Latest Developments in Minimally Invasive Spinal Treatment

A special issue of Journal of Clinical Medicine (ISSN 2077-0383). This special issue belongs to the section "General Surgery".

Deadline for manuscript submissions: closed (20 February 2024) | Viewed by 8003

Special Issue Editor


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Guest Editor
Department of Neurosurgery, Orthopedics and Biomedical Engineering, Mayo Clinic School of Medicine, 200 1st St. SW, Rochester, MN 55905, USA
Interests: degenerative spine pathology; complex adult spinal deformities; spinal stenosis; scoliosis/kyphosis; spine tumors; spinal cord tumors; spinal fusion; herniated discs; craniocervical junction pathology; normal pressure hydrocephalus; tissue engineering strategies for spinal fusion
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Special Issue Information

Dear Colleagues,

The use of minimally invasive strategies for the surgical treatment of spinal pathology has significantly increased, including expansion to techniques for treating spinal tumors and spinal deformities. Additionally, there has been an explosion of new technologies over the past decade including spinal robotics and new navigation-based techniques that have made some of these techniques more accessible and increased patient safety. However, it has been challenging to identify the optimal assessments at follow-up to discern the most appropriate strategy for each patient. This Special Issue intends to provide room for new concepts, new ideas, and new strategies which will help to address the future needs of our patients.

Dr. Benjamin D. Elder
Guest Editor

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Keywords

  • minimally invasive spine surgery
  • spinal fusion
  • discectomy
  • endoscopic
  • spinal deformity surgery
  • robotic spine surgery
  • neuronavigation

Published Papers (8 papers)

