Transforaminal lumbar interbody fusion (TLIF) versus posterolateral instrumented fusion (PLF) in degenerative lumbar disorders

Eur Spine J (2013) 22:2022–2029

The aim of the present study was to analyze outcome, with respect to functional disability, pain, fusion rate, and complications of patients treated with transforaminal lumbar interbody fusion (TLIF) in compared to instrumented poserolateral fusion (PLF) alone, in low back pain. Spinal fusion has become a major procedure worldwide. However, conflicting results exist. Theoretical circumferential fusion could improve functional outcome. However, the theoretical advantages lack scientific documentation.

Methods Prospective randomized clinical study with a 2-year follow-up period. From November 2003 to November 2008, 100 patients with severe low back pain and radicular pain were randomly selected for either posterolateral lumbar fusion [titanium TSRH (Medtronic)] or transforaminal lumbar interbody fusion [titanium TSRH (Medtronic)] with anterior intervertebral support by tantalum cage (Implex/Zimmer). The primary outcome scores were obtained using Dallas Pain Questionnaire (DPQ), Oswestry disability Index, SF-36, and low back pain Rating Scale. All measures assessed the endpoints at 2-year follow-up after surgery.

Results The overall follow-up rate was 94 %. Sex ratio was 40/58. 51 patients had TLIF, 47 PLF. Mean age 49(TLIF)/45(PLF). No statistic difference in outcome between groups could be detected concerning daily activity, work leisure, anxiety/depression or social interest. We found no statistic difference concerning back pain or leg  pain. In both the TLIF and the PLF groups the patients had significant improvement in functional outcome, back pain, and leg pain compared to preoperatively. Operation time and blood loss in the TLIF group were significantly higher than in the PLF group (p \ 0.001). No statistic difference in fusion rates was detected.

Conclusions Transforaminal interbody fusion did not improve functional outcome in patients compared to posterolateral fusion. Both groups improved significantly in all categories compared to preoperatively. Operation time and blood loss were significantly higher in the TLIF group.

Clinical and Radiological Mid-Term Outcomes of Lumbar Single-Level Total Disc Replacement

Spine 2018;43:105–113

Study Design. Prospective single-center case cohort study. Objective. Evaluation of clinical and radiographic outcomes of a consecutive 122-patient cohort with discogenic back pain, at 2- to 10-year follow-up periods, treated by a single surgeon, with CHARITE Artificial Disc (DePuy Spine, Raynham, MA).

Summary of Background Data. Minimum 2-year clinical and radiographic level 1 data for the first lumbar artificial disc, the CHARITE Artificial Disc (DePuy Spine), have recently been published, demonstrating sustained clinical benefit of the device for the treatment of degenerative disc disease.

Methods. Patients were assessed preoperatively using clinical outcome measures, including visual analog scale (VAS) score back and leg, Oswestry Disability Index (ODI), 36-Item Short Form Health Survey (SF-36), and Roland-Morris Questionnaires (RMDQ), and further assessed postoperatively, 3-, 6-, 12-months, and yearly thereafter.

Results. Average follow-up was 44.9±3.3 months (n=122). The median age at surgery was 43.0±9.0 years. Preoperative diagnosis included degenerative disc disease in 118 (96.7%) and internal disc disruption in 4 (3.3%). Surgery was performed at L5–S1 in 96 (77.9%) patients and at L4–L5 in 27 (22.1%). Statistically significant clinical improvements from baseline were observed on VAS (back and leg), ODI, SF-36 PCS, SF-36 MCS, and RMDQ 3 months onward. Back VAS scores decreased from 78.221.3 preoperatively to 21.927.8 by final follow-up. ODI scores decreased from 51.117.3 to 16.217.9 at last follow-up. The RMDQ scores also decreased from 16.7±4.7 to 4.2±5.8. SF-36 PCS and MCS increased from 25.7±11.0 to 46.4±10.3 for PCS and from 35.5±17.4 to 51.6±10.8 for MCS. Patient satisfaction surveys indicated that 90.56% patients rated their satisfaction with the surgery as ‘‘excellent’’ or ‘‘good’’ at 2 years. Range of motion averaged 8.6±3.5 (median=8.08) at the last follow-up time point.

Conclusion. Outcomes verify the clinical efficacy of total disc replacement for treatment of discogenic back pain with or without radiculopathy. The outcomes instruments demonstrated statistically significant improvements 3 months onward.

Microdiscectomy Improves Pain-Associated Depression, Somatic Anxiety, and Mental Well- Being in Patients With Herniated Lumbar Disc

Neurosurgery 70:306–311, 2012 DOI: 10.1227/NEU.0b013e3182302ec3

Emotional distress and depression are common psychological disturbances associated with low-back and leg pain. The effects of lumbar discectomy on pain, disability, and physical quality of life are well described. The effects of discectomy on emotional distress and mental well-being are less well understood.

OBJECTIVE: To assess the effect of microdiscectomy on depression, somatization, and mental well-being in patients with herniated lumbar discs.

