microscopic tubular technique transforaminal lumbar interbody (MT-TLIF) in patients with single- or two-segment lumbar spinal stenosis with or without spondylolisthesis.

STUDY DESIGN

A retrospective cohort study.

PATIENT SAMPLE

One hundred two participants with neurogenic intermittent claudication or lumbar radiculopathy with single- or two-level lumbar spinal stenosis with or without spondylolisthesis.

OUTCOME MEASURES

Clinical outcomes were assessed using the visual analog scale (VAS) score for the back and leg pain, Oswestry Disability Index (ODI), and the Short Form-36 health survey Questionnaire (SF-36). Demographic data, operative data (total operation time, estimated blood loss, amount of surgical drain, postoperative transfusion, and length of hospital stay), and laboratory results (plasma hemoglobin, serum creatine phosphokinase, and C-reactive protein) were also evaluated. The fusion rate was assessed using the Bridwell interbody fusion grading system. Postoperative complications were also noted.

METHODS

Patients were divided into two groups: group A (BE-TLIF) and group B (MT-TLIF). The clinical outcomes, including VAS-Back and VAS-Leg, ODI, and SF-36 scores, were evaluated at 1 month, 6 months, and 1 year after surgery. Differences in demographics, operative data, and the laboratory and radiological results were assessed between the two groups. The fusion rate was assessed using standard standing lumbar radiographs and computed tomography scans conducted 1 year after surgery.

RESULTS

Seventy-nine patients were analyzed in this study, 47 from group A and 32 from group B. Demographic and operative data were comparable for both the groups. The VAS-Back and SF-36 scores were more significantly improved in group A than in group B at 1 month after surgery. However, there were no significant differences between groups for the mean VAS-Back, VAS-Leg, ODI, and SF-36 scores at 1year after the surgery. Although the total operation time was significantly longer in group A, the estimated blood loss and the amount of surgical drainage was significantly higher in group B (p < .001). There were no between-group differences for the fusion rate and postoperative complications.

CONCLUSION

Both BE-TLIF and MT-TLIF provided equivalent and favorable clinical outcomes and fusion rates. Further large-scale, randomized, controlled trials with long-term follow-ups are warranted.

Introduction

Minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) with the microscopic tubular technique (MT) uses a muscle splitting approach with paramedian incisions and a tubular retractor system to minimize the paravertebral musculature injury, blood loss, postoperative pain, opioid consumption, and to improve the mobilization, recovery, and the length of hospital stay during the immediate postoperative period. It possesses equivalent fusion rates and long-term functional outcomes compared to the conventional posterior lumbar interbody fusion (PLIF) and TLIF [1], [2], [3], [4], [5], [6]. Microscopic tubular technique transforaminal lumbar interbody fusion (MT-TLIF) requires a high degree of dependence on tubular retractor systems, leading to a challenge for achieving sufficient neural decompression and interbody grafting due to the limited surgical visualization and a risk of a significantly increased radiation exposure [7]. A few studies reported that MT-TLIF resulted in a relatively long operation time, increased revision and readmission rates, increased hardware-related complications, and a higher incidence of nerve root injury, which may be associated with the deep learning curve [8,9].

A recently introduced biportal endoscopy (BE)-assisted technique for spine surgery separates the viewing and working channels and allows for continuous fluid irrigation through two independent surgical ports, in contrast to the uniportal endoscopic spine surgery. Using two independent transmuscular tracts as viewing and working portals results in free movement of the surgical view and dynamic handling of surgical instruments, allowing for a relatively short learning curve [10,11]. BE can be used for all MIS spinal decompression procedures, such as unilateral laminotomy for lumbar discectomy, unilateral laminotomy for bilateral decompression, and unilateral foraminotomy for decompression, all of which have demonstrated good clinical efficacy [12]. Furthermore, BE can be applied to lumbar interbody fusion surgery [13], [14], [15].

In prospective clinical trials, BE-assisted decompressive laminectomy is comparable to conventional microscopic decompressive laminectomy in long-term outcomes of up to 2-years, with advantages that include decreased postoperative pain and opioid consumption and earlier rehabilitation [16], [17], [18], [19]. These advantages by BE could be useful for lumbar interbody fusion surgery; however, there is a lack of clinical evidence for BE-assisted transforaminal lumbar interbody fusion (BE-TLIF). The purpose of this study was to compare the clinical and radiological outcomes of BE-TLIF with MT-TLIF after at least 1 year.