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Research

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14 pages, 2480 KiB  
Article
Significant Reduction in Bone Density as Measured by Hounsfield Units in Patients with Ankylosing Spondylitis or Diffuse Idiopathic Skeletal Hyperostosis
by Alexander Swart, Abdelrahman Hamouda, Zach Pennington, Nikita Lakomkin, Anthony L. Mikula, Michael L. Martini, Mahnoor Shafi, Thirusivapragasam Subramaniam, Arjun S. Sebastian, Brett A. Freedman, Ahmad N. Nassr, Jeremy L. Fogelson and Benjamin D. Elder
J. Clin. Med. 2024, 13(5), 1430; https://doi.org/10.3390/jcm13051430 - 01 Mar 2024
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Abstract
Background: Multisegmental pathologic autofusion occurs in patients with ankylosing spondylitis (AS) and diffuse idiopathic skeletal hyperostosis (DISH). It may lead to reduced vertebral bone density due to stress shielding. Methods: This study aimed to determine the effects of autofusion on bone density by [...] Read more.
Background: Multisegmental pathologic autofusion occurs in patients with ankylosing spondylitis (AS) and diffuse idiopathic skeletal hyperostosis (DISH). It may lead to reduced vertebral bone density due to stress shielding. Methods: This study aimed to determine the effects of autofusion on bone density by measuring Hounsfield units (HU) in the mobile and immobile spinal segments of patients with AS and DISH treated at a tertiary care center. The mean HU was calculated for five distinct regions—cranial adjacent mobile segment, cranial fused segment, mid-construct fused segment, caudal fused segment, and caudal adjacent mobile segment. Means for each region were compared using paired-sample t-tests. Multivariable regression was used to determine independent predictors of mid-fused segment HUs. Results: One hundred patients were included (mean age 76 ± 11 years, 74% male). The mean HU for the mid-construct fused segment (100, 95% CI [86, 113]) was significantly lower than both cranial and caudal fused segments (174 and 108, respectively; both p < 0.001), and cranial and caudal adjacent mobile segments (195 and 115, respectively; both p < 0.001). Multivariable regression showed the mid-construct HUs were predicted by history of smoking (−30 HU, p = 0.009). Conclusions: HUs were significantly reduced in the middle of long-segment autofusion, which was consistent with stress shielding. Such shielding may contribute to the diminution of vertebral bone integrity in AS/DISH patients and potentially increased fracture risk. Full article
(This article belongs to the Special Issue Latest Developments in Minimally Invasive Spinal Treatment)
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12 pages, 7325 KiB  
Article
Who Can Be Discharged Home after Adult Spinal Deformity Surgery?
by Soren Jonzzon, Hani Chanbour, Graham W. Johnson, Jeffrey W. Chen, Tyler Metcalf, Alexander T. Lyons, Iyan Younus, Campbell Liles, Amir M. Abtahi, Byron F. Stephens and Scott L. Zuckerman
J. Clin. Med. 2024, 13(5), 1340; https://doi.org/10.3390/jcm13051340 - 27 Feb 2024
Viewed by 425
Abstract
Introduction: After adult spinal deformity (ASD) surgery, patients often require postoperative rehabilitation at an inpatient rehabilitation (IPR) center or a skilled nursing facility (SNF). However, home discharge is often preferred by patients and hsas been shown to decrease costs. In a cohort of [...] Read more.
Introduction: After adult spinal deformity (ASD) surgery, patients often require postoperative rehabilitation at an inpatient rehabilitation (IPR) center or a skilled nursing facility (SNF). However, home discharge is often preferred by patients and hsas been shown to decrease costs. In a cohort of patients undergoing ASD surgery, we sought to (1) report the incidence of discharge to home, (2) determine the factors significantly associated with discharge to home in the form of a simple scoring system, and (3) evaluate the impact of discharge disposition on patient-reported outcome measures (PROMs). Methods: A single-institution, retrospective cohort study was undertaken for patients undergoing ASD surgery from 2009 to 2021. Inclusion criteria were ≥ 5-level fusion, sagittal/coronal deformity, and at least 2-year follow-up. Exposure variables included preoperative, perioperative, and radiographic data. The primary outcome was discharge status (dichotomized as home vs. IPR/SNF). Secondary outcomes included PROMs, such as the numeric rating scales (NRSs) for back and leg pain, the Oswestry Disability Index (ODI), and EQ-5D. A subanalysis comparing IPR to SNF discharge was conducted. Univariate analysis was performed. Results: Of 221 patients undergoing ASD surgery with a mean age of 63.6 ± 17.6, 112 (50.6%) were discharged home, 71 (32.2%) were discharged to an IPR center, and 38 (17.2%) were discharged to an SNF. Patients discharged home were significantly younger (55.7 ± 20.1 vs. 71.8 ± 9.1, p < 0.001), had lower rate of 2+ comorbidities (38.4% vs. 45.0%, p = 0.001), and had less hypertension (57.1% vs. 75.2%, p = 0.005). Perioperatively, patients who were discharged home had significantly fewer levels instrumented (10.0 ± 3.0 vs. 11.0 ± 3.4 levels, p = 0.030), shorter operative times (381.4 ± 139.9 vs. 461.6 ± 149.8 mins, p < 0.001), less blood loss (1101.0 ± 977.8 vs. 1739.7 ± 1332.9 mL, p < 0.001), and shorter length of stay (5.4 ± 2.8 vs. 9.3 ± 13.9 days, p < 0.001). Radiographically, preoperative SVA (9.1 ± 6.5 vs. 5.2 ± 6.8 cm, p < 0.001), PT (27.5 ± 11.1° vs. 23.4 ± 10.8°, p = 0.031), and T1PA (28.9 ± 12.7° vs. 21.6 ± 13.6°, p < 0.001) were significantly higher in patients who were discharged to an IPR center/SNF. Additionally, the operating surgeon also significantly influenced the disposition status (p < 0.001). A scoring system of the listed factors was proposed and was validated using univariate logistic regression (OR = 1.55, 95%CI = 1.34–1.78, p < 0.001) and ROC analysis, which revealed a cutoff value of > 6 points as a predictor of non-home discharge (AUC = 0.75, 95%CI = 0.68–0.80, p < 0.001, sensitivity = 63.3%, specificity = 74.1%). The factors in the scoring system were age > 56, comorbidities ≥ 2, hypertension, TIL ≥ 10, operative time > 357 mins, EBL > 1200 mL, preop SVA > 6.6 cm, preop PT > 33.6°, and preop T1PA > 15°. When comparing IPR (n = 71) vs. SNF (n = 38), patients discharged to an SNF were significantly older (74.4 ± 8.6 vs. 70.4 ± 9.1, p = 0.029) and were more likely to be female (89.5% vs. 70.4%, p = 0.024). Conclusions: Approximately 50% of patients were discharged home after ASD surgery. A simple scoring system based on age > 56, comorbidities ≥ 2, hypertension, total instrumented levels ≥ 10, operative time > 357 mins, EBL > 1200 mL, preop SVA > 6.6 cm, preop PT > 33.6°, and preop T1PA > 15° was proposed to predict non-home discharge. These findings may help guide postoperative expectations and resource allocation after ASD surgery. Full article
