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Disc Space Preparation in Transforaminal Lumbar Interbody Fusion: A Comparison of Minimally Invasive and Open Approaches

  • Symposium: Minimally Invasive Spine Surgery
  • Published:
Clinical Orthopaedics and Related Research®

Abstract

Background

Minimally invasive surgical (MIS) approaches to transforaminal lumbar interbody fusion (TLIF) have been developed as an alternative to the open approach. However, concerns remain regarding the adequacy of disc space preparation that can be achieved through a minimally invasive approach to TLIF.

Questions/purposes

The purpose of this cadaver study is to compare the adequacy of disc space preparation through MIS and open approaches to TLIF. Specifically we sought to compare the two approaches with respect to (1) the time required to perform a discectomy and the number of endplate violations; (2) the percentage of disc removed; and (3) the anatomic location where residual disc would remain after discectomy.

Methods

Forty lumbar levels (ie, L1-2 to L5-S1 in eight fresh cadaver specimens) were randomly assigned to open and MIS groups. Both surgeons were fellowship-trained spine surgeons proficient in the assigned approach used. Time required for discectomy, endplate violations, and percentage of disc removed by volume and mass were recorded for each level. A digital imaging software program (ImageJ; US National Institutes of Health, Bethesda, MD, USA) was used to measure the percent disc removed by area for the total disc and for each quadrant of the endplate.

Results

The open approach was associated with a shorter discectomy time (9 versus 12 minutes, p = 0.01) and fewer endplate violations (one versus three, p = 0.04) when compared with an MIS approach, percent disc removed by volume (80% versus 77%, p = 0.41), percent disc removed by mass (77% versus 75%, p = 0.55), and percent total disc removed by area (73% versus 71%, p = 0.63) between the open and MIS approaches, respectively. The posterior contralateral quadrant was associated with the lowest percent of disc removed compared with the other three quadrants in both open and MIS groups (50% and 60%, respectively).

Conclusions

When performed by a surgeon experienced with MIS TLIF, MIS and open approaches are similar in regard to the adequacy of disc space preparation. The least amount of disc by percentage is removed from the posterior contralateral quadrant regardless of the approach; surgeons should pay particular attention to this anatomic location during the discectomy portion of the procedure to minimize the likelihood of pseudarthrosis.

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Authors and Affiliations

  1. Department of Orthopaedic Surgery, Thomas Jefferson University Hospital, The Rothman Institute, 925 Chestnut Street, 5th Floor, Philadelphia, PA, 19107, USA

    Jeffrey A. Rihn MD, Alexander R. Vaccaro MD, PhD, Alan S. Hilibrand MD, Todd J. Albert MD & David G. Anderson MD

  2. Drexel University College of Medicine, Philadelphia, PA, USA

    Sapan D. Gandhi BS

  3. Department of Orthopaedic Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA

    Patrick Sheehan BBA

Authors
  1. Jeffrey A. Rihn MD
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  2. Sapan D. Gandhi BS
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  3. Patrick Sheehan BBA
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  4. Alexander R. Vaccaro MD, PhD
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  5. Alan S. Hilibrand MD
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  6. Todd J. Albert MD
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  7. David G. Anderson MD
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Corresponding author

Correspondence to Jeffrey A. Rihn MD.

Additional information

One or more of the authors certifies that he (JAR, ARV, ASH, TJA, DGA) has received benefits during the study period, in the form of an institutional research grant, an amount of USD 10,000 to USD 100,000, from DePuy Spine Inc (Raynham, MA, USA).

All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research editors and board members are on file with the publication and can be viewed on request.

Clinical Orthopaedics and Related Research neither advocates nor endorses the use of any treatment, drug, or device. Readers are encouraged to always seek additional information, including FDA-approval status, of any drug or device prior to clinical use.

Each author certifies that his or her institution approved the human protocol for this investigation, that all investigations were conducted in conformity with ethical principles of research, and that informed consent for participation in the study was obtained.

This work was performed at Thomas Jefferson University Hospital, Philadelphia, PA, USA.

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Rihn, J.A., Gandhi, S.D., Sheehan, P. et al. Disc Space Preparation in Transforaminal Lumbar Interbody Fusion: A Comparison of Minimally Invasive and Open Approaches. Clin Orthop Relat Res 472, 1800–1805 (2014). https://doi.org/10.1007/s11999-014-3479-z

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  • DOI: https://doi.org/10.1007/s11999-014-3479-z

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