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EBMComparative outcomes of Minimally invasive surgery for posterior lumbar fusion
Fellow 陳磊晏
骨科微創手術 Knee scope
Shoulder scope
MIS THR
MIS TKR
Trauma
MIS Spine surgery
Size Dose Matter !?
Minimal invasive physically and psychologically
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
Disadvantage
Inadequate decompression
Longer surigical time
More radiation exposure
Learning curve
Sanjay.S J Neurosurg Spine 2008
Nature Reviews Neurology 8, 363-365 (July 2012)
Surgical procedure under fluoroscopy
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
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”
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
Study identification and exclsuion
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.
J Neurosurg Spine, 2008 Retrospective cohort
Each arm n=21
Grad I spondylolisthesis , single level
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
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: 447.4 ml,MIS: 50.6 ml, p<0.05)
No post-operative drainage (open: 528.9 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).
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).
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
Chang. W. Spine 2009 Prospective study
Gr I II listhesis + LBP + radiculopathy
N=29 each , MIS TLIF vs Open TLIF
Back pain and leg pain VAS P>0.05
ODI score P>0.05
Fusion grading P>0.05
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 7
11.28+/-6.70 5.41 +/-1.85
Atrophy ratio : L3 L3-4 differ
T2 change:L5-S1 S1 differ
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
Results
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
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: 10.7–33 for MIS versus 6.4–33.7 for open).
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.
Adverse Events
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
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
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
Thank you for your attention
大小不重要傷口