(This article belongs to the Special Issue Latest Developments in Minimally Invasive Spinal Treatment)
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12 pages, 1559 KiB  
Article
Assessing Procedural Accuracy in Lateral Spine Surgery: A Retrospective Analysis of Percutaneous Pedicle Screw Placement with Intraoperative CT Navigation
by Akihiko Hiyama, Daisuke Sakai, Hiroyuki Katoh, Satoshi Nomura and Masahiko Watanabe
J. Clin. Med. 2023, 12(21), 6914; https://doi.org/10.3390/jcm12216914 - 03 Nov 2023
Cited by 1 | Viewed by 547
Abstract
Percutaneous pedicle screws (PPSs) are commonly used in posterior spinal fusion to treat spine conditions such as trauma, tumors, and degenerative diseases. Precise PPS placement is essential in preventing neurological complications and improving patient outcomes. Recent studies have suggested that intraoperative computed tomography [...] Read more.
Percutaneous pedicle screws (PPSs) are commonly used in posterior spinal fusion to treat spine conditions such as trauma, tumors, and degenerative diseases. Precise PPS placement is essential in preventing neurological complications and improving patient outcomes. Recent studies have suggested that intraoperative computed tomography (CT) navigation can reduce the dependence on extensive surgical expertise for achieving accurate PPS placement. However, more comprehensive documentation is needed regarding the procedural accuracy of lateral spine surgery (LSS). In this retrospective study, we investigated patients who underwent posterior instrumentation with PPSs in the thoracic to lumbar spine, utilizing an intraoperative CT navigation system, between April 2019 and September 2023. The system’s methodology involved real-time CT-based guidance during PPS placement, ensuring precision. Our study included 170 patients (151 undergoing LLIF procedures and 19 trauma patients), resulting in 836 PPS placements. The overall PPS deviation rate, assessed using the Ravi scale, was 2.5%, with a notably higher incidence of deviations observed in the thoracic spine (7.4%) compared to the lumbar spine (1.9%). Interestingly, we found no statistically significant difference in screw deviation rates between upside and downside PPS placements. Regarding perioperative complications, three patients experienced issues related to intraoperative CT navigation. The observed higher rate of inaccuracies in the thoracic spine suggests that various factors may contribute to these differences in accuracy, including screw size and anatomical variations. Further research is required to refine PPS insertion techniques, particularly in the context of LSS. In conclusion, this retrospective study sheds light on the challenges associated with achieving precise PPS placement in the lateral decubitus position, with a significantly higher deviation rate observed in the thoracic spine compared to the lumbar spine. This study emphasizes the need for ongoing research to improve PPS insertion techniques, leading to enhanced patient outcomes in spine surgery. Full article
(This article belongs to the Special Issue Latest Developments in Minimally Invasive Spinal Treatment)
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19 pages, 1246 KiB  
Article
Latest Developments in Minimally Invasive Spinal Treatment in Slovakia and Its Comparison with an Open Approach for the Treatment of Lumbar Degenerative Diseases
by Marina Potašová, Peter Filipp, Róbert Rusnák, Eva Moraučíková, Katarína Repová and Peter Kutiš
J. Clin. Med. 2023, 12(14), 4755; https://doi.org/10.3390/jcm12144755 - 18 Jul 2023
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Abstract
The study describes the benefits of MIS-TLIF (minimally invasive transforaminal lumbar interbody fusion) and compares them with OTLIF (open transforaminal lumbar interbody fusion). It compares blood loss, length of hospitalization stays (LOS), operation time, and return of the patient to the environment. A [...] Read more.
The study describes the benefits of MIS-TLIF (minimally invasive transforaminal lumbar interbody fusion) and compares them with OTLIF (open transforaminal lumbar interbody fusion). It compares blood loss, length of hospitalization stays (LOS), operation time, and return of the patient to the environment. A total of 250 adults (109 males and 141 females), mean age 59.5 ± 12.6, who underwent MIS-TLIF in the Neurosurgery Clinic (NSC) Ruzomberok, Slovakia, because of lumbar degenerative diseases (LDD), participated in this retrospective study. Data were obtained from the patients’ medical records and from the standardized Oswestry Disability Index (ODI) index questionnaire. To compare ODI in our study sample, we used the Student’s Paired Sample Test. To compare the MIS-TLIF and OTLIF approaches, a meta-analysis was conducted. Confidence intervals were 95% CI. The test of homogeneity (Chi-square (Q)) and the degree of heterogeneity (I2 test) among the included studies were used. Statistical analyses were two-sided (α = 0.05). All monitored parameters were significantly better in MIS-TLIF group: blood loss (p < 0.001), operation time (p < 0.001), and ODI changes (p < 0.001). LOS (p < 0.042) were close to the significance level. ODI in the study sample decreased by 33.44% points after MIS-TLIF, and it significantly increased as well (p < 0.001). The percentage of patients who were satisfied with the surgery they underwent was 84.8%. The study confirmed that the MIS-TLIF method is in general gentler for the patient and allows the faster regeneration of patient’s health status compared to OTLIF. Full article
(This article belongs to the Special Issue Latest Developments in Minimally Invasive Spinal Treatment)
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Review

