Acta Neurochirurgica

, Volume 161, Issue 12, pp 2415–2420 | Cite as

Midline lumbar interbody fusion (MIDLIF) with cortical screws: initial experience and learning curve

  • Fábia SilvaEmail author
  • Pedro Santos Silva
  • Rui Vaz
  • Paulo Pereira
Original Article - Spine degenerative
Part of the following topical collections:
  1. Spine degenerative



A variety of surgical techniques can be used to achieve lumbar spinal fusion for management of degenerative conditions. Transforaminal lumbar interbody fusion (TLIF) is the most popular technique; however, midline lumbar interbody fusion (MIDLIF) is a valid alternative to the more traditional pedicle screw trajectory with potential advantages. The aim of this study is to evaluate the clinical outcomes from a cohort of patients submitted to MIDLIF in a single hospital during the surgical team’s initial learning period.


The first 30 consecutive patients who underwent single- or two-level MIDLIF surgery for lumbar degenerative disease were included in this retrospective study. Patients’ demographics, surgical data, length of hospitalisation, and perioperative complications were analysed. Preoperative and postoperative radiographic parameters were obtained. Validated questionnaires, Core Outcome Measure Index for the back, Euro-QoL 5-Dimensional Questionnaire, and Oswestry Disability Index, were used for clinical assessment.


Mean surgery time was 278.53 ± 82.16 min and mean hospitalisation time was 6.17 ± 3.51 days. Six patients experienced complications, four of which being dural tears with no consequences, and two required reoperations during the mean follow-up of 25.23 ± 9.74 months. Preoperative and postoperative radiological parameters did not demonstrate significant differences. All clinical parameters significantly improved after surgery (p < 0.001). A complexity score was developed to more accurately compare the different procedures, and it strongly correlated with surgery duration (r = 0.719, p < 0.001). Furthermore, a moderate correlation was found between a developed Duration Index and the patient’s order number (r = − 0.539, p = 0.002).


In our initial experience, MIDLIF showed to be effective in significantly improving the patients’ functional status, pain scores, and quality of life. The technique seems safe, with an acceptably low complication rate. Hence, MIDLIF can be considered as a promising alternative to more traditional TLIF and PLIF techniques even at the beginning of the learning curve.


MIDLIF Midline lumbar interbody fusion Minimally invasive spine surgery Lumbar arthrodesis Cortical bone trajectory screws Learning curve 


Compliance with ethical standards

Conflict of interest

PP has an education and training and consultancy agreement with Medtronic Sofamor Danek, USA. FS, PSS, and RV certify that they have no affiliations with or involvement in any organisation or entity with any financial interest (such as honoraria; educational grants; participation in speakers’ bureaus; membership, employment, consultancies, stock ownership, or other equity interest; and expert testimony or patent-licensing arrangements) or non-financial interest (such as personal or professional relationships, affiliations, knowledge, or beliefs) in the subject matter or materials discussed in this manuscript.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional research committee (Comissão de Ética para a Saúde do Centro Hospitalar Universitário de São João) and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. For this type of study, formal consent is not required.