METHODS: Patients undergoing surgical discectomy for single-level, herniated lumbar disc were prospectively evaluated preoperatively, and at 6 weeks and 3, 6, and 12 months postoperatively. Back and leg pain, depression, somatic perception, and mental well-being were assessed.

RESULTS: One hundred patients were enrolled. All were available for 1-year follow-up. Preoperatively, the visual analog scale for low-back pain (BP-VAS), visual analog scale for leg pain (LP-VAS), Zung Self-Rating Depression Scale (ZUNG), Modified Somatic Perception Questionnaire (MSPQ), and Medical Outcomes Short Form-36 mental component summary scale (SF-36-MCS) were 6.3 6 2.5, 6.3 6 2.5, 19 6 11, 9 6 7, and 4 6 14. BP-VAS and LP-VAS significantly improved by 6 weeks. Significant improvement in SF-36-MCS was observed by 6 weeks postoperatively, improvement in MSPQ score was observed 3 months postoperatively, and improvement in the ZUNG depression score was observed 12 months postoperatively. No statistical difference occurred during the remainder of follow-up for any outcome measured once improvement reached statistical significance. Eighteen patients were somatized preoperatively, 67% of which were nonsomatized 1 year postoperatively. Ten patients were clinically depressed preoperatively, 70% of which were nondepressed 1 year postoperatively. Improvement in SF-36-MCS, ZUNG, and MSPQ correlated (P , .001) with improvement in BP-VAS and LP-VAS.

CONCLUSION: The majority of patients somatized or depressed preoperatively returned to good mental well-being postoperatively. Improvement in pain and overall mental wellbeing was seen immediately after discectomy. Improvement in somatic anxiety and depression occurred months later. Microdiscectomy significantly improves pain-associated depression, somatic anxiety, and mental well-being in patients with herniated lumbar disc.

Clinical Outcomes of Bryan Cervical Disc Arthroplasty A Prospective, Randomized, Controlled, Single Site Trial With 48-Month Follow-up

J Spinal Disord Tech 2010;23:367–371

Study Design: Prospective, randomized, controlled. Level 1 evidence.

Objective: To report functional outcomes at 48 months followup on prospectively randomized patients to either the Bryan cervical disc prosthesis or anterior cervical discectomy and fusion (ACDF) at a single site.

Summary of Background Data: Surgical treatment of cervical disc pathology can involve discectomy and fusion (ACDF), the gold standard technique. The safety and effectiveness of this procedure has been established and demonstrated in the literature, however, limitations have evolved and alternatives such as disc replacement are being investigated. Intervertebral disc replacement is designed to preserve motion, both at affected and adjacent levels avoiding limitations of fusion such as adjacent level degeneration. New onset degenerative changes and possible recurring neurologic symptoms may be deferred or eliminated with cervical disc replacement. A recent multicenter trial with 24 months follow-up has shown the Bryan disc to compare favorably with ACDF. Continued follow-up is needed to further evaluate and compare functional outcomes in both these cohorts.

Methods: A total of 47 patients were enrolled at our site as part of an ongoing multicenter prospectively randomized study investigating ACDF versus Bryan cervical disc prosthesis. Functional outcomes are now reported at 48 months follow-up for our cohort of participants. Neck disability index score (NDI), VAS neck and arm and SF-36 both physical and mental as well as complications and reoperations will be reported.

Results: Functional outcome data collected at routine follow-up for 48-months has favorably demonstrated improved functional outcomes for NDI, neck/arm pain VAS scores, and the SF-36 physical/mental health component scores for the Bryan arthroplasty and ACDF cohorts. The NDI scores for the Bryan arthroplasty preoperatively was 51 and at 48 months 10. For ACDF preoperative NDI score was also 51 and at 48 months 16.7. At 48 months NDI success, measured by Z15 points NDI improvement demonstrated a 93.3% success for Bryan arthroplasty and an 82.4%success for ACDF. VAS neck pain scores for the Bryan arthroplasty preoperatively was 76.2 and at 48 months was 13.6. VAS neck pain scores for ACDF preoperatively was 80.6 and at 48 months was 28.1. Arm Pain scores were also measured and for the Bryan arthroplasty preoperatively measured 78.8 and at 48 months 10.8. For ACDF arm pain scores preoperatively measured 77.1 and at 48 months 21.7. These outcomes have not been associated with any degradation of outcome measures from 2 to 4 years. During the 48 months of follow-up at our institution we also report 6 secondary surgeries in our control group (ACDF) and only 1 in our investigational group (Bryan). Of the 6 surgeries in the control group performed, 3 or 12% to date were for adjacent level degenerative disease and 1 or 4% for remote level degenerative disc disease. The remaining 2 surgeries were performed on the same patient for a pseudarthrosis. In the investigational group there was only 1 secondary surgery performed to date for adjacent level disease 5%.

Conclusions: At 48 months, cervical arthroplasty with the Bryan cervical disc prosthesis continues to compare favorably to ACDF at our institution. There has been no degradation of functional outcomes from 24 to 48 months for NDI, VAS of neck and arm, and SF-36. There has been a lower incidence of secondary surgeries for the Bryan arthroplasty cohort to date.