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19 pages, 4900 KiB  
Review
Advancing Prone-Transpsoas Spine Surgery: A Narrative Review and Evolution of Indications with Representative Cases
by Peter N. Drossopoulos, Anas Bardeesi, Timothy Y. Wang, Chuan-Ching Huang, Favour C. Ononogbu-uche, Khoi D. Than, Clifford Crutcher, Gabriel Pokorny, Christopher I. Shaffrey, John Pollina, William Taylor, Deb A. Bhowmick, Luiz Pimenta and Muhammad M. Abd-El-Barr
J. Clin. Med. 2024, 13(4), 1112; https://doi.org/10.3390/jcm13041112 - 16 Feb 2024
Viewed by 942
Abstract
The Prone Transpsoas (PTP) approach to lumbar spine surgery, emerging as an evolution of lateral lumbar interbody fusion (LLIF), offers significant advantages over traditional methods. PTP has demonstrated increased lumbar lordosis gains compared to LLIF, owing to the natural increase in lordosis afforded [...] Read more.
The Prone Transpsoas (PTP) approach to lumbar spine surgery, emerging as an evolution of lateral lumbar interbody fusion (LLIF), offers significant advantages over traditional methods. PTP has demonstrated increased lumbar lordosis gains compared to LLIF, owing to the natural increase in lordosis afforded by prone positioning. Additionally, the prone position offers anatomical advantages, with shifts in the psoas muscle and lumbar plexus, reducing the likelihood of postoperative femoral plexopathy and moving critical peritoneal contents away from the approach. Furthermore, operative efficiency is a notable benefit of PTP. By eliminating the need for intraoperative position changes, PTP reduces surgical time, which in turn decreases the risk of complications and operative costs. Finally, its versatility extends to various lumbar pathologies, including degeneration, adjacent segment disease, and deformities. The growing body of evidence indicates that PTP is at least as safe as traditional approaches, with a potentially better complication profile. In this narrative review, we review the historical evolution of lateral interbody fusion, culminating in the prone transpsoas approach. We also describe several adjuncts of PTP, including robotics and radiation-reduction methods. Finally, we illustrate the versatility of PTP and its uses, ranging from ‘simple’ degenerative cases to complex deformity surgeries. Full article
(This article belongs to the Special Issue Latest Developments in Minimally Invasive Spinal Treatment)
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14 pages, 2351 KiB  
Review
Management of Spinal Metastasis by Minimally Invasive Surgical Techniques: Surgical Principles and Indications—A Literature Review
by Mikael Meyer, Kaissar Farah, Toquart Aurélie, Thomas Graillon, Henry Dufour and Stephane Fuentes
J. Clin. Med. 2023, 12(16), 5165; https://doi.org/10.3390/jcm12165165 - 08 Aug 2023
Viewed by 968
Abstract
Background: Spinal metastasis is becoming more frequent. This raises the topics of pain and neurological complications, which worsen the functional and survival prognosis of oncological population patients. Surgical treatment must be as complete as possible in order to decompress and stabilize without delaying [...] Read more.
Background: Spinal metastasis is becoming more frequent. This raises the topics of pain and neurological complications, which worsen the functional and survival prognosis of oncological population patients. Surgical treatment must be as complete as possible in order to decompress and stabilize without delaying the management of the oncological disease. Minimally invasive spine surgical techniques inflict less damage on the musculocutaneous plan than opened ones. Methods: Different minimally invasive techniques are proposed in this paper for the management of spinal metastasis. We used our experience, developed degenerative and traumatic pathologies, and referred to many authors, establishing a narrative review of our local practice. Results: Forty-eight articles were selected, and these allowed us to describe the different techniques: percutaneous methods such as vertebro/kyphoplasty, osteosynthesis, mini-open surgery, or that through a posterior or anterior approach. Also, some studies detail the contribution of new technologies, such as intraoperative CT scan and robotic assistance. Conclusions: It seems essential to offer a lasting solution to a spinal problem, such as in the form of pain relief, stabilization, and decompression. Our department has embraced a multidisciplinary and multidimensional approach to MISS, incorporating cutting-edge technologies and evidence-based practices. Full article
(This article belongs to the Special Issue Latest Developments in Minimally Invasive Spinal Treatment)
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19 pages, 4282 KiB  
Review
Utility of MRI in Quantifying Tissue Injury in Cervical Spondylotic Myelopathy
by Ali Fahim Khan, Grace Haynes, Esmaeil Mohammadi, Fauziyya Muhammad, Sanaa Hameed and Zachary A. Smith
J. Clin. Med. 2023, 12(9), 3337; https://doi.org/10.3390/jcm12093337 - 08 May 2023
Cited by 7 | Viewed by 2240
Abstract
Cervical spondylotic myelopathy (CSM) is a progressive disease that worsens over time if untreated. However, the rate of progression can vary among individuals and may be influenced by various factors, such as the age of the patients, underlying conditions, and the severity and [...] Read more.
Cervical spondylotic myelopathy (CSM) is a progressive disease that worsens over time if untreated. However, the rate of progression can vary among individuals and may be influenced by various factors, such as the age of the patients, underlying conditions, and the severity and location of the spinal cord compression. Early diagnosis and prompt treatment can help slow the progression of CSM and improve symptoms. There has been an increased use of magnetic resonance imaging (MRI) methods in diagnosing and managing CSM. MRI methods provide detailed images and quantitative structural and functional data of the cervical spinal cord and brain, allowing for an accurate evaluation of the extent and location of tissue injury. This review aims to provide an understanding of the use of MRI methods in interrogating functional and structural changes in the central nervous system in CSM. Further, we identified several challenges hindering the clinical utility of these neuroimaging methods. Full article
(This article belongs to the Special Issue Latest Developments in Minimally Invasive Spinal Treatment)
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Other

