EBM. Comparative outcomes of Minimally invasive surgery for posterior lumbar fusion. Fellow 陳磊晏

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1 EBM Comparative outcomes of Minimally invasive surgery for posterior lumbar fusion Fellow 陳磊晏

2 Knee scope Shoulder scope MIS THR MIS TKR Trauma MIS Spine surgery 骨科微創手術

3 Size Dose Matter!?

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5 Minimal invasive physically and psychologically

6 Potential advantage of MIS spine surgery Smaller incisions and scars Minimal soft-tissue destruction and scarring Less surgical blood loss Shorter hospital stay Less postoperative pain Less need for postoperative pain medicine Faster return to work and daily activities

7 Disadvantage Inadequate decompression Longer surigical time More radiation exposure Learning curve Sanjay.S J Neurosurg Spine 2008

8 Nature Reviews Neurology 8, (July 2012)

9 Surgical procedure under fluoroscopy

10 CORR 2014 Compared MIS and open transforaminal or posterior lumbar interbody fusion (TLIF/PLIF) (1) surgical end points (including EBL, surgical time, and fluoroscopy time) (2) clinical outcomes (Oswestry Disability Index [ODI] and VAS pain scores) (3) adverse events

11 Material and methods MEDLINE,Embase, Web of Science, and Cochrane Library from database computer data to May 2012 (MeSH) search terms included derivatives of minimally invasive / minimal access lumbar spine / lumbar vertebrae fusion / surgical procedures Pubmed search minimal invasive spine surgery

12 Inclusion criteria (1)10 or more patients per study arm and reporting at least one of the following (2)a. surgical end points b. clinical outcome (ODI or VAS pain scores) c. adverse events

13 Study identification and exclsuion

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15 J Spinal Disord Tech,2011 Retrospective MIS TLIF vs Open TLIF N=15 each arm Grade I spondylolisthesis Hospital day : MIS vs open 3 vs 5.5 day, P=0.001 Return to work: MIS vs open 8.5 vs 17.1 wk, P=0.02. No difference in 2-year VAS of back pain, leg pain, Oswestry disability index, and EuroQol-5D scores.

16 J Neurosurg Spine, 2008 Retrospective cohort Each arm n=21 Grad I spondylolisthesis, single level

17 Neurosurgery,2010 Prospective Spondylolisthesis with radiculopathy MIS PLIF n=23, Open PLIF n=24 MIS shorter hospital stay and ambulate earlier (median 7 vs 4 days ; 4 vs 2 days) Reduce leg and back pain and restore function(sf-36 ) to a similar in 12 months

18 Kong Hwee Lee. Eur Spine J (2012) Prospective observational cohort study Single level MIS TLIF vs Open TLIF N=72 each group Longer fluoroscopic time (open: 17.6 s, MIS: 49.0 s, p<0.05), Less blood loss (open: ml,mis: 50.6 ml, p<0.05) No post-operative drainage (open: ml, MIS: 0 ml, p<0.05) MIS needed less morphine (open: 33.5 mg, MIS: 3.4 mg, p<0.05) Ambulate earlier (open: 3.4 days, MIS: 1.2 days, P<0.05) MBD earlier (open: 6.8 days, MIS: 3.2 days, p<0.05).

19 6 months: clinical outcome improving significantly and similarly in VAS, ODI, SF-36 Radiological analysis: similar grade 1 fusion rates (open: 52.2 %, MIS: 59.4 %, p>0.05) Asymptomatic cage migration (open: 8.7 %, MIS: 5.8 %, p>0.05) 2 years: Grade 1 fusion (open: 98.5 %, MIS: 97.0 %, P>0.05) with minimal cage migration (open: 1.4 %, MIS: 0 %, p>0.05).

20 Prosepctive cohort N=41, MIS PLIF vs open PLIF MIS approach shorter hospital stay, time to ambulate, lower opioid use and total complication rates. R.J. Mobbs. J Clinical Neuroscience 2012

21 Chang. W. Spine 2009 Prospective study Gr I II listhesis + LBP + radiculopathy N=29 each, MIS TLIF vs Open TLIF ODI score P>0.05 Back pain and leg pain VAS P>0.05 Fusion grading P>0.05

22 Comparison of Paraspinal Muscle Damage and Slip Reduction Takahiro.T. Spine 2009 L4-5, MIS PLIF vs Open PLIF N=10 each Multifidus atrophy by MRI pre op and post 1 yr at L3-4, L5-S1 level The serum creatinine phosphokinase (CPK) level at post op day 1 and / /-1.85

23 Atrophy ratio : L3 L3-4 differ T2 change: L5-S1 S1 differ

24 Jian. W. Eur Spine J 2010 Prospective Single level, lytic or deg. spondylolisthesis MIS TLIF (n=42) vs Open TLIF (n=43) MIS group significantly lesser blood loss, need for BT, lesser postop back pain, and shorter hospital stay. The X ray time longer

25 Results

26 Surgical end points Surgical time tended to be equivalent between the MIS and open cohorts (n = 23 studies 104 to 390 minutes and 132 to 365 minutes in the MIS and open EBL ranging from 51 to 496 ml in MIS 125 to 1147 ml in open Fluoroscopy time was consistently higher in the MIS groups (n = 7 studies, with 49 to 297 sec compared to 24 to 123 sec in open

27 Patient-reported Outcomes Postoperative pain was found to be equivalent in the 15 studies ODI values were reported in 13 studies between 12 and 36 months postoperatively were generally equivalent between the MIS and open cohorts (range: for MIS versus for open).

28 Patient-reported Outcomes Hospital stay was shorter for the MIS cohorts (n = 21 ) with MIS patients experiencing a 1.8- to 11-day hospitalization compared to 3 to 15 days for the open patient. Lack of randomization may have led to selection bias regarding case complexity and a trend toward lower EBL and shorter hospital LOS in MIS patients.

29 Adverse Events

30 Conclusion In this systematic review, including more than 1600 patients from 26 studies, showed lower EBL shorter hospital LOS equivalent patient-reported outcomes (VAS pain scores and ODI values, intermediate-term) a trend toward lower surgical and medical complications in patients

31 Limitation Sample size n=10~76 each arm Decision making, non-randomized, selection bias (severity, patient expectation, social economic status..) Patient selection impacts on the rates of complications

32 Summary Equivalent clinical patient-reported outcomes Possible improved surgical outcomes and lower complication rates in MIS Need well-designed prospective observational studies or randomized trials

33 傷口大小不重要 Thank you for your attention