  1. 1.
    Bielecki M, Kunert P, Prokopienko M, Nowak A, Czernicki T, Marchel A (2016) Midline lumbar fusion using cortical bone trajectory screws. Preliminary report. Videosurgery Miniinv 3:156–163CrossRefGoogle Scholar
  2. 2.
    Bosacco SJ, Gardner MJ, Guille JT (2001) Evaluation and treatment of dural tears in lumbar spine surgery: a review. Clin Orthop Relat Res 389:238–247CrossRefGoogle Scholar
  3. 3.
    Copay AG, Glassman SD, Subach BR, Berven S, Schuler TC, Carreon LY (2008) Minimum clinically important difference in lumbar spine surgery patients: a choice of methods using the Oswestry Disability Index, Medical Outcomes Study questionnaire Short Form 36, and Pain Scales. Spine J 8(6):968–974CrossRefGoogle Scholar
  4. 4.
    Dabbous B, Brown D, Tsitlakidis A, Arzoglou V (2016) Clinical outcomes during the learning curve of MIDline Lumbar Fusion (MIDLF®) using the cortical bone trajectory. Acta Neurochir 158(7):1413–1420CrossRefGoogle Scholar
  5. 5.
    Damasceno LHF, Rocha PAG, Barbosa ES, Barros CAM, Canto FT, Defino HLA, Mannion AF (2012) Cross-cultural adaptation and assessment of the reliability and validity of the Core Outcome Measures Index (COMI) for the Brazilian-Portuguese language. Eur Spine J 21(7):1273–1282CrossRefGoogle Scholar
  6. 6.
    Elmekaty M, Kotani Y, El Mehy E, Robinson Y, El Tantawy A, Sekiguchi I, Fujita R (2018) Clinical and radiological comparison between three different minimally invasive surgical fusion techniques for single-level lumbar isthmic and degenerative spondylolisthesis: Minimally invasive surgical posterolateral fusion versus minimally invasive surgical transforaminal lumbar interbody fusion versus midline lumbar fusion. Asian Spine J 12(5):870–879CrossRefGoogle Scholar
  7. 7.
    Fairbank JC, Pynsent PB (2000) The Oswestry Disability Index. Spine 25(22):2940–2952CrossRefGoogle Scholar
  8. 8.
    Huang HM, Chen CH, Lee HC, Chuang HY, Chen DC, Chu YT, Cho DY (2018) Minimal invasive surgical technique in midline lumbar inter-body fusion: a technique note. J Clin Neurosci 55:103–108CrossRefGoogle Scholar
  9. 9.
    Lan T, Hu SY, Zhang YT, Zheng YC, Zhang R, Shen Z, Yang XJ (2018) Comparison between posterior lumbar interbody fusion and transforaminal lumbar interbody fusion for the treatment of lumbar degenerative diseases: a systematic review and meta-analysis. World Neurosurg 112:86–93CrossRefGoogle Scholar
  10. 10.
    Lee CS, Eoh W, Chung SS, Lee SH, Kim ES, Kim MK (2011) The impact of sagittal balance on clinical results after posterior interbody fusion for patients with degenerative spondylolisthesis: a pilot study. BMC Musculoskelet Disord 12(1)Google Scholar
  11. 11.
    Lee JC, Jang HD, Shin BJ (2012) Learning curve and clinical outcomes of minimally invasive transforaminal lumbar interbody fusion: Our experience in 86 consecutive cases. Spine 37(18):1548–1557CrossRefGoogle Scholar
  12. 12.
    Maeng DH, Min JH, Lee SH, Jang JS, Kim JM, Han KM (2009) Can patients with sagittally well-compensated lumbar degenerative kyphosis benefit from surgical treatment for intractable back pain? Neurosurg 64(1):115–121CrossRefGoogle Scholar
  13. 13.
    Mannion AF, Vila-Casademunt A, Domingo-Sàbat M, Wunderlin S, Pellisé F, Bago J et al (2016) The Core Outcome Measures Index (COMI) is a responsive instrument for assessing the outcome of treatment for adult spinal deformity. Eur Spine J 25(8):2638–2648CrossRefGoogle Scholar
  14. 14.
    Miller JA, Derakhshan A, Lubelski D, Alvin MD, McGirt MJ, Benzel EC, Mroz TE (2015) The impact of pre-operative depression on quality of life outcomes after lumbar surgery. Spine J 15(1):58–64CrossRefGoogle Scholar
  15. 15.
    Mizuno M, Kuraishi K, Umeda Y, Sano T, Tsuji M, Suzuki H (2014) Midline lumbar fusion with cortical bone trajectory screw. Neurol Med-Chir 54(9):716–721CrossRefGoogle Scholar
  16. 16.
    Phillips JT (2017) Comparing mid lumbar interbody fusion (MIDLF) with traditional posterior lumbar interbody fusion (PLIF). Electronic Thesis And Dissertation Repository, 4541Google Scholar
  17. 17.
    Rodriguez A, Neal MT, Liu A, Somasundaram A, Hsu W, Branch CL (2014) Novel placement of cortical bone trajectory screws in previously instrumented pedicles for adjacent-segment lumbar disease using CT image-guided navigation. Neurosurg Focus 36(3):E9CrossRefGoogle Scholar
  18. 18.
    Schnake KJ, Rappert D, Storzer B, Schreyer S, Hilber F, Mehren C (2018) Lumbale Spondylodese – Indikationen und Techniken. Der Orthop:50–58CrossRefGoogle Scholar
  19. 19.
    Silva PS, Silva PA, Monteiro P, Vaz R, Pereira P (2013) Learning curve and complications of minimally invasive transforaminal lumbar interbody fusion. Neurosurg Focus 35(8):E7CrossRefGoogle Scholar
  20. 20.
    Smith S, Weldring T (2013) Patient-reported outcomes (PROs) and patient-reported outcome measures (PROMs). Health Services Insights 61Google Scholar
  21. 21.
    Solberg T, Johnsen LG, Nygaard ØP, Grotle M (2013) Can we define success criteria for lumbar disc surgery? Estimates for a substantial amount of improvement in core outcome measures. Acta Orthop 84(2):196–201CrossRefGoogle Scholar
  22. 22.
    The EuroQol Group (1990) EuroQol-a new facility for the measurement of health-related quality of life. Health Policy 16(3):199–208CrossRefGoogle Scholar
  23. 23.
    Tuomainen I, Pakarinen M, Aalto T, Sinikallio S, Kröger H, Viinamäki H, Airaksinen O (2018) Depression is associated with the long-term outcome of lumbar spinal stenosis surgery: a 10-year follow-up study. Spine J 18(3):458–463CrossRefGoogle Scholar

Copyright information

© Springer-Verlag GmbH Austria, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Faculty of MedicineUniversity of PortoPortoPortugal
  2. 2.Department of NeurosurgeryCentro Hospitalar Universitário de São JoãoPortoPortugal
  3. 3.Neurosciences Center CUFPortoPortugal

Personalised recommendations