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10 pages, 10226 KiB  
Case Report
Using Augmented Reality Technology to Optimize Transfacet Lumbar Interbody Fusion: A Case Report
by Anas Bardeesi, Troy Q. Tabarestani, Stephen M. Bergin, Chuan-Ching Huang, Christopher I. Shaffrey, Walter F. Wiggins and Muhammad M. Abd-El-Barr
J. Clin. Med. 2024, 13(5), 1513; https://doi.org/10.3390/jcm13051513 - 06 Mar 2024
Viewed by 831
Abstract
The transfacet minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) is a novel approach available for the management of lumbar spondylolisthesis. It avoids the need to manipulate either of the exiting or traversing nerve roots, both protected by the bony boundaries of the approach. [...] Read more.
The transfacet minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) is a novel approach available for the management of lumbar spondylolisthesis. It avoids the need to manipulate either of the exiting or traversing nerve roots, both protected by the bony boundaries of the approach. With the advancement in operative technologies such as navigation, mapping, segmentation, and augmented reality (AR), surgeons are prompted to utilize these technologies to enhance their surgical outcomes. A 36-year-old male patient was complaining of chronic progressive lower back pain. He was found to have grade 2 L4/5 spondylolisthesis. We studied the feasibility of a trans-Kambin or a transfacet MIS-TLIF, and decided to proceed with the latter given the wider corridor it provides. Preoperative trajectory planning and level segmentation in addition to intraoperative navigation and image merging were all utilized to provide an AR model to guide us through the surgery. The use of AR can build on the safety and learning of novel surgical approaches to spine pathologies. However, larger high-quality studies are needed to further objectively analyze its impact on surgical outcomes and to expand on its application. Full article
(This article belongs to the Special Issue Latest Developments in Minimally Invasive Spinal Treatment)
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